Urinary Elimination Patient Care PDF

CHAPTER 12 Urinary Elimination FOCUSING ON PATIENT CARE This chapter will help you develop some of the skills needed to care for the following patients: Ralph Bellows, age 73 years, has been admitted with a stroke. Due to incontinence and skin breakdown, Ralph’s nurse has decided to include the application of a condom catheter in his plan of care. Grace Halligan, age 24, is pregnant and has been placed on bed rest. She needs to void but cannot get out of bed. Mike Wimmer, age 36, receives peritoneal dialysis. Mike has noticed that the insertion site around his catheter is becoming tender and reddened. LEARNING OBJECTIVES After studying this chapter, you will be able to: 1. Assist with the use of a bedpan. 8. Remove an indwelling urinary catheter. 2. Assist with use of a urinal. 9. Administer intermittent closed-catheter irrigation. 3. Assist with use of a bedside commode. 10. Administer closed continuous-bladder irrigation. 4. Assess bladder volume using an ultrasound bladder scanner. 11. Empty and change a stoma appliance on an ileal conduit. 5. Apply an external condom catheter. 12. Care for a suprapubic urinary catheter. 6. Catheterize a female patient’s urinary bladder. 13. Care for a peritoneal dialysis catheter. 7. Catheterize a male patient’s urinary bladder. 14. Care for hemodialysis access. KEY TERMS arteriovenous fistula: a surgically created passage connecting an artery and a vein, used in hemodialysis arteriovenous graft: a surgically created connection between an artery and vein using synthetic material; used in hemodialysis bruit: a sound caused by turbulent blood flow external condom catheter: soft, pliable sheath made of silicone material, applied externally to the penis, connected to drainage tubing and a collection bag fenestrated: having a window-like opening continued 595 LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 596 Aptara 596 UNIT II KEY TERMS Promoting Healthy Physiologic Responses continued hemodialysis: removal from the body, by means of blood filtration, of toxins and fluid that are normally removed by the kidneys ileal conduit: a surgical diversion formed by bringing the ureters to the ileum; urine is excreted through a stoma indwelling urethral catheter (retention or Foley catheters): a catheter (tube) through the urethra into the bladder for the purpose of continuous drainage of urine; a balloon is inflated to ensure that the catheter remains in the bladder once it is inserted intermittent urethral catheter (straight catheter): a catheter through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes) peritoneal dialysis: removal of toxins and fluid from the body by the principles of diffusion and osmosis; accomplished by introducing a solution (dialysate) into the peritoneal cavity peritonitis: inflammation of the peritoneal membrane personal protective equipment (PPE): equipment and supplies necessary to minimize or prevent exposure to infectious material, including gloves, gowns, masks, and protective eye gear sediment: precipitate found at the bottom of a container of urine stoma: artificial opening on the body surface suprapubic urinary catheter: a urinary catheter surgically inserted through a small incision above the pubic area into the bladder symphysis pubis: the anterior midline junction of the pubic bones; the bony projection under the pubic hair thrill: palpable feeling caused by turbulent blood flow This chapter covers skills that the nurse may use to promote urinary elimination. An assessment of the urinary system is required as part of the assessment related to many of the skills. See Fundamentals Review 12-1 for a review of the male and female genitourinary tract. Fundamentals Review 12-2 summarizes factors that affect urinary elimination. The patient who has an indwelling catheter requires special care. Care of the patient with an indwelling catheter is summarized in Fundamentals Review 12-3. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 597 Aptara CHAPTER 12 Urinary Elimination 597 Fundamentals Review 12-1 ANATOMY OF THE GENITOURINARY TRACT The main components of the urinary tract are the kidneys, ureters, bladder, and urethra. The average female urethra is 1.5 to 2.5 inches (3.7 to 6.2 cm) long; the average male urethra is 7 to 8 inches (18 to 20 cm) long. The male urethra is divided into three segments: cavernous, membranous, and prostatic. The average age at which men begin to have prostatic enlargement is 50. Urinary tract, showing kidneys, ureter, bladder, and urethra. Urinary bladder Symphysis pubis Prostate Prostatic urethra Cavernous urethra Membranous urethra Glans Urethral orifice Male urethra. Scrotum LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 598 Aptara 598 UNIT II Promoting Healthy Physiologic Responses Fundamentals Review 12-2 FACTORS AFFECTING URINARY ELIMINATION Numerous factors affect the amount and quality of urine produced by the body and the manner in which it is excreted. EFFECTS OF AGING Diminished ability of kidneys to concentrate urine may result in nocturia. Decreased bladder muscle tone may reduce the capacity of the bladder to hold urine, resulting in increased frequency of urination. Decreased bladder contractility leading to urine retention and stasis with an increased risk of urinary tract infection. Neuromuscular problems, degenerative joint problems, alterations in thought processes, and weakness may interfere with voluntary control of urination and the ability to reach a toilet in time. FOOD AND FLUID INTAKE Dehydration leads to increased fluid reabsorption by the kidneys, leading to decreased and concentrated urine production. Fluid overload leads to excretion of large quantity of dilute urine. Consumption of caffeine-containing beverages (e.g., cola, coffee, tea) leads to increased urine production due to their diuretic effect. Consumption of alcoholic beverages leads to increased urine production due to their inhibition of antidiuretic hormone release. Ingestion of foods high in water content may increase urine production. Ingestion of foods and beverages high in sodium content leads to decreased urine formation due to sodium and water reabsorption and retention. Ingestion of certain foods (e.g., asparagus, onions, beets) may lead to alterations in the odor or color of urine. PSYCHOLOGICAL VARIABLES Individual, family, and sociocultural variables may influence voiding habits. Patients may view voiding as a personal and private act. The need to ask for assistance may lead to embarrassment and/or anxiety. Stress may lead to voiding of smaller amounts of urine at more frequent intervals. Stress may lead to difficulty emptying the bladder due to its effects on relaxation of perineal muscles and the external urethral sphincter. ACTIVITY AND MUSCLE TONE Regular exercise increases metabolism and optimal urine production and elimination. Prolonged periods of immobility may lead to poor urinary control and urinary stasis due to decreased bladder and sphincter tone. Use of indwelling urinary catheters leads to loss of bladder tone because the bladder muscle is not being stretched by filling with urine. Childbearing, muscle atrophy related to menopausal hormonal changes, and trauma-related muscle damage lead to decreased muscle tone. PATHOLOGIC CONDITIONS Congenital urinary tract abnormalities, polycystic kidney disease, urinary tract infection, urinary calculi (kidney stones), hypertension, diabetes mellitus, gout, and certain connective tissue disorders lead to altered quantity and quality of urine. Diseases that reduce physical activity or lead to generalized weakness (e.g., arthritis, Parkinson’s disease, degenerative joint disease) interfere with toileting. Cognitive deficits and psychiatric conditions may interfere with ability or desire to control urination voluntarily. Fever and diaphoresis (profuse perspiration) lead to conservation of body fluids. Other pathologic conditions, such as congestive heart failure, may lead to fluid retention and decreased urine output. High blood–glucose levels, such as with diabetes mellitus, may lead to increased urine output due to osmotic diuresis. MEDICATIONS Abuse of analgesics, such as aspirin or ibuprofen (Advil) can cause kidney damage (nephrotoxic). Use of some antibiotics, such as gentamicin, can cause kidney damage. Use of diuretics can lead to moderate to severe increases in production and excretion of dilute urine, related to their prevention of water and certain electrolyte reabsorption in the renal tubules. Use of cholinergic medications may lead to increased urination due to stimulation of detrusor muscle contraction. Use of some analgesics and tranquilizers interferes with urination due to the diminished effectiveness of the neural reflex for voiding because of suppression of the central nervous system. Use of certain drugs causes changes to the color of urine. Anticoagulants may cause hematuria (blood in the urine) or a pink or red color. Diuretics can lighten the color of urine to pale yellow. Phenazopyridine (Pyridium) can cause orange or orangered urine. Amitriptyline (Elavil) and B-complex vitamins can cause green or blue-green urine. Levodopa (L-dopa) and injectable iron compounds can cause brown or black urine. 599 CHAPTER 12 Urinary Elimination Fundamentals Review 12-3 GUIDELINES FOR CARE OF THE PATIENT WITH AN INDWELLING CATHETER Use an indwelling catheter only when necessary. Employ strict hand hygiene principles. Use sterile technique when inserting a catheter. Secure the catheter properly to the patient’s thigh or abdomen after insertion. Maintain a closed system whenever possible. If necessary, obtain urine samples using aseptic technique via a closed system. Keep the catheter free from obstruction to maintain free flow to the urine. Use the smallest appropriate-size catheter. 12-1 Avoid irrigation unless needed to relieve or prevent obstruction. Ensure that patient maintains adequate fluid intake. Empty the drainage bag when half to two-thirds full or every 3 to 6 hours. Clean drainage bags daily using a commercial cleaning product or vinegar solution (1 part vinegar to 3 parts water). Provide daily routine personal hygiene as outlined in Chapter 7, Hygiene; there is no need to apply antibiotic ointment or betadine to the urethral meatus. Assisting With the Use of a Bedpan Patients who cannot get out of bed because of physical limitations or physician’s orders need to use a bedpan or urinal for voiding. Male patients confined to bed usually prefer to use the urinal for voiding and the bedpan for defecation; female patients usually prefer to use the bedpan for both. Many patients find it difficult and embarrassing to use the bedpan. When a patient uses a bedpan, promote comfort and normalcy and respect the patient’s privacy as much as possible. Be sure to maintain a professional manner. In addition, provide skin care and perineal hygiene after bedpan use. Regular bedpans have a rounded, smooth upper end and a tapered, open lower end. The upper end fits under the patient’s buttocks toward the sacrum, with the open end toward the foot of the bed (Figure 1). A special bedpan called a fracture bedpan is frequently used for patients with frac- A. Regular bedpan B. Fracture pan FIGURE 1. (A) Standard bedpan. Position a standard bedpan like a regular toilet seat—the buttocks are placed on the wide, rounded shelf, with the open end pointed toward the foot of the bed. (B) Fracture pan. Position a fracture pan with the thin edge toward the head of the bed. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 600 Aptara 600 UNIT II Promoting Healthy Physiologic Responses 12-1 Assisting With the Use of a Bedpan continued tures of the femur or lower spine. Smaller and flatter than the ordinary bedpan, this type of bedpan is helpful for patients who cannot easily raise themselves onto the regular bedpan (see Figure 1). Very thin or elderly patients often find it easier and more comfortable to use the fracture bedpan. The fracture pan has a shallow, narrow upper end with a flat wide rim, and a deeper, open lower end. The upper end fits under the patient’s buttocks toward the sacrum, with the deeper, open lower end toward the foot of the bed. EQUIPMENT ASSESSMENT Assess the patient’s normal elimination habits. Determine why the patient needs to use a bedpan (e.g., a medical order for strict bed rest or immobilization). Also assess the patient’s degree of limitation and ability to help with activity. Assess for activity limitations, such as hip surgery or spinal injury, which would contraindicate certain actions by the patient. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, traction, or any other devices that could interfere with the patient’s ability to help with the procedure or that could become dislodged. Assess the characteristics of the urine and the patient’s skin. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Physical Mobility Deficient Knowledge Impaired Urinary Elimination Functional Urinary Incontinence Toileting Self-Care Deficit OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when offering a bedpan is that the patient is able to void with assistance. Other appropriate outcomes may include the following: the patient maintains continence; the patient demonstrates how to use the bedpan with assistance; and the patient maintains skin integrity. Bedpan (regular or fracture) Toilet tissue Disposable clean gloves Additional PPE, as indicated Cover for bedpan or urinal (disposable waterproof pad or cover) IMPLEMENTATION ACTION R AT I O N A L E 1. Review the patient’s chart for any limitations in physical activity. (See Skill Variation: Assisting With Use of a Bedpan When the Patient Has Limited Movement.) Activity limitations may contraindicate certain actions by the patient. 2. Bring bedpan and other necessary equipment to the bedside stand or overbed table. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 601 Aptara CHAPTER 12 Urinary Elimination ACTION 601 R AT I O N A L E 6. Unless contraindicated, apply powder to the rim of the bedpan. Place bedpan and cover on chair next to bed. Put on gloves. Powder helps keep the bedpan from sticking to the patient’s skin and makes it easier to remove. Powder is not applied if the patient has respiratory problems, is allergic to powder, or if a urine specimen is needed (could contaminate the specimen). The bedpan on the chair allows for easy access. Gloves prevent contact with blood and body fluids. 7. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place the patient in a supine position, with the head of the bed elevated about 30 degrees, unless contraindicated. Having the bed at the proper height prevents back and muscle strain. Supine position is necessary for correct placement of patient on bedpan. 8. Fold top linen back just enough to allow placement of bedpan. If there is no waterproof pad on the bed and time allows, consider placing a waterproof pad under patient’s buttocks before placing bedpan (Figure 2). Folding back the linen in this manner minimizes unnecessary exposure while still allowing the nurse to place the bedpan. The waterproof pad will protect the bed should there be a spill. 9. Ask the patient to bend the knees. Have the patient lift his or her hips upward. Assist patient, if necessary, by placing your hand that is closest to the patient palm up, under the lower back, and assist with lifting. Slip the bedpan into place with other hand (Figure 3). The nurse uses less energy when the patient can assist by placing some of his or her weight on the heels. FIGURE 2. Placing waterproof pad under the patient’s buttocks. FIGURE 3. Assisting patient to raise self in bed to position the (Note: Covers should only be folded back just enough to work, not expose patient unnecessarily. Covers in this series of photos have been pulled back to show action.) bedpan. 10. Ensure that bedpan is in proper position and patient’s buttocks are resting on the rounded shelf of the regular bedpan or the shallow rim of the fracture bedpan. Having the bedpan in the proper position prevents spills onto the bed, ensures patient comfort, and prevents injury to the skin from a misplaced bedpan. 11. Raise head of bed as near to sitting position as tolerated, unless contraindicated. Cover the patient with bed linens. This position makes it easier for the patient to void or defecate, avoids strain on the patient’s back, and allows gravity to aid in elimination. Covering promotes warmth and privacy. 12. Place call bell and toilet tissue within easy reach. Place the bed in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately (Figure 4). Falls can be prevented if the patient does not have to reach for items he or she needs. Placing the bed in the lowest position promotes patient safety. Leaving the patient alone, if possible, promotes self-esteem and shows respect for privacy. Side rails assist the patient in repositioning. 13. Remove gloves and additional PPE, if used. Perform hand hygiene. Proper removal of PPE prevents transmission of microorganisms. Hand hygiene deters the spread of microorganisms. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 602 Aptara 602 UNIT II 12-1 Promoting Healthy Physiologic Responses Assisting With the Use of a Bedpan ACTION continued R AT I O N A L E FIGURE 4. Placing call bell within patient’s reach and handing patient toilet tissue. Removing the Bedpan 14. Perform hand hygiene and put on gloves and additional PPE, as indicated. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Have a receptacle, such as plastic trash bag, handy for discarding tissue. Hand hygiene deters the spread of microorganisms. Gloves prevent exposure to blood and body fluids. Having the bed at the proper height prevents back and muscle strain. Proper disposal of soiled tissue prevents transmission of microorganisms. 15. Lower the head of the bed, if necessary, to about 30 degrees. Remove bedpan in the same manner in which it was offered, being careful to hold it steady. Ask the patient to bend the knees and lift the buttocks up from the bedpan. Assist patient, if necessary, by placing your hand that is closest to the patient palm up, under the lower back, and assist with lifting. Place the bedpan on the bedside chair and cover it. Holding the bedpan steady prevents spills. The nurse uses less energy when the patient can assist by placing some of his or her weight on the heels. Covering the bedpan helps to prevent the spread of microorganisms. 16. If patient needs assistance with hygiene, wrap tissue around the hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue, and use more until patient is clean. Place patient on his or her side and spread buttocks to clean anal area. Cleaning area from front to back minimizes fecal contamination of the vagina and urinary meatus. Cleaning the patient after he or she has used the bedpan prevents offensive odors and irritation to the skin. 17. Do not place toilet tissue in the bedpan if a specimen is required or if output is being recorded. Place toilet tissue in appropriate receptacle. Mixing toilet tissue with a specimen makes laboratory examination more difficult and interferes with accurate output measurement. 18. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Replace or remove pad under the patient, as necessary. Remove your gloves and ensure that the patient is covered. Positioning helps to promote patient comfort. Removing contaminated gloves prevents spread of microorganisms. 19. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Reattach call bell. These actions promote patient safety. 20. Offer patient supplies to wash and dry his or her hands, assisting as necessary. Washing hands after using the urinal helps prevent the spread of microorganisms. 21. Put on clean gloves. Empty and clean the bedpan, measuring urine in graduated container, as necessary. Discard trash receptacle with used toilet paper per facility policy. Gloves prevent exposure to blood and body fluids. Cleaning reusable equipment helps prevent the spread of microorganisms. 22. Remove additional PPE, if used. Perform hand hygiene. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 603 Aptara 603 CHAPTER 12 Urinary Elimination EVALUATION The expected outcome is met when the patient voids using the bedpan. Other outcomes are met when the patient remains dry, the patient does not experience episodes of incontinence, the patient demonstrates measures to assist with using the bedpan, and the patient does not experience impaired skin integrity. DOCUMENTATION Guidelines Document the patient’s tolerance of the activity. Record the amount of urine voided on the intake and output record, if appropriate. Document any other assessments, such as unusual urine characteristics or alterations in the patient’s skin. Sample Documentation 12/06/12 0730 Patient placed on fracture bedpan with a two-person assist. Voided 400 mL dark yellow urine; strong odor noted. Specimen sent for urinalysis as ordered. —S. Barnes, RN SPECIAL CONSIDERATIONS A fracture bedpan is usually more comfortable for the patient, but it does not hold as large a volume as the regular bedpan (See Figure 1). Bedpan should not be left in place for extended periods because this can result in excessive pressure and irritation to the patient’s skin. Skill Variation Assisting With Use of a Bedpan When the Patient Has Limited Movement Patients who are unable to lift themselves onto the bedpan or who have activity limitations that prohibit the required actions can be assisted onto the bedpan in an alternate manner using these actions: 1. Discuss procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences. Review chart for any limitations in physical activity. 2. Bring bedpan and other necessary equipment to bedside. Put on PPE, as indicated and perform hand hygiene. Check the patient’s identification band. FIGURE A. Rolling patient on side to place the bedpan. 3. Unless contraindicated, apply powder to the rim of the bedpan. 4. Place bedpan and cover on chair next to bed. Close curtains around bed and close the door to the room, if possible. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place the patient in a supine position, with the head of the bed elevated about 30 degrees, unless contraindicated. Put on disposable gloves. 6. Fold top linen just enough to turn the patient, while minimizing exposure. If there is no waterproof pad on the bed and time allows, consider placing a waterproof pad under patient’s buttocks before placing bedpan. 7. Assist the patient to roll to the opposite side or turn the patient into a side-lying position. (Note: Covers should only be folded back just enough to work, not expose patient unnecessarily. Covers in photo pulled back to show action for photo.) 8. Hold the bedpan firmly against the patient’s buttocks, with the upper end of the bedpan under the patient’s buttocks toward the sacrum, and down into the mattress (Figure A). 9. Keep one hand against the bedpan. Apply gentle pressure to ensure the bedpan remains in place as you assist the patient to roll back onto the bedpan. 10. Ensure that bedpan is in proper position and the patient’s buttocks are resting on rounded shelf of the regular bedpan or the shallow rim of the fracture bedpan. 11. Raise the head of bed as near to sitting position as tolerated, unless contraindicated. Cover the patient with bed linens. 12. Place call bell and toilet tissue within easy reach. Place the bed in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately. (continued) 604 UNIT II 12-1 Promoting Healthy Physiologic Responses Assisting With the Use of a Bedpan continued Skill Variation Assisting With Use of a Bedpan When the Patient Has Limited Movement continued 13. Remove gloves, and PPE, if used. Perform hand hygiene. 16. Wrap tissue around the hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue in an appropriate receptacle, and use more until patient is clean. Do not place toilet tissue in the bedpan if a specimen is required or if output is being recorded. Spread buttocks to clean anal area. 14. To remove the bedpan, perform hand hygiene and put on disposable gloves, and additional PPE, as indicated. Raise the bed to a comfortable working height. Have a receptacle handy for discarding tissue. 17. Return the patient to a comfortable position. Make sure the linens under the patient are dry and that the patient is covered. 15. Lower the head of the bed. Grasp the closest side of the bedpan. Apply gentle pressure to hold the bedpan flat and steady. Assist the patient to roll to the opposite side or turn the patient into a side-lying position with the assistance of a second caregiver. Remove the bedpan and set on chair. Cover the bedpan. 12-2 18. Remove your gloves. Offer patient supplies to wash and dry his or her hands, assisting as necessary. 19. Raise side rail. Lower bed height and adjust head of bed to a comfortable position. Reattach call bell. 20. Put on clean gloves. Empty and clean the bedpan, measuring urine in graduated container, as necessary. Remove gloves and additional PPE, if used. Perform hand hygiene. Assisting With the Use of a Urinal Male patients confined to bed usually prefer to use the urinal for voiding. Often, male patients prefer to use the urinal at the bedside as a matter of convenience (Figure 1). The use of a urinal in the standing position facilitates emptying of the bladder. Patients who are unable to stand alone may benefit from assistance when voiding into a urinal. If the patient is unable to stand, the urinal may be used in bed. Patients may also use a urinal in the bathroom to facilitate measurement of urinary output. Many patients find it embarrassing to use the urinal. Promote comfort and normalcy as much as possible, while respecting the patient’s privacy. Provide skin care and perineal hygiene after urinal use and maintain a professional manner. FIGURE 1. Urinal. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 605 Aptara CHAPTER 12 Urinary Elimination 605 EQUIPMENT ASSESSMENT Assess the patient’s normal elimination habits. Determine why the patient needs to use a urinal, such as a physician’s order for strict bed rest or immobilization. Also assess the patient’s degree of limitation and ability to help with activity. Assess for activity limitations, such as hip surgery or spinal injury, which would contraindicate certain actions by the patient. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, traction, or any other devices that could interfere with the patient’s ability to help with the procedure or that could become dislodged. Assess the characteristics of the urine and the patient’s skin. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Physical Mobility Deficient Knowledge Impaired Urinary Elimination Functional Urinary Incontinence Toileting Self-Care Deficit OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when offering a urinal is that the patient is able to void with assistance. Other appropriate outcomes may include the following: the patient maintains continence; the patient demonstrates how to use the urinal; and the patient maintains skin integrity. Urinal with end cover (usually attached) Toilet tissue Clean gloves Additional PPE, as indicated IMPLEMENTATION ACTION R AT I O N A L E 1. Review the patient’s chart for any limitations in physical activity. Activity limitations may contraindicate certain actions by the patient. 2. Bring urinal and other necessary equipment to the bedside stand or overbed table. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close the curtains around the bed and close the door to the room, if possible. Discuss procedure with patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. 6. Put on gloves. Gloves prevent exposure to blood and body fluids. 7. Assist the patient to an appropriate position, as necessary: standing at the bedside, lying on one side or back, sitting in bed with the head elevated, or sitting on the side of the bed. These positions facilitate voiding and emptying of the bladder. 8. If the patient remains in the bed, fold the linens just enough to allow for proper placement of the urinal. Folding back the linen in this manner minimizes unnecessary exposure while still allowing the nurse to place the urinal. 9. If the patient is not standing, have him spread his legs slightly. Hold the urinal close to the penis and position the penis completely within the urinal (Figure 2). Keep the bottom of the urinal lower than the penis. If necessary, assist the patient to hold the urinal in place. Slight spreading of the legs allows for proper positioning of the urinal. Placing penis completely within the urinal and keeping the bottom lower than the penis avoids urine spills. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 606 Aptara 606 UNIT II 12-2 Promoting Healthy Physiologic Responses Assisting With the Use of a Urinal ACTION continued R AT I O N A L E FIGURE 2. Positioning urinal in place for a male patient. (Note: Covers should only be folded back just enough to work, not expose patient unnecessarily. Covers have been pulled back to show action.) 10. Cover the patient with the bed linens. Covering promotes warmth and privacy. 11. Place call bell and toilet tissue within easy reach. Have a receptacle, such as plastic trash bag, handy for discarding tissue. Ensure the bed is in the lowest position. Leave patient if it is safe to do so. Use side rails appropriately. Falls can be prevented if the patient does not have to reach for items he needs. Placing the bed in the lowest position promotes patient safety. Leaving the patient alone, if possible, promotes self-esteem and shows respect for privacy. Side rails assist the patient in repositioning. 12. Remove gloves and additional PPE, if used. Perform hand hygiene. Proper removal of PPE reduces transmission of microorganisms. Hand hygiene deters the spread of microorganisms. Removing the Urinal 13. Perform hand hygiene. Put on gloves and additional PPE, as indicated. Hand hygiene and PPE prevent the spread of microorganisms. Gloves prevent exposure to blood and body fluids. PPE is required based on transmission precautions. 14. Pull back the patient’s bed linens just enough to remove the urinal. Remove the urinal. Cover the open end of the urinal. Place on the bedside chair. If patient needs assistance with hygiene, wrap tissue around the hand several times, and wipe patient clean. Place tissue in receptacle. Covering the end of the urinal helps to prevent the spread of microorganisms. 15. Return the patient to a comfortable position. Make sure the linens under the patient are dry. Remove your gloves and ensure that the patient is covered. Proper positioning promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 16. Ensure patient call bell is in reach. Promotes patient safety. 17. Offer patient supplies to wash and dry his hands, assisting as necessary. Washing hands after using the urinal helps prevent the spread of microorganisms. 18. Put on clean gloves. Empty and clean the urinal, measuring urine in graduated container, as necessary. Discard trash receptacle with used toilet paper per facility policy. Measurement of urine volume is required for accurate intake and output records. 19. Remove gloves and additional PPE, if used, and perform hand hygiene. EVALUATION Gloves prevent exposure to blood and body fluids. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient voids using the urinal. Other outcomes are met when the patient remains dry; the patient does not experience episodes of incontinence; the patient demonstrates measures to assist with using the urinal; and the patient does not experience impaired skin integrity. CHAPTER 12 Urinary Elimination 607 DOCUMENTATION Guidelines Document the patient’s tolerance of the activity. Record the amount of urine voided on the intake and output record, if appropriate. Document any other assessments, such as unusual urine characteristics or alterations in the patient’s skin. Sample Documentation 12/06/12 0730 Patient using urinal at bedside to void. Voided 600 mL yellow urine. Reinforced need for continued use of urinal for recording accurate output. Patient verbalized an understanding of instructions. —S. Barnes, RN SPECIAL CONSIDERATIONS 12-3 Urinal should not be left in place for extended periods because pressure and irritation to the patient’s skin can result. If patient is unable to use alone or with assistance, consider other interventions, such as commode or external condom catheter. It may be necessary to assist patients who have difficulty holding the urinal in place, such as those with limited upper extremity movement or alteration in mentation, to prevent spillage of urine. The urinal may also be used standing or sitting at the bedside or in the patient’s bathroom, if patient is able to do so. Assisting With the Use of a Bedside Commode Patients who experience difficulty getting to the bathroom may benefit from the use of a bedside commode. Bedside commodes are portable toilet substitutes that can be used for voiding and defecation (Figure 1). A bedside commode can be placed close to the bed for easy use. Many have armrests attached to the legs that may interfere with ease of transfer. The legs usually have some type of end cap on the bottom to reduce movement, but care must be taken to prevent the commode from moving during transfer, resulting in patient injury or falls. FIGURE 1. Bedside commode. EQUIPMENT Commode with cover (usually attached) Toilet tissue Nonsterile gloves Additional PPE, as indicated (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 608 Aptara 608 UNIT II Promoting Healthy Physiologic Responses 12-3 Assisting With the Use of a Bedside Commode continued ASSESSMENT Assess the patient’s normal elimination habits. Determine why the patient needs to use a commode, such as weakness or unsteady gait. Assess the patient’s degree of limitation and ability to help with activity. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, or other devices that could interfere with the patient’s ability to help with the procedure or that could become dislodged. Assess the characteristics of the urine and the patient’s skin. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Physical Mobility Deficient Knowledge Risk for Falls Functional Urinary Incontinence Impaired Urinary Elimination Toileting Self-Care Deficit OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when assisting with the use of a commode is that the patient is able to void with assistance. Other appropriate outcomes may include the following: the patient maintains continence; the patient demonstrates how to use the commode; the patient maintains skin integrity; and the patient remains free from injury. IMPLEMENTATION ACTION R AT I O N A L E 1. Review the patient’s chart for any limitations in physical activity. Physical limitations may require adaptations in performing the skill. 2. Bring the commode and other necessary equipment to the bedside. Obtain assistance for patient transfer from another staff member, if necessary. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. Assistance from another person may be required to transfer patient safely to the commode. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close the curtains around the bed and close the door to the room, if possible. Discuss procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. 6. Place the commode close to, and parallel with, the bed. Raise or remove the seat cover. Refer to Figure 1, above. Allows for easy access. 7. Assist the patient to a standing position and then help the patient pivot to the commode. While bracing one commode leg with your foot, ask the patient to place his or her hands one at a time on the armrests. Assist the patient to lower himself/herself slowly onto the commode seat. Standing and then pivoting ensures safe patient transfer. Bracing the commode leg with a foot prevents the commode from shifting while the patient is sitting down. 8. Cover the patient with a blanket. Place call bell and toilet tissue within easy reach. Leave patient if it is safe to do so. Covering patient promotes warmth. Falls can be prevented if the patient does not have to reach for items he or she needs. Leaving patient alone, if possible, promotes self-esteem and shows respect for privacy. Assisting Patient Off Commode 9. Perform hand hygiene. Put on gloves and additional PPE, as indicated. Hand hygiene deters the spread of microorganisms. Gloves prevent exposure to blood and body fluids. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 609 Aptara CHAPTER 12 Urinary Elimination ACTION 609 R AT I O N A L E 10. Assist the patient to a standing position. If patient needs assistance with hygiene, wrap toilet tissue around your hand several times, and wipe patient clean, using one stroke from the pubic area toward the anal area. Discard tissue in an appropriate receptacle, according to facility policy, and continue with additional tissue until patient is clean. Cleaning area from front to back minimizes fecal contamination of the vagina and urinary meatus. Cleaning the patient after he or she has used the commode prevents offensive odors and irritation to the skin. 11. Do not place toilet tissue in the commode if a specimen is required or if output is being recorded. Replace or lower the seat cover. Mixing toilet tissue with a specimen makes laboratory examination more difficult and interferes with accurate output measurement. Covering the commode helps to prevent the spread of microorganisms. 12. Remove your gloves. Return the patient to the bed or chair. If the patient returns to the bed, raise side rails, as appropriate. Ensure that the patient is covered and call bell is readily within reach. Removing contaminated gloves prevents spread of microorganisms. Returning the patient to the bed or chair promotes patient comfort. Side rails assist with patient movement in the bed. Having the call bell readily available promotes patient safety. 13. Offer patient supplies to wash and dry his or her hands, assisting as necessary. Washing hands after using the commode helps prevent the spread of microorganisms. 14. Put on clean gloves. Empty and clean the commode, measuring urine in graduated container, as necessary. Gloves prevent exposure to blood and body fluids. Accurate measurement of urine is necessary for accurate intake and output records. 15. Remove gloves and additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the patient successfully uses the bedside commode. Other outcomes are met when the patient remains dry, does not experience episodes of incontinence, demonstrates measures to assist with using the commode, and does not experience impaired skin integrity or falls. DOCUMENTATION Guidelines Sample Documentation Document the patient’s tolerance of the activity, including his or her ability to use the commode. Record the amount of urine voided and/or stool passed on the intake and output record, if appropriate. Document any other assessments, such as unusual urine or stool characteristics or alterations in the patient’s skin. 07/06/12 0730 Patient using commode at bedside to void with assistance of one for transfer. Voided 325 mL yellow urine. Reinforced need for continued use of commode related to patient’s unsteady gait. Patient verbalized an understanding of instructions and states she will call for assistance when getting up to use commode. —S. Barnes, RN SPECIAL CONSIDERATIONS Commode can be left within patient’s reach, to be used without assistance, if appropriate and safe to do so, based on patient’s activity limitations and mobility. Adjust room door or curtain to provide privacy for the patient in the event the commode is used. 610 UNIT II Promoting Healthy Physiologic Responses 12-4 Assessing Bladder Volume Using an Ultrasound Bladder Scanner Portable bladder ultrasound devices are accurate, reliable, and noninvasive devices used to assess bladder volume. Bladder scanners do not pose a risk for the development of a urinary tract infection, unlike intermittent catheterization, which is also used to determine bladder volume. They are used when there is urinary frequency, absent or decreased urine output, bladder distention, or inability to void, and when establishing intermittent catheterization schedules. Protocols can be established to guide the decision to catheterize a patient. Some scanners offer the ability to print the scan results for documentation purposes. Results are most accurate when the patient is in the supine position during the scanning. The device must be programmed for the gender of the patient by pushing the correct button on the device. If a female patient has had a hysterectomy, the male button is pushed (Altschuler & Diaz, 2006). A postvoid residual (PVR) volume less than 50 mL indicates adequate bladder emptying. A PVR of greater than 150 mL is often recommended as the guideline for catheterization, because residual urine volumes of greater than 150 mL have been associated with the development of urinary tract infections (Stevens, 2005). EQUIPMENT ASSESSMENT Assess the patient for the need to check bladder volume, including signs of urinary retention, measurement of postvoid residual volume, verification that bladder is empty, identification of obstruction in an indwelling catheter, and evaluation of bladder distension to determine if catheterization is necessary. Verify medical order, if required by facility. Many facilities allow the use of a bladder scanner as a nursing judgment. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Urinary Elimination Urinary Retention OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when using a bladder scanner is that the volume of urine in the bladder will be accurately measured. Other appropriate outcomes may include the following: patient’s urinary elimination will be maintained, with a urine output of at least 30 mL/hour; and the patient’s bladder will not be distended. Bladder scanner Ultrasound gel or bladder scan gel pad Alcohol wipe or other sanitizer recommended by the scanner manufacturer and/or facility policy Clean gloves Additional PPE, as indicated Paper towel or washcloth IMPLEMENTATION ACTION R AT I O N A L E 1. Review the patient’s chart for any limitations in physical activity. Physical limitations may require adaptations in performing the skill. 2. Bring the bladder scanner and other necessary equipment to the bedside. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 611 Aptara 611 CHAPTER 12 Urinary Elimination ACTION R AT I O N A L E 5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure, as well as personal hygiene preferences. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. 6. Adjust the bed to a comfortable working height; usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Place the patient in a supine position. Drape patient. Stand on the patient’s right side if you are right-handed, patient’s left side if you are left-handed. Having the bed at the proper height prevents back and muscle strain. Proper positioning allows accurate assessment of bladder volume. Keeping the patient covered as much as possible promotes patient comfort and privacy. Positioning allows for ease of use of dominant hand for the procedure. 7. Put on clean gloves. Gloves prevent contact with blood and body fluids. 8. Press the ON button. Wait until the device warms up. Press the SCAN button to turn on the scanning screen. Many devices require a few minutes to prepare the internal programs. 9. Press the appropriate gender button. The appropriate icon for male or female will appear on the screen (Figure 1). The device must be programmed for the gender of the patient by pushing the correct button on the device. If a female patient has had a hysterectomy, the male button is pushed (Altschuler & Diaz, 2006). 10. Clean the scanner head with the appropriate cleaner (Figure 2). Cleaning the scanner head deters transmission of microorganisms. FIGURE 1. Identifying the icon for the patient’s gender. (Photo FIGURE 2. Cleaning scanner head. (Photo by B. Proud.) by B. Proud.) 11. Gently palpate the patient’s symphysis pubis. Place a generous amount of ultrasound gel or gel pad midline on the patient’s abdomen, about 1 to 1.5 inches above the symphysis pubis (anterior midline junction of pubic bones) (Figure 3). A Palpation identifies the proper location and allows for correct placement of scanner head over the patient’s bladder. B FIGURE 3. (A) Placing ultrasound gel about 1 to 11⁄2 inches above symphysis pubis. (Photo by B. Proud.) (B) Gel pad. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:09 PM Page 612 Aptara 612 UNIT II 12-4 Promoting Healthy Physiologic Responses Assessing Bladder Volume Using an Ultrasound Bladder Scanner continued ACTION R AT I O N A L E 12. Place the scanner head on the gel or gel pad, with the directional icon on the scanner head toward the patient’s head. Aim the scanner head toward the bladder (point the scanner head slightly downward toward the coccyx) (Patraca, 2005). Press and release the scan button (Figure 4). A Proper placement allows for accurate reading of urine in bladder. B FIGURE 4. (A) Positioning the scanner head with directional icon toward the patient’s head. (B) Pressing the scan button. (Photos by B. Proud.) 13. Observe the image on the scanner screen. Adjust the scanner head to center the bladder image on the crossbars (Figure 5). This action allows for accurate reading of urine in bladder. Aiming icon FIGURE 5. Centering the image on the crossbars. (From Patraca, K. (2005). Measure bladder volume without catheterization. Nursing, 35(4), 47.) 14. Press and hold the DONE button until it beeps. Read the volume measurement on the screen. Print the results, if required, by pressing PRINT. This action provides for accurate documentation of reading. 15. Use a washcloth or paper towel to remove remaining gel from the patient’s skin. Alternately, gently remove gel pad from patient’s skin. Return the patient to a comfortable position. Remove your gloves and ensure that the patient is covered. Removal of the gel promotes patient comfort. Removing contaminated gloves prevents spread of microorganisms. 16. Lower bed height and adjust head of bed to a comfortable position. Reattach call bell, if necessary. These actions promote patient safety. CHAPTER 12 Urinary Elimination ACTION 613 R AT I O N A L E 17. Remove additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the volume of urine in the bladder is accurately measured, the patient’s urinary elimination is maintained, with a urine output of at least 30 mL/hour; and the patient’s bladder is not distended. DOCUMENTATION Guidelines Document the assessment data that led to the use of the bladder scanner, the urine volume measured, and the patient’s response. Sample Documentation 7/06/12 1130 Patient has not voided 8 hours after catheter removal. Patient denies feelings of discomfort, pressure, and pain. Bladder not palpable. Bladder scanned for 120 mL of urine. Patient encouraged to increase oral fluid intake to eight 6-oz. glasses today. Dr. Liu notified of assessment. Orders received to rescan in 4 hours if patient does not void. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS 12-5 You press wrong icon for patient’s gender when initiating scanner: Turn scanner off and back on. Re-enter information using correct gender button. You have reason to believe bladder is full, based on assessment data, but scanner reveals little to no urine in bladder: Ensure proper positioning of scanner head. Place a generous amount of ultrasound gel or gel pad midline on the patient’s abdomen, about 1 to 1.5 inches above the symphysis pubis. Place the scanner head on the gel or gel pad, with the directional icon on the scanner head toward the patient’s head. Aim the scanner head toward the bladder (point the scanner head slightly downward toward the coccyx). Ensure that the bladder image is centered on the crossbars. Applying an External Condom Catheter When voluntary control of urination is not possible for male patients, an alternative to an indwelling catheter is the external condom catheter. This soft, pliable sheath made of silicone material is applied externally to the penis. Most devices are self-adhesive. The condom catheter is connected to drainage tubing and a collection bag. The collection bag may be a leg bag. The risk for urinary tract infection with a condom catheter is lower than the risk associated with an indwelling urinary catheter. Nursing care of a patient with a condom catheter includes vigilant skin care to prevent excoriation. This includes removing the condom catheter daily, washing the penis with soap and water and drying carefully, and inspecting the skin for irritation. In hot and humid weather, more frequent changing may be required. Always follow the manufacturer’s instructions for applying the condom catheter because there are several variations. In all cases, take care to fasten the condom securely enough to prevent leakage, yet not so tightly as to constrict the blood vessels in the area. In addition, the tip of the tubing should be kept 1 to 2 inches (2.5 to 5 cm) beyond the tip of the penis to prevent irritation to the sensitive glans area. Maintaining free urinary drainage is another nursing priority. Institute measures to prevent the tubing from becoming kinked and urine from backing up in the tubing. Urine can lead to excoriation of the glans, so position the tubing that collects the urine from the condom so that it draws urine away from the penis. Always use a measuring or sizing guide supplied by the manufacturer to ensure the correct size of sheath is applied. Skin barriers, such as 3M or Skin Prep can be applied to the penis to protect penile skin from irritation and changes in integrity. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 614 Aptara 614 UNIT II Promoting Healthy Physiologic Responses 12-5 Applying an External Condom Catheter continued EQUIPMENT ASSESSMENT Assess the patient’s knowledge of the need for catheterization. Ask the patient about any allergies, especially to latex or tape. Assess the size of the patient’s penis to ensure that the appropriate-sized condom catheter is used. Inspect the skin in the groin and scrotal area, noting any areas of redness, irritation, or breakdown. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Possible nursing diagnoses may include: Impaired Urinary Elimination Risk for Impaired Skin Integrity Functional Urinary Incontinence OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when applying a condom catheter is that the patient’s urinary elimination will be maintained, with a urine output of at least 30 mL/hour, and the bladder is not distended. Other outcomes may include the following: the patient’s skin remains clean, dry, and intact, without evidence of irritation or breakdown. Condom sheath in appropriate size Skin protectant, such as 3M or Skin Prep Bath blanket Reusable leg bag with tubing or urinary drainage setup Basin of warm water and soap Disposable gloves Additional PPE, as indicated Washcloth and towel Scissors IMPLEMENTATION ACTION 1. Bring necessary equipment to the bedside. R AT I O N A L E Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. 2. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 3. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 4. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with patient. Ask the patient if he has any allergies, especially to latex. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. Some condom catheters are made of latex. 5. Adjust bed to comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are right-handed, or on patient’s left side if you are left-handed. Having the bed at the proper height prevents back and muscle strain. Positioning on one side allows for ease of use of dominant hand for catheter application. 6. Prepare urinary drainage setup or reusable leg bag for attachment to condom sheath. Provides for an organized approach to the task. 7. Position patient on his back with thighs slightly apart. Drape patient so that only the area around the penis is exposed. Slide waterproof pad under patient. Positioning allows access to site. Draping prevents unnecessary exposure and promotes warmth. The waterproof pad will protect bed linens from moisture. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 615 Aptara 615 CHAPTER 12 Urinary Elimination ACTION 8. Put on disposable gloves. Trim any long pubic hair that is in contact with penis. 9. Clean the genital area with washcloth, skin cleanser, and warm water. If patient is uncircumcised, retract foreskin and clean glans of penis. Replace foreskin. Clean the tip of the penis first, moving the washcloth in a circular motion from the meatus outward. Wash the shaft of the penis using downward strokes toward the pubic area. Rinse and dry. Remove gloves. Perform hand hygiene again. R AT I O N A L E Gloves prevent contact with blood and body fluids. Trimming pubic hair prevents pulling of hair by adhesive without the risk of infection associated with shaving. Washing removes urine, secretions, and microorganisms. The penis must be clean and dry to minimize skin irritation. If the foreskin is left retracted, it may cause venous congestion in the glans of the penis, leading to edema. 10. Apply skin protectant to penis and allow to dry. Skin protectant minimizes the risk of skin irritation from adhesive and moisture and increases adhesive’s ability to adhere to skin. 11. Roll condom sheath outward onto itself. Grasp penis firmly with nondominant hand. Apply condom sheath by rolling it onto penis with dominant hand (Figure 1). Leave 1 to 2 inches (2.5 to 5 cm) of space between tip of penis and end of condom sheath. Rolling the condom sheath outward allows for easier application. The space prevents irritation to tip of penis and allows free drainage of urine. 12. Apply pressure to sheath at the base of penis for 10 to 15 seconds. Application of pressure ensures good adherence of adhesive with skin. 13. Connect condom sheath to drainage setup (Figure 2). Avoid kinking or twisting drainage tubing. The collection device keeps the patient dry. Kinked tubing encourages backflow of urine. FIGURE 1. Unrolling sheath onto penis. FIGURE 2. Connecting condom sheath to drainage setup. 14. Remove gloves. Secure drainage tubing to the patient’s inner thigh with Velcro leg strap or tape. Leave some slack in tubing for leg movement. Proper attachment prevents tension on the sheath and potential inadvertent removal. 15. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. Positioning and covering provide warmth and promote comfort. Bed in the lowest position promotes patient safety. 16. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with the drainage bag. This facilitates drainage of urine and prevents the backflow of urine. 17. Remove equipment. Remove gloves and additional PPE, if used. Perform hand hygiene. Proper disposal of equipment prevents transmission of microorganisms. Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. (continued) 616 UNIT II 12-5 Promoting Healthy Physiologic Responses Applying an External Condom Catheter EVALUATION continued The expected outcome is met when the condom catheter is applied without adverse effect; the patient’s urinary elimination is maintained, with a urine output of at least 30 mL/hour; and the patient’s skin remains clean, dry, and intact, without evidence of irritation or breakdown. DOCUMENTATION Guidelines Document the application of the condom catheter and the condition of the patient’s skin. Record urine output on the intake and output record. Sample Documentation 7/12/12 1910 Patient incontinent of urine; states: “It just comes too fast. I can’t get to the bathroom in time.” Perineal skin slightly reddened. Discussed rationale for use of condom catheter. Patient and wife agreeable to trying condom catheter. Medium-sized condom catheter applied; 200 mL of clear urine returned. Leg bag in place for daytime use. Patient verbalized understanding of need to call for assistance to empty drainage bag. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS 12-6 Condom catheter leaks with every voiding: Check size of condom catheter. If it is too big or too small, it may leak. Check space between tip of penis and end of condom sheath. If this space is too small, the urine has no place to go and will leak out. Condom catheter will not stay on patient: Ensure that condom catheter is correct size and that penis is thoroughly dried before applying condom catheter. Remind patient that condom catheter is in place, so that patient does not tug at tubing. If the patient has a retracted penis, a condom catheter may not be the best choice; there are pouches made for patients with a retracted penis. When assessing patient’s penis, you find a break in skin integrity: Do not reapply condom catheter. Allow skin to be open to air as much as possible. If institution has a wound, ostomy, and continence nurse, a consult would be appropriate. Catheterizing the Female Urinary Bladder Urinary catheterization is the introduction of a catheter (tube) through the urethra into the bladder for the purpose of withdrawing urine. Urinary catheterization is considered the most common cause of nosocomial infections (infections acquired in a hospital). Therefore, catheterization should be avoided whenever possible. When it is deemed necessary, it should be performed using aseptic technique. Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods (5 to 10 minutes) (Figure 1B). If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. The indwelling urethral catheter is designed so that it does not slip out of the bladder. A balloon is inflated to ensure that the catheter remains in the bladder once it is inserted (Figure 1A). The following procedure reviews insertion of an indwelling catheter. The procedure for an intermittent catheter follows as a Skill Variation. Guidelines for caring for a patient with an indwelling catheter are summarized in Box 12-1. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 617 Aptara CHAPTER 12 Urinary Elimination 617 Inflated balloon Catheter tip A Balloon inflation Urine drainage Cross section Catheter tip B Urine drainage Cross section FIGURE 1. (A) Indwelling urethral catheter. (B) Intermittent urethral catheter. BOX 12-1 GUIDELINES FOR CARE OF THE PATIENT WITH AN INDWELLING CATHETER Use an indwelling catheter only when necessary. Use strict hand hygiene principles. Use sterile technique when inserting a catheter. Secure the catheter properly to the patient’s thigh or abdomen after insertion. Keep the drainage bag below the level of the patient’s bladder to maintain drainage of urine and prevent the backflow of urine into the patient’s bladder. Keep the drainage bag and tubing off the ground. Maintain a closed system whenever possible. If necessary, obtain urine samples using aseptic technique via a closed system. Keep the catheter free from obstruction to maintain free flow to the urine. EQUIPMENT Avoid irrigation unless needed to relieve or prevent obstruction. Ensure that patient maintains adequate fluid intake. Empty the drainage bag when one-half to two-thirds full or every 3 to 6 hours. (When emptying the drainage bag, do not touch drainage bag spout to the collection device.) Clean drainage bags daily using a commercial cleaning product or vinegar solution (1 part vinegar to 3 parts water). Provide daily routine personal hygiene as outlined in Chapter 7, Hygiene; no need to apply antibiotic ointment or povidone-iodine (Betadine) to the urethral meatus. Sterile catheter kit that contains: Sterile gloves Sterile drapes (one of which is fenestrated [having a window-like opening]) Sterile catheter (Use the smallest appropriate-size catheter, usually a 14F to 16F catheter with a 5- to 10-mL balloon [Mercer Smith, 2003; Newman, 2008]). Antiseptic cleansing solution and cotton balls or gauze squares; antiseptic swabs Lubricant Forceps Prefilled syringe with sterile water (sufficient to inflate indwelling catheter balloon) Sterile basin (usually base of kit serves as this) Sterile specimen container (if specimen is required) Flashlight or lamp Waterproof, disposable pad Sterile, disposable urine collection bag and drainage tubing (may be connected to catheter in catheter kit) Velcro leg strap or tape Disposable gloves Additional PPE, as indicated Washcloth and warm water to perform perineal hygiene before and after catheterization (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 618 Aptara 618 UNIT II Promoting Healthy Physiologic Responses 12-6 Catheterizing the Female Urinary Bladder continued ASSESSMENT Assess the patient’s normal elimination habits. Assess the patient’s degree of limitations and ability to help with activity. Assess for activity limitations, such as hip surgery or spinal injury, which would contraindicate certain actions by the patient. Assess for the presence of any other conditions that may interfere with passage of the catheter or contraindicate insertion of the catheter, such as urethral strictures or bladder cancer. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, traction, or any other devices that could interfere with the patient’s ability to help with the procedure or that could become dislodged. Assess bladder fullness before performing procedure, either by palpation or with a handheld bladder ultrasound device. Question patient about any allergies, especially to latex and iodine. Ask the patient if she has ever been catheterized. If she had an indwelling catheter previously, ask why and for how long it was used. The patient may have urethral strictures, which may make catheter insertion more difficult. Assess the characteristics of the urine and the patient’s skin. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Urinary Elimination Risk for Infection Urinary Retention Risk for Impaired Skin Integrity Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when inserting a female urinary catheter is that the patient’s urinary elimination will be maintained, with a urine output of at least 30 mL/hour, and the patient’s bladder will not be distended. Other appropriate outcomes may include the following: the patient’s skin remains clean, dry, and intact, without evidence of irritation or breakdown; and the patient verbalizes an understanding of the purpose for, and care of, the catheter, as appropriate. IMPLEMENTATION ACTION R AT I O N A L E 1. Review the patient’s chart for any limitations in physical activity. Confirm the medical order for indwelling catheter insertion. Physical limitations may require adaptations in performing the skill. Verifying the medical order ensures that the correct intervention is administered to the right patient. 2. Bring the catheter kit and other necessary equipment to the bedside. Obtain assistance from another staff member, if necessary. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. Assistance from another person may be required to perform the intervention safely. 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure. Ask the patient if she has any allergies, especially to latex or iodine. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. Some catheters and gloves in kits are made of latex. Some antiseptic solutions contain iodine. 6. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach. Good lighting is necessary to see the meatus clearly. A readily available trash receptacle allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 619 Aptara CHAPTER 12 Urinary Elimination ACTION 619 R AT I O N A L E 7. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are right-handed, patient’s left side if you are left-handed. Having the bed at the proper height prevents back and muscle strain. Positioning allows for ease of use of dominant hand for catheter insertion. 8. Assist the patient to a dorsal recumbent position with knees flexed, feet about 2 feet apart, with her legs abducted. Drape patient (Figure 2). Alternately, the Sims’, or lateral, position can be used. Place the patient’s buttocks near the edge of the bed with her shoulders at the opposite edge and her knees drawn toward her chest (Figure 3). Allow the patient to lie on either side, depending on which position is easiest for the nurse and best for the patient’s comfort. Slide waterproof pad under patient. Proper positioning allows adequate visualization of the urinary meatus. Embarrassment, chilliness, and tension can interfere with catheter insertion; draping the patient will promote comfort and relaxation. The Sims’ position may allow better visualization and be more comfortable for the patient, especially if hip and knee movements are difficult. The smaller area of exposure is also less stressful for the patient. The waterproof pad will protect bed linens from moisture. FIGURE 2. Patient in dorsal recumbent position and draped FIGURE 3. Demonstration of side-lying position. properly. 9. Put on clean gloves. Clean the perineal area with washcloth, skin cleanser, and warm water, using a different corner of the washcloth with each stroke. Wipe from above orifice downward toward sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene again. Gloves reduce the risk of exposure to blood and body fluids. Cleaning reduces microorganisms near the urethral meatus and provides an opportunity to visualize the perineum and landmarks before the procedure. Hand hygiene reduces the spread of microorganisms. 10. Prepare urine drainage setup if a separate urine collection system is to be used. Secure to bed frame according to manufacturer’s directions. This facilitates connection of the catheter to the drainage system and provides for easy access. 11. Open sterile catheterization tray on a clean overbed table using sterile technique. Placement of equipment near the worksite increases efficiency. Sterile technique protects patient and prevents transmission of microorganisms. 12. Put on sterile gloves. Grasp upper corners of drape and unfold drape without touching unsterile areas. Fold back a corner on each side to make a cuff over gloved hands. Ask patient to lift her buttocks and slide sterile drape under her with gloves protected by cuff. The drape provides a sterile field close to the meatus. Covering the gloved hands will help keep the gloves sterile while placing the drape. 13. Based on facility policy, position the fenestrated sterile drape. Place a fenestrated sterile drape over the perineal area, exposing the labia (Figure 4). (Note: the fenestrated drape is not shown in the remaining illustrations in order to provide a clear view of the procedure.) The drape expands the sterile field and protects against contamination. Use of a fenestrated drape may limit visualization and is considered optional by some practitioners and/or facility policies. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 620 Aptara 620 UNIT II 12-6 Promoting Healthy Physiologic Responses Catheterizing the Female Urinary Bladder ACTION continued R AT I O N A L E FIGURE 4. Patient with fenestrated drape in place over perineum. 14. Place sterile tray on drape between patient’s thighs. This provides easy access to supplies. 15. Open all the supplies. Fluff cotton balls in tray before pouring antiseptic solution over them. Alternately, open package of antiseptic swabs. Open specimen container if specimen is to be obtained. It is necessary to open all supplies and prepare for the procedure while both hands are sterile. 16. Lubricate 1 to 2 inches of catheter tip. Lubrication facilitates catheter insertion and reduces tissue trauma. 17. With thumb and one finger of nondominant hand, spread labia and identify meatus. Be prepared to maintain separation of labia with one hand until catheter is inserted and urine is flowing well and continuously (Figure 5). If the patient is in the side-lying position, lift the upper buttock and labia to expose the urinary meatus (Figure 6). Smoothing the area immediately surrounding the meatus helps to make it visible. Allowing the labia to drop back into position may contaminate the area around the meatus, as well as the catheter. The nondominant hand is now contaminated. Vagina Clitoris Urethral meatus FIGURE 5. Using dominant hand to separate and hold labia open. FIGURE 6. Exposing the urinary meatus with the patient in the side-lying position. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 621 Aptara CHAPTER 12 Urinary Elimination ACTION 621 R AT I O N A L E 18. Use the dominant hand to pick up a cotton ball or antiseptic swab. Clean one labial fold, top to bottom (from above the meatus down toward the rectum), then discard the cotton ball. Using a new cotton ball/swab for each stroke, continue to clean the other labial fold, then directly over the meatus (Figure 7). Moving from an area where there is likely to be less contamination to an area where there is more contamination helps prevent the spread of microorganisms. Cleaning the meatus last helps reduce the possibility of introducing microorganisms into the bladder. 19. With your uncontaminated, dominant hand, place the drainage end of the catheter in receptacle. If the catheter is preattached to sterile tubing and drainage container (closed drainage system), position catheter and setup within easy reach on sterile field. Ensure that clamp on drainage bag is closed. This facilitates drainage of urine and minimizes risk of contaminating sterile equipment. 20. Using your dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra (Figure 8). Advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]). Once urine drains, advance catheter another 2 to 3 inches (4.8 to 7.2 cm). Do not force catheter through urethra into bladder. Ask patient to breathe deeply, and rotate catheter gently if slight resistance is met as catheter reaches external sphincter. The female urethra is about 1.5 to 2.5 inches (3.6 to 6.0 cm) long. Applying force on the catheter is likely to injure mucous membranes. The sphincter relaxes and the catheter can enter the bladder easily when the patient relaxes. Advancing an indwelling catheter an additional 2 to 3 inches (4.8 to 7.2 cm) ensures placement in the bladder and facilitates inflation of the balloon without damaging the urethra. FIGURE 7. Wiping perineum with cotton ball held by forceps. FIGURE 8. Inserting catheter with dominant hand while non- Wipe in one direction—from top to bottom. dominant hand holds labia apart. 21. Hold the catheter securely at the meatus with your nondominant hand. Use your dominant hand to inflate the catheter balloon (Figure 9). Inject entire volume of sterile water supplied in prefilled syringe. Bladder or sphincter contraction could push the catheter out. The balloon anchors the catheter in place in the bladder. Manufacturer provides appropriate amount of sterile water for the size of catheter in the kit; as a result, use entire syringe provided in the kit. 22. Pull gently on catheter after balloon is inflated to feel resistance. Improper inflation can cause patient discomfort and malpositioning of catheter. 23. Attach catheter to drainage system if not already preattached (Figure 10). Closed drainage system minimizes the risk for microorganisms being introduced into the bladder. 24. Remove equipment and dispose of it according to facility policy. Discard syringe in sharps container. Wash and dry the perineal area, as needed. Proper disposal prevents the spread of microorganisms. Placing syringe in sharps container prevents reuse. Cleaning promotes comfort and appropriate personal hygiene. 25. Remove gloves. Secure catheter tubing to the patient’s inner thigh with Velcro leg strap or tape (Figure 11). Leave some slack in catheter for leg movement. Proper attachment prevents trauma to the urethra and meatus from tension on the tubing. Whether to tape the drainage tubing over or under the leg depends on gravity flow, patient’s mobility, and comfort of the patient. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 622 Aptara 622 UNIT II 12-6 Promoting Healthy Physiologic Responses Catheterizing the Female Urinary Bladder ACTION continued R AT I O N A L E FIGURE 9. Inflating balloon of indwelling catheter. FIGURE 10. Attaching catheter to drainage bag. FIGURE 11. Catheter attached to leg. 26. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. Positioning and covering provides warmth and promotes comfort. 27. Secure drainage bag below the level of the bladder. Check that drainage tubing is not kinked and that movement of side rails does not interfere with catheter or drainage bag. This facilitates drainage of urine and prevents the backflow of urine. 28. Put on clean gloves. Obtain urine specimen immediately, if needed, from drainage bag. Label specimen. Send urine specimen to the laboratory promptly or refrigerate it. Catheter system is sterile. Obtaining specimen immediately allows access to sterile system. Keeping urine at room temperature may cause microorganisms, if present, to grow and distort laboratory findings. 29. Remove gloves and additional PPE, if used. Perform hand hygiene. EVALUATION Removing PPE properly reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms. The expected outcome is met when the catheter is inserted using sterile technique, results in the immediate flow of urine, and the bladder is not distended. Other outcomes are met when the patient does not experience trauma, reports little to no pain on insertion, and the perineal area remains clean and dry. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 623 Aptara CHAPTER 12 Urinary Elimination 623 DOCUMENTATION Guidelines Sample Documentation Document the type and size of catheter and balloon inserted, as well as the amount of fluid used to inflate the balloon. Document the patient’s tolerance of the activity. Record the amount of urine obtained through the catheter and any specimen obtained. Document any other assessments, such as unusual urine characteristics or alterations in the patient’s skin. Record urine amount on intake and output record, if appropriate. 7/14/12 0915 Primary care provider notified of palpable bladder (3 cm below umbilicus) and patient’s inability to void; 750 mL of urine noted with bladder scan. A 16F Foley catheter inserted without difficulty; 10 mL of sterile water injected into balloon port; 700 mL clear yellow urine returned. Patient states, “Oh, I feel much better now.” Bladder is no longer palpable. Patient tolerated procedure without adverse event. —B. Clapp, RN UNEXPECTED SITUATIONS AND ASSOCIATED INTERVENTIONS No urine flow is obtained, and you note that catheter is in vaginal orifice: Leave catheter in place as a marker. Obtain new sterile gloves and catheter kit. Start the procedure over and attempt to place new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Because of the risk of cross-infection, never remove a catheter from the vagina and insert it into the urethra (Robinson, 2004). Patient moves legs during procedure: If no supplies have been contaminated, ask patient to hold still and continue with procedure. If supplies have been contaminated, stop procedure and start over. If necessary, get an assistant to remind the patient to hold still. Urine flow is initially well established and urine is clear, but after several hours flow dwindles: Check tubing for kinking. If patient has changed position, the tubing and drainage bag may need to be moved to facilitate drainage of urine. Patient complains of extreme pain when you are inflating balloon: Stop inflation of balloon. Balloon is most likely still in urethra. Withdraw the solution from the balloon. Insert catheter an additional 0.5 to 1 inch (1.2 to 2.4 cm) and slowly attempt to inflate balloon again. Urine leaks out of meatus around the catheter: Do not increase the size of the indwelling catheter. Make sure the smallest sized catheter with a 10-mL balloon is used. Large catheters cause bladder and urethral irritation and trauma. Large balloon-fill volumes occupy more space inside the bladder and put added weight on the base of the bladder. Irritation of the bladder wall and detrusor muscle can cause leakage. If leakage persists, consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon. Underfilling the balloon can cause the catheter to dislodge into the urethra, causing urethral spasm, pain, and discomfort. If you suspect underfill, do not attempt to push the catheter further into the bladder. Remove the catheter and replace. Assess the patient for constipation. Bowel full of stool can cause pressure on the catheter lumen and prevent the drainage of urine. Implement interventions to prevent/treat constipation (Mercer Smith, 2003; Robinson, 2004). SPECIAL CONSIDERATIONS General Considerations In the past, pretesting of the catheter balloon was recommended to prevent insertion of a defective catheter. Most catheter manufacturers in the United States no longer recommend pretesting because the balloons are pretested during the manufacturing process. Pretesting silicone balloons is not recommended; the silicone can form a cuff or crease in the balloon area that can cause trauma to the urethra during catheter insertion (Mercer Smith, 2003). Be familiar with facility policy and/or primary practitioner guidelines for the maximum amount of urine to remove from bladder at the time of insertion. If patient is unable to lift buttocks or maintain required position for the procedure, the assistance of another staff member may be necessary to place the drape under the patient and to help the patient maintain the required position. Supplies can be opened and prepared on the overbed table, moving the tray onto the bed just before cleansing the patient. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 624 Aptara 624 UNIT II 12-6 Promoting Healthy Physiologic Responses Catheterizing the Female Urinary Bladder continued If there is not an immediate flow of urine after the catheter has been inserted, several measures may prove helpful: Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles. Rotate the catheter slightly, because a drainage hole may be resting against the bladder wall. Raise the head of the patient’s bed to increase pressure in the bladder area. Assess the patient’s intake to ensure adequate fluid intake for urine production. Assess the catheter and drainage tubing for kinks and occlusion. If the catheter cannot be advanced, have the patient take several deep breaths. Rotate the catheter half a turn and try to advance. If you are still unable to advance, remove the catheter. Notify the primary care provider. Some catheter kits do not contain the catheter. This allows you to select a catheter and balloon size separately. Infant and Child Considerations Size 5F to 8F is used for infants and young children. Size 8F to 12F catheters are commonly used for older children (Hockenberry & Wilson, 2008). Distraction, such as blowing bubbles, deep breathing, or singing a song, can help the child relax. Lidocaine jelly is often used to anesthetize and lubricate the area before insertion of the catheter, decreasing the child’s discomfort and anxiety. Skill Variation Intermittent Female Urethral Catheterization 1. Check the medical record for the order for intermittent urethral catheterization. Review the patient’s chart for any limitations in physical activity. Bring the catheter kit and other necessary equipment to the bedside. Obtain assistance from another staff member, if necessary. Perform hand hygiene. Put on PPE, as indicated, based on transmission precautions. 2. Identify the patient. Discuss the procedure with the patient and assess the patient’s ability to assist with the procedure. Ask the patient if she has any allergies, especially to latex or iodine. 3. Close curtains around bed and close the door to the room, if possible. 4. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach. 5. Raise the bed to a comfortable working height. Stand on the patient’s right side if you are right-handed, patient’s left side if you are left-handed. 6. Put on disposable gloves. Assist the patient to dorsal recumbent position with knees flexed, feet about 2 feet apart, with her legs abducted. Drape patient. Alternately, use the Sims’, or lateral, position. Place the patient’s buttocks near the edge of the bed with her shoulders at the opposite edge and her knees drawn toward her chest. Slide waterproof drape under patient. 7. Put on clean gloves. Clean the perineal area with washcloth, skin cleanser, and warm water, using a different corner of the washcloth with each stroke. Wipe from above the orifice downward toward the sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene again. 8. Open sterile catheterization tray on a clean overbed table using sterile technique. 9. Put on sterile gloves. Grasp upper corners of drape and unfold drape without touching unsterile areas. Fold back a corner on each side to make a cuff over gloved hands. Ask patient to lift her buttocks and slide sterile drape under her with gloves protected by cuff. 10. Place a fenestrated sterile drape over the perineal area, exposing the labia, if appropriate. 11. Place sterile tray on drape between patient’s thighs. 12. Open all the supplies. Fluff cotton balls in tray before pouring antiseptic solution over them. Alternately, open package of antiseptic swabs. Open specimen container if specimen is to be obtained. 13. Lubricate 1 to 2 inches of catheter tip. 14. With thumb and one finger of nondominant hand, spread labia and identify meatus. If the patient is in the side-lying position, lift the upper buttock and labia to expose the urinary meatus. Be prepared to maintain separation of labia with one hand until catheter is inserted and urine is flowing well and continuously. 15. Use the dominant hand to pick up a cotton ball. Clean one labial fold, top to bottom (from above the meatus down toward the rectum), then discard the cotton ball. Using a new cotton ball for each stroke, continue to clean the other labial fold, then directly over the meatus. 16. With the uncontaminated, dominant hand, place drainage end of catheter in receptacle. If a specimen is required, place the end into the specimen container in the receptacle. 625 CHAPTER 12 Urinary Elimination Skill Variation Intermittent Female Urethral Catheterization 17. Using the dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra. Advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]). Do not force the catheter through the urethra into the bladder. Ask the patient to breathe deeply, and rotate the catheter gently if slight resistance is met as the catheter reaches external sphincter. 18. Hold the catheter securely at the meatus with the nondominant hand while the bladder empties. If a specimen is being collected, remove the drainage end of the tubing from the specimen container after required amount is obtained and allow urine to flow into receptacle. Set specimen container aside and place lid on container. 19. Allow the bladder to empty. Withdraw catheter slowly and smoothly after urine has stopped flowing. Remove equipment and dispose of it according to facility policy. Discard EVIDENCE FOR PRACTICE continued syringe in sharps container to prevent reuse. Wash and dry the perineal area, as needed. 20. Remove gloves. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position. 21. Put on clean gloves. Secure the container lid and label specimen. Send urine specimen to the laboratory promptly or refrigerate it. 22. Remove gloves and additional PPE, if used. Perform hand hygiene. Note: Intermittent catheterization in the home is performed using clean technique. The bladder’s natural resistance to the microorganisms normally found in the home makes sterile technique unnecessary. Catheters are washed, dried, and stored for repeated use. U.S. Department of Health and Human Services. Centers for Disease Control and Prevention. (2005). Guidelines for prevention of catheter-associated urinary tract infections. Available at http://www.cdc.gov/ncidod/dhqp/gl_catheter_assoc.html. Accessed April 10, 2009. Society of Urologic Nurses and Associates. (2005a). Care of the patient with an indwelling catheter: Clinical practice guideline. Available at www.suna.org/. Accessed November 15, 2005. Society of Urologic Nurses and Associates. (2005b). Female urethral catheterization: Clinical practice guideline. Available at www.suna.org/. Accessed November 15, 2005. These guidelines provide evidence-based recommendations to guide care for patients requiring catheterization of the urinary bladder. Recommendations are included related to the catheterization procedure, patient care once a catheter is in place, and prevention of catheter-associated urinary tract infections. 12-7 Catheterizing the Male Urinary Bladder Urinary catheterization is the introduction of a catheter (tube) through the urethra into the bladder for the purpose of withdrawing urine. Catheterization is considered the most common cause of nosocomial infections (infections acquired in a hospital). Therefore, catheterization should be avoided whenever possible. When it is deemed necessary, it should be performed using aseptic technique. Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. The indwelling urethral catheter is designed so that it does not slip out of the bladder. A balloon is inflated to ensure that the catheter remains in the bladder once it is inserted (Figure 1; Skill 12-6). The following procedure reviews insertion of an indwelling catheter into the male urinary bladder. The procedure for an intermittent catheter of a male bladder follows as a Skill Variation. Guidelines for caring for a patient with an indwelling catheter are summarized in Box 12-1, located within Skill 12-6. (continued) LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 626 Aptara 626 UNIT II Promoting Healthy Physiologic Responses 12-7 Catheterizing the Male Urinary Bladder continued EQUIPMENT Sterile catheter kit that contains: Sterile gloves Sterile drapes (one of which is fenestrated [having a window-like opening]) Sterile catheter (Use the smallest appropriate-size catheter, usually a 14F to 16F catheter with a 5- to 10-mL balloon [Mercer Smith, 2003; Newman, 2008]). Antiseptic cleansing solution and cotton balls or gauze squares; antiseptic swabs Lubricant Forceps Prefilled syringe with sterile water (sufficient to inflate indwelling catheter balloon) Sterile basin (usually base of kit serves as this) Sterile specimen container (if specimen is required) Flashlight or lamp Waterproof, disposable pad Sterile, disposable urine collection bag and drainage tubing (may be connected to catheter in catheter kit) Velcro leg strap or tape Disposable gloves Additional PPE, as indicated Washcloth and warm water to perform perineal hygiene before and after catheterization ASSESSMENT Assess the patient’s normal elimination habits. Assess the patient’s degree of limitations and ability to help with activity. Assess for activity limitations, such as hip surgery or spinal injury, which would contraindicate certain actions by the patient. Assess for the presence of any other conditions that may interfere with passage of the catheter or contraindicate insertion of the catheter, such as urethral strictures or bladder cancer. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, traction, or any other devices that could interfere with the patient’s ability to help with the procedure or that could become dislodged. Assess bladder fullness before performing procedure, either by palpation or with a handheld bladder ultrasound device, and question patient about any allergies, especially to latex and iodine. Ask the patient if he has ever been catheterized. If he had an indwelling catheter previously, ask why and for how long it was used. The patient may have urethral strictures, which may make catheter insertion more difficult. If the patient is 50 years of age or older, ask if he has had any prostate problems. Prostate enlargement typically is noted around the age of 50 years. Assess the characteristics of the urine and the patient’s skin. NURSING DIAGNOSIS Determine the related factors for the nursing diagnosis based on the patient’s current status. Appropriate nursing diagnoses may include: Impaired Urinary Elimination Urinary Retention Risk for Infection Risk for Impaired Skin Integrity Risk for Injury OUTCOME IDENTIFICATION AND PLANNING The expected outcome to achieve when inserting a male urinary catheter is that the patient’s urinary elimination will be maintained, with a urine output of at least 30 mL/hour, and the patient’s bladder will not be distended. Other appropriate outcomes may include the following: the patient’s skin remains clean, dry, and intact, without evidence of irritation or breakdown; and the patient verbalizes an understanding of the purpose for, and care of, the catheter, as appropriate. IMPLEMENTATION ACTION R AT I O N A L E 1. Review chart for any limitations in physical activity. Confirm the medical order for indwelling catheter insertion. Physical limitations may require adaptations in performing the skill. Verifying the medical order ensures that the correct intervention is administered to the right patient. 2. Bring catheter kit and other necessary equipment to the bedside. Obtain assistance from another staff member, if necessary. Bringing everything to the bedside conserves time and energy. Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse. Assistance from another person may be required to perform the intervention safely. LWBK545_C12_p595-659.qxd 8/6/10 8:10 PM Page 627 Aptara CHAPTER 12 Urinary Elimination ACTION 627 R AT I O N A L E 3. Perform hand hygiene and put on PPE, if indicated. Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions. 4. Identify the patient. Identifying the patient ensures the right patient receives the intervention and helps prevent errors. 5. Close curtains around bed and close the door to the room, if possible. Discuss the procedure with the patient and assess patient’s ability to assist with the procedure. Ask the patient if he has any allergies, especially to latex or iodine. This ensures the patient’s privacy. This discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. Some catheters and gloves in kits are made of latex. Some antiseptic solutions contain iodine. 6. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach. Good lighting is necessary to see the meatus clearly. A readily available trash receptacle allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field. 7. Adjust the bed to a comfortable working height, usually elbow height of the caregiver (VISN 8 Patient Safety Center, 2009). Stand on the patient’s right side if you are righthanded, patient’s left side if you are left-handed. Having the bed at the proper height prevents bac

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