Urinary Elimination and Catheterization

Labs and Hydration Status

• Labs, including Complete Metabolic Panels (CMPs), indicate hydration status.
• Fasting labs may show elevated BUN and creatinine due to lack of fluid intake before the test.
• Trending values are more important than single values. Monitor if BUN and creatinine are trending up or down.
• Early intervention involves identifying the reason for changes and holding nephrotoxic medications to prevent kidney damage.
• Monitor kidney function, electrolyte balance, water balance, and hydration status for medication management and to prevent drug toxicity.
• Elderly patients with impaired renal function are particularly susceptible to drug toxicity.

BUN (Blood Urea Nitrogen)

• BUN, often pronounced as "fun", is done in conjunction with creatinine.
• Both BUN and creatinine must be elevated or low to indicate kidney issues.
• Normal range: 7 to 20 milligrams per deciliter (varies by lab).
• Elevated BUN is a primary concern, but low BUN can indicate malnutrition.
• Elevated BUN can be due to a high-protein diet or GI bleed.

Clinical Examples

• High BUN with elevated creatinine suggests kidney impairment.
• Isolated high BUN may point to dehydration.
• BUN measures the metabolism of protein.

Creatinine

• Creatinine indicates normal metabolism/breakdown of muscle.
• High creatinine can indicate kidney function issues or dehydration.
• Monitor medication dosages to avoid toxicity if creatinine is high.

Clinical example:

• If creatinine levels increase, monitor urine output and fluid balance and report to the provider.
• Creatinine is more accurate for kidney function than BUN. Both are typically tested together.
• Elevated creatinine can occur during muscle breakdown or with a high-protein diet.
• Creatinine levels are typically lower in women due to lower muscle mass.
• Sugary foods and caffeine usually do not impact creatinine unless levels are trending upwards with dehydration.

Urine Specific Gravity

• Urine specific gravity is a urine test performed using reagent strips.
• Urine samples collected in the morning have higher solute concentrations.
• Normal range: 1.003 to 1.03 (or 1.005 based on the lab).
• Reagent strips test for ketones, bilirubin, glucose, and solutes.
• High urine specific gravity indicates high solute density (e.g., in UTIs due to leukocytes).
• Strips also assess for leukocytes, nitrates, liver function, protein, pH, and blood.
• If the test shows low specific gravity at bedside, redo it.

Dipstick procedure:

• Dip the strip, dry it off, and compare it to the color chart.
• The strip can also be pH.

Urinary Tract Infections (UTIs)

• UTIs often present with elevated specific gravity, BUN, and creatinine.
• Classic UTI symptoms: frequency, urgency, dysuria (burning and difficulty urinating), hematuria (blood in urine), and cloudy urine with white blood cells.
• Elderly patients may only exhibit acute confusion without typical UTI symptoms (abdominal pain, fever).

Elderly and UTIs

• Acute confusion should prompt a UTI test.
• Immobility can increase the risk of UTIs in the elderly and those with Alzheimer's.
• UTIs can be fatal in the elderly.
• Older patients might not exhibit fever; confusion, increased falls, and behavioral changes are more common.

Cystitis and Pyelonephritis

• Cystitis is inflammation of the bladder associated with UTIs.
• Pyelonephritis occurs when the infection ascends to the kidneys.
• The goal with UTIs is prompt treatment and education to prevent sepsis.

Causes and Risk Factors for UTIs

• Nosocomial infections, particularly catheter-associated UTIs (CAUTI), are a primary cause.
• Half of catheterized patients develop a UTI within the first week.
  • Other risk factors: sexually active women, spermicide use, pregnancy (hormones and pressure), postmenopausal women (lack of estrogen causing vaginal atrophy).
• Spermicides disrupt natural microorganisms and change mucosa.
• Not urinating after intercourse allows bacteria to migrate to the bladder.
• Diabetes: high sugar levels promote bacterial growth. Retain urine because of lack of that's not as elastic. Their bladder just go back to shape, so they retain.
• Enlarged prostate causes urinary retention, promoting bacterial growth.

Prevention Education

• Urinate after intercourse to wash out the urethra.
• Drink plenty of water (but not excessively).
• Avoid baths, especially bubble baths; if taken, urinate afterward.
• Wipe front to back for females.
• Wear cotton underwear.
• Limited evidence supports cranberry or blueberry juice to prevent bacteria from adhering to the bladder walls.
• Avoid bubble baths. Sometimes go through several antibiotics
• Medications like Azo or Pyridium (turns urine orange) can help with bladder spasms.
• UTIs may resolve on their own, but antibiotics are best.

Urinary Incontinence:

• Incontinence (involuntary urine loss) does not cause UTIs; however, incontinence is not a normal sign of aging, although its prevalence increases with age.

Causes and Concerns

• Acronyms can help remember causes, such as "DIAPPERS" or "BRIEFS" (not specified what each stands for).
• Decreased cognition, sensation, restricted mobility, and infections (like UTIs) can lead to incontinence.
• Medications, especially diuretics, can cause urinary incontinence.
• One in four women experience incontinence.
• Major concern: skin breakdown due to urine acidity (turns alkaline and causes breakdown).
• Keep skin clean, dry, and use barrier creams.
• Other causes: vaginal deliveries, pelvic floor trauma, perimenopause, high BMI, and cigarette smoking.

Types of Incontinence

• Stress incontinence: Increased intra-abdominal pressure due to weak pelvic floor (childbirth, pelvic surgeries). Causes urine leakage when jumping, jogging, coughing, sneezing, or laughing.
• Urge incontinence: Sudden need to urinate with loss of urine before reaching the bathroom, often associated with overactive bladder or UTIs.
• Mixed incontinence: Combination of stress and urge incontinence, common in older females.
• Reflex incontinence: Unconscious, involuntary urination due to a full bladder without awareness; internal and external sphincters release.
• Functional incontinence: Physical or cognitive impairments prevent getting to the toilet or managing clothing (ADLs).
• Transient incontinence: Short-lived, often due to diuretics or UTIs.
• Overflow incontinence: Blockage prevents complete bladder emptying, causing constant leakage; often due to enlarged prostate or fecal impaction; can also result from neurological disorders.

Case Example: Mrs. Patel

• Likely has urge incontinence (overactive bladder) and functional incontinence (difficulty reaching the bathroom).
• Also experiencing transient incontinence due to a UTI.

Risk factors:

• Age, decreased mobility, stairs, diabetes.

Non-pharmacological Interventions

• Bladder retraining and scheduled voiding. Go to the bathroom every 1-2 hours.
• Pelvic floor rehabilitation (Kegels).
  • To perform Kegels, tighten the pelvic floor muscles and hold for ten seconds; repeat 30-80 times daily.
• Use of vaginal weights to build pelvic floor strength.
• Keep a diary; schedule restroom breaks.

Management Strategies

• Those with overflow incontinence may self-catheterize.
• Biofeedback helps patients perform Kegels correctly.
  • Electrodes and ultrasound show which muscles are contracting.
• Supportive interventions include peri-care.
• Make sure Cognitive impairment patients follows a scheduled voiding plan.

Lifestyle Modifications

• Weight loss (if high BMI).
• Smoking cessation.
• Reduce caffeine (bladder irritant and diuretic).
• Reduce sugary drinks.

Surgical Interventions

*   Bladder sling: Holds the bladder up so it tilts better and empties.
*   Bladder augmentation: Wraps the bladder to aid squeezing.
*   Bulking agents (collagen) can be injected into the urethra.
*  Botox injections are used for urge incontinence.
* Artificial sphincter: Implanted device that closes the urethra until the patient presses a button to open it.
*Sacral nerve stimulator: Helps with urge incontinence to prevent bladder spasms.
*Prostate resection: Can sometimes cause incontinence.

Devices

• Internal urethral meatal plug: One-time use, inserted into the urethra (mostly for stress incontinence).
• Pessary: Inserted vaginally to hold up pelvic organs and relieve bladder pressure (for prolapsed uterus or vagina).
• Penis clamp: External clamp to prevent leakage; used for elderly men with dementia.
• External collection devices: Condom catheters.
• PureWick: Female external catheter. Place soft side against urethra and vagina with constant suction. Has a reservoir.
• Male External Catheter.

Promoting Normal Urinary Elimination

• Ask when was the last time the patient urinated and their norms.
• Allow time to void; provide privacy.
• Best position: sitting (or standing for men).
• Encourage patients to take their time and not delay urination.
• Address retention issues.
• Teach and observe proper hygiene (meatus down or front to back).

Catheterization

• Catheterization should be a last resort and removed ASAP.
• Reasons to catheterize: sterile urine specimen (straight cath), urinary retention (measure post-void residual), pressure injury/bed sore protection, end-of-life comfort, surgical procedures.

Catheter Types include:

• Indwelling catheters (double lumen): Used for longer periods.
  • One side is for filling the balloon, the other connects to the drainage bag (Foley).
  • The pig tail is colored which indicates the balloon port.
  • It should tell you how many milliliters go into the balloon.
  • Do not overflow those balloon
• Straight catheters: Used for immediate drainage.
  *SILICONE CLEAN CATHETERS: Are tiny for self cathetering.

Care for Patients with Indwelling Catheters

*Five goals listed in book. Keep closed, flowing, and clean.

• Prevent CAUTI (catheter-associated urinary tract infection) as the number one goal.
  *Catheter care should be done at least every shift
• Do not disconnect the tubing, if you do sterilize before reattaching.
  *When emptying the drain do the tubing cannot touch the ground, always sterilize after venting.
  *Drain every 8 hours or half full
• Make sure that kink doesn't not exist.

Promoting Normal Urine Production

• Hydration.
  *Keeping the skin and mucosal tissues healthy is extremely important. Securing them with a stat lock. It's best if no powders or creams are being used on the insertion areas.

Catheter Skills Pass Off

• Prepare the Kit in the order listed. Place the hole in the same matter.
  *Males in the frog leg position
  *Left handed place on the left. opposite of right handed.
• When cleaning the perium. Use three wipes. discard one after each wipe.
• Remove gloves, wash hands, put on new gloves before opening the kit
  *Don't cross over things that need to be sterile.
  *Insert with Dominant hang and hold with the non dominant hand. You can't remove it.
  *For women it's where you see urine and 2 inches apart. Mens insert to bifurcation.
  *Tell patient to breath to prevent a clench.
  *Stay 2 cm apart from the area to prevent contaminating.

Interventions if Patient Doesn't Pee 12 Hours After Catheter Removal

• Do a bladder scan to see if there's anything
  *Take them to the restroom
  *Ask if they had any drink.
  *What's the norm from them
  *Has there been prostate re section to stop it from clumping.

Catheter Types and Their Functions

*Used a Valve catheter. Like a tap when you want to empty

• Suprapubic: Inserted through the abdomen; lower risk of UTI but long term usage. It goes past the urgthrow.

Urinary Diversions

• Ileal conduit (conventional urostomy): Surgical opening from ureters to outside.
  • Created for Bladder cancer, strictures and cystitis.
• Has characteristics mucous within the urine. It happens when the small intestine. Sowed pack together and creates a little hole.
  • Normal urine characteristics include mucus.
• Indiana pouch: Pouch inside body; patient catheterizes.

Care and Teaching for Urostomies

• Huge physical and and psychological challenge
• Teach them to take care of it.
  • Inspect stoma daily for these normal characteristics include a beefy red and must come after. And is dark pink and red.
  • Measure input and outputs. Empty half to 3/4 away
    *Keep free of odors.
  • It always gets moist and wet so keep it dry
  • Mucus is normal.
  • Give emotionsl support help them work it out themselves.