Unit 4.docx

**Unit 4** **NP120.07.01 Assessing Bowel Function and Elimination**\ NP120.07.01.01 Explain the processes of digestion, absorption, metabolism, and elimination in the GI tract **Process of digestion:** - Mechanical digestion is the physical breakdown of food caused by chewing and the moveme...

**Unit 4** **NP120.07.01 Assessing Bowel Function and Elimination**\ NP120.07.01.01 Explain the processes of digestion, absorption, metabolism, and elimination in the GI tract **Process of digestion:** - Mechanical digestion is the physical breakdown of food caused by chewing and the movement of food in the digestive tract. Breaking food into smaller pieces exposes more food surface area to the effects of enzymes, acids, and other chemicals. - Chemical digestion is the breakdown of chemical bonds in food, with the addition of enzymes, acids, and water. Some digestive processes begin in the mouth, pharynx, and stomach, but most digestion occurs in the duodenum. **Absorption:** Absorption of nutrients into the bloodstream occurs via the small intestine. The body cannot use these food materials, however, until the bloodstream delivers them to the cells by transporting the particles across each cell\'s membrane. **Metabolism:** - Catabolism (destructive metabolism): breaking down foods into usable substances (generates heat, carbon dioxide, water, and ATP) - Anabolism (constructive metabolism): using products of catabolism to build and repair body cells and maintain life **Elimination:** Since there are no enzymes in the colon, minimal digestion occurs there. Whatever nutrients are not reabsorbed and sent to the portal (liver) circulation are eliminated as solid intestinal wastes (defecation, *bowel movement, egestion*).  *The stages of digestion are:* - **Ingestion---taking in of food** - **Breakdown---mechanical and chemical conversion of food into usable molecules** - **Absorption---transfer of nutrients into circulatory/lymphatic systems for use by the body** - **Egestion---elimination of waste products by defecation** NP120.07.01.02 Describe nursing assessments specific to the GI system A table with text overlay Description automatically generated NP120.07.01.03 Summarize age-related changes of the GI system and describe appropriate nursing interventions to address these changes  **NP120.07.02 Assisting with Bowel Elimination**\ NP120.07.02.01 Define constipation, diarrhea, nausea, and vomiting and state nursing interventions to manage each condition **Constipation** is a condition in which the client has infrequent, hard bowel movements accompanied by mucus. Constipation may be an acute or chronic condition. The client may have a fecal impaction with loose, watery stool and mucus traveling around the constipated stool. Dehydration, cancer, chemical dependency, or mechanical obstruction may cause this condition. Encourage the client to avoid worrying about constipation because undue concern can compound the problem. Teach the client to drink a great deal of fluids, drink prune juice or eat bran, increase dietary bulk, exercise, and follow a regular schedule for defecation. Explain the importance of evacuating the bowel whenever the client feels the urge; postponing the act desensitizes the bowel to the presence of feces. **Diarrhea* ***consists of stools that are liquid or semiliquid and often very light-colored. They may be foul-smelling and contain mucus, pus, blood, or fats. You may need to restrict the client\'s diet to clear liquids and then reintroduce fluids and foods slowly to observe for improvement or worsening. Client and family teaching include criteria to prevent food contamination with *S. aureus* and *Salmonella,* which are often sources of diarrhea. **Nausea* ***is an unpleasant abdominal sensation, sometimes followed by vomiting. *Vomiting,* also called emesis*,* is an involuntary action that expels stomach contents. Place a cool, damp washcloth on the client\'s forehead.** *Rationale:* *This is soothing to the client and may help him or her to relax. Relaxation helps prevent vomiting.*** Help the client to take slow, deep breaths through the nose.** *Rationale:* *Deep breathing helps relax the client and distracts from the nauseated feeling. Adding oxygen to the blood, and thus the control center in the medulla of the brain, helps relieve nausea.*** **Vomitus** means stomach contents. Its appearance and odor may indicate the cause of emesis. Assess for particles, color, odor, and consistency. Vomitus may contain bright red blood, a sign of gastric or esophageal bleeding or coffee-ground material, a sign of bleeding in the lower digestive tract. Observe the nature of vomiting. Was it violent or projectile? How does the client describe the episode? If you are monitoring the client\'s I&O, consider vomitus as output. Report the vomiting episode. Carefully document all observations. Always wear gloves when assisting the client who is vomiting or when taking a specimen of vomitus. *Rationale:* *Gloves must always be worn when working with any body fluids.* Measure and document the amount of vomitus, if possible. Always save any unusual vomitus for inspection.  NP120.07.02.02 Describe the nursing considerations and processes for administering a rectal suppository, administering an enema, and removing a fecal impaction **NURSING PROCEDURE 63-3 Administering a Rectal Suppository** **Supplies and Equipment** Medication scanner or MAR Gloves Medication (suppository) Lubricant, if needed Applicator, if needed Scissors Hazardous waste container *Note:* Follow steps in Nursing Care Guidelines 63-1 and 63-2 before proceeding. Steps 1\. Assist the client to the Sims' position and cover the client as much as possible. Generally, the left-side lying position is preferable. Wear gloves. *Rationale:* *This position provides easy visualization of, and access to, the rectum.* 2\. Leave the suppository in the refrigerator as long as possible before the procedure, unless it is a non-refrigerated type. Cut the wrapper off the suppository. *Rationale:* *The suppository will retain its shape better if it is cold. By the time it is inserted, it will not be uncomfortably cold. Cutting the wrapper or foil helps preserve the shape of the suppository. (Squeezing the suppository out of the wrapper melts it and distorts the shape.)* 3\. Lubricate the suppository, if necessary. Wearing gloves, insert the suppository into the client\'s anal canal, pointed end first. It is inserted at least 4 in for an adult and 2 in for a child. You should be able to feel the suppository pass through the anal sphincter as you insert the suppository. *Rationale:* *Inserting it this far ensures placement of the suppository above the client\'s internal sphincter and helps the client to retain it, maximizing medication absorption.* *Inserting the rectal suppository past the internal anal sphincter against the rectal wall, with gloved finger. (Timby, 2005.)* 4\. Ask the client to maintain the Sims' position for 15 to 20 minutes and not to expel the suppository. *Rationale:* *Maintaining the position allows time for the suppository to melt and release the medication.* **Special Reminder** - ** Check on the client in 20 to 30 minutes and document the client\'s response. *Rationale:* *Follow-up determines if the medication was effective and maintains communication with other members of the healthcare team.*** **NURSING CARE GUIDELINES 51-7 Administering an Enema** The following guidelines apply, whether using the bag-and-tubing or the small-volume enema. - Wash hands before and after giving an enema. Always wear gloves. A face shield may also be needed, if there is any chance of splashing fluids. Rationale: Handwashing and wearing gloves, as well as other protective gear, help prevent the spread of microorganisms and protect the nurse. Feces are highly contaminated. - Check the package for the manufacturer\'s specific instructions for that type of enema. Rationale: Each type of enema may have slightly different instructions. - Check to make sure the client does not have a latex allergy, or use a latex-free enema. Rationale: If a latex-containing enema is used for a client with an allergy, a severe reaction may occur. (Most enemas are latex-free.) - Know the correct amount of solution or size of enema to use, by reviewing the provider\'s order. If the client is a child, take the child\'s size into consideration (see Nursing Procedure 51-4). Rationale: Too much fluid could cause damage or discomfort. - Know what type of enema solution and type of enema to use. Rationale: The client could be injured by receiving an incorrect type of enema or the wrong solution. *Ask the client to lie on the left side for most enemas. (Evans-Smith, 2005.)* - Store enemas and enema solutions at room temperature; never store them in a cold or hot place. Make sure the solution is just above body temperature before instillation. Use a thermometer, if possible. The temperature of the solution should not exceed 39°C (102.2°F). A cold solution can cause intestinal cramping and could cause shock. It could also make it impossible for the client to relax enough to defecate. Excess heat could cause the solution to deteriorate and/or damage intestinal mucosa. - Ask the client to lie on the side (preferably the left---Sims' position) for the cleansing enema, if possible. Place a waterproof pad under the client\'s buttocks. Rationale: The colon\'s position within the body makes this position the most effective. A semi-Fowler position will cause solution leakage and the pad will protect the bed. - If the client is in traction or a cast, give the enema with the client supine (lying on the back). Rationale: This is the next-best position for an enema. It is important not to injure this client by changing their position. - Place the client in a knee-chest (genupectoral) position for a retention enema (or rectal tube), if the client can tolerate this. Rationale: This position encourages fluid retention for a longer period of time. (It is very difficult to give an enema effectively with the client sitting up.) - Drape the client, covering his or her body as much as possible. Rationale: Preserves the client\'s privacy. This client will be more relaxed and more able to have good results from the enema. - Even though the tip of the enema or the tubing is pre-lubricated, lubricate it again. Rationale: This will increase comfort for the client. - When using the bag-and-tubing method, clear the tube of air by opening the clamp until the solution flows. Rationale: This avoids introduction of air into the colon, which could cause discomfort and reduce the amount of fluid the client can retain. - Use judgment to decide when to stop instilling fluid, based on the client\'s reactions. If the client complains of cramping, stop the instillation for a short time. Rationale: Each person has a different limit for the amount of fluid he or she can retain. - Give the solution slowly. Instruct the client to retain the enema as long as possible. Rationale: Both cleansing and retention enemas are held longer if given slowly. Longer retention enhances the enema\'s effectiveness. - Place a bedpan for the client or make sure he or she can get to the bedside commode or bathroom quickly. Make sure IVs and other equipment are out of the way. Be sure the signal cord or pager is within reach. Check back frequently with the client. Rationale: Some clients may become weak or faint or may have difficulty getting to the bathroom. The client may need to get to the bathroom or commode quickly. - Offer the client the opportunity to wash his or her hands after the procedure is completed. Be sure to wash your hands thoroughly as well. Help the client to assume a comfortable position in bed or chair. Rationale: Make the client comfortable and teach good hygiene habits. - Observe or ask the client about the results. Rationale: It is important to determine if the enema was effective. - Document administration of the enema, the results, and the client\'s reactions. Document the type of solution used, its temperature, and the amount instilled. Rationale: Documentation promotes communication and continuity of care. NURSING PROCEDURE 51-5 **Performing Manual Disimpaction** - - **Supplies and Equipment** - Gloves - Waterproof pad - Toilet tissue - Bedpan - Water-soluble lubricant - **Steps** - ***Follow LPN WELCOME Steps and Then*** - 1\. Check the provider\'s order. A specific order is required for this procedure. ***Rationale:**This procedure carries a potential for vagal nerve stimulation, producing a lowered heart rate and blood pressure.* - 2\. Take the client\'s vital signs. ***Rationale:*** *Baseline vital signs are necessary for comparison, if the client shows signs of inappropriate vagal stimulation.* - 3\. Wear two pairs of clean, disposable gloves for this procedure. ***Rationale:*** *The feces are highly contaminated. Your gloved hands will be in direct contact with feces.* - 4\. Place a disposable waterproof pad under the buttocks. ***Rationale:*** *A pad helps to prevent soiling of the bed.* - 5\. Position the client on the left side, with the knees (especially the upper knee) drawn up as far as possible (Sims' position). ***Rationale:*** *This position is comfortable for the client and allows an easy view of, and access to, the anal area.* - 6\. Drape the client so as much of the body as possible is covered. ***Rationale:*** *Proper draping preserves the client\'s privacy as much as possible.* - 7\. Instruct the client to take short, panting breaths during the procedure. ***Rationale:**Panting helps relax the anal sphincter.* - 8\. Using two pairs of gloves, lubricate the first or second finger well and insert it *carefully*into the rectum until you feel the stool; then, rotate the finger gently in a scissors motion, to slice off small pieces of stool. ***Rationale:*** *This helps break up the stool. Usually this procedure is all that is needed to assist the client to expel impacted feces.* - 9\. Before removing your finger, gently stimulate the anal sphincter with a rotating motion. ***Rationale:*** *This stimulation helps cause a natural response to defecate.* - - *Insert the finger into the rectum until you feel the stool and then rotate the finger gently and slowly, to break up the stool. Gently stimulate the anal sphincter, which usually causes defecation.* - 10\. Assist the client to the bathroom, commode, or bedpan as needed. ***Rationale:*** *Client may be uncomfortable or weak and may need assistance.* - 11\. Leave the client\'s signal cord or pager within reach. ***Rationale:*** *The person may need the bedpan again in a short time. Diarrhea often occurs after nonroutine manual disimpaction.* - 12\. Provide a washcloth and soap for the client to use for cleansing the rectal area, or clean the area if the client cannot. Leave the waterproof pad in place, to protect the bed. Dispose of gloves and wash hands. Provide handwashing supplies for the client to wash his or her hands. ***Rationale:*** *Keeping the client and the bed area clean helps to prevent the spread of microorganisms.* - ***Note:*** In some cases, the client will perform manual disimpaction on himself or herself on a daily basis. - ***Follow ENDDD Steps*** - **Special Reminder** - Documentation of this procedure includes any particular client reactions, as well as the amount, color, consistency, and odor of any stool obtained or expelled. If the client is unable to expel impacted feces, report this immediately. ***Rationale:*** *Documentation is important to provide continuity of care. Impacted stool must be reported immediately, because it could become a bowel obstruction, which is life threatening.* NP120.07.02.03 Discuss bowel retraining and use of a fecal incontinence pouch to manage clients with impaired elimination **Bowel restraining:** Bowel retraining may be necessary if the client is unable to have a bowel movement naturally or is incontinent of stool. This procedure is often used for the client with paralysis. Because the bowel responds to specific stimuli to function, natural means may be used to stimulate peristalsis. Some clients have an external colostomy, to evacuate stool. Bowel retraining can be helpful to these clients. These factors are helpful in bowel training: Timing*:* The client is assisted with elimination at the same time each day. Physical activity: The more exercise the client receives, the more likely it is that he or she will be able to achieve bowel control. Fluid intake: A high oral fluid intake is recommended. The fluids should be varied, including water and fruit juices. Diet: Recommended is a diet to assist in maintaining a fairly solid fecal consistency without causing constipation or diarrhea. Fruits and vegetables and foods high in fiber are often helpful. Probiotics may be helpful. Encourage the client to avoid foods that have caused loose stools and excess gas (flatus) in the past. If possible, assist the client to use the bathroom, rather than a bedpan or commode. Rationale: Moving about helps stimulate a bowel movement, to achieve normalcy, and enhances the client\'s self-esteem. **Fecal incontinence Pouch**: In some cases, the client has very frequent liquid stools. This is very irritating to the skin, due to the acidic nature of the stool. To prevent the skin from becoming excoriated and raw, an incontinence pouch may be ordered. (If the skin is already excoriated, a skin barrier should be applied before applying the pouch.) Figure 51-10 shows the steps in applying the fecal incontinence pouch. It is important for the nurse to check the bag to determine if stool is being passed and frequently to check the condition of the client\'s perianal (around the anus) skin. NP120.07.02.04 Summarize nursing considerations and care of a client with a bowel diversion Nursing considerations/ care guidelines: NURSING CARE GUIDELINES 88-2 Giving Care for a Gastrostomy, Colostomy, or Ileostomy - Be gentle, yet professional, about everything you do for the client. *Rationale:* *These types of invasive alterations to body image often interfere with the client\'s self-esteem and sense of body image. The nurse needs to be supportive and nonjudgmental.* - Carefully observe the condition of the new stoma. *Rationale:* *Changes in the condition and size of a stoma are common, especially when the stoma is new. Early intervention can prevent complications or even death.* - Cleanliness is important. Change everything that becomes soiled. *Rationale:* *The client needs to feel clean, especially before mealtime. Prevent infection.* - When changing an ileostomy appliance, check for undissolved tablets or capsules. *Rationale:* *The digestive tract may be functioning incorrectly. If medication is excreted unchanged, the client is not getting the benefit of the drug.* - Give special skin care around the stoma. After the gastrostomy or stoma has healed, clean it with soap and water. Do not use soap if it irritates the client\'s skin. Do not use alcohol. *Rationale:* *Soap and alcohol can cause skin dryness, which can lead to skin breakdown. If a client\'s skin is damaged around a stoma, appliances do not fit properly and generally leak, leading to further skin breakdown.* - If redness or a yeast-appearing growth appears, consult with the healthcare provider. An order to treat the area with an antifungal, such as nystatin (Mycostatin), powder may be given. *Rationale:* *Complications, such as yeast infections, lead to longer healing times and poorly fitting appliances.* - A wafer of Stomahesive to *peritube* (around the tube) skin will protect it from drainage. Stomahesive paste also may be used. A drain tube attachment device (DTAD) can help to secure the tube. *Rationale:* *Many commercial products are available that assist with the care of an ostomy. Each client will have his or her own unique needs. A priority is to prevent breakdown of the skin around the stoma.* - Encourage and teach the client to be independent as soon as possible: Teach how to remove and apply a new appliance, how to perform skin care around the stoma, and how and what to report about bowel changes. *Rationale:* *As the client becomes physically able to take care of the stoma, a sense of freedom and independence is created. Many teaching sessions may be necessary to wean the client from the dependence of nursing care to independent self-care. Family members and friends may also be part of the teaching--learning process.* - Allow the client to express feelings. Encourage questions and correct any misconceptions the client might have. *Rationale:* *It might be a long time before the client can truly accept the stoma, although the client may be able to care for it physically within 4 to 5 days. Grief reaction to loss of body function is common.* **NP120.08.01 Assessing Urinary Function and Elimination**\ NP120.08.01.01 Describe the processes of urine formation and elimination **Urine formation:** Urine production is influenced by: - Kidney functioning (glomerular filtration rate) - Renal blood flow - Hormonal balances - Changes in the body\'s fluid/electrolyte status - Salt intake - General physical condition, illnesses, exercise - Some medications **Urinary elimination:** Urine is excreted from the kidneys into the bladder and out via the urethra. The total adult urine output varies, according to the person\'s fluid intake and kidney efficiency. In addition, urine output is also influenced by normal processes, such as respiration, perspiration, salt intake, and the fluid contained in feces, although these cannot be specifically measured. When the body freely perspires due to hot weather, exercise, or fever, urine volumes decrease. If the body retains water because of impaired circulation or kidney function, it forms and excretes less urine. In some disorders, such as diabetes mellitus and diabetes insipidus, more urine is excreted. NP120.08.01.02 Explain nursing assessments specific to the urinary system **DATA GATHERING IN NURSING 89-1 Urinary System** - Urinary history, including previous providers and treatments - General health history - Family health history - Exposure to toxins - Presence of related disorders (e.g., type 1 diabetes mellitus, heart or blood vessel disorders, infections, cancer) - Character of urine, abnormal components - Intake and output amounts - Urinary residual - Difficulty or pain in voiding - Any incontinence and type - Sudden weight gain or loss - Diet and fluids - Presence of symptoms, such as edema or poor skin turgor NP120.08.01.03 Discuss age-related changes of the urinary system and nursing interventions to address these changes **SPECIAL CONSIDERATIONS: Lifespan** **Urinary Tract Infections in Older Adults** - A change in mental status may be the only presenting symptom of urinary tract infections in older adults. Always monitor and report older clients who present with subtle or sudden, acute changes in mental status. - Older adults metabolize medications more slowly than do younger clients. Consider this fact when choosing doses and times for as needed (PRN) medications. - Older adults often have several chronic disorders. Always be aware of how these disorders and their treatments influence kidney function. Be alert to subtle changes in behavior, personality, or daily functioning. Report these changes to the healthcare provider. Document your observations carefully. A table of medical information Description automatically generated with medium confidence **NP120.08.02 Assisting with Urinary Elimination** NP120.08.02.01 Summarize nursing considerations associated with assisting clients in using the commode, bedpan, or urinal  **Giving and Removing a Bedpan or Urinal** Male clients confined to bed use a *bedpan* for defecation and a *urinal* for voiding. Female clients use the bedpan for both; a *female urinal* is also available, but not frequently used. Always wear gloves when working with bedpans or urinals. In Practice: Nursing Procedure 51-1 lists the steps for giving and removing a bedpan. Bedpans and urinals are disposable and discarded when the client no longer needs them. *Rationale:* *This helps prevent the spread of infection.* +-----------------------------------------------------------------------+ | **Nursing Alert** | | | | Be sure to check whether a urine or stool specimen is required before | | assisting a client with a bedpan or urinal. | +-----------------------------------------------------------------------+ **The Bedpan** A bedpan is a shallow disposable vessel of plastic or nylon resin, used for urination and defecation by clients confined to bed (Fig. 51-2 ). A child\'s bedpan is smaller than the standard size. Use a pediatric bedpan or fracture pan for an adult who requires complete assistance or who is unable to lie on the larger pan. A *fracture bedpan* (*fracture pan*) is smaller and shallower than a full-size bedpan and has one flat end (see Fig. 51-2B ). This type of pan is intended for clients with fractured hips, those who are recovering from hip replacement or repair, or clients who are in skeletal traction or full-body casts. However, this pan may be used for any client unable to raise the hips high enough or to roll over enough to get onto a standard-sized bedpan. +-----------------------------------------------------------------------+ | **Nursing Alert** | | | | Remember that getting onto a bedpan in bed can be very difficult. | | Also remember that the fracture pan holds less and spills more easily | | than does the standard bedpan. Be sure to place a pad under the pan, | | to protect the bed. | +-----------------------------------------------------------------------+ Help the client as needed to get onto a bedpan. Provide as much privacy as possible; otherwise, the client may be unable to relax enough to void or defecate. If a client is confused or unable to follow directions, stay with the person. A full bladder is uncomfortable. Offer a bedpan or urinal to the client before meals and visiting hours and when he or she settles for the night. Avoid keeping a client waiting for a bedpan; holding urine or feces weakens sphincter tone and is physically and emotionally distressing. If a client does not have prompt attention before or after using the bedpan, he or she may try to walk to the bathroom alone and fall, may upset the bedpan, or may be incontinent in bed. **Helping the Client to Use a Commode** **The Bedside Commode** The client may find it difficult to urinate or defecate when using a bedpan. This client may be able to use a bedside commode (Fig. 51-3B). Wear gloves when helping the client to the commode. Transfer the person from the bed to the commode as you would from the bed to any chair. Stay with the client if there is any chance that he or she will become light-headed or dizzy. Be sure to provide privacy. The procedure for using and cleaning a commode is the same as that for a bedpan. Wash the client\'s hands, note the contents of the commode container, discard the urine or feces, rinse the commode container after use, properly dispose of gloves, and wash your hands. If the commode cannot be kept out of sight, it may be closed and kept at the bedside. However, it is best to keep it in the bathroom. **The Raised Toilet Seat or Over-Toilet Commode** Sometimes, it is difficult for the client to use a regular toilet. A raised commode can be placed over the toilet; therefore, the client does not have to bend as far and can use the handrails for support when sitting or standing (Fig. 51-3A). The toilet is then flushed, eliminating the need to clean a commode. Assist the client as necessary. NP120.08.02.02 Differentiate between types of urinary catheters **The Suprapubic Catheter** In some cases, a catheter is inserted via a very small incision (a "stab wound") through the lower abdominal wall above the symphysis pubis and into the urinary bladder (Fig. 51-4C). This is called a *suprapubic* (SP) catheter ("supra" means above; "pubic" refers to the pubic bone in the pelvis). **Using External Catheter Systems** An *external catheter* or *condom catheter* is a noninvasive approach to managing urinary incontinence in the male client. The elastic rubberized sheath is applied to the penis, much like a condom is applied. The sheath is attached to a urinary drainage bag and allows urine to flow out of the penis into the bag. The nurse should monitor the client closely for any associated complications. Some condom catheters are self-adhesive, and some require the application of elastic adhesive tape. Follow the manufacturer\'s instructions for application (In Practice: Nursing Care Guidelines 51-4). The drainage bag for the external catheter is either a large drainage bag similar to that used with a retention catheter or a small, supple plastic bag that the client wears strapped to the leg (Fig. 51-7). The smaller bags, called leg bags, have an outlet at the lower end, which is opened to drain urine. This drainage system is considered *clean,* not sterile. When caring for the client with a leg bag: NP120.08.02.03 Describe the procedures for inserting an indwelling catheter, providing catheter care, emptying, irrigating, and removing the catheter **Assisting With Urinary Elimination** **Inserting the Catheter** This section describes the technique for inserting a catheter, a sterile procedure that must be performed with utmost care, to avoid introducing bacteria into the client\'s bladder. Indwelling catheters have been a major cause of hospital-acquired infections and many protocols are in place to prevent these infections. Most retention catheters are packaged with a continuous tubing and drainage bag, to avoid contamination. The bag is lightweight and hung on the bed frame, but it can easily be fastened to an IV pole or wheelchair or held by the client while he or she is out of bed (see Nursing Care Guidelines 51-3). Any closed urine drainage system collection bag must never be higher than the level of the client\'s bladder. *Rationale:* *Raising the bag could cause urine in the bag to flow back into the bladder, possibly leading to infection.* Nursing Alert Many clients and healthcare workers are developing *latex sensitivity.* Be sure to ask about latex allergy before inserting a catheter. If the client is allergic to latex, use a vinyl or other latex-free catheter. **Catheterizing the Female Client**\ Placement of a retention catheter may be necessary when a woman has had pelvic surgery or bladder tumors. In Practice: Nursing Procedure 57-3 summarizes steps for catheterizing the female client. (In some cases, a suprapubic catheter is inserted during surgery. **The Side-Lying Position**\ If a female client is unable to lie on her back for catheterization, or cannot relax her legs because of contractures, use the side-lying position (Fig. 57-3 ). Many women are more comfortable in this position than on the back and some nurses prefer to always use this position for female clients. This position facilitates accurate sterile technique, because the nurse needs to hold only one side of the labia in position. Contamination of the catheter is less likely because this position is easier for the client to maintain, and the nurse does not need to reach over the client's leg. The client lies on her side with knees drawn up to her chest. If the nurse is right-handed, the client lies on her left side, and vice versa. Raise the level of the bed to a comfortable height. Position the client's buttocks near your side of the bed, and the client's shoulders near the far side. Stand behind the client, near her buttocks. Sterile technique and general steps are the same as for the supine client. **Catheterizing the Male Client**\ Catheterization of the male offers challenges, because the male urethra is longer and more curved and the man may have an enlarged prostate constricting or obstructing the urethra. Previous urethral infection can also cause strictures. **Caring for the Catheter** When the client has a retention catheter in place, check both the equipment and its function frequently. Make sure the catheter remains securely in place and the tubing is not kinked or pulling against the urethra. The tubing should pass *over the client\'s leg* when the client is in bed (Fig. 51-6). To prevent pulling, tape or fasten the catheter to the thigh in the female client and the abdomen in the male client, allowing for some slack before taping it in place. *Do not* allow tubing to hang below the level of the bag. Make sure the bag is hung below the level of the bladder, whether the client is in or out of bed. Observe for urine flow through the tubing leading to the collecting bag. Measure the amount of urine in the bag and empty it regularly. When the catheter is changed, an entire new setup is required. In Practice: Nursing Care Guidelines 51-3  gives steps for routine catheter care. +-----------------------------------------------------------------------+ | *N PRACTICE* | | | | NURSING PROCEDURE 51-2 Emptying the Urinary Drainage Bag | | | | Supplies and Equipment | | | | Disposable gloves | | | | Face shield | | | | Measuring container (graduate) | | | | Steps | | | | 1\. Wash hands, put on gloves, and wear a face shield, according to | | agency protocol. *Rationale:* *Gloves are worn when handling any | | body fluids. A face shield protects against splashing urine.* | | | | 2\. Carefully pull the drain tube (on the bottom of the bag) out of | | the storage pocket, without touching it below the level of the | | clamp. Hold the tube over the graduate and release the clamp, | | making sure that the drain tube does not touch | | anything. *Rationale:This helps prevent introducing pathogens into | | the bladder.* | | | | 3\. When the urine has drained out, clamp the tube and carefully | | replace it in the storage pocket. Be sure the clamp is far enough | | up the tube to allow most of the tube to fit into the pocket. Do | | not move the clamp on the tube. *Rationale:* *These procedures help | | maintain the sterility of the catheter\'s closed drainage system.* | | | | 4\. Measure the urine, if intake and output (I&O) is ordered. | | Observe the characteristics of the urine. *Rationale:* *I&O and | | observation of the urine provide information about the client\'s | | hydration status and kidney function. Possible significant changes | | may be identified.* | | | | *Pull the drainage tube out of the pocket on the bag and do not allow | | it to touch anything. Drain the urine into the measuring container. | | (Carter, 2012.)* | | | | 5\. Discard urine (unless a specimen is required) and rinse the | | graduated container with cool water. *Rationale:* *Hot water will | | coagulate proteins in urine and cause odor.* | | | | Special Reminders | | | | -  If the client will be discharged from the facility with a | | catheter, explain each step of catheter use to the client and | | family. *Rationale:* *They need instruction about caring for the | | drainage system to prevent complications.* | | | | - Ask the client or a family member to do a return demonstration | | after you have demonstrated the procedure. (They should practice | | several times.) Offer gloves to them. *Rationale:* *A return | | demonstration ensures that the client and family understand the | | procedure, so later they can do it themselves.* | +-----------------------------------------------------------------------+   **Irrigating the Catheter** Catheters may be irrigated, to ensure patency and remove clots or debris that may obstruct free urinary flow. Irrigation is a sterile procedure and requires a *specific order* from the primary provider. +-----------------------------------------------------------------------+ | **Nursing Alert** | | | | Any catheter placed in the urinary bladder is a potential source of | | infection. The catheter must be inserted using sterile technique. In | | addition, care must be taken to maintain the integrity of the sterile | | system and prevent contamination. | +-----------------------------------------------------------------------+ NP120.08.02.04 Discuss types of urinary incontinence and urinary retention and summarize nursing interventions to manage these conditions Urinary incontinence types: Urinary retention: they are retaining urine and cannot go to the bathroom. - Nursing intervention: bladder scanning and straight Cath NP120.08.02.05 Summarize nursing considerations and care of a client with a urinary diversion Urinary diversion 2 types: #### **Cutaneous Diversions** *Cutaneous diversions* involve the drainage of urine through a surgical opening (*stoma*) created in the abdominal wall. Several versions of cutaneous diversions are seen in Figure 89-4. The client must always wear an appliance over the surgically designed stoma, which continuously collects urine drainage. The client often has no voluntary control of urinary flow. **Continent Diversions** *Continent diversions* involve surgical creation of a new reservoir for urine from a portion of the intestine. This type of diversion is done depending on the client\'s preference and anatomy (see Box 89-1). Various methods of urinary diversions may provide the client with voluntary bladder control as shown in Figure 89-4. **Nursing Considerations** Pre- and postsurgical consultations with the wound, ostomy, and continence nurse or wound care ostomy nurse (WOCN, WCON), who may also be referred to as the enterostomal therapy (ET) nurse, is one of the primary steps in preparation for long-term physical and emotional adaption to diversions. Urinary diversion may strongly affect the person\'s body image. Bladder removal for men is often associated with permanent sexual dysfunction. Adapting to cancer, loss of the bladder, and loss of body image can be devastating. Be supportive. Listening to the client\'s concerns is an important aspect of nursing care.