Urine Elimination Care (PDF)

CARE OF URINARY ELIMINATION The ability to urinate requiresan integrated operative functioning of the bladder, urethra, brain, spinal cord and peripheral nerves supplying the bladder and urethra. A nurse must understand the integrated operative function of urination and identify the expected ch...

CARE OF URINARY ELIMINATION The ability to urinate requiresan integrated operative functioning of the bladder, urethra, brain, spinal cord and peripheral nerves supplying the bladder and urethra. A nurse must understand the integrated operative function of urination and identify the expected characteristics of patient\'s urine and common problems associated with the urinary system to better meet the patient\'s urinary elimination needs. It is important to be open to the patient\'s needs and respect privacy ofthe patient. 4.1 Factors influencing urinary elimination Many factors influence the volume and quality of urine and the patient\'s ability to urinate. Some pathophysiological conditions are acute and reversible (urinary tract infection), whereas others are chronic and irreversible (slow, progressive development of renal dysfunction). Psychological factors, fluid balance, surgical and diagnostic procedures affect urine and urination in several ways. Medications, including anaesthesia, interfere with both the production and characteristics of urine, affect the act of urination and affect the ability to completely empty or control voiding. Understanding these factors will aid nurses and physicians in assessing patients, maintaining a non-judgmental attitude when working with diverse individuals and planning individualized nursing and medical care of urine elimination. 4.2 Assessment of urine Physical and chemical characteristics of urine as a biological material are important indicators of the health status of a person. Urine is observed for colour, clarity, odour, volume, specific gravity, acidity and abnormal components. The nurse makes these observations as part of routine daily data collection. Colour of urine. Freshly voided urine is light yellowor amber in colour. The degree of colour in urine varies with the body\'s level of hydration. Overhydration results in dilute urine that is nearly colourless. Dehydration results in concentrated urine that is dark amber or orange-brown. In addition, certain medications, abnormal components and foods can alter the colour of urine (see Table 2). Table 2 Colour variations in urine Urine colour Causes of colour variation clear, colourless (dilute) large amount of intake liquids, diabetes mellitus, diuretics (particularly if overused), liver disorders cloudy pyuria (pus in the urine in case of an urinary tract infection), bacteriuria (bacteria in urine), proteinuria (proteins in urine), epithelial cells, white blood cells, kidney stones dark yellow low fluid intake, dehydration (concentrated urine), inability of kidneys to dilute urine, bile pigments in urine pink, red blood in urine (kidney or bladder infection, cancer, urine stones), some laxatives, some foods (red berries, food dye, beets, some red juices) orange, red brown some medications (e.g. warfarin), some food colouring, dehydration dark brown some medications (e.g iron), haematuria (blood in urine), bile pigments in urine (liver disorders especially with light stools and jaundice urine looks as black beer) 33 Clarity of urine. Freshly eliminated urine is clear or transparent. It appears cloudy if it contains abnormal substances, such as bacteria, blood, proteins, mucous shreds, pus or if it is standing for a period of time in a collection container. Odour of urine. Freshly voided urine has a characteristic aromatic odour. Dilute urine has fewer odours than concentrated urine. When it is exposed to the air for some time, urine decomposes and emits a strong, ammonia-like odour. Ammonia-likeor Acidit is, the gret acidic, a normal un helps to Abn fetid odour indicates a urinary tract infection, sweet odour indicates a high glucose content in urine, other characteristic odours indicate intake of certain foods or drugs that as urea, urine and can cause characteristic odours (e.g. garlic, asparagus, onions, antibiotics, vitamin B). Usually a strongly offensive odour from freshly voided urine suggests an abnormality, Table such as a urinary tract infection, dehydration. Abnorr Volume of urine. There are many factors that can affect urine volume. The typical amount of urine that an adult voids at one time ranges between 250 and 400 ml. The proteir amount of urinary excretion per 24 hours is called diuresis. Physiological diuresis in adult is from 1200 to 1500 ml of urine per 24 hours and depends on: glycos developmental period: urinary excretion changes during human life, type of food and fluids intake: fruits, vegetables, liquids such as tea and caffeine keton promotes urine elimination, bilir environment temperature: in a warm environment a person loses of fluid by per- spiration, health status: some disease processes, e.g. kidney diseases, cardiovascular disea- (blo ses change of the amount of urinary excretion, some types of medication, forexample, diuretics increase volume of urination. Pathological changes in the amount of urine excretion are: Polyuria- the amount of urinary excretion is more than 3000 ml per 24 hours. Causes of polyuria include, for example, uncontrolled diabetes mellitus, kidney disease, diuretics and increased fluid intake, especially fluids containing alcohol and caffeine. Oliguria- the amount of eliminated urine is from 100 to 500 ml per 24 hours; it is. for example, a sign of dehydration, heart failure, chronic renal failure, severe burns, hypovolemic shock, urinary tract obstruction, enlarged prostate gland. the amount of urinary excretion is less than 100 ml per 24 hours. Anuria is a grave sign of kidneyfailure and indicating that death may ensue if circulatory status or waste product removal is not improved. Fluid balance monitoring is the daily recording of per 24 hours. These intake and output of fluid measurements are important to help evaluate the patient\'s fluid and electrolyte imbalance, tosuggest various diagnoses andallow prompt intervention to correct any imbalances. Patients whose health status indicates the need for fluid balance monitoring should have fluid intake and output accurately documented nursing staff on the fluid balance chart. by Specific gravity of urine. The specific gravity is the weight or degree of concentration of a substance compared with an equal volume of water. The concentration of dissolved substances in the urine aids in determination of Normal urine has a patient\'s fluid balance. pectie gawity of pure nie ain specific gravity, when ticosnsompnced wein maet of compared with water,of 1015- 1025 (the laboratory as part of a routine urine analysis. measured by the 34 Acidity of urine. Most body fluids are is, the greater the hydrogen ion slightly alkaline. The more acidic a solution concentration and the lower the pH. A pH below 7 is acidic, a ph of 7 is neutral and a pH above 7 is alkaline. Unlike many other body fluids, normal urine is slightly acidic, having a usual pH of about 45 to 65. This acidic condition helps to control bacterial growth in urine. Abnormal substance in urine. Normally, urine contains water and wastes. such as urea, uric acid, creatinine and some ions. Some common abnormal constituents of urine and the implication of their presence are described below in Table 3. Table 3 Some condition indicated abnormalities in the urine Abnormal substance in urine Some possible condition proteinuriaor albuminuria (protein) urinary tract infection, kidney stones, renal circulatory difficulties, infection,trauma, glycosuria (sugar) \[diabetes mellitus, shock ketonuria (ketones) diabetes, hunger-strike, dehydratation bilirubinuria (bile pigments) liver diseases, biliary obstruction, hepatitis (blood) urinary tract infection, stones, cancer, trauma, bleeding disorder pyuria (pus, white blood cells) urinary tract infection bacteriuria (bacteria) urinary tract infection 4.3 Altered urinary elimination Although observation of the appearance of a patient\'s urine can indicate renal or urinary problems,a change in the usual pattern of urinary elimination is just as significant finding. Impaired urinary elimination is characterized by the following signs and symptoms: Dysuria is a painful or burning sensation when passing urine (commonly associated with urethra infection). The patient may also experience cramping or shooting pain in the pelvis. Stranguria is cuttingcase urinary tract infection or a painful urination in obstruction (e.g. with urinary stones). Nocturia is excessive voiding at night (nocturia greater than once per night in adults younger than 65 years old, nocturia greater than twice per night in older adults). Common causes of nocturia include pregnancy, urinary tract infection, stress, diuretics. increased fluid intake, prostate enlargement in men. Nocturnal enuresis is the loss of urine during sleep after the age of 4 or 5, when most children can avoid night-time voiding. Diurnal enuresis is the loss of urine during the day that often occurs because a child delays voiding too long because of Playor other distractions, but may be secondary to pathology. of the small volume of urine (most Pollakisuria is frequently urination commonly associated with urinary tract infection, enlarged prostate gland, etc.). 35 Incontinence of urine refers to involuntary voiding or urine loss when patient is not able to control urination. Incontinence occurs, for example, in case of urinary tract infections, prostate tumor, any obstructions near or around urinary bladder, some neurological problems (spinal cord injury, multiple sclerosis), aging. Nursing care of incontinent patients includes using of disposable absorbent products that reduce wetness, odour and help to maintain the patient\'s comfort (e.g. panty shields, pant guards, undergarments, combination pad-pant systems, adult diaper garments and special bed pads), daily hygienic care of genital and perineal area, care of permanent catheter. Bladder distention is abnormal extension and enlargementof the bladder. It is the most commonly caused by retention of urine due to impossibility of urine to be passed. Bladder distention occurs, for example, as a multiple sclerosis symptom, in case of urethral narrowing, or enlarged prostate gland. Retention of urine is inability to empty the bladder or if residual volume of urine in bladder is greater than 150- 200 ml. Urinary retention can be: Acute urinary retentionhappens suddenly and lasts only a short time. Patients withacute urinary retention cannot urinate at all. bladder. Acute urinary retention even though they have a full Chronic urinary retention requires immediate emergency treatment. can be a long-lasting medical condition. Patients or the hine urinary retention can urinate, but they do not -completely emaieall the urine from their bladders. Urinaryretention can result from: obstruction of the urethra urinary tract (e.g. benign prostatic stones, constipation, cancers). tumor, urethral narrowing, nerve problems (e.g. vaginal childbirth. brain injuries, diabetes, stroke, or spinal cord infections or medications pelvic injury or trauma). weakened bladder lee. antidepressants, opioid analgesics). muscles (in aging), postoperative retention A imdatinemnicturition relexof patient with urinary A patient\'s ability to void depends retention control the urethral sphincter and to promoterelaxation and on feelingtheurgeto urinate,beingable to to relax and stimulate the ability to void. being able torelax during voiding. Nurse can help the reflex to void helping patients to assume the nor- the patient a squatting position on a bedpan, or bedside commode. A to void in a squatting orsitting use toilet facilities, position in the standing position. If the man him or her in at the bedside or lie to perform Credé\'smethod or on the bed andcannotreach toiletfacilities,havehore man voids more easily structs into a plastic or metal urinal. stand the patient to manual compressionof the bladder.Nurse in- place both hands flat on the abdomen below andabove the symphysispubrswith the umbilicus der dome. Have him the or hercompress the fingers pointed downtoward the blad- handsdownward againstthe of the biadier while tiehteningtheperineum,contractingthe absinstthe wallsof urethral sphincter. 36holding thebreath. The manoeuvre promotes bladder emptying byrelaxing the when patient to provide sensory stimuli to promote voiding (pouring warm water over the pati- of urinary ent\'s genitals and create the sensation to urinate. the sound of running water helps ry bladder, many patients void through the power of suggestion, put the patient\'s hands in g\. Nursing warm water, warm shower or bath may help). ducts that to perform intermittent catheterisation or permanent catheterisation. ty shields, garments 4.4 Urinary catheterisation care of The urinary tract is the most common site of hospital-acquired infections, Ider. It is to be ptom, in accounting for approximately 40 percent of hospital infections. The intent of this study text is to not only give guidance for urinary catheterisation maintenance techniques, but also to assist in the prevention of catheter-associated urinary tract infections of patients. Urinary catheterisation is the sterile procedure of inserting a sterile catheter through the urethra into the bladder to facilitate urine drainage. Catheterisation is an invasive procedure that can cause embarrassment, physical full and psychological discomfort and impact on the patient\'s self-image. In clinical practice, catheterisation is performedusing sterile technique, because the bladder tients and urinary system are considered sterile. Urinary catheterisation is performed under all sterile conditions in order to ensure that foreign microorganisms are not introduced into the urethra and bladder. In clinical practice, female catheterisation is performed by an experienced nurse or by a physician, male catheterisation is performed only ing, by physician with a nurse assistance. Children are catheterized by physicians with nurse assistance, after previous medication, only when it is absolutely necessary. or There are two forms of urinary bladder catheterisation through the urethra intermittent (one-time, short term) and permanent (indwelling, retention, long term) catheterisation. The purpose of urinarycatheterisation is to facilitate urine drainage when medically necessary. Urinary catheterisation is performed only under the direction of a physician order. Urinary catheters should not be used solely for the convenience of health care workers. Permanent urinary catheters must be evaluated every day for need and removed promptly when no longer necessary. Medically reasons of urinary bladder catheterisation through the urethra are listed in the following Table 4. Table 4 Indications for one time and permanent catheterisation Indications for one-time catheterisation Indications for permanent catheterisation to sample of sterile urine for diagnostic purposes (e.g. bacteriological examination) to empty the bladder before examination, delivery,surgery insertion of contrast substance before healing of open sacral or perineal wounds diagnostic examination improve palliative/hospice comfort care detection of bladder after physiological urination prolonged immobilization bladder irrigation or drug instillation incontinence urinary retention bladder outlet obstruction ccurate measurements of hourly urinary output volume of residual urine in repeated bladder flushing or drug administration urinary retention post-operative needs (e.g. urological, gynaecological) 37 Contraindications for urethral catheterisation include acute prostatitis (infection of prostate gland) and suspicion of urethral trauma. Because bladder catheterisation carries the risk of a urinary tract infection and trauma tothe urethra,itis preferable to rely on other measures for either specimen collection or management of incontinence. 4.4.1 Urinary catheter selection Clinical guidelines for appropriate urinary catheter selection in practice are as follows: or prostate Urinary catheters material selection. Sterile urinary catheters are individually packed in sterile packaging and they are available in various materials (plastic, latex, or silicone catheters). Some catheters are coated inside, for example, with silicone, teflon, hydrogel, silver or antibiotics. Issues that should be considered when choosing a catheter include ease of use, tissue compatibility, allergy (latex), tendency for encrustation and formation of biofilm, comfort for the patient, for example, some manufacturers produce catheters without phthalates and PVC-free catheters. Types of urinary catheters. In clinical practice, the following two basic groups of urinary catheters are used according to the form of catheterisation: 1. One time use urinary catheters (single-use, direct catheters) are suitable for short term, one-time or intermittent catheterisation. The one-time catheters are used for one sample only and removed from bladder. These include: Nelaton catheter is a tube with straight soft rounded distal tip (see Figure 28) for atraumatic insertion through urethra that has two lateral eyes for efficient drainage of urine. Proximal end is fitted with universal funnel shaped coloured connector for ex- tension and identification of sizes. Nelaton catheters are available in male, female and paediatric versions. Tiemann catheter has anelongated, tapered tip (see Figure 28) and is made to be more pliable than the other catheter types. The catheter tip Figure 28 Nelaton and Tiemann works best for navigating narrowing urethra, version catheters in one time and permanent distended bladder enlarged prostate. or Tiemann catheter, with a ball-shapedor rounded tip, enables the enlarged prostate gland to be circumnavigated in an especially careful manner. Tiemann catheter is used the most often in male. Length 2. Permanent urinary catheters (long term use, indwelling, retention catheters) are suitable for long term catheterisation. This group of permanent urinary catheters includes Foley catheter that has a small inflatable balloon that encircles the catheter just under the tip of catheter After insertion of the catheter into urinary bladder the inflated balloon rests against the bladder outlet to anchor the catheter in place. The Foley catheter often has two or three lumens that encircle the body of the catheter (see Figure 29). One-way drains urine through the catheter into a collecting bag. The second way carries sterile water for injections or physiological saline to and from the balloon when it is inflated or deflated. The third (optional) way is sometimes used to instil fluids or medications into the bladder or for bladder irrigation. Three-way catheter IS primarily used following urological surgery or in case of bleeding from a bladder or prostate tumour and the bladder may need continuous or intermittent irrigation to clear blood clots or debris. Foley catheter may have distal tip in a Nelaton version (for permanent catheterisation of male, female and infant)or a Tiemann version (for permanent catheterisation of male with enlarged prostate). Diameter sizes of permanent catheter are measured in the Charriére scale (Chor CH, see Figure 30), also known as French Gauge (F, Fr or FG), and indicate the external diameter (1 mm = 3 Ch),i.e., 18 Ch indicates a diameter of 6 mm. In clinical practice the sizes of catheter range from Ch 6 to 30, but most commonly are used size from Ch 10 to 28. A larger size is necessary when the urine is thick, bloody, or contains large amounts of sediment. In general, children require 8- 10 Ch catheters, female require 14- 16 Ch catheters and male require 16 18 Ch catheters, haematuria with moderate clots requires a 20 24 Ch catheter. Larger sizes than 18 Ch create discomfort, increase the risk of blockage and lead to urinary tract infection, urethral irritation and erosion. The size of the catheter is marked at the inflation way as well as with an (international) colour-coded sleeve around the valve for reliable size identification. Balloon size of permanent catheter is important in appropriate selecting a permanent catheter. Balloon sizes range from 3 ml (paediatric use) to 30 ml (postoperative volume). In adults sizes from 5 ml to 10 ml are the most common, but the 5 ml size of balloon allows for optimal drainage. When catheter has been placed in the bladder, the balloon can be inflated. Sterile water or sodium chloride can be used for latex catheters. Inflation of silicone catheters with water can sometimes lead to water loss from the balloon over time, with an associated risk of the catheter falling out. Some catheter manufacturers provide sterile prefilled syringes with sterile aqueous glycerine 10 % solution inside the silicone catheter packing. The advantage of aqueous glycerine solution is that in comparison to sterile water it does not diffuse through the wall of a silicone catheter balloon. This reduces the loss of filling and balloon shrinking which often results in catheter dislocation. The balloon size is indicated at the catheter connection behindthe diameter size of the catheter as a minimum and maximum ml or cc (cm3), e.g. Ch 14/ 10 ml (see Figure 30). Length of permanent catheter. The standard male catheter length IS 41 45 cm and can be used for males and females, but a shorter female length of 25 cm can be more comfortable and discrete for some women. Male standard length is recommended for female patients who Figure 30 Diameter and balloon sizes of permanent catheter 39 are bedbound. immobile, clinically obese with fat thighs, critically ill, post-operative and in emergency situations. Paediatric catheters are normally about 30 cm long. 4.4.2 Urinary drainage system selection Clinical appropriate urinary guidelines for drainage system selection in practice are as follows: When the catheter is inserted in the urinary bladder using aseptic technique, it is directly connected to the sterile urinary bag, because an aseptic closed urinary drainage system minimises the risk of catheter associated urinary tract infections. Unnecessary disconnection of a closed drainage system should be avoided, but if it occurs, the catheter and collectingsystem haveto be replaced using aseptic technique and sterile equipment. There are several different bags available. Selection of the bag depends on whether it IS for short-term drainage at the hospitalor for long-term use, on the patient\'s mobility, cognitive function, daily routine, quality life, etc. The goal is to select a system that is easy for the patientor nurse to manage and that minimize any embarrassment or psychological discomfort associated with use of a permanent catheter. In clinical practice, different types of the urinary drainage systems are used, e.g. pre-connected drainage systems (see Figure 31), anti- reflux valve drainage bags, drainage bags with sampling port, leg bag, bedside bag.