Chapter 45 Urinary Elimination Normal elimination of urinary wastes is a function that affects all body systems. Patients with alterations in urinary elimination may suffer emotionally from body image changes. It is important to know the reasons for urinary elimination problems, to find acceptable solutions, and to provide understanding of and sensitivity to all patients’ needs.

Objectives Describe the process of elimination Insert a urinary catheter correctly Discuss nursing measures to reduce urinary tract infection Irrigate a urinary catheter correctly.

Scientific Knowledge Base: Organs of Urinary Elimination Kidneys Remove waste from the blood to form urine Ureters Transport urine from the kidneys to the bladder Bladder Reservoir for urine until the urge to urinate develops Urethra Urine travels from the bladder and exits through the urethral meatus. Urinary elimination depends on the function of the kidneys, ureters, bladder, and urethra. Kidneys remove wastes from the blood to form urine. Ureters transport urine from the kidneys to the bladder. The bladder holds urine until the urge to urinate develops. Urine leaves the body through the urethra. All organs of the urinary system must be intact and functional for successful removal of urinary wastes. Intact efferent and afferent nerves from the bladder to the spinal cord and brain must be present. [You may wish to ask students to review the anatomy and physiology of the urinary system in their textbooks.]

Urinary System Urinary System Organs Renal Nephron The kidneys lie on either side of the vertebral column behind the peritoneum and against the deep muscles of the back. Kidneys filter waste products of metabolism that collect in the blood. The blood reaches each kidney by a renal (kidney) artery that branches from the abdominal aorta. The nephron, the functional unit of the kidney (on the right), forms the urine. It is composed of the glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal tubule, and collecting duct. Ureters are tubular structures that enter the urinary bladder. Urine draining from the ureters to the bladder is usually sterile. The ureters enter obliquely through the posterior bladder wall. This arrangement prevents the reflux of urine from the bladder into the ureters during the act of micturition by compression of the ureter at the ureterovesical junction (the juncture of the ureters with the bladder). An obstruction within a ureter such as a kidney stone (renal calculus) results in strong peristaltic waves that attempt to move the obstruction into the bladder. These waves result in pain, often referred to as renal colic. The urinary bladder is a hollow, distensible, muscular organ (detrusor muscle) that stores and excretes urine. When empty, the bladder lies in the pelvic cavity behind the symphysis pubis. In men, the bladder lies against the anterior wall of the rectum, and in women, it rests against the anterior walls of the uterus and vagina. When the bladder is full, it expands and extends above the symphysis pubis. A greatly distended bladder may reach the level of the umbilicus. The trigone (a smooth triangular area on the inner surface of the bladder) is at the base of the bladder. An opening exists at each of the three angles of the trigone. Two are for the ureters, and one is for the urethra. Urine exits the bladder through the urethra and passes out of the body through the urethral meatus. Normally, the turbulent flow of urine through the urethra washes it free of bacteria. Mucous membrane lines the urethra, and urethral glands secrete mucus into the urethral canal. Thick layers of smooth muscle surround the urethra. In addition, it descends through a layer of skeletal muscles called the pelvic floor muscles. When these muscles are contracted, it is possible to prevent urine flow through the urethra. In women, the urethra is approximately 4 to 6.5 cm (1 1/2 to 2 1/2 inches) long. The short length of the urethra predisposes women and girls to infection. It is easy for bacteria to enter the urethra from the perineal area. In men, the urethra, which is both a urinary canal and a passageway for cells and secretions from reproductive organs, is about 20 cm (8 inches) long. The male urethra has three sections: prostatic, membranous, and penile.

Catheterization Catheter insertion Closed drainage systems Catheter care Perineal hygiene Fluid intake Catheter irrigations and instillations Removal of indwelling catheter Alternative to urethral catheterization Catheterization involves introducing a tube through the urethra into the urinary bladder. This procedure can cause UTI, blockage, and trauma to the urethra. [Box 45-7 on text p. 1061 presents indications for catheterization.] •Catheterization can be intermittent or indwelling. A catheter drainage system should be a closed system positioned to allow free drainage of urine by gravity. You need an order to insert a catheter. You must use sterile aseptic technique. In the nursing skills lab, you will learn how to insert both straight and indwelling catheters. After inserting an indwelling catheter, maintain a closed urinary drainage system to minimize the risk of infection. Sites for breakage in the system include the drainage bag, spigot, bag juncture, and junction of the tube and bag. Most drainage bags contain an antireflux valve to prevent urine in the bag from reentering the drainage tubing and contaminating the patient’s bladder. [Box 45-10 on text p. 1063 presents tips for preventing infection in catheterized patients.] Follow specific guidelines for catheter selection, so the catheter does not cause harm. Nurses provide perineal hygiene at least 3 times daily or as needed for a patient with a retention catheter. You will need to check your health care facility’s policies and procedures for catheter care. All patients with catheters should have a daily intake of 2000 to 2500 mL if permitted. Catheter irrigations and instillations can be used to maintain the patency of an indwelling urinary catheter. Blood, pus, or sediment can collect in the tubing, causing bladder distention and buildup of urine. An indwelling urinary catheter remains in the bladder for an extended period, making the risk of infection greater than with intermittent catheterization. When removing an indwelling catheter, promote normal bladder function and prevent trauma to the urethra. Suprapubic and condom catheters are two alternatives to indwelling catheters. Suprapubic catheterization requires surgical placement of a catheter through the abdominal wall above the symphysis pubis into the urinary bladder. Maintenance of the tubing and bag is the same as for an indwelling catheter. A condom catheter is used for male patients. [Box 45-11 presents procedural guidelines for condom catheters.] [See the next slide for illustrations of catheters from Figure 45-12 Types of urinary catheters on text p. 1061.]

Types of Urinary Catheters Intermittent and indwelling retention catheterizations are the two forms of catheter insertion. With the intermittent technique, you introduce a straight single-use catheter (A) long enough to drain the bladder (5 to 10 minutes). When the bladder is empty, you immediately withdraw the catheter. You can repeat intermittent catheterization as necessary, but each catheter insertion increases risks of trauma and infection. It is common for people with spinal cord injury or other neurological problems such as multiple sclerosis to perform self–intermittent catheterization up to every 4 hours daily for months or years. If done correctly with the use of clean technique, they frequently do not experience more UTIs; in fact, the UTI rate is lower than for patients with long-term indwelling catheters. An indwelling or Foley catheter (B) remains in place for a longer period—until a patient is able to void voluntarily, or until continuous accurate urine measurements are no longer needed. A second type of intermittent catheter has a curved tip. A Coudé catheter is used on male patients who may have enlarged prostates that partially obstruct the urethra. It is less traumatic during insertion because it is stiffer and easier to control than the straight-tip catheter. Catheters are available in many diameters to fit the size of a patient’s urethral canal. [Box 45-8 on text p. 1062 provides suggestions for how to make appropriate decisions regarding catheter selection.] [Shown is Figure 45-12 from text p. 1061.]

Indications for catheterization Intermittent catheterization Bladder distention, providing decompression Assessing residual urine after urination Managing patients with spinal cord injuries or other neurological problems Short term indwelling catheterization prostate enlargement (obstruction of urine flow) surgical repair of bladder prevention of urethral obstruction from blood clots measurement of urinary output in critically ill patients.

Continue Continues or intermittent bladder irrigations. Long term indwelling catheterization Severe urinary retention with recurrent episodes of uti Skin rashes, ulcers, or wounds irritated by contact with urine Terminal illness when bed linen changes are painful for patient.

Guidelines for appropriate catheter selection Generally women require a 14-16 –fr and men require a 16-18-fr Ballon size is important in selecting an indwelling catheter – adults the 5-ml for optimal drainage and 30- ml after prostatectomies to promote hemostatis of the prostatic bed. Use sterile water to inflate the balloon. If leakage occurs around the catheter a change in lumen size or antispasmodic med.

Catheter Insertion Use strict aseptic technique Inserting indwelling and single –use catheters basically the same Difference lies in the procedure taken to inflate the indwelling catheter balloon and secure the catheter. Maintain a closed drainage system to minimize infection. Drainage bags hold 1000 to 1500 ml of urine. Special port in the tubing to collect specimen.

Catheter irrigations and instillations Use sterile solution and follow sterile aseptic technique. Change catheter if pus or sediment is on tubing. Irrigation after surgery for blood clots Antiseptic or antibiotic bladder irrigations to wash out the bladder or treat local infections Maintenance of closed system

continue For frequent and continues irrigations through use of a three –way catheter

Removal of indwelling catheter Requires a clean technique A sterile syringe the same size as the volume of solution within the inflated balloon of the catheter. Insert the syringe into the balloon insertion port and slowly withdraw all of the solution to deflate the balloon. Patient will feel a burning sensation as the catheter is removed.

Continue Assess the patient’s urinary function by noting the first voiding after catheter removal

3 way catheter

Indwelling cath leg bag