1. 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.

2. 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.]

3. 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.

4. Quick Quiz!
1. A patient with a long-standing history of diabetes mellitus is voicing concerns about kidney disease. The patient asks the nurse where urine is formed in the kidney. The nurse’s response is the A. Bladder. B. Kidney. C. Nephron. D. Ureter.
Answer: C [Discuss.]

5. Case Study
Mrs. Vallero is a 65-year-old woman who has been in the hospital for 4 days with problems related to heart failure, fluid retention, and diabetes. She has a history of urinary retention secondary to neuropathy caused by her diabetes.
Mrs. Vallero’s indwelling urinary catheter was removed 2 days ago and subsequently was replaced yesterday at 6 am because of her inability to urinate more than 100 mL at a time, being incontinent of small amounts of urine, complaints of urinary urgency, and lower abdominal pain.
[Sandy, the nursing student, learns about Mrs. Vallero at the 3 pm shift report. What questions would you have if you were Sandy?]

6. Additional Kidney Functions
Production of erythropoietin is essential to maintaining a normal red blood cell (RBC) volume.
Erythropoietin stimulates bone marrow to produce RBCs and prolongs the life of mature RBCs.
Production of renin, prostaglandin E2, and prostacyclin affects blood pressure.
Renin starts a chain of events that cause water retention, thereby increasing blood volume.
Prostaglandin E2 and prostacyclin aid vasodilation.
Kidneys affect calcium and phosphate regulation
In addition to filtering blood and creating urine, the kidneys have other amazing functions.
They produce several substances vital to red blood cell (RBC) production, blood pressure, and bone mineralization. They are responsible for maintaining a normal RBC volume by producing erythropoietin. Erythropoietin functions within the bone marrow to stimulate RBC production and maturation and prolongs the life of mature RBCs. Patients with chronic kidney conditions cannot produce sufficient quantities of this hormone; therefore, they are prone to anemia.
Renal hormones affect blood pressure regulation in several ways. In times of renal ischemia (decreased blood supply), renin is released from juxtaglomerular cells.
[More details are shown on the next slide.]
The kidneys affect calcium and phosphate regulation by producing a substance that converts vitamin D into its active form. Patients with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D. They are prone to develop renal bone disease resulting from the demineralization of bone caused by impaired calcium absorption.

7. Renin-Angiotensin Mechanism
The physiological effects of the renin-angiotensin mechanism are shown in this diagram.
Renin functions as an enzyme to convert angiotensinogen (a substance synthesized by the liver) into angiotensin I. Angiotensin I is converted to angiotensin II in the lungs.
Angiotensin II causes vasoconstriction and stimulates aldosterone release from the adrenal cortex. Aldosterone causes retention of water, which increases blood volume.
The kidneys also produce prostaglandin E2 and prostacyclin, which help maintain renal blood flow through vasodilation. These mechanisms increase arterial blood pressure and renal blood flow.
[Shown is Figure 45-3 from text p ]

8. Act of Urination Brain structures influence bladder function.
Voiding: Bladder contraction + Urethral sphincter and pelvic floor muscle relaxation
1. Stretching of bladder wall signals the micturition center in the sacral spinal cord.
2. Impulses from the micturition center in the brain respond to or ignore this urge, thus making urination under voluntary control.
3. When a person is ready to void, the external sphincter relaxes, the micturition reflex stimulates the detrusor muscle to contract, and the bladder empties.
Voluntary control from higher brain centers and involuntary control from the spinal cord influence the act of micturition or voiding.
Brain structures that influence bladder function (cerebral cortex, thalamus, hypothalamus, and brain stem) inhibit the urge to void or allow voiding.
Normal voiding requires the contraction of the bladder and coordinated relaxation of the urethral sphincter and pelvic floor muscles.
It is vital that nurses understand the process of normal voiding to be able to assess and determine which form of incontinence or which bladder problem may be occurring.
Bladder capacity varies with the individual but ranges from 600 to 1000 mL of urine; an adult normally voids every 2 to 4 hours. As the volume increases, the bladder walls stretch, sending sensory impulses to the micturition center in the sacral spinal cord.
Incontinence is classified as functional, overflow, stress, urge, or total. Each type has specific nursing interventions.
Damage to the spinal cord above the sacral region causes reflex incontinence. This condition causes loss of voluntary control of urination, but the micturition reflex pathway often remains intact, allowing urination to occur without sensation of the need to void. If a chronic obstruction caused by neurological damage such as prostate enlargement hinders bladder emptying, over time the micturition reflex changes, causing bladder overactivity and possibly causing the bladder to not empty completely.
Overflow incontinence occurs when the bladder is overly full and bladder pressure exceeds sphincter pressure, resulting in involuntary leakage of urine. Causes often include head injury; spinal injury; multiple sclerosis; diabetes; trauma to the urinary system; and postanesthesia sedative-hypnotics, tricyclics, and analgesia.
Hyperreflexia, a life-threatening problem that affects heart rate and blood pressure, is caused by an overly full bladder. It is usually neurogenic in nature; however, it can be caused functionally by blockage.

9. Factors Influencing Urination
Disease conditions
Medications and medical procedures
Socioeconomic factors (need for privacy)
Psychological factors (anxiety, stress, privacy)
Fluid balance
Nocturia, polyuria, oliguria, anuria
Diuresis
Fever
[Disease conditions, medications, and procedures that affect urination are discussed on subsequent slides.]
Socioeconomic factors will determine the degree of privacy needed for urination.
Psychological factors include anxiety and emotional stress and privacy issues.
The kidneys primarily maintain the balance between retention and excretion of fluids.
Symptoms common to urinary disturbances include frequency, urgency, dysuria, polyuria, oliguria, incontinence, and difficulty in starting the urinary stream.
Nocturia is awakening to void one or more times at night.
Polyuria is an excessive output of urine.
Oliguria is a decreased urinary output in spite of adequate fluid intake.
Anuria occurs when the kidneys produce no urine.
Diuresis is increased urine formation.
Fever causes an increase in body metabolism and accumulation of body wastes. Although urine volume is reduced, it is highly concentrated.

10. Case Study (cont’d)
Sandy notes that the urinary catheter was removed at 7 am this morning, and the patient has no recorded urine output for the day. Mrs. Vallero verifies that she has only “dribbled” urine. While making rounds, Sandy talks with Mrs. Vallero, who says she is worried because “I thought this was all under control.”
The health care provider is notified, and an order is obtained for an intermittent catheterization. The registered nurse on the day shift catheterizes Mrs. Vallero at 3 pm with a return of 600 mL of pale, clear yellow urine.
[Ask students: What do you think is happening with Mrs. Vallero? Discuss.]

11. Disease Conditions Affecting Urination
Prerenal, renal, postrenal classification
Conditions of the lower urinary tract
Diabetes mellitus and neuromuscular diseases such as multiple sclerosis
Benign prostatic hyperplasia
Cognitive impairments (e.g., Alzheimer’s)
Diseases that slow or hinder physical activity
Conditions that make it difficult to reach and use toilet facilities
End-stage renal disease, uremic syndrome
Disease processes that affect urine elimination affect renal function (changes in urine volume or quality), the act of urine elimination, or both.
Conditions that affect urine volume and quality are generally categorized as prerenal, renal, or postrenal in origin.
Diabetes mellitus and neuromuscular diseases such as multiple sclerosis cause changes in nerve functions that can lead to possible loss of bladder tone, reduced sensation of bladder fullness, or inability to inhibit bladder contractions.
Conditions of the lower urinary tract, including narrowing of the urethra, altered innervation of the bladder, or weakened pelvic and/or perineal muscles, affect urinary elimination.
Decreased blood flow to and through the kidney (prerenal), disease conditions of renal tissue (renal), and obstruction in the lower urinary tract that prevents urine flow from the kidneys (postrenal) sometimes alter renal function.
Older men often suffer from benign prostatic hyperplasia (BPH), which makes them prone to urinary retention and incontinence.
Degenerative joint disease and parkinsonism are examples of conditions that make it difficult to reach and use toilet facilities.
Diseases that slow or hinder physical activity interfere with the ability to void.
Some patients with cognitive impairments, such as Alzheimer’s disease, lose the ability to sense a full bladder or are unable to recall the procedure for voiding.
Diseases that cause irreversible damage to kidney tissue result in end-stage renal disease (ESRD). Eventually, the patient has symptoms resulting from uremic syndrome. An increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions characterize this syndrome.
Dialysis takes one of two forms—peritoneal dialysis or hemodialysis. Patients can use both dialysis modalities for a short or long term, but these treatments require specialized equipment and nurses with specialized education.
Dialysis and organ transplantation are two methods of renal replacement.
As the uremic symptoms worsen, aggressive treatment is indicated for survival. These treatments are renal replacement therapies.
Peritoneal dialysis is an indirect method of cleaning the blood of waste products using osmosis and diffusion, with the peritoneum functioning as a semi-permeable membrane. This method removes excess fluid and waste products from the bloodstream when a sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via a surgically placed catheter. The dialysate remains in the cavity for a prescribed time interval and then is drained out by gravity, taking accumulated wastes and excess fluid and electrolytes with it.
Hemodialysis requires a machine equipped with a semi-permeable filtering membrane (artificial kidney) that removes accumulated waste products and excess fluids from the blood. In the dialysis machine, dialysate fluid is pumped through one side of the filter membrane (artificial kidney), while the patient’s blood passes through the other side. The processes of diffusion, osmosis, and ultrafiltration clean the patient’s blood. Then the blood returns through a specially placed vascular access device (Gore-Tex graft, arteriovenous fistula, or hemodialysis catheter). Organ transplantation is the replacement of a patient’s diseased kidney with a healthy one from a living or cadaver donor of compatible blood and tissue type. The new organ is surgically implanted into the abdomen. Special medications (immunosuppressives) are administered, often for life, to prevent the body from rejecting the transplanted organ. Unlike other treatments, successful organ transplantation offers patients the potential for restoration of normal kidney function.

12. Indications for Dialysis
Renal failure that can no longer be controlled by conservative management
Worsening of uremic syndrome associated with end-stage renal disease (ESRD)
Severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures
Indications for dialysis include the following:
Renal failure that can no longer be controlled by conservative management (Conservative management would include dietary modifications and the administration of medications to correct electrolyte abnormalities.)
Worsening of uremic syndrome associated with ESRD, which would include nausea, vomiting, neurological changes, and pericarditis
Severe electrolyte and/or fluid abnormalities that cannot be controlled by simpler measures (These abnormalities would include hyperkalemia and pulmonary edema.)
[This slide covers Box 45-1 Indications for Dialysis from text p ]

13. Case Study (cont’d)
As Sandy prepares to assess Mrs. Vallero again, she remembers that urinary problems are common in patients who have diabetes and in older adults. Age alone does not cause incontinence. She recalls that patients with urinary retention sometimes leak or “dribble” urine and are then misdiagnosed as incontinent.
She knows that patients generally void at least every 6 to 8 hours, and that Mrs. Vallero’s recent catheterization, her decreased mobility, and her history of diabetes make her more prone to urinary retention, incontinence of small amounts of urine, and urinary tract infection (UTI).
[Ask students: What should Sandy do at the next assessment? Discuss.]

14. Medical Interventions Affecting Urination
Surgical procedures
Restriction of fluid intake lowers urine output.
Stress causes fluid retention.
Medications
Some cause urinary retention and/or overflow incontinence.
Some cause urgency and incontinence.
Some change the color of urine.
Diagnostic examinations
Direct visualization causes localized trauma and edema; patients may have difficulty voiding.
Preoperative orders of nothing by mouth or an underlying disease condition affects fluid balance before surgery; this reduces urine output. In addition, the stress response releases an increased amount of antidiuretic hormone (ADH), which increases water resorption. Stress also elevates the level of aldosterone, causing retention of sodium and water. Both of these substances reduce urine output in an effort to maintain circulatory fluid volume.
Anesthetics and narcotic analgesics slow the glomerular filtration rate, reducing urine output. These pharmacological agents also impair sensory and motor impulses traveling among the bladder, spinal cord, and brain. Patients are often unable to sense bladder fullness and initiate or inhibit micturition. Spinal anesthetics, in particular, create the risk of urinary retention because of an inability to sense the need to void and possible inability of the bladder muscles and urethral sphincters to respond.
Surgery of lower abdominal and pelvic structures sometimes impairs urination because of local trauma to surrounding tissues. After returning from surgery involving the ureters, bladder, and urethra, patients routinely have urinary catheters.
Many medications directly or indirectly contribute to urinary dysfunction. Antipsychotics, antidepressants, alpha-adrenergic agonists, and calcium channel blockers can cause urinary retention and overflow incontinence. Alpha-antagonists, diuretics, sedative-hypnotics, opioid analgesics, angiotensin-converting enzyme (ACE) inhibitors, and antihistamines can cause urinary incontinence. Antiparkinson medications may cause urinary urgency and subsequent incontinence. Always consider these medications as the cause of new-onset urinary incontinence, especially in older adults.
Some medications change the color of urine. For example, phenazopyridine (Pyridium) colors the urine a bright orange to rust, amitriptyline causes a green or blue discoloration, and levodopa discolors the urine to brown or black. Cancer chemotherapy drugs also color the urine and are often toxic to the bladder and/or kidneys. Patients with impaired kidney function require dosage adjustments in medications excreted by the kidneys.
Examination of the urinary system influences micturition. Some procedures such as an intravenous pyelogram (IVP) require patients to limit fluids before the test. A restriction in fluid intake commonly lowers urine output. Diagnostic examinations (e.g., cystoscopy) involving direct visualization of urinary structures cause localized edema of the urethral passageway and spasm of the bladder sphincter. After the procedure, a patient may have difficulty voiding or may have red or pink urine caused by trauma to the urethral or bladder mucosa.

15. Alterations in Urinary Elimination
Urinary retention
An accumulation of urine due to the inability of the bladder to empty
Urinary tract infection
Results from catheterization or procedure
Urinary incontinence
Involuntary leakage of urine
Urinary diversion
Diversion of urine to external source
As urinary retention progresses, retention with overflow develops. Bladder distention is apparent. With retention, the patient may void small amounts of urine 2 to 3 times an hour with no real relief.
Urinary tract infections (UTIs) are usually caused by Escherichia coli. Bacteriuria (bacteria in the urine) leads to the spread of organisms into the kidneys, and possibly to bacteremia (bacteria in the bloodstream). Microorganisms commonly enter the urinary tract through the ascending urethral route. Bacteria inhabit the distal urethra, the external genitalia, and the vagina in women. Women are more susceptible to infection because of a short urethra and close proximity to the anus.
Burning during urination is known as dysuria as urine passes through inflamed tissues. An irritated bladder is known as cystitis. Irritation of the bladder and urethral mucosa causes hematuria. If infection spreads to the kidneys, pyelonephritis occurs, with symptoms of flank pain, tenderness, fever, and chills.
Urinary incontinence (UI) can be temporary or permanent and continuous or intermittent. UI can affect patients of any age, but it is very prevalent in the elderly. Causes can include problems with movement, removing clothing, and mental incapacity.
Some patients may have a urinary stoma to divert the flow of urine from the kidneys to an external source. This may be necessary because of trauma, cancer, radiation, fistula, or chronic cystitis. The types of diversion include ileal loop or conduit, continent pouch, and nephrostomy.
[See slide 21, Figure 45-4 Types of urinary diversions from text p ]

16. Older Adults
Provide frequent opportunities to void. Older adults have a smaller bladder capacity than younger adults.
Encourage older adults to empty the bladder completely before and after meals and at bedtime.
Encourage patients to increase fluid intake to at least six to eight glasses a day unless medically contraindicated.
Provide frequent opportunities to void. Older adults have a smaller bladder capacity than younger adults.
Encourage older adults to empty the bladder completely before and after meals and at bedtime.
Discourage drinking of coffee, tea, brown cola, and alcohol because these have a diuretic effect and increase urinary frequency.
Make fluids such as cranberry juice available as part of the patient’s fluid intake. Cranberry juice and vitamin C help acidify the urine to decrease
bacterial infections of the bladder.
Restricting fluid intake does not decrease urinary incontinence severity or frequency.
Avoid routine use of indwelling catheters. If one is necessary, use it no longer than necessary. The risk of infection increases dramatically for
catheterized patients.
Note that incontinence is not a normal part of aging, and make efforts to assess incontinence and provide interventions to promote return to continence.
[See Box 45-2 from text p Focus on Older Adults Promoting Urinary Health.]

17. Quick Quiz!
2. A health care provider may suspect that a patient is experiencing urinary retention when the patient has
A. Large amounts of voided cloudy urine.
B. Pain in the suprapubic region.
C. Spasms and difficulty during urination.
D. Small amounts of urine voided 2 to 3 times per hour.
Answer: D [Discuss.]

18. Case Study (cont’d)
Sandy knows that she will need to assess whether Mrs. Vallero feels the urge to urinate. She determines that no one has taken Mrs. Vallero to the bathroom recently. Sandy also needs to find out more about her patient’s urination patterns at home because Mrs. Vallero has verbalized anxiety about her present voiding patterns.
Previous clinical experience has taught Sandy that palpation of the abdomen over a distended bladder causes some discomfort, and that the patient often experiences an urge to urinate. Mrs. Vallero grimaces when her abdomen is palpated and says she has a little dolor (pain).
Because heart failure and bed rest have left Mrs. Vallero in a weakened state, Sandy is flexible and creative in designing a plan of care to meet the patient’s elimination needs.
[Ask students: What additional assessment activities should be performed routinely? What would you incorporate into Mrs. Vallero’s plan? Discuss.]

19. Types of Urinary Diversions
Conditions such as bladder cancer, radiation, injury to the bladder, and chronic urinary infection may necessitate a urinary diversion to drain urine from a diseased or dysfunctional bladder.
Two types of continent urinary diversions may be performed:
A continent urinary reservoir is created from a distal portion of the ileum and a proximal portion of the colon. The ureters are embedded in the reservoir. This reservoir is situated under the abdominal wall and has a narrow ileal segment brought out through the abdominal wall to form a small stoma. The ileocecal valve creates a one-way valve in the pouch, through which a catheter is inserted to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives.
The second type is an orthotopic neobladder that also uses an ileal pouch to replace the bladder. Anatomically, the pouch is in the same position in which the bladder was before removal, allowing patients to void normally. Incontinent urinary diversions are less commonly performed. Surgery involves connecting the ureters to a section of the intestinal ileum with formation of a stoma on the abdominal wall. Urine drains continuously because the patient has no sensation or control over urinary output, requiring the application of a collection pouch at all times. Some patients need urinary drainage directly from one or both kidneys. In this case, a tube is placed directly into the renal pelvis. This procedure is called a nephrostomy. Any urinary diversion poses threats to a patient’s body image. The patient must learn how to manage the diversion, and those who do not have a continent urinary diversion must wear an artificial device at all times. However, most patients are able to wear normal clothing, engage in physical activity, travel, and have sexual relations. Care must be taken not to pull on tubing, especially with a nephrostomy, because it can be pulled out, causing tissue and organ damage and infection. Most nephrostomies are sutured into the kidney.
Refer patients with a urinary diversion to an ostomy nurse (a nurse with specialized education in this area). This specialist is a valuable resource for assisting a patient and family with matters pertaining to all aspects of care. The ostomy nurse often meets with the patient and family before surgery. In addition, refer the patient to the United Ostomy Associations of America (www. uoaa.org). This organization provides information about support groups to enhance coping and adaptation to lifestyle and body image changes.
[Shown is Figure 45-4 Types of urinary diversions on text p ]

20. Nursing Knowledge Base
Infection control and hygiene
Growth and development
Muscle tone
Psychosocial considerations
Cultural considerations
Recall that, for many, the act of urinary elimination is a private process. Students need to be cognizant of the many issues affecting this process.
The urinary tract is sterile. The use of infection control principles will help to prevent the spread of UTI.
Increased fluid intake results in increased diluted urine formation, which reduces the risk of urinary tract infection.
Growth and development factors will determine the patient’s ability to control the act of urination across the life span. Infants, children, and the elderly experience problems with urination. The young need to learn to recognize the need to urinate. The elderly need to deal with decreased functioning that accompanies aging.
Weak abdominal and pelvic floor muscles impair the ability of the urinary sphincter to maintain tone. Immobility, muscle damage during vaginal delivery, and muscle atrophy or trauma contribute to problems with urination.
Psychosocial issues such as body image, self-esteem, roles, and identity may influence urination. Gender differences also occur: Males stand and females sit.
Culture influences the act of urination. Urinary problems may not be treated in the western tradition. Culture may also dictate how and when a patient urinates. In some cultures, patients urinate in a squatting position. It will be important to render culturally competent care.

21. Nursing Process: Assessment
Nursing history
Patterns of urination
Symptoms of urinary alterations
Factors affecting urination
Nursing history includes a review of elimination patterns, symptoms of alterations, and other factors.
[Box 45-4 on text p presents nursing assessment questions to ask.]
[Table 45-1 on test p presents common types of urinary alterations.]
Factors that affect urinary alteration include environmental factors, medication history, psychological factors, muscle tone, fluid balance, current surgical or diagnostic procedures, and the presence of disease.
[Also see Figure 45-5 Critical thinking model for urinary elimination assessment on text p. 1050; and Box 45-3 on text p Cultural Aspects of Care: Urinary Elimination.]

22. Case Study (cont’d) Findings:
Patient is able to palpate bladder, indicating bladder distention. During palpation, patient states she has the sensation of bladder fullness.
Patient complains of dribbling frequently and being unable to urinate.
What are the specific assessment activities that produced these findings?
What other assessment questions should be asked?
[Discuss with students the findings from this case study assessment. Discuss the procedure of palpating the bladder to detect bladder distention every 2 hours on the even hours. Discuss assessment of the patient’s voiding pattern, including volume at each voiding, frequency, times of day, and history of any changes.]

23. Urine Collection in Children
Specimen collection from infants and children is often difficult.
Adolescents and school-aged children usually are able to cooperate.
Preschool children and toddlers have difficulty voiding on request.
It often helps to offer the child fluids 30 minutes before requesting a specimen.
You need to use terms for urination that the child is able to understand.
A young child is often reluctant to void in unfamiliar receptacles. A potty chair or specimen hat placed under the toilet seat is usually effective.
You will need to use special collection devices for infants or toddlers who are not toilet-trained. You can attach clear plastic, single-use bags with self-adhering material over the child’s urethral meatus.
Do not obtain specimens by squeezing urine from the diaper because the results will be inaccurate.

24. Quick Quiz!
3. A young girl is having problems urinating postoperatively. You remember that children may have trouble voiding
A. In bathrooms other than their own.
B. In a urinal.
C. While lying in bed.
D. In the presence of a person other than their parents.
Answer: D [Discuss.]

25. Physical Assessment
Gather nursing history for the patient’s urination pattern and symptoms, and factors affecting urination.
Conduct physical assessment of the patient’s body systems potentially affected by urinary change.
Assess characteristics of urine.
Assess the patient’s perception of urinary problems as it affects self-concept and sexuality.
Gather relevant laboratory and diagnostic test data.
Your knowledge, experience, standards, and attitudes will play critical roles in the assessment process.
Apply the nursing process, and use a critical thinking approach in the care of patients.
The nursing process provides a clinical decision-making approach by which you can develop and implement an individualized plan of care.
During the assessment process, thoroughly assess each patient and critically analyze findings to ensure that you make patient-centered clinical decisions required for safe nursing care.
Successful critical thinking requires synthesis of knowledge, experience, information gathered from patients, critical thinking attitudes, and intellectual and professional standards.
Clinical judgments require you to collect necessary information, analyze the data, and anticipate and make decisions regarding patient care.
[See also Figure 45-5 Critical thinking model for urinary elimination assessment from text p ]

26. Physical Assessment Skin and mucosal membranes Kidneys Bladder
Assess hydration.
Kidneys
Flank pain may occur with infection or inflammation.
Bladder
Distended bladder rises above symphysis pubis.
Urethral meatus
Observe for discharge, inflammation, and lesions.
To identify a urinary elimination problem and gather data for a care plan, use scientific and nursing knowledge, conduct a nursing history, perform a physical assessment, assess the patient’s urine, and review information from diagnostic tests and examinations. Use critical thinking to synthesize this information as assessment proceeds.
Skin and mucosa: Assess the skin’s hydration by looking at turgor and texture.
Kidneys: Nurses with advanced skills learn to palpate the kidneys.
Bladder normally sits below the symphysis pubis. Gentle palpation on a distended bladder causes the patient to feel tenderness, pain, or the urge to urinate. Percussion produces a dull tone.
Urethral meatus: The female patient will need to lie in the dorsal recumbent position to expose the genitalia. Using gloved hands, retract the labia to observe the urethral meatus. Look for drainage or lesions and ask the patient if this is uncomfortable. Drainage indicates infection.
The male’s meatus is normally a small opening at the tip of the penis. Inspect the meatus for discharge lesions and inflammation. For the uncircumcised patient, you will need to retract the foreskin.

27. Assessment of Urine Intake and output Characteristics of urine
Color
Pale-straw to amber color
Clarity
Transparent unless pathology is present
Odor
Ammonia in nature
Urine testing
Specimen collection
In the skills lab, you will learn how to measure and document intake and output. Remember that hourly output of less than 30 mL for longer than 2 hours is cause for concern and further assessment.
The color of urine should be pale-straw to amber. Urine will be more concentrated in the morning. Medications can change color, as can beets, rhubarb, or blackberries. Dark amber urine is the result of bilirubin from liver disease.
Stagnant urine has a strong ammonia odor. A sweet or fruity odor is seen with diabetes mellitus or starvation.
You will learn how to collect specimens in the nursing skills lab. These specimens can be random, clean, voided or midstream, and sterile or timed.

28. Urine Tests and Diagnostic Examinations
Urinalysis
Specific gravity
Culture
Noninvasive procedures
Invasive procedures
To analyze a urine sample, you must correctly collect it. Refer to your specific health care facility for policies and procedures.
[Table 45-3 Routine Urinalysis on text p lists normal values for urinalysis.]
Specific gravity is the weight or degree of concentration of a substance compared with an equal volume of water.
When collected properly, a clean-voided urine specimen does not contain bacteria from the urethral meatus.
A urine culture requires a sterile or clean-voided urine sample. It will take 24 to 48 hours to reveal the findings of bacterial growth. The test for sensitivity will determine which antibiotic will be most effective.
Noninvasive examinations include KUB (abdominal roentgenogram [plain film; kidney, ureter, bladder, or flat plate]), CT (computed axial tomography scan), and IVP (intravenous pyelogram) or urodynamic testing (uroflowmetry).
Invasive examinations include cystoscopy and arteriography.
Remember that each examination has a specific indication and use, bowel preparation, and patient education. Some examinations will require a signed consent form. Some will require injection of a dye. You will need to assess the patient’s sensitivity to the dye.
[See also Table 45-4 on text p Diagnostic Examinations.]

29. Urine Drainage Bag
When you measure urine from a drainage bag, a separate plastic graduated measuring receptacle is used to obtain more precise measurement of urine output.
Each patient needs to have a graduated receptacle for his or her exclusive use to prevent potential cross-contamination. Label each container with patient name.
The container needs to be rinsed after emptying, and the tubing that drains the bag securely clamped and cleaned with alcohol before it is put back in the holder.
Report any extreme increase or decrease in urine volume. An individual’s daily output generally ranges from 1200 to 1500 mL of urine. Hourly output of less than 30 mL for longer than 2 consecutive hours is cause for concern. Similarly, you need to report consistently high volumes of urine (polyuria) (i.e., over 2000 to 2500 mL daily).
[Shown is Figure 45-6 Urine drainage bag on text p ]

30. Urine Specimen Collection
The nurse collects random, clean-voided or midstream, sterile, and timed specimens.
The method of collection varies according to the patient’s developmental level and the type of specimen ordered.
[See Table 45-2 from text p ]
[Shown is Figure 45-7 from text p Urine specimen collection: aspiration from a collection port in drainage tubing of indwelling catheter (needleless technique).]

31. Checking Results of a Chemical Reagent Strip
Here you see a care provider checking the results of a chemical reagent strip dipped in urine.
For a quick screening, perform certain portions of the urinalysis with special reagent strips. Dip the strips into the urine, and observe for a color change in the time interval designated on the package.
[Shown is Figure 45-8 from text p ]

32. Nursing Diagnosis and Planning
• Social isolation
• Disturbed body image
• Pain
(acute, chronic)
• Urinary incontinence (functional, stress, urge, overflow)
• Risk for infection
• Toileting self-care deficit
• Impaired skin integrity
• Impaired urinary elimination
• Constipation
• Urinary retention
Some nursing diagnoses common to patients with urine elimination alterations are shown on the slide.
A general goal is often normal urinary elimination, but sometimes the individual goal differs, depending on the problem.
Consider the patient’s home environment and normal elimination routines when planning therapies. Collaborate with several health care disciplines, the patient, and the patient’s family.
[See also Box 45-5 on text p Nursing Diagnostic Process: Stress Urinary Incontinence Related to Weakened Pelvic Musculature; Figure 45-9 on text p Critical thinking model for urinary elimination planning; Figure Concept map; and Nursing Care Plan: Stress Urinary Incontinence on text pp ]

33. Case Study (cont’d)
Nursing diagnosis: Urinary retention related to weakened detrusor muscle and recent removal of indwelling urinary catheter
Goal: Mrs. Vallero will have normal micturition within 1 month.
What expected outcomes would you establish to measure goal achievement?
[Discuss with students the expected outcomes, which could include urinary elimination, urinary continence, and symptom severity measures:
Mrs. Vallero will void more than 150 mL each time.
Mrs. Vallero will verbalize no episodes of dribbling or incontinence.
Mrs. Vallero will verbalize relief of lower abdominal discomfort.]

34. Implementation Health promotion Stimulating micturition reflex
Patient education
Promoting normal micturition
Stimulating micturition reflex
Maintaining elimination habits
Maintaining adequate fluid intake
Promoting complete bladder emptying
Preventing infection
Maintaining normal urinary elimination helps to prevent many urination problems.
Many nursing measures promote normal voiding in patients at risk for urination difficulties and in those with established urination problems.
Methods of promoting the micturition reflex help patients sense the urge to urinate and control urethral sphincter relaxation.
A patient’s ability to void depends on feeling the urge to urinate, being able to control the urethral sphincter, and being able to relax during voiding. Help patients learn to relax, and stimulate the reflex to void by helping them assume the normal position for voiding.
A woman is better able to void in a squatting or sitting position. If the patient is unable to use toilet facilities, position him or her in a squatting position on a bedpan or bedside commode.
Other measures that promote relaxation and the ability to void include sensory stimuli. The sound of running water helps many patients void through the power of suggestion. Stroking the inner aspect of the thigh stimulates sensory nerves and promotes the micturition reflex. You can also pour warm water over the patient’s perineum and create the sensation to urinate. If you need to measure urine output, first measure the volume of water that you pour over the perineal area.
Integrating patients’ habits into the care plan fosters normal voiding and helps prevent problems related to urination.
A simple method of promoting normal micturition is maintaining optimal fluid intake.
Encouraging patients to wait until urine stops flowing or to attempt to void again (double voiding) can improve bladder emptying.
One of the most important considerations is to prevent infection of the urinary system.
[See also Table 45-5 on text p Urinary Incontinence and Treatment Options; and Box 45-6 on text p Patient Teaching: Urinary Elimination Problems Related to Urinary Sphincter Dysfunction.]

35. Types of Male Urinals
A man voids more easily in the standing position. If the man cannot reach toilet facilities, have him stand at the bedside and void into a urinal (a metal or plastic receptacle for urine) such as those shown here.
At times, it is necessary for one or more nurses to help a man stand.
[Shown is Figure Types of male urinals.]

36. Case Study (cont’d) Interventions for urinary retention care include:
Assist with toileting every 2 to 3 hours while awake.
Instruct the patient/family to record urinary output as appropriate.
Have Mrs. Vallero take a warm bath if unable to urinate.
Use Credé’s method with each attempted void.
[Discuss (or ask the students to offer) the rationales for each intervention:
Scheduled toileting is the primary behavioral intervention used for chronic retention and is used to reduce bladder capacity.
Keeping a record of urinary output is important to confirm voiding in small amounts. Also, it is important to note the amount urinated before obtaining residual urine.
Relaxing in a bath eases discomfort and induces micturition.
Credé’s method involves putting pressure on the suprapubic area and is used for the relief of urinary retention.]

37. Implementation Acute care Maintaining elimination habits Medications
Allow time and provide privacy.
Medications
Parasympathetic stimulation of the detrusor muscle aids emptying.
Cholinergic drugs increase bladder contraction and improve emptying.
Catheterization
Patients usually require time to void. Requesting a urine specimen on demand does not contribute to relaxation and normal voiding habits. Give patients at least 30 minutes to provide a specimen.
Many patients need privacy for voiding. If a patient cannot reach the bathroom and uses a bedside commode or bedpan, make sure that the bedside curtain is closed.
Drug therapy given alone or with other therapies often helps problems of incontinence or retention. The bladder is innervated by the parasympathetic nervous system. Drugs that block the muscarinic receptors suppress bladder contractions and reduce incontinence caused by bladder irritation.
When the bladder empties, the detrusor muscle contracts in response to parasympathetic stimulation. Incomplete bladder emptying results from impaired innervation or weakness of the detrusor muscle. The patient experiences retention and possible overflow incontinence. Cholinergic drugs increase contraction of the bladder and improve emptying.
Catheterization of the bladder involves introducing a latex or plastic tube through the urethra and into the bladder. The catheter provides continuous flow of urine in patients unable to control micturition and in those with obstructions.

38. 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 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 on text p 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 presents procedural guidelines for condom catheters.]
[See the next slide for illustrations of catheters from Figure Types of urinary catheters on text p ]

39. 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 provides suggestions for how to make appropriate decisions regarding catheter selection.]
[Shown is Figure from text p ]

40. Urinary Drainage System and Infectious Organisms
[Shown here in Figure from text p are the potential sites for introduction of infectious organisms into a urinary drainage system.]
[The following points are taken from Box Tips for Preventing Infection in Patients with Catheters on text p ]
Follow good hand hygiene techniques.
Do not allow the spigot on the drainage system to touch a contaminated surface.
Only use sterile technique to collect specimens from a closed drainage system.
If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting.
Ensure that each patient has a separate receptacle for measuring urine to prevent cross-contamination.
Prevent pooling of urine in the tubing and reflux of urine into the bladder.
Avoid raising the drainage bag above the level of the bladder.
If it becomes necessary to raise the bag during transfer of the patient to a bed or stretcher, clamp the tubing or empty its contents into the drainage bag first.
Provide for drainage of urine from the tubing to the bag by positioning the tubing.
Before exercise or ambulation, drain all urine from the tubing into the drainage bag.
Avoid prolonged kinking or clamping of the tubing.
Empty the drainage bag at least every 8 hours. If you note large outputs, empty more frequently.
Encourage fluid intake (if not contraindicated).
Remove the catheter as soon as clinically necessary.
Tape or secure the catheter appropriately for the patient.
Perform routine perineal hygiene per agency policy and after defecation or bowel incontinence.

41. Applying a Condom Catheter
The condom catheter is suitable for incontinent or comatose men who still have complete and spontaneous bladder emptying.
The condom is a soft, pliable, latex sheath that slips over the penis.
Patients wear it only at night or continuously, depending on their needs.
After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP).
Be sensitive to the privacy needs of patients.
Be sure that the skin of the penile shaft is intact and free from swelling, redness, or open lesions before applying the condom catheter.
Ask for assistance if the NAP is uncertain how to apply the adhesive strip that secures the condom catheter.
[Image shows the distance between the end of the penis and the tip of the condom = Step 12 on text p Box Procedural Guidelines: Applying a Condom Catheter.]
[See Box Procedural Guidelines: Applying a Condom Catheter on text p ]

42. Applying a Condom Catheter (cont’d)
Three general methods may be used to secure a condom catheter:
1. The first method uses a strip of elastic tape or rubber that encircles the top of the condom to secure it in place.
2. Another type uses a self-adhesive condom sheath.
3. The third method uses an inflatable ring within the condom to secure placement.
Take care to ensure that, whatever type or size is used, blood supply to the penis is not impaired. Never use standard adhesive tape to secure a condom catheter because it does not expand with change in penis size and is painful to remove. After assessing the patient for latex allergy, you can delegate the skill of applying a condom catheter to nursing assistive personnel (NAP).
Be sensitive to the privacy needs of patients.
[Image shows the application of elastic tape in a spiral fashion to secure condom catheter to penis = Step 13a on text p. 1065, Box Procedural Guidelines: Applying a Condom Catheter.]

43. Applying a Condom Catheter (cont’d)
The end of the condom is attached to plastic drainage tubing and a bag that you attach to the side of the bed or strap to the patient’s leg.
The condom catheter itself poses little risk of UTI. Infection usually results from buildup of secretions around the urethra, trauma to the urethral meatus, or buildup of pressure in the outflow tubing.
If the condom catheter is made of opaque material, remove it daily to check for skin irritation. Some new condom catheters are more transparent, and you are able to observe the skin through them more easily.
Change the condom catheter daily. With each catheter change, thoroughly clean the urethral meatus and penis.
Check the drainage tubing often for patency because twisting the condom at the drainage tube attachment irritates the skin and obstructs urine outflow.
Make sure that the tip of the penis is at the end of the catheter. If space is noted between the end of the penis and the catheter, urine can pool in this space and excoriate the end of the penis.
[Image shows attaching the condom catheter tubing to leg bag = Step 14 on text p Box Procedural Guidelines: Applying a Condom Catheter.]

44. External Urinary Device
For a man with a retracted penis, maintaining a conventional condom catheter often proves difficult. Special devices are available to help alleviate this problem (see Fig ). Consult manufacturer guidelines for product application.
No collection devices for women are as effective as the condom catheter is for men; thus frequently the only devices used are pads and protective clothing.
To maintain dignity, do not refer to pads and protective clothing as adult diapers, and change them frequently to control odor. Use these products only temporarily to minimize or prevent episodes of incontinence while treatment is ongoing.
Monitor patients frequently and provide good skin care to prevent irritation caused by urine.
Some manufacturers have developed a female urinal; however, its ease of use may be an issue.
[Shown is Figure from text p Retracted penis pouch external urinary device.]

45. Implementation: Restorative Care
Strengthening pelvic floor muscles
Bladder retraining
Habit training
Self-catheterization
Maintenance of skin integrity
Promotion of comfort
Patients who have stress or urge urinary incontinence and difficulty starting and stopping urination may benefit from pelvic floor exercises. Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups.
The goal of bladder retraining is to reduce voiding frequency and perhaps bladder capacity. This method provides a specific program for patients who have a decreased urge to void or have stress incontinence because it keeps the bladder from getting full; thus less dribbling occurs.
A patient with functional incontinence benefits from habit training, which helps patients improve voluntary control over urination. A patient establishes a flexible toileting schedule based on his or her pattern.
Some patients with chronic disorders such as spinal cord injury learn to perform self-catheterization.
The normal acidity of urine is irritating to skin. Urine that is allowed to remain in contact with the skin becomes alkaline, causing encrustations or precipitates to collect on it, fostering breakdown.
Patients with urinary alterations become uncomfortable as a result of the symptoms of urinary problems. Frequent or unpredictable voiding, dysuria, and painful distention are sources of discomfort. The incontinent patient gains comfort from having clean, dry clothing.

46. Evaluation Evaluate whether the patient has met outcomes and goals.
Check how the patient reports progress made.
Help the patient redefine goals if necessary.
Revise nursing interventions as indicated.
The patient is the best source of evaluation of outcomes and responses to nursing care.
Note the patient’s responses to questions about urination. Does he or she seem hesitant or embarrassed?
Psychosocial factors such as culture or sexuality sometimes influence the patient’s response. Because urination is often considered a private matter, some people find it difficult to talk about their voiding habits.
Remember that urinary elimination problems are not just physiological in nature. Be sensitive to any changes in self-concept and sexuality.
Self-concept, which includes body image, self-esteem, roles, and identity, develops over a life span. Because the penis is an organ for both urination and sex, urinary dysfunction often greatly affects a man’s self concept.
[See Figure Critical thinking model for urinary elimination evaluation from text p ]
[Ask students: What are some examples of questions to ask during the evaluation step? Possible answers include:
“Tell me, How frequently are you voiding now?”
“Do you continue to have the feeling of urgency every time you void?”
“Have the symptoms of urgency decreased since you changed your caffeine intake?”
“Do you still have burning when you pass urine?”
“Do you still feel uncomfortable over your lower abdomen?”

47. Case Study (cont’d)
Sandy talks with Mrs. Vallero the next evening. The patient’s care plan incorporates scheduled voiding, oral fluids, and use of Credé’s method of manual compression during voiding. She palpates Mrs.Vallero’s bladder and then assists her to the toilet.
After making sure she is comfortable and leaving the call light in place, Sandy instructs her to use Credé’s method of manual compression. She returns to measure Mrs. Vallero’s urinary output and evaluates for bladder residual using an ultrasound bladder scan.
[Ask students: What would Sandy put in the documentation note about this stage? Discuss.]

48. Case Study (cont’d)
Ask Mrs. Vallero about her urge to void, sensation of bladder fullness, and dribbling episodes.
Have Mrs. Vallero keep a log of her pattern of elimination, including urine output volumes with each voiding, during the 1-month period.
Ask Mrs. Vallero if she continues to have lower abdominal pain.
[Ask students: What responses would be consistent with achievement of each outcome? Possible responses:
Dribbling episodes and sense of urgency are relieved.
Urinary output is greater than 150 mL with each void.
Lower abdominal discomfort is absent. Discuss.]

49. Case Study (cont’d)
Mrs. Vallero is concerned about regaining her urinary function. Sandy develops the following outcome for her: At the end of the teaching session, Mrs. Vallero will be able to describe approaches to promote normal urinary elimination habits.
What teaching strategies would you put into the plan?
What evaluation strategies would you use?
[Ensure that each of these teaching and evaluation strategies was covered, and discuss them with students:
TEACHING:
Establish rapport with Mrs. Vallero.
Find out what Mrs. Vallero already knows about good practices for urinary health.
Use the correct terms for the anatomy that you will discuss, but explain them so Mrs. Vallero knows what they are.
Provide appropriate visual diagrams and written materials for Mrs. Vallero.
Instruct her in observations to make regarding urinary output.
Instruct her in adequate fluid intake, incorporating her fluid preferences.
Discuss how to do intake and output measurement at home.
Reinforce correct perineal hygiene measures to reduce the risk for urinary tract infection.
Provide Mrs. Vallero with pertinent signs and symptoms of infection to report to her health care provider.
EVALUATION:
Use open-ended questions to determine level of learning.
Ask Mrs. Vallero to verbalize her understanding of normal urinary function.
Ask Mrs. Vallero to verbalize abnormal signs and symptoms to report to her health care provider.
Have Mrs. Vallero measure water in a container to simulate intake and output measures.]

50. Safety Guidelines
Follow principles of surgical and medical asepsis as indicated when performing catheterizations, handling urine specimens, or helping patients with their toileting needs.
Identify patients at risk for latex allergy (i.e., patients with history of hay fever; asthma; and allergies to certain foods such as bananas, grapes, apricots, kiwi fruit, and hazelnuts).
Identify patients with allergies to povidone-iodine (Betadine). Provide alternatives such as chlorhexidine.
Ensuring patient safety is an essential role of the professional nurse.
To ensure patient safety, communicate clearly with members of the health care team, assess and incorporate a patient’s priorities of care and preferences, and use the best evidence when making decisions about your patient’s care.
When performing the skills in this chapter, remember the points on the slide to ensure safe individualized patient care.