Promoting Urinary Elimination PDF

ch a p te r 29 Promoting Urinary Elimination http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Review the structure and functions of the urinary system. 2. Determine abnormal appearance of a urine specimen....

ch a p te r 29 Promoting Urinary Elimination http://evolve.elsevier.com/Williams/fundamental Objectives Upon completing this chapter, you should be able to do the following: Theory 1. Review the structure and functions of the urinary system. 2. Determine abnormal appearance of a urine specimen. 3. Describe three nursing measures to help patients urinate normally. 4. Compare and contrast the purposes and principles of indwelling and intermittent catheterization. 5. Summarize the rationale for using a continuous bladder irrigation system. 6. Analyze different methods of managing urinary incontinence. Clinical Practice 1. Assess a patient’s urinary status. 2. Perform a urine dipstick test accurately. 3. Teach a patient how to obtain a “clean-catch” (midstream) specimen. 4. Assist patients with toileting. 5. Insert an indwelling catheter using sterile technique. 6. Perform catheter care. 7. Teach a patient how to perform Kegel exercises. Skills & Steps Skills Skill Skill Skill Skill Skill 29.1 29.2 29.3 29.4 29.5 Steps Placing and Removing a Bedpan 551 Applying a Condom Catheter 555 Catheterizing the Female Patient 556 Catheterizing the Male Patient 560 Performing Intermittent Bladder Irrigation and Instillation 565 Obtaining a Urine Specimen from an Indwelling Catheter 547 Steps 29.2 Removing an Indwelling Catheter 564 Steps 29.3 Continence Training 569 Steps 29.1 Key Terms anuria (ă-NŪ-rē-ă, p. 543) catheterization (kă-thĕ-tĕr-ĭ-ZĀ-shŭn, p. 553) commode chair (kō-MŌD, p. 548) condom catheter (KŎN-dŏm KĂ-thĕ-tĕr, p. 554) Credé maneuver (krā-DĀ mă-NŪ-vĕr, p. 553) cystitis (sĭs-TĪ-tĭs, p. 544) dysuria (dĭs-Ū-rē-ă, p. 544) glycosuria (glī-kōs-Ū-rē-ă, p. 545) hematuria (hĕm-ă-TŪ-rē-ă, p. 545) instillation (p. 544) ketonuria (kē-tō-NŪ-rē-ă, p. 545) micturition (mĭk-tū-RĬSH-ŭn, p. 543) nocturia (nŏk-TŪ-rē-ă, p. 543) oliguria (ŏl-ĭ-GŪ-rē-ă, p. 544) polyuria (pŏl-ē-Ū-rē-ă, p. 544) proteinuria (prō-tēn-YŪR-ē-ă, p. 545) pyuria (pī-Ū-rē-ă, p. 545) residual urine (rĕ-ZĬ-dū-ăl Ū-rĭn, p. 543) stricture (STRĬK-chŭr, p. 553) suprapubic (SŪ-pră-PYŪ-bĭk, p. 553) urinary incontinence (ĭn-KŎN-tĭ-nĕns, p. 543) urinary retention (rē-TĔN-shŭn, p. 543) urination (ūr-ĭ-NĀ-shŭn, p. 542) urinometer (yūr-ĭ-NŎ-mĕ-tĕr, p. 544) urostomy (yūr-Ŏ-stō-mē, p. 569) void (VŎYD, p. 543) 541 542 UNIT VI Meeting Basic Physiologic Needs Concepts Covered in This Chapter • • • • • • • • • • • • • • Acid-base balance Anxiety Communication Culture Elimination Evidence Infection Inflammation Mobility Pain Patient education Perfusion Safety Stress OVERVIEW OF STRUCTURE AND FUNCTION OF THE URINARY SYSTEM WHICH STRUCTURES ARE INVOLVED IN URINARY ELIMINATION? • The kidneys are bean shaped, approximately 2½ inches wide, 5 inches long, and 1 inch thick (6 × 12 × 3 cm3), and are located at the level of L1 on each side of the spine (Fig. 29.1). • Each kidney contains approximately 1 million nephrons, which are the working units. • Within each nephron is a glomerulus consisting of a cluster of capillaries, surrounded by Bowman capsule, and a system of tubules. • The ureters are hollow tubes about 10 to 12 inches (25 to 30 cm) long in the adult, and they connect each kidney to the bladder. • The bladder is a hollow, muscular organ located in the lower pelvis. • The urethra is a tube attached to the base of the bladder extending to the outside of the body. In the male, it is about 8 inches (20 cm) long and goes through the penis, ending at its tip. This exit point is the urinary meatus (Fig. 29.2). In the female, the urethra is from 1½ to 2½ inches (4 to 6.5 cm) in length, and it goes to the urinary meatus located beneath the clitoris, between the folds of the labia. • The internal and external urinary sphincters control the low of urine out of the body. WHAT ARE THE FUNCTIONS OF THE URINARY STRUCTURES FOR ELIMINATION? • The kidneys ilter blood through the nephrons, and metabolic waste and excess water are extracted. The kidneys regulate electrolytes in the body by excreting excess amounts, and assist in acid-base balance by retaining or excreting hydrogen ions (H+) and bicarbonate ions (HCO3−). The waste products are diluted with water and excreted as urine. The tubules secrete, excrete, or reabsorb electrolytes, water, and other substances. Kidney Ureter Bladder Urethra FIGURE 29.1 Structures of the urinary system. Bladder Prostate Urethra Testicle Penis Scrotum Urinary meatus FIGURE 29.2 Tract of the male urethra. • The kidneys manufacture 1 to 1.5 L of urine on average in 24 hours. Urine output is related to the amount of luid intake and it can vary considerably. • The ureters carry urine from the kidneys to the bladder. • The bladder stores urine and sends a signal to the spinal cord when it becomes full to signal the need for emptying. The signal usually occurs when the bladder contains between 250 and 400 mL of urine. • The bladder can hold 1000 to 1800 mL of urine. Average urine output is 1000 to 1500 mL/day. • The urethra carries urine from the bladder to the outside of the body. • The urinary meatus is the exit point for urination (expelling urine) and the entrance point for a catheter. Promoting Urinary Elimination CHAPTER 29 • The internal sphincter relaxes in response to the micturition (urination) relex. • Voluntary contraction of the external sphincter stops the expulsion of urine. Relaxing the external sphincter starts the low of urine for excretion. WHAT FACTORS CAN INTERFERE WITH URINARY ELIMINATION? • Total loss of the kidney’s ability to manufacture urine (kidney failure) may result in anuria (absence of urine). • Decreased kidney perfusion (e.g., from shock or severe dehydration) can lead to kidney damage. • Blockage of the ureters prevents the urine from traveling to the bladder. Blockage may occur because of the presence of a stone in the ureter, pressure from a tumor in the abdominal cavity, or trauma to the lower abdomen. • Disruption of the bladder by tumor or trauma may impede the low of urine out of the bladder or decrease its holding capacity. • Pressure on the urethra from an enlarged prostate can make emptying the bladder dificult. Trauma to the urethra from any cause can impede the elimination of urine. Childbirth sometimes alters the position of the bladder and urethra and predisposes the woman to incidences of urinary incontinence (inability to prevent passing urine). • Infection in any part of the urinary system causes inlammation and may alter the low of urine. • Neurologic damage to the nerves that control the internal and external sphincters or the muscular wall of the bladder may cause alteration in urinary patterns. • Prostate surgery may damage the external urinary sphincter and cause temporary or permanent urinary incontinence in the male. WHAT CHANGES IN THE SYSTEM OCCUR WITH AGING? • There is a decrease in the number of functioning nephrons and a reduction in the rate of renal iltration with aging. Because of these changes, even minor body stress can cause a decrease in renal function. • The bladder muscle tone decreases, and its capacity lessens, causing nocturia (urinating during the night). Decreased muscle tone may interfere with the external urinary sphincter and predispose the person to incontinence. Incontinence is not a normal part of aging. • Decreased bladder and muscle tone may cause incomplete bladder emptying and residual urine (urine left in the bladder after urination). Residual urine becomes stagnant and predisposes the person to infection. • Lower estrogen levels in women can result in tissue atrophy in the urethra, the vagina, and the bladder, which predisposes the person to infection and incontinence. 543 NORMAL URINARY ELIMINATION The frequency of urination varies. Infants void (excrete urine) from 5 to 40 times a day. The preschool child may void every 2 hours. The adult voids from 5 to 10 times a day. On average, the adult male voids 300 to 500 mL each time, and the adult female voids 250 mL. There should be at least an hourly urine output of 30 mL. This relects adequate kidney perfusion. People usually have the urge to void on awakening in the morning, after each meal, at bedtime, and after drinking extra luid. Urine production is decreased during sleep, and many people can sleep through the night without voiding, but voiding once during the middle of the night is considered normal. FACTORS AFFECTING NORMAL URINATION Urinary elimination is affected by neurologic and muscle development; alterations in spinal cord integrity; the volume of luid intake; the amount of luid lost by perspiration, vomiting, or diarrhea; and the amount of antidiuretic hormone (ADH) secreted by the pituitary gland. Anxiety may increase muscle tension and cause a more frequent urge to void. Most people need privacy for urination to occur freely. Life-Span Considerations Older Adult The older adult male is likely to experience urinary retention (urine retained in the bladder after voiding), as the prostate gland undergoes hyperplasia with aging. Retention may predispose the man to episodes of urinary tract infection (UTI). If your patient is receiving medication but continues to have persistent retention, report your indings to the primary care provider, because prostate surgery may be considered to prevent kidney damage. CHARACTERISTICS OF NORMAL URINE Color Urine is normally some shade of yellow, with the average being straw colored or amber. The color may darken when the urine is more concentrated. Smoky red or dark brown urine may indicate the presence of blood or myoglobin, which is a by-product of muscle tissue injury. Very dark amber urine may be due to the presence of bilirubin. Other color variations may occur from medications the patient is taking or from water-soluble dyes consumed in food. Think Critically Your older adult patient is upset and concerned because his urine is a different color. What questions could you ask him to obtain more information about the color change? 544 UNIT VI Meeting Basic Physiologic Needs Clarity Urine should be transparent or only slightly cloudy. Cloudy urine may contain bacteria or large amounts of protein. Odor Normal urine smells faintly like ammonia. If the odor is foul, infection may be present. If the odor resembles acetone, ketones are probably present. Other odors may occur depending on what foods or vitamins the person has ingested. Specific Gravity Speciic gravity is the thinness or thickness of the urine. It may be measured by a urinometer, an instrument that reads the amount of light the urine absorbs, or by a chemical dipstick. The normal range is 1.010 to 1.030, but conditions such as dehydration and luid excess may extend the range slightly in either direction. pH. The acidity or alkalinity of urine is measured in units called pH. The pH of normal urine is slightly acidic, ranging from 5.5 to 7.0. Health Promotion How to Prevent Recurrent Cystitis Cystitis and other UTIs may be avoided by: • Increasing luid intake to 2500 to 3000 mL/day. • Avoiding citrus fruits and juice (if prone to frequent reoccurrence) because they cause alkaline urine; bacteria grow more readily in alkaline urine. • Always wiping the rectal area from front to back after a bowel movement. This is especially important in female patients. • For the female patient, avoiding wearing tight clothing and nylon pantyhose that cause continual perineal moisture; wearing cotton underwear. • Not sitting around in a wet bathing suit for extended periods. • For the female patient, not using bubble bath or feminine hygiene sprays. • For the female patient, emptying the bladder promptly after intercourse and drinking two glasses of water to lush out microorganisms that may have entered the bladder. • Bathing or showering daily (both females and males). • Emptying the bladder every 2 to 3 hours to prevent stasis and potential for bacteria to multiply if present. ALTERATIONS IN URINARY ELIMINATION Alterations in urinary elimination patterns are listed in Box 29.1. Urine is normally sterile, but provides a good medium for the growth of infectious organisms if they are introduced into the bladder. A common UTI is cystitis (inlammation of the bladder). Cystitis may be caused by irritation of Box 29.1 Alterations in Urinary Elimination Patterns • Anuria is present when less than 100 mL of urine is excreted in 24 hours. It may be caused by urinary suppression (the kidneys are not forming urine) or to the retention of urine (all urine is not expelled from the bladder during voiding). • Dysuria (painful or dificult urination) occurs when there is inlammation present in the bladder or urethra, usually because of infection or trauma. • Incontinence (involuntary release of urine) occurs with a variety of pathologic conditions. When it is due to decreased muscle tone, special exercises (see Patient Education, p. 569) may prevent it. • Nocturia occurs when the person must get up to urinate during the night more than once or twice. • Oliguria (decreased amount of urine output) occurs when urine output falls below 400 mL/24 h. It may be a sign of kidney failure, blockage of urine outlow somewhere in the system, or retention. • Polyuria (excessive urination) occurs when large amounts of urine are voided, with an output of greater than 1500 mL/24 h. It is usually associated with either diabetes mellitus, in which there is an absence of insulin, or diabetes insipidus, in which there is decreased production of ADH. highly concentrated urine, pathogenic bacteria, injury, or instillation (putting in a solution) of an irritating substance. A break in aseptic technique when inserting or caring for an indwelling catheter is a frequent cause of cystitis. Often the Escherichia coli bacterium is responsible for cystitis, especially in females. Symptoms of cystitis are frequency, urgency, dysuria (painful urination), burning, malaise, foul-smelling urine, and a slight temperature elevation (Foxman, 2014). Episodes of recurrent cystitis predispose the patient to kidney infection and consequent kidney damage. In accordance with Healthy People 2020, measures should be taken to prevent long-term kidney disease. Life-Span Considerations Older Adult Your older adult patient may develop an infection and not manifest a fever. In fact, the temperature may be lower than normal. Subtle changes in mental status may be the irst symptom of an infection, so monitor the older adult closely for changes in alertness and orientation. QSEN Considerations: Evidence-Based Practice Complementary and Alternative Therapies CRANBERRY PRODUCTS TO PREVENT BLADDER INFECTIONS Cranberries have long been recommended in the prevention of UTIs. Evidence-based practice indicates that cranberry products, speciically juice and tablets, are particularly effective (Geerlings et al., 2014). Promoting Urinary Elimination CHAPTER 29 545 Complementary and Alternative Therapies Probiotics for Urinary Tract Infections In a study focused on preventing UTIs, the use of a vaginal suppository containing Lactobacillus crispatus reduced recurrence of urinary tract infections (Geerlings et al., 2014). QSEN Considerations: Evidence-Based Practice Vaginal Estrogen Evidence-based practice indicates that if a postmenopausal woman experiences recurrent UTIs, she should be offered vaginal estrogen (Mody & Juthani-Mehta, 2014). APPLICATION OF THE NURSING PROCESS FIGURE 29.3 Urine collection devices. Fracture pan (left front), standard bedpan (right front), urinal (left rear), and in-toilet “hat” (right rear). ASSESSMENT (DATA COLLECTION) Obtain a history of the patient’s usual urinary elimination pattern. Inquire about any incidences of incontinence. Ask if there is a need to urinate frequently, burning when urinating, or a sense of urgency in inding a toilet. Does the patient frequently need to get up to urinate at night? Has the appearance of the urine changed? At what times of the day does the patient usually void? Does the bladder usually feel completely empty after urinating, or does the patient need to void again in less than 2 hours? How much luid is taken in a 24-hour period? Is there a urinary catheter in place? Is there a history of urinary problems? What is the total 24-hour intake and output? Is it normal? Assess the patient’s mobility to determine whether it is safe to allow ambulation to the bathroom unassisted. Note when the patient last voided. Each patient should void at least every 8 hours unless an indwelling catheter is in place. If voided amounts are small and intake is normal, gently palpate the bladder to see if it is distended. To do this, feel with the palm of the hand for a bulge indicating a full bladder above the symphysis pubis. Think Critically Your patient is voiding only 100 mL of urine at a time. What further assessments should you make? What questions should you ask this patient? Urine Specimen Collection Voided Specimen for Urinalysis. Inspection of the urine is the next step in the assessment. For a simple voided specimen for urinalysis, ask the patient to void into a clean bedpan, urinal, collection bottle, or plastic “hat” collection device placed inside the front of the toilet (Fig. 29.3). Provide privacy for the patient. Explain to the female how to hold the urine bottle or cup so that it surrounds the urethra. She should stand in a slightly squatting position, or sit over the toilet and hold the collection container steady to catch the urine as she voids. Explain to Box 29.2 Abnormalities Commonly Found in Urinalysis • Glycosuria (glucose in the urine) is present when there is too much glucose in the blood (hyperglycemia) or when the renal threshold for glucose is lowered for some reason. • Proteinuria (protein in the urine) occurs at times of stress, when infection is present, after strenuous exercise, or when there is a disorder of the glomeruli. • Hematuria (blood in the urine) occurs from bleeding somewhere in the urinary system. • Pyuria (purulent exudate in the urine) occurs when there is a bacterial infection in the kidney or the bladder. Bacteria will be present in the urine in large numbers. • Ketonuria (ketones in the urine) occurs when the patient is in ketoacidosis. This occurs in uncontrolled diabetes mellitus. • Casts occur in increased numbers in the presence of bacteria or protein and indicate urinary calculi (stones) or kidney disease. • Red blood cells in the urine greater than 0 to 2 cells/ high-power ield may indicate a stone, tumor, glomerular disorder, cystitis (bladder inlammation), or bleeding disorder. • White blood cells in the urine mean there is an infectious or inlammatory process somewhere in the urinary tract. • Bilirubin in the urine suggests liver disease or obstruction of the bile duct. both men and women that only about 1½ inches of urine is needed. If the specimen is to go to the laboratory, transfer it to the specimen container, label it properly, and send it to the laboratory within 5 to 10 minutes. Urine that stands for 15 minutes or more changes characteristics, and the urinalysis will not be accurate. Box 29.2 shows some common abnormalities found by urinalysis. Dipstick tests, containing chemical reagents, are routinely performed in most medical ofices and outpatient clinics. They may test for a variety of components, 546 UNIT VI Meeting Basic Physiologic Needs FIGURE 29.4 Timing the reading of a urine dipstick. including glucose, ketones, protein, blood, speciic gravity, pH, nitrate, bilirubin, and leukocytes. To perform a dipstick test, follow the directions on the side of the bottle of test strips. Exact timing for checking each component is essential for accuracy of the result (Fig. 29.4). Midstream (Clean-Catch) Urine Specimen. This procedure is used to obtain a specimen for a culture and sensitivity test when a UTI is suspected. The purpose is to obtain a specimen that is relatively free from external contamination. Patient Education How to Obtain a Midstream Urine Specimen FOR THE FEMALE PATIENT • Perform hand hygiene. • Open the midstream kit and remove the lid of the specimen container, being careful not to touch the inside of the container. Place the lid upside down on the sink or counter. • Sit on the toilet. • Open the packets of cleaning swabs. • With the index inger and thumb of the nondominant hand, spread the labia apart. The labia need to be held apart during cleaning and until the specimen is obtained. • Clean the right side of the area from front to back in one stroke; discard the swab. • With a new swab, clean the left side of the area from front to back in one stroke; discard the swab. • With another swab, clean down the center of the area from front to back in one stroke; discard the swab. • Pick up the specimen container by the outside; void a small amount of urine into the toilet; catch the middle portion of urine by moving the container into the stream. Collect about 1 oz of urine. Do not let the specimen container touch the skin or pubic hair. Set the container on the sink or on a paper towel, being careful not to touch the inside or the rim. Finish voiding into the toilet. • Place the lid on the container tightly; do not touch the inside of the lid. • Rinse and dry the outside of the container. • Perform hand hygiene. FOR THE MALE PATIENT • Perform hand hygiene. • Open the midstream kit; remove the lid of the specimen container and place it on the sink or counter upside down; be careful not to touch the inside of the container or the lid. • Open the packets of cleansing swabs. • If you are uncircumcised, retract the foreskin. Cleanse the end of the penis: start at the urinary meatus (opening) and work outward in circles; discard the swab. • Repeat the cleansing process with one more swab. • Pick up the specimen container; with the foreskin still retracted, begin urinating and pass a small amount of urine. • Move the specimen container into the stream and collect about 1 oz of urine without touching the container to the skin. Put the container down on the sink or on a paper towel. • Finish urinating into the toilet. Replace the foreskin. • Replace the lid on the container, being careful not to touch the inside of the container or lid. • Rinse and dry the outside of the container. • Perform hand hygiene. FOR THE PATIENT AT HOME • After collecting the specimen, label the container with name, date, time, and primary care provider’s name. • Take the specimen to the medical ofice or laboratory, or place it in a plastic bag and refrigerate until the specimen can be transported. Specimen from an Indwelling Catheter. A specimen may be obtained from the self-sealing port of an indwelling catheter system (Fig. 29.5, Steps 29.1). Sterile Catheterized Specimen. When a sterile specimen is ordered and the patient does not have an indwelling catheter in place, the patient is catheterized with a straight catheter (no balloon) that may be attached to a small collection bag, or the urine may be collected by placing the distal end of the catheter into a sterile specimen container. 24-Hour Urine Specimen. All urine voided during the 24-hour period is collected in the designated container and stored on ice if necessary. The laboratory analysis is done to determine the amount of a speciied chemical that is excreted through the urine in a 24-hour period. If some urine is accidentally thrown out, the test is invalid and must be started over. A sign should be posted over the bed and over the toilet, indicating that all urine is to be saved. The patient’s bladder should be empty at the beginning and at the conclusion of the test. The patient empties the bladder just before beginning the collection, and that urine is discarded. At the ending time the patient voids, and that urine is added to the collection container. Check with the laboratory before beginning the test to be certain the right container with preservative is on hand and to see whether the specimen must be kept cold during the 24-hour period (see Chapter 24). Promoting Urinary Elimination CHAPTER 29 547 Urinary Collection Bag. This device is used to obtain a urine specimen from an infant or toddler. The skin is cleaned, and then the device is attached to the skin by an adhesive backing and is placed so that it surrounds the genitalia. When suficient urine has collected in the bag for a specimen, the bag is carefully removed and the urine is poured into a specimen container. Strained Specimen. If patient is suspected of having a urinary stone, all urine is strained when voided. Usually a ine sieve is used. If a stone is found, it should be saved and sent to the laboratory for analysis. FIGURE 29.5 Aspirating urine from drainage port. Steps 29.1 NURSING DIAGNOSIS Nursing diagnoses for patients with problems of urinary elimination are as follows: • Urinary elimination, impaired • Urinary retention • Urinary incontinence (urge, stress, relex, overlow, or functional) • Body image, disturbed • Infection, risk for • Pain (acute or chronic) • Injury, risk for (to kidney from urine blockage) • Self-care deicit, toileting • Risk for impaired skin integrity • Knowledge, deicient The speciic deining characteristics are added to the diagnosis stem for the individual patient. Obtaining a Urine Specimen from an Indwelling Catheter If it is suspected that the patient is developing a urinary tract infection, the primary care provider may order a urine culture and sensitivity test. The specimen is taken from the port on the catheter or connecting tubing using sterile technique. The specimen should not be taken from the drainage bag or the tube used to empty the bag. 4. Review and carry out the Standard Steps in Appendix A. ACTION (RATIONALE) 1. Clamp the tubing below the aspiration port with a clamp, or double it over and secure with a rubber band. Note the time. Leave it clamped for 15 to 30 minutes per agency policy. (Ensures there will be fresh urine near the port for the removal of the specimen.) 2. Perform hand hygiene and don gloves. Scrub the aspiration port of the drainage tubing with alcohol or antimicrobial swab. (Maintains asepsis and prevents contamination of catheter.) 3. Insert a 25-gauge needle (or a needleless connector) attached to a 5- to 10-mL syringe into the aspiration 5. 6. 7. port at a 30- to 45-degree angle. (Use of small-bore needle and angle decreases coring. Needleless connectors are safer, but some aspiration ports may require a needle. Ask for assistance before starting the procedure.) Aspirate 3 mL of urine by gently pulling back on the plunger of the syringe. Remove the needle or connector from the port. Swab the aspiration port with the alcohol or antimicrobial pad. (Pulling hard on the plunger may collapse the catheter and prevent urine from lowing into the syringe.) Empty the syringe into the sterile specimen container without touching inner surface of the container. Dispose of syringe in sharps container. Close and label the specimen container. Unclamp the catheter. (Keeps specimen sterile. Unclamping catheter allows free low of urine again.) Ensure the specimen goes to the laboratory within 15 minutes, or refrigerate the specimen. (Changes can occur in urine that sits at room temperature for more than 15 minutes.) Remove gloves and perform hand hygiene. (Reduces transfer of microorganisms.) 548 UNIT VI Meeting Basic Physiologic Needs PLANNING If a patient has been prone to UTIs, plan to increase luids, unless contraindicated, and reinforce patient education regarding ways to prevent further UTIs. When you need a specimen, inform the patient in advance so he is able to produce the urine. In planning care for your patient, remember to be culturally sensitive in helping your patient meet his toileting needs. QSEN Considerations: Patient-Centered Care Toileting Preferences CULTURAL AWARENESS FOR TOILETING PREFERENCES Rather than using toilet paper, patients from other cultures may feel more comfortable if a source of lowing water (e.g., pericare bottle or bidet) is available to clean the perineal area after toileting. For the patient prone to urinary retention, note the amount of each voiding and palpate the bladder for distention if output falls below normal. If the patient needs assistive devices for toileting, place a bedpan and/or urinal in the bedside stand or obtain an order for the device needed. Discharge planning includes ensuring that arrangements are made before the patient goes home for devices such as grab bars by the toilet, a commode chair (chair with a container inserted to catch urine or feces), or a raised toilet seat (Fig. 29.6). Clinical Cues Every patient who has an abnormality of urinary elimination should be placed on intake and output (I & O) recording. Place an I & O recording sheet by the patient’s bed, and record the I & O in the medical record. All urine voided is recorded as output. Keep in mind that urinary elimination is usually an independent function, and most people are embarrassed about needing assistance. The insertion of a catheter causes a disturbance in body image even if the catheter is temporary. Some examples of expected outcomes can be found in Nursing Care Plan 29.1. IMPLEMENTATION Assisting patients with urinary elimination is a basic nursing function. Patients who can ambulate can be assisted to the bathroom to use the toilet. Others may use a commode chair for bowel or bladder elimination. It is usually placed by the bedside or a short distance away. The patient is transferred from the bed to the commode and then back again. The receptacle is emptied after each use. Patients who have dificulty with hip lexion or who have had a hip replacement need to use a raised toilet seat. This is usually a frame device that its over the toilet bowl, and has a toilet seat attached to it at a higher point than is usual. QSEN Considerations: Safety Life-Span Considerations Older Adult Falls Plan additional time in your schedule; older adult patients ambulate at a slower pace and may need assistance with clothing fasteners before toileting. RISK FOR FALLS An important Joint Commission National Patient Safety Goal is to identify preemptively patients at risk for falls. Patients who need assistance with toileting are likely to have physical or cognitive deicits that increase their fall risk. For example, a commode chair can tip over if an unsteady patient suddenly grabs one handle of the chair. Life-Span Considerations Older Adult The older adult may experience incontinence because of mobility problems or neurologic deicits. Timed toileting can be helpful in keeping these patients dry. FIGURE 29.6 Grab bars and raised toilet seat in home. Patients on bed rest are provided with a bedpan for elimination (see Fig. 29.3). Each patient has an individual bedpan stored in the bedside stand during the hospital stay. The female uses it for both urine and bowel elimination, whereas the male uses it for bowel elimination only. The bedpan should be covered if it must be carried outside the patient’s room. Paper towels or a small hand towel may be used. The fracture pan (see Fig. 29.3) is used when patients are unable to sit on a regular-sized bedpan. It is smaller in surface area and height compared with the regular bedpan. It is used for patients with musculoskeletal 549 Promoting Urinary Elimination CHAPTER 29 Nursing Care Plan 29.1 Care of the Patient With Cystitis SCENARIO Ms. Juarez, age 33, comes to the outpatient clinic. She states that she has been experiencing burning, urgency, and lower pelvic discomfort for 3 days. She needs to urinate several times an hour. She has had a bladder infection before and is afraid that she has one again. “How do I get these infections? What should I do?” Her blood pressure and pulse are normal, but her temperature is 100.8°F (38.2°C). You ask her to obtain a midstream urine specimen and provide the instructions for obtaining the specimen. You check her urine with a dipstick, and it shows that she has leukocytes in the urine. The primary care provider examines the patient and concludes that she does have cystitis. Trimethoprim-sulfamethoxazole and phenazopyridine HCl are prescribed. PROBLEM/NURSING DIAGNOSIS Burning and lower pelvic discomfort/Pain related to cystitis with urination and lower pelvic discomfort. Supporting Assessment Data Subjective: Discomfort in lower pelvic area for 3 days. States, “It burns.” Objective: Facial expression shows discomfort. Goals/Expected Outcomes Nursing Interventions Selected Rationale Evaluation How did patient respond to the treatments? Pain will be lessened within 6 h. Review instructions for taking phenazopyridine HCl and trimethoprimsulfamethoxazole. Pain will be relieved within 72 h. Explain that phenazopyridine HCl will turn the urine red or orange. Patient might be frightened if After taking the medicared or orange urine is not tions and luids for expected. 24 h, patient stated in follow-up phone call that discomfort is almost gone. Encourage patient to take trimethoprim-sulfamethoxazole exactly as directed to kill the causative organism. Patient will feel better after several days of antibiotic; however, failure to complete the full course creates resistant strains of bacteria. Encourage patient to increase luid in- Increasing luid intake take to 3000 mL/day to keep urine lushes the bladder and dilute and lessen bladder irritation. decreases bacteria population; thus, irritation is decreased. Explain that sitting in a hot sitz bath with water up to the umbilicus for 20 min two or three times a day will help to increase blood low to the bladder and lessen bladder irritation and pain. Hot water increases circulation in the pelvic area. Meeting expected outcomes. PROBLEM/NURSING DIAGNOSIS Does not know how to prevent infection/Deicient knowledge related to factors that predispose to UTI. Supporting Assessment Data Subjective: Asks, “How do I get these infections? What should I do?” Objective: Unable to state how much luid she should drink in a day. Unable to identify any factors that predispose her to UTI when asked. Continued 550 UNIT VI Meeting Basic Physiologic Needs Nursing Care Plan 29.1 Care of the Patient With Cystitis—cont’d Goals/Expected Outcomes Patient will verbalize ive ways to help prevent recurrence of UTI at the follow-up visit in 10 days. Nursing Interventions Selected Rationale Evaluation Instruct patient to continue to drink at least 2500 mL of luid per day. Understanding risk factors and measures to prevent infection is essential to prevent another bladder infection. Was patient able to verbalize ways to prevent recurrent UTIs? Verbalized ive measures to prevent UTIs during follow-up visit. Urine is clear of bacteria. Met expected outcomes. Void immediately after intercourse and drink at least a full glass of water. Voiding after intercourse lushes bacteria from the urethra. Refrain from wearing clothing that is tight in the groin area. Tight clothing creates a warm, moist environment for bacteria growth. Bathe daily and thoroughly cleanse the perineal area. Keeping perineal area clean decreases bacteria that can travel up the urethra. Always wipe perineum from front to back only. Prevents feces from coming into contact with the urethra. Drink cranberry juice. Acidiies the urine, which discourages growth of bacteria. Empty the bladder at least every 3 h while awake. Stagnant urine creates a medium for bacterial growth. CRITICAL THINKING QUESTIONS 1. Why do you think that many women develop cystitis after having intercourse? 2. What is the rationale for asking a patient to have another urine specimen checked a day after inishing a course of treatment for cystitis? problems. The lat end with the wide rim is placed under the patient by separating the patient’s legs and slipping the pan under the buttocks. The greater depth at the front of the pan helps keep the urine from spilling on the bed. Remove the pan carefully to avoid spilling urine. Skill 29.1 presents instructions on how to place and remove a bedpan. For the ambulatory patient who needs urine output recorded, place a plastic “hat” device toward the front of the toilet bowel between the bowl and the seat. The inside is graduated to allow recording of the amount of output. After each voiding empty, rinse, and replace the container so that it is ready for the next voiding. Whatever method is used for urinary elimination, provide an opportunity for hand hygiene after toileting. Leave the patient comfortable, with side rails up and the call bell within reach. Cultural Considerations Hand Hygiene For nurses, hand hygiene is second nature, but for many people, this is not an automatic behavior. For example, a study was conducted with families giving hands-on care to patients in Bangladesh. Although they perceived that washing hands with soap reduced transmission of disease, they rarely were observed washing their hands after contact with bodily luids. (Islam et al., 2014). In accordance with Healthy People 2020, improvements in personal and domestic hygiene are needed to reduce the global incidence of disease. Assisting With Use of a Urinal When a male requires assistance to use a urinal, the nurse assists the patient to stand beside the bed, if possible. The male urinal is a bottle with a round neck, a handle, rectangular sides, and a lat base (see Fig. 29.3). It may or may not have a lid. The patient who is conined to bed can use the urinal in any one of four positions: lying supine, lying on either the right or the left side, or lying in Fowler position. Provide privacy by closing the door or curtain, don gloves, lower the side rail, and ask the patient to spread his legs. Hold the urinal by the handle and direct it at an angle between the legs so that the lat side rests on the bed. Lift the penis and place it well within the urinal. After urination, carefully remove the urinal and empty it immediately, measuring and recording the urine voided. Be certain the penis is dry. Clean the urinal and return it to the proper place. Promoting Urinary Elimination CHAPTER 29 551 Skill 29.1 Placing and Removing a Bedpan The female patient who is very weak or who has bed rest ordered uses a bedpan to void or to have a bowel movement. The male uses a urinal to void, but uses the bedpan to evacuate the bowel. Supplies • Bedpan • Toilet tissue • Gloves • Underpad Review and carry out the Standard Steps in Appendix A. NURSING ACTION (RATIONALE) Assessment (Data Collection) 1. Inquire if the patient needs to void. (Checks for bladder distention and establishes need to void.) 2. Determine mobility to see if the patient can use a full-size bedpan or if fracture pan is needed. (Fracture pan use prevents further injury from turning or raising the hips.) Planning 3. Gather equipment. Raise the bed to proper working height. (Facilitates work organization. Prevents back strain.) 4. Close the door and/or the privacy curtains. (Protects privacy.) Implementation 5. Perform hand hygiene and don gloves. (Reduces transfer of microorganisms.) 6. Lower the side rail if up, and raise the top linen enough to determine location of the hips and buttocks. (Provides access to place bedpan.) 7. Ask patient to bend the knees and press down with the feet while you slip one hand under the lower back for assistance; place an absorbent pad under the hips and buttocks. Ask the patient to repeat this maneuver and place bedpan under the patient with the back rim at the end of the sacrum. (Placing your hand palm up under the small of the back and your elbow on the mattress helps lift the patient onto the bedpan. The buttocks will form a seal along the rim of the pan.) Step 7 8. Raise the head of the bed to 30 degrees if not contraindicated. Place the toilet tissue and call light within reach. If urine is to be measured, instruct patient to put used toilet tissue in wastebasket. (A sitting position makes voiding easier. Patient can signal for assistance. If toilet tissue is left in the bedpan, it is more dificult to get an accurate output measurement.) 9. Ask the patient to lex the knees, place the feet on the mattress, and raise the hips. Remove bedpan. Place it on the chair or the loor. (Allows for removal of the bedpan.) For the Helpless Patient 10. Turn the patient on one side; place the bedpan irmly against the buttocks with the top of the bedpan at the top of the fold of the buttocks. Place one hand on the hip and hold the bedpan in place with the other hand. Roll the patient onto the bedpan and check position for comfort. (The weak patient cannot assist.) 11. Raise the head of the bed to 30 degrees if not contraindicated. (Sitting is an easier position for voiding.) 12. When the patient is inished, lower the head of the bed and assist the patient to turn to the far side of the bed. Hold the bedpan to prevent spilling. Remove the bedpan and set it on the loor. (Lowering the head and then turning the patient is easier than trying to lift the patient off the pan.) 552 UNIT VI Meeting Basic Physiologic Needs A B Step 10 13. Wipe the perineal area dry with toilet tissue, stroking from the front of the vulva to the anus. (Cleansing from front to back prevents contamination of urinary meatus and vaginal area.) 14. Measure the urine, note unusual characteristics, and record the amount on the intake and output record as needed. Discard the urine and clean and dry the bedpan and store it in its proper place. (Output and characteristics are documented for trends. Dirty bedpans have an odor and are a source of infection.) 15. Have patient perform hand hygiene. Remove gloves and perform hand hygiene. (Reduces transfer of microorganisms.) 16. Lower the bed and restore the unit. Place call light within reach; raise side rails. (Makes patient comfortable and institutes safety measures.) Evaluation 17. Ask patient if bladder feels empty. Did any urine spill? If so, what would you do differently next time? Has the patient performed hand hygiene? Is the patient comfortable? (Determines whether procedure went smoothly and accomplished the goal.) Documentation 18. Document on the low sheet or in the nurse’s notes depending on agency policy. Note time, amount of voiding, and characteristics of the urine. (Veriies patient’s voiding pattern.) Documentation Example Voided 240 mL clear, pale yellow urine in bedpan. (Nurse’s electronic signature) Special Considerations • When the patient cannot raise the hips or turn to the side, a fracture pan is used. It can be slid into place from between the patient’s legs. The lattened portion of the pan is slipped under the buttocks. A trapeze bar requires upper arm strength, but the patient can self-position on the pan. Life-Span Considerations Older Adult • The older adult patient may be especially reluctant to have the nurse cleanse the perineum. Be matter of fact and protect dignity, but ensure that the patient is clean. Critical Thinking Questions 1. What would you do to make it as easy as possible to place and remove a bedpan for a patient who has an external ixation device on his lower leg? 2. How would you make certain the patient who cannot turn to the side is properly cleansed after a bowel movement? Promoting Urinary Elimination CHAPTER 29 Helping a Patient Urinate Patients often have dificulty urinating after surgery and anesthesia, childbirth, or other trauma to the perineum. All efforts are made to help the patient void naturally before resorting to catheterization (insertion of a tube into the bladder). Some methods of helping patients initiate the voiding relex are: • Run water in a nearby sink so the patient hears the sound. • Have the patient deep breathe, relax, and visualize a peaceful place with a bubbling brook. Encourage the patient to drink a cup of warm caffeinated coffee or tea. • Help the male stand by the side of the bed (with a documented order). • Have the female blow through a straw in a glass of water, causing bubbling, while sitting on the toilet or bedpan. • Measure several cups of warm water, then pour the water over the perineum while the patient attempts to void. Subtract the measured amount from the total volume to determine how much the patient voided. • With an order, gently but irmly use Credé maneuver over the bladder (massage from top of bladder to bottom by starting above the pubic bone and rocking the palm of the hand steadily downward). This is primarily used for patients with neurogenic urinary dysfunction. • Obtain an order for a sitz bath and have the patient sit in the warm water. Encourage the patient to void while in the bath. Cleanse the perineum afterward. When a patient cannot empty the bladder naturally for a period longer than 8 hours, a bladder scan may be performed using an ultrasound machine designed for that purpose (Fig. 29.7). If the bladder contains a large amount of urine, an order is obtained for catheterization. The bladder scan can also disclose the amount of residual urine in the bladder after voiding. This tells the primary care provider whether the bladder is emptying suficiently. If needed, the care provider orders either a straight “in-and-out” catheterization or the insertion of an indwelling urinary catheter. Other reasons for catheterization include: • Preparing a patient for a surgical procedure or obstetric delivery. • Keeping the genitalia and perineum clean after obstetric or surgical procedures. • Dilating a urethral stricture (narrowed lumen). • Splinting the urethra following surgery on the urethra (the catheter is inserted by the surgeon). • Measuring the amount of residual urine in the bladder (also accomplished by using a portable ultrasound bladder scanner). • Monitoring hourly urine output or obtaining exact measurements of total output. 553 FIGURE 29.7 Using a bladder scanner to determine the amount of urine in the bladder. • Performing irrigation or instillation and drainage of chemotherapeutic solutions into the bladder. • Assisting with the re-toning of the bladder muscle after surgery on the bladder. Think Critically Your patient returned from surgery at 10:30 am and is awake and alert. She had spinal anesthesia, but has recovered the feeling in her lower extremities. It is now 7:00 pm, and she still has not voided since her return to the unit. What would you do to help her void? If she has not voided by 8:00 pm, what would you do? Types of Urinary Catheters Catheters come in several sizes and shapes and are either rubber or plastic. Some are Telon coated. They are sized using the French system, with the average size used for an adult woman being 14 to 16 Fr. and for the man 18 to 20 Fr. (Fig. 29.8). A straight catheter (e.g., the Robinson) is used (1) to relieve retention when a patient is temporarily unable to void or (2) to obtain a sterile specimen. The Foley (retention catheter) is the most common indwelling catheter; it can remain in the bladder for an extended period. A Foley catheter has two lumens, one to drain urine and one for inlation of the balloon holding the catheter in the bladder to prevent it from slipping out the urethra. The balloon usually holds 5 to 10 mL of sterile water. This catheter is used for continuous drainage, particularly after surgery, and it can also be used for suprapubic (above the pubic bone) drainage. The Coudé catheter, a variation of the Robinson catheter, is curved and has a rounded or bulbous tip that is 554 UNIT VI Meeting Basic Physiologic Needs Single lumen Straight, rounded tip Malecot tip (retention catheter) Mushroom tip (de Pezzer) retention catheter Double lumen (retention catheter with rounded tip) Drainage Sterile water for balloon inflation Triple lumen Alcock (retention catheter with Coudé tip) Drainage Irrigation Sterile water for balloon inflation FIGURE 29.8 Common urinary catheters. easier to insert into the male urethra when the prostate is enlarged. It is usually inserted by a urologist. The Alcock catheter, used for continuous bladder irrigation following prostate or bladder surgery, is a Foley-type catheter with two drainage eyes. It has three lumens, one for urine drainage, one for inlation of the balloon, and one for instillation of irrigation luid. The de Pezzer catheter, which has a tip shaped like a mushroom, is used for suprapubic drainage. The Malecot catheter, which has a large single tube with a tip shaped like wings, is often used as a nephrostomy tube; it is placed into the pelvis of the kidney. A condom catheter consists of a condom with a tube attached to the distal end that is attached to a drainage bag. It is used to provide continuous urine drainage for the male in a noninvasive manner. Read the directions that come with the speciic catheter. See Skill 29.2 for additional information. Performing Catheterization Sterile equipment and strict aseptic technique must be used to catheterize a patient. Any break in aseptic technique causing contamination must be corrected before continuing with the procedure. One of the National Patient Safety Goals is to follow protocols that protect patients from infection. Catheter kits can be used for males or females. The procedure for male and female catheterization is similar except for variations in the positioning, draping, and cleansing of the urinary meatus. In the male, the catheter is inserted farther (about 7 to 8 inches). When inserting a catheter, gently insert until you see the urine low and then insert 1 to 2 more inches. This will ensure the balloon will not damage the urethra during inlation. Skills 29.3 and 29.4 give the steps for catheterization of the female patient and the male patient, respectively. Communication Talking to the Patient About Catheter Insertion James Stanton is suffering from urinary retention. He is in the emergency department because he cannot urinate and is in pain. His primary care provider ordered an indwelling urinary catheter to be inserted. Mr. Stanton has expressed reluctance about having a catheter. The nurse explains the procedure to him. Nurse: “Hi, Mr. Stanton; I’m Karen. How are you feeling?” Mr. Stanton: “I’m very uncomfortable.” Nurse: “Can you tell me about your discomfort?” Mr. Stanton: “I can’t pee and I have an ache down low.” (Nurse gently palpates the lower abdomen above the symphysis pubis.) Continued on page 562 Promoting Urinary Elimination CHAPTER 29 555 Skill 29.2 Applying a Condom Catheter A condom catheter is used for the male who is able to pass urine, but is incontinent. It is preferable to use a condom catheter rather than an indwelling catheter because bladder infection is less likely to occur. There are different brands of condom catheters and different methods of attachment; follow the speciic directions on the package. Condom catheter Connected to drainage tube Review and carry out the Standard Steps in Appendix A. Supplies • Condom catheter • Gloves • Adherent elastic tape strip • Basin, warm water, soap, washcloth, and towel • Skin prep pads or solution • Clippers for hair removal if needed • Urine collection bag with drainage tubing or leg bag and straps ACTION (RATIONALE) Assessment (Data Collection) 1. Assess need for and patient’s willingness to use a condom catheter. (Condom catheters are easily detached.) 2. Assess condition of skin on penis. (Urine incontinence places the skin at risk for breakdown.) Planning 3. Gather equipment and prepare the working space by raising bed to the proper height. (Promotes work eficiency and prevents back strain.) 4. Close the door and/or draw the privacy curtains. (Protects the patient’s privacy.) 5. Explain the procedure. (Promotes cooperation and reduces anxiety.) 6. Lower the side rail if up. Place patient in a supine position, drape the upper torso with a bath blanket, and then fold the sheet down so it covers the legs and can be lowered to expose the genitalia. (Provides comfort, conserves body heat, and prevents unnecessary exposure.) 7. Prepare the urinary drainage collection system by clamping the drainage bag discard spout and positioning the bag for easy attachment to the condom catheter. Roll the wider tip of the condom sheath toward the narrower tip. (If the discard spout is not clamped, urine can spill out. Rolling the condom downward will prepare the condom for rolling it upward over the penis.) Step 7 Implementation 8. Perform hand hygiene and don gloves. (Prevents transfer of microorganisms.) 9. Wash and dry the penis and surrounding skin, clip the hair at the base of the penis, apply the skin prep, and allow to dry. (Cleansing and skin prep protects the skin and provides an adherent surface.) 10. Apply the double-sided elastic tape in a spiral fashion from the base of the penis downward. (Provides a surface on which the condom catheter can be attached without impeding circulation in the penis. Some condom catheters attach with a Velcro strip over the sheath.) 11. Grasp the penis along the shaft with the nondominant hand. Hold the condom sheath at the tip of the penis and smoothly roll the sheath onto the penis, leaving 1 to 2 inches of space between the tip of the penis and the drainage tube of the condom sheath. (Positions the condom catheter on the penis. Allows free passage of urine into the collecting tube and drainage bag. Keeps penis away from collecting urine.) Step 11 556 UNIT VI Meeting Basic Physiologic Needs 12. Gently press the sheath to the underlying adhesive strip with the palm of the hand in a grasp, being careful not to wrinkle the rubber sheath. Hold for 1 minute. Explain the rationale for holding. (Wrinkles in the sheath may cause urine leakage. The warmth of the hand for 1 minute activates the adhesive.) 13. Position the penis downward; connect the drainage tube to the collection bag. (Urine lows downward.) 14. Return bed to low position and make patient comfortable; place call light within reach. Raise side rails. (Prevents accidents and provides comfort and security.) 15. Remove gloves and perform hand hygiene. (Reduces transfer of microorganisms.) 16. Check the penis after 30 minutes and then every 2 hours and ensure that the catheter is not twisted so that urine can drain freely. (Ensures that the catheter is not too tight and impairing circulation.) 17. If a leg bag is used, empty it when it is partially illed with urine. (Weight can pull the catheter off.) Documentation Example Skin on genitalia slightly reddened from contact with incontinent urine. Area cleansed, prepped, and condom catheter applied with Velcro strip. Patient states does not feel too tight. Attached to leg bag. Draining clear, yellow urine. (Nurse’s electronic signature) Evaluation 18. Does the catheter it smoothly and adhere irmly to the penis? Is there evidence of irritation to the skin or impaired circulation? Is urine draining into the bag? Is there any leakage of urine? (Determines whether system is functioning effectively without problems.) Special Considerations • If the condom catheter is the newer self-adhesive type, apply catheter as in Step 11 and apply gentle pressure around the penile shaft for 10 to 15 seconds to secure the catheter. • The catheter must be checked frequently because the end of the sheath is prone to twist, preventing the urine from lowing into the drainage tube. Do not allow any pull on the drainage tubing when repositioning or ambulating the patient because this may dislodge the catheter. • Remove and change the catheter daily or more often if it its improperly. • Wash the used catheter and collection bag with mild soap and water, rinse with a 1:7 strength vinegar solution, and allow it to dry completely. • If the rolled-over portion at the base of the penis seems too tight, clip the roll a tiny bit to loosen it. It should not constrict the penis and interfere with blood low. • Check for swelling, discoloration of the penis, and complaints of discomfort. Documentation 19. Note date, condition of genital area, size and type of catheter applied, type of skin prep used, type of drainage collection attached to catheter, amount of urine obtained in bag and its color and character, and patient’s tolerance of the procedure. (Documents use of condom catheter.) Critical Thinking Questions 1. If an older adult man resists the idea of a condom catheter and the only other option is to insert an indwelling catheter, what might you say to him that might make him accept the condom catheter? 2. How would you tell if the condom catheter is too tight? Skill 29.3 Catheterizing the Female Patient An indwelling or retention catheter is used when continuous drainage of urine is desirable because the patient cannot void or if the patient must undergo a long surgical procedure. This type of catheter is also used when it is necessary to track urine output closely hour by hour. The catheter is held in the bladder by a small inlated balloon. Catheter insertion is a sterile procedure, and the student must be supervised when performing catheterization. Supplies • Indwelling urinary catheter kit with appropriate size catheter (adult female: 14 to 16 Fr.) • Sterile 4 × 4 gauze • Bath blanket • Basin with warm water • Towel and washcloth • Mild soap • Catheter securing device • Extra light (standing lamp or lashlight) Review and carry out the Standard Steps in Appendix A. Promoting Urinary Elimination CHAPTER 29 ACTION (RATIONALE) Assessment (Data Collection) 1. Check the primary care provider’s order for type of catheter. (Catheterization requires a medical order.) 2. Assess patient’s knowledge of catheterization and use of a catheter. (Patient education is based on knowledge deicit.) 3. Assess whether patient is allergic to iodine or tape. (Povidone-iodine is often used to cleanse the perineum before catheterization.) 4. Assess woman’s ability to assume the dorsal recumbent (lithotomy) position. (If the female patient cannot assume the dorsal recumbent position, a sidelying position may be used.) Planning 5. Check the patient’s identiication band, gather equipment, and prepare the working space by raising the bed to proper height and positioning the over-the-bed table for use. (Ensures the procedure is performed on the correct patient; promotes work eficiency and prevents back strain.) 6. Close the door and/or privacy curtains. (Protects the patient’s right to privacy.) 7. Explain the procedure. (Patient’s cooperation is necessary to maintain sterility during procedure.) Implementation 8. Perform hand hygiene and don disposable gloves. (Reduces transfer of microorganisms.) 9. Help patient assume the dorsal recumbent position, with thighs relaxed so that hips can externally rotate, and drape with a bath blanket or sheet. (Positions patient for ease of viewing the meatus and inserting the catheter into the bladder.) 10. With the use of good lighting, inspect the perineum. Wash the area if needed. Spread the labia with your nondominant hand and locate the urinary meatus. (An assistant may be needed to hold a lashlight with the beam directed at the perineum.) Urinary meatus Step 10 557 11. Remove gloves and perform hand hygiene. (Reduces transfer of microorganisms.) 12. Open the plastic covering of the catheter kit by tearing along the lined perforated edge. Use the plastic cover as a discard bag and place it to the side of the ield or toward the foot of the bed for waste disposal. (Provides a re