1. CHAPTER 16: URINARY ELIMINATION

2. LEARNING OBJECTIVES Discuss qualities of urine, including signs and symptoms about urine to report Demonstrate how to assist with elimination Describe common diseases and disorders of the urinary system Describe guidelines for urinary catheter care Identify types of urine specimens that are collected Explain types of tests performed on urine Explain guidelines for assisting with bladder retraining

3. SIGNS AND SYMPTOMS ABOUT URINE TO REPORT Normal characteristics of urine Signs and symptoms to report

4. FACTORS AFFECTING URINATION Factors affecting urination Assistive devices

5. SKILL: ASSISTING A RESIDENT WITH THE USE OF A BEDPAN Equipment: bedpan, bedpan cover, protective pad, bath blanket, toilet paper, disposable wipes, towel, 2 pairs of gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe working level, usually waist high. Before placing bedpan, lower the head of the bed. Lock bed wheels. 6. Put on gloves. 7. Cover the resident with the bath blanket and ask him to hold it while you pull down the top covers underneath. Do not expose more of the resident than you need to. 8. Place a protective pad under the resident’s buttocks and hips. To do this, have the resident roll toward you. If the resident cannot do this, you must turn the resident toward you (see Chapter 10). Be sure resident cannot roll off the bed. Move to the empty side of bed and place the protective pad on the area where the resident will lie on his back. The side of protective pad nearest the resident should be fanfolded (folded several times into pleats) and tucked under the resident. Ask the resident to roll onto his back, or roll him as you did before. Unfold the rest of protective pad so it completely covers the area under and around the resident’s hips. 9. Ask the resident to remove undergarments, or help him do so. Continued on next slide

6. SKILL: ASSISTING A RESIDENT WITH THE USE OF A BEDPAN (CONTINUED) 10. Place the bedpan near his hips in the correct position. A standard bedpan should be positioned with the wider end aligned with the resident’s buttocks. A fracture pan should be positioned with the handle toward the foot of bed. 11. If resident is able, ask him to raise his hips by pushing with feet and hands at the count of three. Slide the bedpan under his hips. If the resident cannot do this himself, place your arm under the small of his back and tell him to push with his heels and hands on your signal as you raise his hips. If a resident cannot help you in any way, keep the bed flat and roll the resident away from you. Slip the bedpan under the hips and gently roll the resident back onto the bedpan. Keep the bedpan centered underneath. 12. Remove and discard gloves. Wash your hands. 13. Raise the head of the bed. Prop the resident into a semi-sitting position using pillows. 14. Make sure the bath blanket is still covering the resident. Place toilet paper and disposable wipes within resident’s reach. Ask resident to clean his hands with a wipe when finished if he is able. 15. Place the call light within resident’s reach. Ask resident to signal when done. Leave the room and close the door. 16. When called by the resident, return and put on clean gloves. 17. Lower the head of the bed. Make sure resident is still covered. 18. Remove bedpan carefully and cover bedpan. Continued on next slide

7. SKILL: ASSISTING A RESIDENT WITH THE USE OF A BEDPAN (CONTINUED) 19. Provide perineal care if help is needed. Wipe female residents from front to back. Dry the perineal area with a towel. Help the resident put on undergarment. Cover the resident and remove the bath blanket. 20 Place the towel and bath blanket in a hamper or bag, and discard disposable supplies. 21. Take bedpan to the bathroom. Empty the bedpan carefully into the toilet unless a specimen is needed or urine is being measured for intake/output monitoring. Note color, odor, and consistency of contents before flushing. If you notice anything unusual about the stool or urine (for example, the presence of blood), do not discard it. You will need to inform the nurse. 22. Turn the faucet on with a paper towel. Rinse the bedpan with cold water and empty it into the toilet. Flush the toilet. Place bedpan in proper area for cleaning or clean it according to facility policy. 23. Remove and discard gloves. 24. Wash your hands. 25. Make resident comfortable. 26. Return bed to lowest position. Remove privacy measures. 27. Place call light within resident’s reach. 28. Report any changes in resident to the nurse. 29. Document procedure using facility guidelines.

8. SKILL: ASSISTING A MALE RESIDENT WITH A URINAL Equipment: urinal, protective pad, disposable wipes, 2 pairs of gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe working level, usually waist high. Lock bed wheels. 6. Put on gloves. 7. Place a protective pad under the resident’s buttocks and hips, as in earlier procedure. 8. Hand the urinal to the resident. If the resident is not able to help himself, place urinal between his legs and position the penis inside the urinal. Replace covers. 9. Remove and discard gloves. Wash your hands. 10. Place disposable wipes within resident’s reach. Ask the resident to clean his hands with the hand wipe when finished if he is able. Place the call light within reach while resident is using urinal. Ask resident to signal when done. Leave the room and close the door. Continued on next slide

9. SKILL: ASSISTING A MALE RESIDENT WITH A URINAL (CONTINUED) 11. When called by the resident, return and put on clean gloves. 12. Discard disposable wipes. 13. Remove urinal or have resident hand it to you. Empty contents into toilet unless specimen is needed or the urine is being measured for intake/output monitoring. Note color, odor, and qualities (for example, cloudiness) of contents. 14. Turn the faucet on with a paper towel. Rinse the urinal with cold water and empty it into the toilet. Flush the toilet. Place urinal in proper area for cleaning or clean it according to facility policy. 15. Remove and discard gloves. 16. Wash your hands. 17. Make resident comfortable. 18. Return bed to lowest position. Remove privacy measures. 19. Place call light within resident’s reach. 20. Report any changes in resident to the nurse. 21. Document procedure using facility guidelines.

10. SKILL: ASSISTING A RESIDENT TO USE A PORTABLE COMMODE OR TOILET Equipment: portable commode with basin, toilet paper, disposable wipes, towel, 3 pairs of gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Lock bed wheels. Make sure resident is wearing non-skid shoes and that the laces are tied. Help resident out of bed and to the portable commode or bathroom. 6. Put on gloves. 7. If needed, help resident remove clothing and sit comfortably on toilet seat. Put toilet paper and disposable wipes within reach. Ask resident to clean his hands with a wipe when finished if he is able. 8. Remove and discard your gloves. Wash your hands. 9. Provide privacy. Place call light within reach while resident is using commode. Ask resident to signal when done. Leave the room and close the door. 10. When called by resident, return and put on clean gloves. Provide perineal care if help is needed. Wipe female residents from front to back. Dry the perineal area with a towel. Help the resident put on clothing. Continued on next slide

11. SKILL: ASSISTING A RESIDENT TO USE A PORTABLE COMMODE OR TOILET (CONTINUED) 11. Place the towel in a hamper or bag, and discard disposable supplies. 12. Remove and discard gloves. Wash your hands. 13. Help resident back to bed. Make resident comfortable. 14. Put on clean gloves. 15. When using a portable commode, remove waste container. Empty it into the toilet unless a specimen is needed or the urine is being measured for intake/output monitoring. Empty into toilet. Note color, odor, and consistency of contents. 16. Turn the faucet on with a paper towel. Rinse the container with cold water and empty it into the toilet. Flush the toilet. Place container in proper area for cleaning or clean it according to facility policy. 17. Remove and discard gloves. 18. Wash your hands. 19. Make sure bed is in lowest position. Remove privacy measures. 20. Place call light within resident’s reach. 21. Report any changes in resident to the nurse. 22. Document procedure using facility guidelines.

12. COMMON DISEASES AND DISORDERS OF THE URINARY SYSTEM Urinary incontinence  Types  Guidelines Urinary tract infection  Facts  Guidelines for prevention Renal calculi  Symptoms Nephritis  Facts Renovascular hypertension  Facts Chronic renal failure  Symptoms

13. GUIDELINES FOR CATHETER CARE Catheter  Straight catheter  Indwelling catheter  Condom catheter Guidelines What to observe and report

14. SKILL: PROVIDING CATHETER CARE Equipment: bath blanket, protective pad, bath basin with warm water, soap, bath thermometer, 2-4 washcloths or disposable wipes, towel, gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe working level, usually waist high. Lock bed wheels. 6. Lower head of bed. Position resident lying flat on her back. 7. Remove or fold back top bedding, keeping resident covered with bath blanket. 8. Test water temperature with thermometer or on the inside of your wrist to ensure it is safe. Water temperature should be no higher than 105°F. Have resident check water temperature. Adjust if necessary. 9. Put on gloves. 10. Ask the resident to flex her knees and raise her buttocks off the bed by pushing against the mattress with her feet. Place clean protective pad under her buttocks. 11. Expose only the area necessary to clean the catheter. Avoid overexposing the resident. 12. Place towel or pad under catheter tubing before washing. Continued on next slide

15. SKILL: PROVIDING CATHETER CARE (CONTINUED) 13. Wet washcloth in basin and apply soap to washcloth. Clean area around meatus. Use a clean area of the washcloth for each stroke. 14. Hold catheter near meatus to avoid tugging the catheter. 15. Clean at least four inches of catheter nearest the meatus. Move in only one direction, away from the meatus. Use a clean area of the cloth for each stroke. 16. Dip a clean washcloth in the water. Rinse area around the meatus, using a clean area of washcloth for each stroke. 17. Dip a clean washcloth in the water. Rinse at least four inches of catheter nearest the meatus. Move in only one direction, away from the meatus. Use a clean area of the washcloth for each stroke. 18. Remove towel or pad from under catheter tubing. Replace top covers and remove bath blanket. 19. Dispose of linen in proper containers. 20.Empty basin into the toilet and flush. Place basin in proper area for cleaning or clean and store it according to facility policy. 21. Remove and discard gloves. 22. Wash your hands. 23. Remove bath blanket and replace top covers. Make resident comfortable. Check that the catheter tubing is free from kinks and twists and that it is securely fastened to the leg. 24. Return bed to lowest position. Remove privacy measures. 25. Place call light within resident’s reach. 26. Report any changes in resident to the nurse. 27. Document procedure using facility guidelines.

16. SKILL: EMPTYING THE CATHETER DRAINAGE BAG Equipment: graduate (measuring container), alcohol wipes, paper towels, gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Put on gloves. 6. Place paper towel on the floor under the drainage bag. Place graduate on the paper towel. 7. Open the drain or spout on the bag so that the urine flows out of the bag and into the graduate. Do not let spout or clamp touch the graduate. 8. When urine has drained, close spout. Using alcohol wipes, clean the drain spout. Replace the drain in its holder on the bag. 9. Go into the bathroom. Place graduate on a flat surface and measure at eye level. Note the amount and the appearance of the urine. Empty into toilet and flush toilet. 10. Clean and store graduate. Discard paper towels. 11. Remove and discard gloves. 12. Wash your hands. 13. Document procedure and amount of urine.

17. SKILL: CHANGING A CONDOM CATHETER Equipment: condom catheter and collection bag, catheter tape, plastic bag, bath blanket, protective pad, supplies for perineal care, gloves 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Adjust bed to a safe level, usually waist high. Lock bed wheels. 6. Lower head of bed. Position resident lying flat on his back. 7. Remove or fold back top bedding, keeping resident covered with bath blanket. 8. Put on gloves. 9. Place a clean protective pad under his buttocks. 10. Adjust bath blanket to only expose genital area. 11. If condom catheter is present, gently remove it. Place condom and tape in the plastic bag. 12. Assist as necessary with perineal care. 13. Move pubic hair away from the penis so it does not get rolled into the condom. Continued on next slide

18. SKILL: CHANGING A CONDOM CATHETER (CONTINUED) 14. Hold penis firmly. Place condom at tip of penis and roll toward base of penis. Leave space (at least one inch) between the drainage tip and glans of penis to prevent irritation. If resident is not circumcised, be sure that foreskin is in normal position. 15. Gently secure condom to penis with special tape provided. Apply tape in a spiral manner. 16. Connect catheter tip to drainage tubing. Make sure tubing is not twisted or kinked. 17. Check to see if collection bag is secured to leg. Make sure drain is closed. 18. Discard used supplies in plastic bag. Place soiled clothing and linens in proper containers. Clean and store supplies. 19. Remove and discard gloves. 20. Wash your hands. 21. Remove bath blanket. Make resident comfortable. 22. Return bed to lowest position. Remove privacy measures. 23. Place call light within resident’s reach. 24. Report any changes in resident to the nurse. 25. Document procedure using facility guidelines.

19. TYPES OF URINE SPECIMENS THAT ARE COLLECTED Guidelines for collecting specimens

20. SKILL: COLLECTING A ROUTINE URINE SPECIMEN Equipment: urine specimen container with completed label (labeled with resident’s name, date of birth, room number, date, and time) and lid, specimen bag, 2 pairs of gloves, bedpan or urinal (if resident cannot use a portable commode or toilet), hat for toilet (if resident uses portable commode or toilet), plastic bag, toilet paper, disposable wipes, paper towels, supplies for perineal care, laboratory slip 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Put on gloves. 6. Fit hat to toilet or commode, or provide resident with bedpan or urinal. 7. Ask resident to void into hat, urinal, or bedpan. Ask the resident not to put toilet paper in with the sample. Provide a plastic bag to discard toilet paper separately. 8. Place toilet paper and disposable wipes within resident’s reach. Ask resident to clean his hands with a wipe when finished if he is able. 9. Remove and discard gloves. Wash your hands. 10. Place the call light within resident’s reach. Ask resident to signal when done. Leave the room and close the door. 11. When called by the resident, return and put on clean gloves. Provide perineal care if help is needed. Continued on next slide

21. SKILL: COLLECTING A ROUTINE URINE SPECIMEN (CONTINUED) 12. Take bedpan, urinal, or hat to the bathroom. 13. Pour urine into the specimen container. Specimen container should be at least half full. 14. Cover the urine container with its lid. Do not touch the inside of container. Wipe off the outside with a paper towel and apply label. 15. Place the container in a clean specimen bag. 16. Discard extra urine in toilet. Turn the faucet on with a paper towel. Rinse the bedpan, urinal, or hat with cold water and empty it into the toilet. Flush the toilet. Place equipment in proper area for cleaning or clean it according to facility policy. 17. Remove and discard gloves. 18. Wash your hands. 19. Remove privacy measures. 20. Place call light within resident’s reach. 21. Report any changes in resident to the nurse. 22. Take specimen and lab slip to proper area. Document procedure using facility guidelines. Note amount and characteristics of urine.

22. SKILL: COLLECTING A CLEAN-CATCH (MID- STREAM) URINE SPECIMEN Equipment: specimen kit with container with completed label (labeled with resident’s name, date of birth, room number, date, and time) and lid, specimen bag, cleaning solution, gloves, bedpan or urinal (if resident cannot use a portable commode or toilet), plastic bag, toilet paper, disposable wipes, paper towels, supplies for perineal care, lab slip 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Put on gloves. 6. Open the specimen kit. Do not touch the inside of the container or the inside of the lid. 7. If the resident cannot clean his or her perineal area, you will need to do it. Use the wipes and cleaning solution to do this. Be sure to use a clean area of the wipe or a clean wipe for each stroke. See bed bath procedure in Chapter 13 for a reminder on how to give perineal care. 8. Ask the resident to urinate a small amount into the bedpan, urinal, or toilet, and to stop before urination is complete. 9. Place the container under the urine stream and have the resident start urinating again. Fill the container at least half full. Ask the resident to stop urinating and remove the container. Have the resident finish urinating in bedpan, urinal, or toilet. Continued on next slide

23. SKILL: COLLECTING A CLEAN-CATCH (MID- STREAM) URINE SPECIMEN (CONTINUED) 10. After urination, provide a plastic bag so resident can discard toilet paper. Give perineal care if help is needed. Ask resident to clean his hands with a wipe if he is able. 11. Cover the urine container with its lid. Do not touch the inside of container. Wipe off the outside with a paper towel and apply label. 12. Place the container in a clean specimen bag. 13. Discard extra urine in toilet. Turn the faucet on with a paper towel. Rinse the bedpan or urinal with cold water and empty it into the toilet. Flush the toilet. Place equipment in proper area for cleaning or clean it according to facility policy. 14. Remove and discard gloves. 15. Wash your hands. 16. Make resident comfortable. 17. Return bed to lowest position if adjusted. Remove privacy measures. 18. Place call light within resident’s reach. 19. Report any changes in resident to the nurse. 20. Take specimen and lab slip to proper area. Document procedure using facility guidelines. Note amount and characteristics of urine.

24. SKILL: COLLECTING A 24-HOUR SPECIMEN Equipment: 24-hour specimen container with lid, bedpan or urinal (for residents confined to bed), hat for toilet (if resident can use portable commode or toilet), gloves, disposable wipes, supplies for perineal care, sign to alert other team members that a 24-hour urine specimen is being collected, form for recording output, laboratory slip 1. Identify yourself by name. Identify the resident by name. 2. Wash your hands. 3. Explain procedure to the resident. Speak clearly, slowly, and directly. Maintain face-to-face contact whenever possible. Emphasize that all urine must be saved. 4. Provide for resident’s privacy with curtain, screen, or door. 5. Place a sign on the resident’s bed to let all care team members know that a 24-hour specimen is being collected. Sign may read “Save all urine for 24-hour specimen.” 6. When starting the collection, have the resident completely empty the bladder. Discard the urine. Note the exact time of this voiding. The collection will run until the same time the next day. 7. Label the container with the resident’s name, date of birth, room number, and dates and times the collection period began and ended. 8. Wash hands and put on gloves each time the resident voids. 9. Pour urine from bedpan, urinal, or hat into the container. Container may be stored at room temperature, in the refrigerator, or on ice. Follow facility policy. 10. After each voiding, help as necessary with perineal care. Ask the resident to clean his hands with a wipe after each voiding. 11. After each voiding, place equipment in proper area for cleaning or clean it according to facility policy. 12. Remove and discard gloves. 13. Wash your hands. 14. After the last void of the 24-hour period, remove the sign. Take specimen and lab slip to proper area. Document procedure using facility guidelines. Make sure to include the time of the last void before the 24-hour collection period began and the last void of the 24-collection period.

25. SKILL: TESTING URINE WITH REAGENT STRIPS Equipment: urine specimen as ordered, reagent strip, gloves 1. Wash your hands. 2. Put on gloves. 3. Take a strip from the bottle and recap bottle. Close it tightly. 4. Dip the strip into the specimen. 5. Follow manufacturer’s instructions for when to remove strip. Remove strip at correct time. 6. Follow manufacturer’s instructions for how long to wait after removing strip. After proper time has passed, compare strip with color chart on bottle. Do not touch bottle with strip. 7. Read results. 8. Discard used items. Discard specimen in the toilet. Flush toilet. 9. Remove and discard gloves. 10. Wash your hands. 11. Document procedure using facility guidelines.

26. GUIDELINES FOR ASSISTING WITH BLADDER RETRAINING Guidelines

27. REVIEW Discuss qualities of urine, including signs and symptoms about urine to report Demonstrate how to assist with elimination Describe common diseases and disorders of the urinary system Describe guidelines for urinary catheter care Identify types of urine specimens that are collected Explain types of tests performed on urine Explain guidelines for assisting with bladder retraining