common urinary elimination problems the most common urinary elimination problems involve the inability to store urine or fully empty urine from the bladder urinary retention inability to partially or completely empty the bladder causing feelings of pressure discomfort slash pain have no your foot over several hours however chronic you are is slow and gradual post void residual pvr is the amount of urine left in the bladder after voiding know that there are different types of incontinence but most importantly what you do for them table 46.1 urinary tract infections ut ice the ice prominent in causing hospital acquired infections what is the most common organism e coli or poop having foley caths increases the chance and cms will not reimburse obviously uti for infection you're going to see some natural immune responses but depending on how long severe the uti has been going on for point age and comorbidities you can see severity in s s that may range from fever pain to bladder altered v slash s because point is becoming septic and confusion esp in the elderly through a urine specimen you will typically see bacteria if we have a symptomatic bacteriuria we don't treat pyelonephritis can develop from serious upper ut ice or life-threatening as they lead to bloodstream infections abt asap urinary incontinence involuntary loss of urine common forms of ui are urge or urgency ui involuntary leakage associated with urgency and stress ui involuntary loss of urine associated with effort or exertion on sneezing or coughing urinary diversions cystectomy removal of bladder be slash s of cancer or some bladder dysfunction maybe from severe tree from severe trauma from mvc this involves creating an artificial opening called the stoma in the wall of the abdomen and will place a storage bag or reservoir to collect the urine can be temp or perm different types of urinary diversions ureterostomy is creating a stoma with one of their ureters nephrostomy tubes are small tubes that are tunneled through the skin into the renal pelvis these tubes are placed to drain the renal pelvis when the ureter is obstructed patients do go home with these tubes and need careful teaching about sight care and signs of infection infection control and hygiene the urinary tract is sterile growth and development small children are humble to associate the sensation of filling and urge with urination until two to three at least after that can hold their urine from one to two hours and communicate their needs nocturnal enuresis is bedwetting at night in early and late pregnancy urinary frequency is common hormonal changes in the pressure of the growing fetus on the bladder cause increased urine production and shrinking bladder capacity normal aging causes changes in the urinary tract and the rest of the body these changes are not the cause of bladder dysfunction but age does increase risk and incidents psychosocial implications when children begin to achieve bladder control and learn the appropriate toileting skills they sometimes resist urinating on the toilet and associate their urine and feces as extensions of self and thus do not want to flush them away incontinence can be devastating to sell image and self-esteem self-care ability do not assume that because a patient has a diagnosis of cognitive impairment that he or she cannot understand or participate in care cultural considerations assess cultural and gender differences related to the very private act of voiding and how they affect nursing assessment and care nursing history assess your patients health literacy nursing history includes a review of the patient's elimination patterns symptoms of urinary alterations an assessment of factors that are affecting the ability to urinate normally box 46.5 pattern of urination ask the patient about daily voiding patterns including frequency in times of day normal volume at each voiding and history of recent changes be sure to ask whether the patient is awakened from sleep with an urge to void and how many times this occurs symptoms of urinary alterations during assessment ask the patient about the presence presence of symptoms related to urination and any precipitating factors that cause aggravation table 46.2 physical assessment kidneys can have tenderness to the flank area aprns or physicians can listen for brutes over the renal artery bladder rests below the symphysis pubis and will rise when full may observe a swelling of lower abd on gentle palpation of the lower abdomen a full bladder may be felt as a smooth and rounded mass obtain a bladder scanner or use slash s device external genitalia and urethral meatus females dorsal recumbent position redness swelling drainage wash hands and wear gloves males if uncircumcised retract foreskin or a patient do so if it cannot retract it's called phymosis which increases rf infections inspect gland's penis for redness swelling drainage always pull the foreskin back can cut off circulation and cause dangerous swelling foleys inspect for same thing do not pull as can damage urinary meatus severe erode meatus peroneal skin assessment of skin exposed to moisture especially urine needs to occur at least daily and more often if incontinence is ongoing intake and output nursing judgment in physician order urinary output is a key indicator of kidney and bladder function change in urine volume can be a significant indicator of fluid imbalance kidney dysfunction or decreased blood volume patients who have not voided for longer than three to six hours and have had fluid intake recorded should be evaluated for urinary retention just helping some patients to a normal position to void prompts voiding assess for any extreme increase or decrease in urine volume urine output of less than 30 milliliters per hour for more than two consecutive hours or excessive urine output priya is a cause for concern and should prompt further assessment and notification of the health care provider when emptying catheter drainage bags follow standard precautions chapter 28 and make sure that the drainage tube is reclamped and secured each patient needs to have a graduated receptacle for individual use to prevent potential cross-contamination label each container with the patient's name or other identifiers according to agency policy the container needs to be rinsed after each used to minimize odor and bacterial growth characteristics of urine color can range from pale straw to amber as the patient drinks more fluids urine becomes less concentrated and the color lightens blood in the urine hematuria is never a normal finding bleeding from the kidneys or ureters usually causes urine to become dark red bleeding from the bladder or urethra usually causes bright red urine hematuria and blood clots are a common cause of urinary catheter blockage pyridium a urinary analgesic void urine that is bright orange eating beets rhubarb and blackberries causes red urine the kidneys excrete special dyes used in four diagnostic studies and this discolors the urine dark amber urine is the result of high concentrations of bilirubin urobilinogen in patients with liver disease report unexpected color changes to the health care provider clarity in patients with renal disease freshly voided urine appears cloudy because of protein concentration urine may also appear thick and cloudy as a result of bacteria and white blood cells early morning voided urine may be cloudy because of urine held in the bladder overnight but will be clear on the next voiding odor urine has a characteristic ammonia odor the more concentrated the urine the stronger the odor a fall loader may indicate a uti review tables 46.3 46.4 and 46.5 in the textbook laboratory and diagnostic testing table 46.3 label all specimens with the patient's name date time and type of collection have patient double void for fresh specimen use second voided specimen to send to lab or use midstream catch no table 46.4 know and understand the ranges so you can recognize when something is abnormal review box 46.7 and 46.8 in the textbook shown as figure 46.9 from the textbook types of male a and female b urinals the courtesy briggs medical service company promoting normal maturation maintaining elimination habits elimination is a very private act create as much privacy as possible by closing the door in bedside curtain asking visitors to leave a room when a bedside commode bedpan or urinal is used and masking the sounds avoiding with running water maintaining adequate fluid intake healthy person with healthy heart should take and approximate two thousand three hundred milliliters fluid q day to prevent nocturia suggest that the patient avoid drinking fluids two hours before bedtime promoting complete bladder emptying urinary retention increases the risk for uti and damage to the kidneys there are other measures that bladder emptying to promote relaxation and stimulate bladder contractions use sensory stimuli example turning on running water putting a patient's hand in a pan of warm water and provide privacy in addition bladder exercises help to improve pelvic muscles which reduces stress incontinence and improves bladder emptying box 40 6.8 to improve bladder emptying encourage patients to wait until the urine flow completely stops when voiding and encourage them to attempt a second void double voiding timed voiding is voiding according to the clock not the urge to void and is a helpful strategy when the bladder does not fully empty preventing infection encourage women to wipe front to back after voiding and defecation and teach them to avoid perfumed perineal washes and sprays bubble baths and tight clothing if a patient has a problem with urine leakage hygiene should be especially stressed patients should use containment products that are designed for urine and wick wetness away from the body prolonged periods of urine wetness should be avoided catheterization placement of a tube through the urethra into the bladder to drain urine risk for catheter associated urinary tract infections caudies intermittent or indwelling excessive accumulation of urine in the bladder is painful for a patient increases the risk for uti and can cause backward flow of urine up the ureters increasing risk for kidney damage types of catheters the difference among urinary catheters is related to the number of catheter lumens the presence of a balloon to keep the indwelling catheter in place the shape of the catheter and a closed drainage system a healthcare provider chooses a catheter on the basis of factors such as latex allergy history of catheter encrustation anatomical factors and susceptibility to infection kudatip catheter this catheter has a curvature at the end that helps it maneuver through the prosthetic urethra in the presence of a large prostate nurses need special training to use this type of catheter sizes based on the french fr scale which reflects the internal diameter of the catheter larger catheter diameters increase the risk for urethral trauma indwelling catheters come in a variety of balloon sizes from 3 milliliters for a child to 30 milliliters long-term use of larger balloons 30 milliliters has been associated with increased patient discomfort irritation and trauma to the urethra increased risk of catheter expulsion and incomplete emptying of the bladder resulting from urine that pulls below the level of the catheter drainage eyes catheter changes when long-term catheterization is required the catheter will need to be changed every four to six weeks whenever possible avoid the use of long-term catheterization due to the increased risk for cauti close drainage systems an indwelling catheter is attached to a urinary drainage bag to collect the continuous flow of urine this is a closed drainage system tubing connections should not be separated to avoid introducing pathogens in patients with indwelling catheter specimens are collected without opening the drainage system by using a special port in the tubing fig 46.12 always hang the drainage bag below the level of the bladder on the bed frame or a chair so that urine will drain down out of the bladder the bag should never touch the floor to prevent accidental contamination during emptying when a patient ambulates carry the bag below the level of the patient's bladder ambulatory patients may use a leg bag this is a bag that attaches to the leg with straps leg bags are usually worn during the day and replaced at night with a standard drainage bag the only drainage bag that does not need to be kept dependent to the bladder is a specially designed drainage bag belly bag that is worn across the abdomen a one-way valve prevents the back flow of urine into the bladder to keep the drainage system patent check for kinks or bends in the tubing avoid positioning the patient on drainage tubing prevent tubing from becoming dependent and observe for clots or sediment that may block the catheter or tubing routine catheter care patients with indwelling catheters require regular perineal hygiene especially after a bowel movement to reduce the risk for cauti in many institutions patients receive catheter care every eight hours as the minimal standard of care empty drainage bags when they are half full an over full drainage bag can create tension and pull on the catheter resulting in trauma to the urethra and or urinary meatus and increasing risk for cauti expect continuous drainage of urine into the drainage bag in the presence of no urine drainage first check to make sure that there are no kinks or obvious occlusion of the drainage tubing or catheter preventing catheter association infection a critical part of routine catheter care is reducing the risk for caudi box 46.9 a key intervention to prevent infection is to maintain a closed urinary drainage system portals for entry of bacteria into the system are illustrated in another key intervention is prevention of urine backflow from the tubing and bag into the bladder many urine drainage systems are equipped with an anti-reflux valve but you should monitor the system to prevent pooling of urine within the tubing and to keep the drainage bag below the level of the bladder catheter irrigations and installations to maintain the patency of indwelling urinary catheters it is sometimes necessary to irrigate or flush a catheter with sterile solution however irrigation poses the risk of causing a uti and thus must be done maintaining a closed urinary drainage system generally if a catheter becomes occluded it is best to change it rather than risk flushing debris into the bladder in some instances the health care provider will determine that irrigations are needed to keep a catheter patent such as after genital urinary surgery when there is high risk for catheter occlusion from blood clots bla review boxes 46.11 and 46.12 in the textbook shown as figure 46.15 from the textbook a placement of superpubic catheter above the synthesis pubis b suprapubic catheter without addressing removal of indwelling catheter caudi are considered a never event percent per cms prompt removal of an indwelling catheter after it is no longer needed is a key intervention that is proven to decrease the incidence and prevalence of hospital acquired utis monitor patients voiding after catheter removal for at least 24 to 48 hours by using avoiding record or bladder diary the bladder diary should require an amount of each voiding including any incontinence the use of ultrasound or a bladder scanner can monitor bladder function by measuring post void residual pvr volume box 46.11 the first few times a patient voids after catheter removal may be accompanied by some discomfort but continued complaints of painful urination addition indicate possible infection abdominal pain and distention a sensation of incomplete emptying incontinence constant dribbling of urine and voiding in very small amounts can indicate inadequate bladder emptying requiring intervention suprapubic catheterization a suprapubic catheter is a urinary drainage tube inserted certain to the bladder through the abdominal wall above the synthesis pubis interferes with sexual functioning daily cleansing of the insertion site and catheter external catheter condom catheter or penile sheath is a soft pliable condom like sheath that fits over the penis providing a safe and non-invasive weight way to contain urine verify that a patient does not have a latex allergy before applying associated with less risk for uti than in dwelling catheters urinary diversions immediately after surgery the patient with an incontinent urinary diversion must wear a pouch to collect the effluent drainage pouch will keep the patient clean and dry protect the skin from damage when changing a pouch gently cleanse the skin surrounding the stoma with warm tap water using a washcloth and pat dry do not use soap because it can leave a residue on the skin measure the stoma and cut the opening in the pouch then apply the pouch after remove moving the protective backing from the adhesive surface press firmly into place over the stoma observe the appearance of the stoma and surrounding skin the stoma is normally red and moist and is located in the right lower quadrant of the abdomen what is it red what does that indicate what are you going to do to do if the stoma is an abnormal color it is important for the patient to have the correct type and fit of an ostomy pouch a specialty ostomy nurse is an essential resource when selecting the right appliance so that the pouch fits snugly against the surface of the skin around the stoma preventing damaging leakage of urine medications a small number of medications and to muscarinics example oxybutynin are used to treat urinary urgency common adverse affects dry mouth constipation and blurred vision and mental status changes in older adults flomax or tamsilosin is used for bph or enlarged prostate help shrink when a patient is newly started on an antimuscarinic monitor for effectiveness including a decrease in urgency frequency and incontinence episodes a bladder diary is one of the best ways to do this in addition regularly assess the patient for side effects such as constipation by monitoring the bowel movement record watch for a decrease in bowel movement frequency straining at bowel movements and changes in stool consistency utis are treated with antibiotics patients with painful urination are sometimes prescribed urinary analgesics that act on the urethral and bladder mucosa example finazopyridine patients taking drugs with phenazopyridine need to be aware that their urine they must drink large amounts of fluids to prevent toxicity from the sulfonamides and maintain optimal flow through the urinary system shown as figure 46.16 from the textbook pelvic floor muscles from lewis s at all medical surgical nursing assessment and management of clinical problems ed 10 st louis 2017 elsevier continuing in restorative care lifestyle changes actions to avoid common irritants such as artificial sweeteners spicy foods citrus products and especially caffeine discourage patients from drinking large volumes of fluid at one time constipation can also impact bladder symptoms and measures to promote bowel regularity should be implemented encourage patient patients with edema to elevate the feet for a minimum of a few hours in the afternoon to help diminish nighttime voiding frequency pelvic floor muscle training techniques that can improve control over bladder emptying and restore some degree of urinary continence involves teaching patients how to identify and contract the pelvic floor muscles in a structured exercise size program equals kegels assists patients with urgency stress and mixed ui bladder retraining behavioral therapy given a schedule of toileting on the basis of their diary avoiding and leaking the schedule is designed to slowly increase the interval between voiding need regular support and positive reinforcement when the urge to void becomes less severe or subsides only then should the patient start his or her trip to the bathroom only highly motivated and cognitively intact patients are candidates for this therapy toileting schedules individualized based on the type of incontinence and functional deceptibility should be the first plan of action when you assess a patient to be incontinent timed voiding or scheduled toileting is toileting based on a fixed schedule not the patient's urge to void using a bladder diary the usual times a patient voids are identified it is at these times that the patient is then toilet catheterization chronic disorders ms diabetes and sci principles of a sepsis the goal for intermittent catheterization is drainage of 400 milliliters of urine with the schedule individualized to meet this goal skin care incontinence associated dermatitis iaiad presents as inflammation of the skin and can also cause blistering and swelling to the affected area the main causes moisture from incontinence so preventing incontinence or having a good management plan when a patient is incontinent is imperative the dues for effective management include identification and treatment use of skin risk assessment tools use of appropriate barrier products and ensuring adequate hydration the don'ts include only using traditional soap and water for cleaning double padding the bed leaving soiled pads in contact with the skin and assuming incontinence is inevitable you