1. Chapter 18
Urinary Elimination

2. Patient-Centered Care
Urinary elimination may be compromised by a wide variety of illnesses and conditions.
Provide assistance.
Physiological support such as invasive procedures
Physical support such as access to toilets or bedpans
Provide privacy and respect.
Consider culture and gender when providing care.

3. Safety
Minimize the risk of introducing pathogens into the urinary tract.
Use aseptic technique when inserting a urinary catheter.
Maintain a closed urinary drainage system.
Keep drainage bags below the level of the bladder.
Provide catheter care using aseptic technique.
Remove urinary catheters as soon as medically indicated.

4. Procedural Guideline 18.1 Assisting with Use of a Urinal
A urinal is a container to hold urine when access to a toilet is restricted because of injury or illness.
Male and female urinals are available.
Provide privacy.
Encourage independence in use if possible.
Assist male to stand to void if able.
Position female supine.
Use absorbent pads if needed.
Assist patient with perineal care after use.

5. Skill 18.1 Applying a Condom-Type External Catheter
External device for noninvasive urine collection for male patients.
Less risk for urinary tract infection (UTI) than indwelling catheter
Held in place by adhesive coating or strips
Refer to manufacturer’s guidelines for application.
Provide perineal care before application.
Avoid catching pubic hair in adhesive when applying.
Ensure that foreskin is replaced in uncircumcised patient.

6. Skill 18.1 Applying a Condom-Type External Catheter (cont’d)
Attach to leg bag or larger urinary drainage bag.
Observe skin under external catheter sheath.
Provide regular perineal care.

7. Procedural Guideline 18.2 Bladder Scan
Bladder scanners provide noninvasive measurement of urine volume in the bladder.
Evaluate new-onset incontinence.
Assess bladder volume for incomplete emptying.
Evaluate suspected bladder distention.
Measure postvoid residual volumes.
Follow manufacturer’s guidelines for accurate imaging.

8. Skill 18.2 Insertion of a Straight or Indwelling Catheter
Urinary catheters remove urine from the bladder for monitoring output, relieving urinary obstruction, or incomplete bladder emptying.
May be temporary or long term
Number of catheter lumens depends on purpose.
Presence of balloon and balloon size depends on purpose.
Catheter changes and length of time used must be individualized.

9. A, Straight catheter (cross-section)
A, Straight catheter (cross-section). B, Indwelling retention catheter (cross-section). C, Triple-lumen catheter (cross-section)

10. Skill 18.2 Insertion of a Straight or Indwelling Catheter (cont’d)
Position patient appropriately for gender.
Provide perineal care and locate urinary meatus.
Maintain sterility of catheter kit when opening.
Identify sequence of supplies in kit to prevent contamination of underlying supplies.
Apply sterile gloves and arrange supplies on sterile field.
Prepare antiseptic solution (cotton balls/swabs).
Follow manufacturer’s instructions regarding balloon test (for indwelling catheter).
Lubricate end of catheter (gender-specific).

11. Skill 18.2 Insertion of a Straight or Indwelling Catheter (cont’d)
Cleanse meatus.
Insert catheter gently through meatus.
Advance catheter until urine flows.
Remove straight catheter after urine stops flowing.
Advance indwelling catheter further to ensure correct placement (gender-specific).
Inflate balloon with recommended fluid amount (indwelling catheter).
Gently pull catheter until resistance is felt.
Secure tubing, allowing some slack.

12. A, Cleansing female perineum. B, Cleansing male urinary meatus

13. Skill 18.3 Removal of Indwelling Catheter
Removal of indwelling catheters reduces risk of catheter-associated infection.
Position and drape patient for maximum privacy.
Place absorbent pad where drips may occur.
Deflate balloon by gravity (passive).
Ensure that balloon is completely deflated and entire amount of fluid is removed.
Gently remove catheter and inspect.
Provide perineal care.
Monitor voiding for 24 to 48 hours after removal.

14. Procedural Guideline 18.3 Care of Indwelling Catheter
Daily meatal care and care after fecal soiling decrease the risk of catheter-associated urinary tract infection (CAUTI).
Position patient and place absorbent pad.
Remove catheter tubing from securing device.
Retract labia or foreskin to expose meatus.
Stabilize catheter at meatus with gloved fingers.
Gently cleanse with soap and water.
Start at meatus and move up catheter using circular motion approximately 10.2 cm (4 inches).
Dry perineum and replace securing device.

15. Skill 18.4 Suprapubic Catheter Care
Surgically placed catheters are secured with sutures, adhesives, or fluid-filled balloons.
Determine how long catheter has been in use.
Established catheters: Cleanse with soap and water.
Newly inserted catheters: Treat as surgical incisions.
Stabilize catheter.
Starting at insertion site, move up length of catheter approximately 5 cm (2 inches) using circular motion.
Apply gauze dressing if indicated.
Secure catheter using tape or securing device.

16. Skill 18.5 Performing Catheter Irrigation
Irrigation is performed intermittently or continuously to maintain catheter patency.
Strict asepsis is required.
Never use force to instill irrigation solution.
Assess for bladder distention during procedure.
Irrigate according to provider orders.
Closed continuous: Adjust drip rate at roller clamp, observe for catheter patency, and monitor outflow.
Closed intermittent: Inject with slow, even pressure.
Allow solution to dwell for prescribed time if ordered.
Open intermittent: Maintain sterility of open tubing during and after irrigation.

17. Chapter 19
Bowel Elimination

18. Patient-Centered Care
Bowel elimination patterns vary among individuals and may be compromised by a wide variety of illnesses and conditions.
Emotional and physical factors affect elimination and may contribute to:
Diarrhea.
Gaseous distention.
Constipation.
Provide privacy and gender-congruent care.
Be aware of cultural influences and practices.

19. Safety Minimize risk of injury to self and patient.
Use safe patient handling practices.
Assist patient to maintain correct position during procedures.
Identify procedural-associated risks:
Bradycardia during fecal impaction removal
Skin breakdown from nasogastric tube
Tube misplacement during nasogastric intubation

20. Procedural Guideline 19.1 Providing a Bedpan
Use for bowel elimination when access to a toilet is restricted because of injury or illness.
Regular bedpan: Most commonly used
Fracture pan: Mobility restrictions
Use adequate staff to place patient on bedpan.
Secure tubes and drains before moving patient.
Determine if specimen is needed.
Instruct patient to lift hips (if able) or turn patient on side and then on back to place on pan.
Raise head of bed 30 degrees unless contraindicated.
Place call bell and toilet tissue within reach.

21. Skill 19.1 Removing a Fecal Impaction
Fecal impactions must be removed when enemas or stool softeners have not been successful.
Determine risks: Anticoagulants, cardiac dysrhythmias
Position patient to left side-lying position.
Insert gloved, lubricated index finger into rectum toward umbilicus; allow anus to relax around finger.
Insert middle finger and work stool from rectal wall to rectum using scissors motion to fragment fecal mass.
Provide perineal care.

22. Skill 19.2 Administering an Enema
An enema promotes bowel evacuation, reduces flatus, increases peristalsis, or instills medications.
Administer prepackaged or standard enema bag.
Position patient in Sims’s position.
Lubricate tip of bottle or enema bag tubing.
Insert appropriate depth for age; never exert force.
Instill ordered amount of warmed solution.
Assist to bathroom or to use bedpan; provide perineal care.

23. Skill 19.3 Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression
Removes gastric secretions or administers solutions into stomach
Levin tube: Single lumen with holes near tip
Salem sump: Has additional “pigtail” air vent lumen
Obtain assistance if patient cannot cooperate.
Place patient in high-Fowler’s position.
Select nostril with greater airflow.
Measure and mark length of tube to insert.
Lubricate end with water-soluble lubricant.

24. Skill 19.3 Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d)
Instruct patient to extend neck back.
Insert tube slowly along floor of nasal passage.
Never use force.
Once past nasopharynx, allow patient to relax.
Instruct patient to flex head forward.
Instruct patient to swallow (sip straw if allowed).
Advance tube to mark 2.5 to 5 cm (1 to 2 inches) with each swallow.
Observe for improper placement.
Coughing, gagging, coiling in back of throat
Anchor tube temporarily.
Verify tube placement per agency policy.

25. Skill 19.3 Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d)
Secure tube using tape or fixation device.
Attach tube to suction as ordered.
Irrigate tube if ordered or needed for patency.
Check for tube placement per agency policy.
Remove from suction and clamp tube.
Insert irrigation syringe, unclamp, and gently inject 30 mL of normal saline.
Aspirate or pull back on syringe to withdraw fluid.
Document as output or intake.
Place 10 mL of air into pigtail.
Reconnect to suction or drainage.

26. Skill 19.3 Insertion, Maintenance, and Removal of a Nasogastric Tube for Gastric Decompression (cont’d)
Discontinue nasogastric (NG) tube.
Turn off suction and remove tube from it.
Provide facial tissue and put towel across chest.
Remove tape or fixation device.
Instruct patient to hold breath.
Kink tube and steadily and smoothly pull it out into towel.
Clean naris and provide mouth care.