Urinary Elimination & Catheterization

urinary and renal systems are …

connected

what is the minimum amount of urine per hour

30mL/hr

physiological needs for urinary system (5)

• excretion of fluid and waste

• electrolyte levels/trends

• weight

• signs of fluid volume deficit

• signs of fluid volume overload

4 parts of nursing care with urinary elimination

1. helping a patient to toilet or bedside commode (BSD)

2. assisting with urinal

3. assisting with bedpan

4. performing catheterization

can assisting a patient with a urinal be delegated to an NAP

yes

4 safety guidelines with urination

1. call bell within reach

2. offer for assistance at regular intervals

3. fall prevention

4. monitor for changes in elimination

how to prevent UTIs (5)

1. adherence to standard precautions

2. proper routine perineal hygiene and catheter care

3. sterile catheterization technique

4. do not break the closed catheter tubing system

5. keep collection bag below level of bladder

4 things to assess with urinary system

1. fluid intake

2. conditions that cause incomplete bladder emptying/blocked urinary tract

3. suppressed immune system

4. other risk factors

for patient centered care a nurse must enhance safety and minimize risk for infection while …

1. understanding patient values and preferences

2. adopting procedures to minimize the invasive nature of catheterization

3. maintaining a patients dignity and respect

4. respecting cultural practices related to elimination, privacy, and gender-specific care

10 factors effecting urination

1. fluid intake

2. renal function

3. disease conditions

4. age

5. muscle tone

6. medications

7. diagnostic testing

8. surgery

9. psychological

10. sociocultural

5 reasons for catheterization

1. operative/postoperative

2. distention/retention

3. sterile specimen

4. post-voiding residual (PVR) measurement

5. long term management of incontinence

2 types of urinary catheterrs

1. straight/intermittent

2. indwelling

3 styles of urinary catheters

1. single lumen (straight/intermittent)

2. double lumen (indwelling)

3. triple lumen (indwelling)

catheter size for adults

14 to 16 Fr

catheter size for older adults

may need smaller 12-14 Fr

size of balloon for adults

5cc-10cc

size of balloon for urologic surgery patients

30 mL

can the task of inserting a straight or indwelling urinary catheter be delegated to an NAP

no

what can the NAP do with catheterizaiton

1. help with patient care

2. report to the nurse post procedure of pt discomfort or fever

3. report changes in urine or catheter

4. empty bag/I&O

8 things for documentation/recording with catheterization

1. reason for catheter

2. type and size

3. amount of fluid used to inflate balloon

4. if specimen was collected

5. how it was secured to pt

6. characteristics and amount of urine

7. patients response to procedure

8. education provided

what to report to MD with catheterization

any persistent catheter-related pain, inadequate urine output, and discomfort

the urethral meatus of an older woman may be difficult to identify because of …

urogenital atrophy

symptoms of UTI are … especially in older adults because …

difficult to recognize; change in mental status or fever

2 reasons for increased risk for UTI

1. increased prevalence of chronic disease (DM and BPH)

2. higher prevalence of incontinence

5 preparations for catheterization

1. providers orders

2. assess individual considerations

3. patient education

4. patient positioning

5. sterile technique

5 unexpected outcomes with catheterization

1. high volume of initial output

2. continued or worse bladder discomfort

3. unable to advance catheter

4. no urine return

5. leakage of catheter

8 parts of catheter care

1. loosen catheter from securement

2. perineal hygiene first, then clean catheter with new wipe/cloth

3. clean 2 inches closest to urinary meatus and clean down tubing

4. secure tubing with fingers to stabilize while cleaning

5. rinse if using soap on washcloth

6. every 8 hours or sooner if gross contamination

7. secure to leg to prevent accidental removal

8. never raise bag higher than the bladder

care/removal of an indwelling catheter

• ensure catheter balloon is fully deflated before removal

• make sure pt has urinary movement after removal

• use a bladder scan to monitor function

• watch for symptoms of UTI even after removal

can performing routine catheter care be delegated to a UAP

yes

can removing an indwelling catheter be delegated to a UAP

yes

7 parts of recording/documentation with catheter removal

1. time of removal

2. amount of water removed from balloon

3. condition of urethral meatus and catheter tip

4. perineal care provided

5. time, amount, and characteristics of first voided urine

6. education related to catheter care, removal, and fluid intake

7. report hematuria, dysuria, inability or difficulty voiding, and any new incontinence after removal

CAUTI

catheter associated urinary tract infection

7 prevention practices to avoid CAUTI

1. aseptically inserting urinary catheters

2. limiting use of indwelling catheter

3. using smallest catheter possible

4. cleansing urethral meatus daily

5. maintaining closed drainage system

6. maintaining free urine flow

7. avoiding urethral trauma

bladder scanner assesses …

bladder volume

PVR

post void residual

when to measure PVR

within 5 to 15 minutes of voiding

can the task of measuring bladder volume by bladder scan be delegated to an NAP

yes

how to obtain a sterile specimen collection from an indwelling catheter

• clamp for 15 mins

• disinfect port

• use 30 mL syringe

• transfer into clean/sterile container

• label

• unclamp tubing

a patient with a suprapubic catheter complains of lower abdominal pain. he is lying in bed on his left side and the nurse notices that the flow of urine has stopped. what should the nurses first action be?

reposition patient

catheter irrigation may be _______ or _______

continuous or intermittent

2 types of catheter irrigations

1. closed

2. open

can the task of catheter irrigation be delegated to an NAP

no

8 parts of recording/documentation of catheter irrigation

1. record irrigation method

2. amount of and type of irrigation solution

3. amount return as drainage

4. characteristics of output

5. urine output

6. pt tolerance

7. report occlusion, sudden bleeding, infection, or increased pain

8. record I&O

how to apply a condom-type external catheter

• available in silicone or latex

• held in place with adhesive or an external strap

• may be used with small or large volumes

• may be associated with less risk of UTI than indwelling

can the task of applying a condom catheter be delegated to an NAP

yes

5 parts of recording/documentation of condom application

1. condition of penis, skin, and scrotum

2. record application

3. urinary output

4. voiding pattern

5. report penile erythema, rashed, and/or skin breakdown

suprapubic catheter

• surgically inserted

• may be sutured to skin, secured with adhesive, or retained with fluid filled balloon

can the task of caring for a NEWLY established suprapubic catheter be delegated to an NAP

no

can the task of caring of an ESTABLISHED suprapubic catheter be delegated to an NAP

yes

4 parts of recording/reporting suprapubic catheter

1. record and report character of urine and type of dressing change

2. assessments of insertion site

3. patient comfort level with catheter and dressing change

4. record urine output on I&O flow sheet

a nurse is caring for a patient with an indwelling urinary catheter. which action is most
appropriate to prevent catheter-associated urinary tract infection (CAUTI)?

check tubing for kinks or clots

the nurse is monitoring a patient with a suprapubic catheter. which findings require
intervention?

• cloudy urine with sediment

• suprapubic drainage and redness

• urine output of 15 mL over 4 hours

• patient reporting lower abdominal pain

after removing an indwelling catheter, which patient behavior indicates successful
bladder function?

voiding 30 mL within 6 hours

a nurse is caring for a patient with continuous bladder irrigation (CBI) following a
transurethral resection of the prostate (TURP). the patient reports bladder spasms and
the nurse notices decreased outflow. what is the next action that the nurse should
perform

check the tubing for kinks or clots

a patient is 12 hours post indwelling catheter removal. which finding indicates the
nurse should notify the healthcare provider?

bladder scan shows 650 mL of urine

what are signs and symptoms of fluid volume overload?

edema, weight gain, hypertension, bounding pulses, crackles in lungs, dyspnea, jugular vein distention, decreased oxygen saturation

what are signs and symptoms of fluid volume deficiency (dehydration)?

weight loss, hypotension, tachycardia, weak pulse, dry mucous membranes, decreased skin turgor, decreased urine output, concentrated urine, dizziness

what urinary elimination tasks can be delegated to a UAP?

measuring intake and output, assisting with toileting, emptying catheter bags, providing perineal care (not sterile), reporting abnormal findings

what urinary tasks should NOT be delegated to a UAP?

catheter insertion, sterile catheter care, assessment of urine, patient education, clinical judgment tasks

what should be documented for urinary elimination?

amount color, clarity, odor of urine, time of voiding, method (voiding, catheter, etc.), patient response, any abnormalities.

what should be documented specifically for catheter use?

catheter type and size, insertion time/date, urine characteristics, output amount, patient tolerance, reason for catheter

when should perineal care be performed?

daily, after bowel movements, and before/after catheter care

when should catheter care be performed?

at least once per shift and after bowel movements

what is an indwelling (Foley) catheter?

catheter left in the bladder for continuous drainage with an inflated balloon to hold it in place

what is a straight catheter?

temporary catheter inserted to drain the bladder and then removed immediately

what is a suprapubic catheter?

catheter inserted surgically through the abdomen directly into the bladder

what are common breaks in sterility during catheter insertion?

touching sterile equipment with non-sterile hands, letting catheter touch non-sterile surfaces, improper field setup

how should a catheter be properly anchored?

secured to the thigh (female) or abdomen/thigh (male) to prevent pulling and trauma

how should the bedside drainage bag be positioned?

below bladder level, never on the floor, tubing free of kinks

what are key differences in female vs male catheter insertion?

• Female: shorter urethra, insert ~2–3 inches

• Male: longer urethra, insert ~6–9 inches

• Male: hold penis at 90° angle

• Female: identify urethral opening between labia

what are special considerations for male catheter insertion?

higher risk of resistance, possible enlarged prostate, never force insertion

what are special considerations for female catheter insertion?

higher risk of contaminating sterile field due to anatomy, may need assistance to visualize urethra