E

urinary catheters part 2

Self-care and functional status in urinary health

  • Assess patient’s ability to perform self-care cognitively and physically

    • Balance issues

    • Assistance needed with toileting

    • Safety concerns regarding urination and daily care

  • Culture of consideration

    • Be sensitive to everyone’s background; recognize that social cues vary

  • Recognize social cues in communication

    • Eye contact, response style, openness

    • Reasons for behavior may be cultural, not personal

    • Terminology: adapt language to the audience (e.g., say "urination" or "go number one" instead of medical jargon like "dysuria")

  • Gender- and anatomy-related considerations

    • Ask about gender-specific alterations (e.g., prostate issues, pelvic organ prolapse)

    • Pelvic floor muscles can affect urinary function; childbirth history may contribute

  • Health literacy and education planning

    • Assess literacy level for health-related discussions

    • Not everyone understands terms like UTI or the letters U-T-I; adapt explanations

    • Literacy can differ from age appearance

  • Illness understanding and assessment of prior knowledge

    • Determine what patients understand about common urinary conditions

  • Nursing history questions to gauge urinary function

    • Classic prompts: troubles voiding, frequency, nocturia, hesitancy, urgency, incontinence

    • Ask about intake (what they drink, how much per day) and any pain on urination

    • Consider age-appropriate explanations and the patient’s level of comprehension

Intake and Output (I&O) concepts

  • I&O purpose

    • Monitor kidney and bladder function

    • Assess fluid balance and potential imbalances

  • Intake definitions

    • IV fluids, oral liquids, semiliquids (e.g., soups)

    • All intake counts toward the 24-hour total

  • Typical 24-hour intake reference

    • About 2300 \, ext{mL} (varies with conditions like heart failure or kidney disease)

    • If fluid restrictions apply, adjust accordingly

  • Output definitions

    • Urine output, emesis (vomit), gastric drainage, wounds/drains (e.g., Jackson-Pratt), etc.

  • Monitoring guidelines

    • If on strict I&O orders, document all intake and output precisely

    • Nursing judgments may prompt more frequent checks outside ordered intervals

  • Urinary output importance

    • Indicator of kidney/bladder function and overall fluid balance

  • Urine output thresholds

    • Normal: ext{Output} \,\ge\;30\;\text{mL/hour}

    • If output falls below 30 mL/hour for two consecutive hours, notify the physician

Urinary symptoms and history assessment

  • Common symptoms to inquire about

    • Dysuria, frequency, urgency, nocturia, hematuria (blood in urine), flank or abdominal pain

    • Fever, burning or pain with urination, incontinence, dribbling, difficulty starting urination

  • Onset, duration, and severity

    • Record when symptoms started, how long they’ve lasted, and how severe they are

  • Impact on daily living

    • Social withdrawal, reduced outings due to incontinence or discomfort

    • Hydration status and dehydration risk due to urinary symptoms

  • Predisposing factors to explore

    • History of heart failure, diabetes, prior surgeries or childbirth, obesity, meds or foods affecting urine

Physical assessment of urinary system

  • Kidney assessment

    • Percussion of costovertebral angle (CVA) to assess for kidney tenderness

  • Bladder assessment

    • Palpation for distension above pubic symphysis; a full bladder may feel as a smooth, rounded mass

  • External genitalia and urethral assessment

    • Female: inspect labia and perineal skin; retract folds for a full view

    • Male: assess foreskin, retract if uncircumcised to inspect glans and urethral meatus; return foreskin to its original position after examination

    • Ensure a clean, dry field to prevent irritation and injury

  • Perineal skin assessment

    • Look for moisture-related irritation, redness, itching, burning

Urine sample collection and analysis: methods and considerations

  • Types of urine samples

    • Random (routine urinalysis) or midstream clean-catch

    • Catheterized sample: from catheter tubing port or catheter bag

    • Sterile specimen vs clean specimen definitions

  • First-void considerations

    • Morning voids can be cloudy due to concentration; subsequent voids should be clearer

  • Sample collection basics

    • For random/midstream: use clean catch with proper cleaning and initiation of urine stream

    • For sterile catheter specimen: clamp catheter briefly, withdraw from port with a sterile syringe, then transfer to sterile cup

    • Do not rely on urine in the catheter bag for clean samples due to bacterial growth

  • Specific collection equipment

    • Urine hat (Texas hat) vs graduated container for measurement

    • Use a graduated cylinder for accurate measurements when documenting volumes

  • 20 mL minimum for routine urinalysis

  • Culture and sensitivity (C&S) samples

    • If a culture is needed, obtain from sterile catheter specimen or other sterile source

    • Culture: identify the organism; Sensitivity: identify effective antibiotics

  • Interpreting urinalysis results

    • Key components: pH, protein, glucose, ketones, blood, specific gravity, WBCs, bacteria, crystals

    • Note normal ranges: pH generally 4.6 \,\le\;pH\;\le\;8.0; protein indicates possible nephron/glomerular damage if elevated; glucose may indicate hyperglycemia; ketones indicate fatty-acid metabolism or dehydration; blood may indicate infection or trauma; specific gravity reflects hydration status

  • Color, clarity, and odor guidance

    • Color: clear to pale yellow is well hydrated; dark amber/orange indicates concentration/dehydration; pink/red may indicate blood; blue/green can be from certain dyes or foods; brown may reflect diet or medications; white/milky could indicate minerals like calcium

    • Clarity: clear, slightly cloudy, cloudy, turbid (very cloudy)

    • Odor: normal is mildly ammonia-like; strong smells can indicate infection or dietary factors (asparagus, certain foods)

  • First void considerations and documentation

    • First void of the morning may be cloudy; verify with multiple samples if needed

Urine analysis interpretation: list of parameters

  • pH: 4.6 \le pH \le 8.0

  • Protein: marker of glomerular or tubular damage if elevated

  • Glucose: indicates hyperglycemia or poor diabetic control; not always pathologic if recently ingested carbohydrates

  • Ketones: can indicate starvation, dehydration, or high-fat metabolism; associated with diabetes in poor control or low caloric intake

  • Blood: indicates injury or disease in urinary tract; dark red vs bright red suggests origin (kidney vs bladder/urethra)

  • Specific gravity: dehydration yields higher gravity; overhydration yields lower gravity

  • White blood cells (WBCs): inflammation or infection

  • Bacteria: infection or contamination; chronic catheters can yield bacteria without symptoms

  • Crystals: can indicate stone formation or metabolic issues

  • Uric acid crystals: associated with gout or stone formation

Imaging and diagnostic tests for urinary issues

  • X-ray (KUB): kidneys, ureters, and bladder; noninvasive; may show stones

  • CT (computed tomography)

    • With contrast: detailed anatomy; assess allergies to iodine/shellfish; ensure hydration post-test

    • Without contrast: alternative if contrast is contraindicated

  • IV contrast considerations

    • Allergies to iodine/shellfish; pre-test assessment and informed consent

    • Hydration to protect kidney function; monitor urine output after contrast

  • IV pyelogram (IVP): similar goals to CT but uses contrast; assesses stones, tumors, obstructions

  • Ultrasound: detects masses, obstructions, and can assess post-void residual

  • Cystoscopy (invasive): direct visualization of bladder via urethra; possible biopsy or instillation of treatments

  • CT vs others: CT is often considered the gold standard for many urinary tract evaluations; choice depends on clinical scenario and allergy history

  • Contrast-related patient education

    • Some people may feel warmth or flushed when contrast is given; monitor for allergic reactions; encourage fluids to flush contrast

Urinary diagnostic tests: sample collection and sources

  • Random urinalysis: standard screening

  • Clean-void midstream sample: patient-cleaned and collected during initiation and midstream

  • Sterile catheter specimen: used when sterile sample is required

  • Specimen collection from catheter tubing (for culture)

    • Clamp catheter for 15 minutes, clean port, attach sterile syringe, draw sample, inject into sterile container

    • Unclamp after sampling to allow drainage

  • Suprapubic catheterization: surgically placed via suprapubic area; requires trained clinician; site care needed

  • External catheters

    • Condom catheters for men (noninvasive but often less secure)

    • PureWick (feminine external urine collection device) sits between labia and connects to suction; collects urine away from the perineal area

  • Catheter irrigation considerations

    • Closed bladder irrigation is common; open irrigation has higher infection risk

    • Continuous bladder irrigation (CBI) uses a three-lumen catheter and irrigation fluid to prevent clots after procedures like TURP

    • Intermittent catheter irrigation uses a sterile syringe to introduce irrigation fluid and then drain; must remain sterile

Catheter types, anatomy, and insertion technique basics

  • Catheter lumens

    • Double lumen: one for urine drainage, one for balloon inflation

    • Triple lumen: adds a third lumen for irrigation or bladder instillation

  • French sizing

    • Catheter size is measured in French; larger numbers mean larger diameter

    • Typical adult size: 14\text{F} or 16\text{F}; smaller sizes may be used for females when appropriate

  • Balloon sizing

    • Standard adult balloon: V_{balloon} = 10\;\text{mL}

    • For continuous bladder irrigation: balloon may be larger, e.g., V_{balloon} = 30\;\text{mL}

  • Coude catheter

    • Curved tip designed to bypass enlarged prostate; requires special training

  • Insertion considerations by gender

    • Female: insert approximately 1–1.5 inches beyond urethral opening; ensure urine return before advancing further

    • Male: advance to the bifurcation (where the urethra splits) for drainage; observe urine return as a sign of correct placement

  • Clean technique and hand positioning

    • Use sterile gloves; nondominant hand remains sterile during cleaning and insertion for females; keep that hand in place once cleaning starts

    • For males, manage the penis in an appropriate anatomical position during insertion

    • If misplacement occurs (e.g., catheter enters the vaginal opening in females), discard and start over with a new catheter

  • Documentation and safe practice reminders

    • Do not move the nondominant hand after initial cleaning until catheter is inserted

    • If resistance or pain occurs when inflating the balloon, withdraw slightly and reattempt advancement to ensure the catheter is in the bladder

Catheter drainage systems and maintenance

  • Drainage system configurations

    • Bed bag: hangs below bladder level; should not sit on the floor or side rail; clips enable attachment beneath bed

    • Leg bag: for ambulatory patients; typically used during the day; switch to bed bag at night due to capacity

    • Belly bag: hangs over the abdomen; includes a valve to prevent backflow into the bladder

  • Ensuring proper drainage and avoiding backflow

    • Keep the drainage bag below bladder level at all times

    • Avoid loops and deep pendents that can kink or trap urine

    • Check for kinks, loops, clots, and sediment that can obstruct flow

  • Catheter care and infection prevention

    • Clean around the urethral opening and perineal area with sterile technique

    • After cleaning, hold catheter at the urethral opening and clean outward with multiple cloths to prevent contamination

    • Empty the drainage bag when half full; do not overfill or leave it full for long periods

    • Maintain a closed drainage system; avoid disconnecting tubing unless a specific irrigation protocol is required

    • Perform catheter care at least every 8 hours and after bowel movements

  • Signs to monitor for catheter-related problems

    • Absence of drainage or reduced drainage: check for kinks or obstruction

    • Urine color and odor changes may indicate infection or complications

  • Suprapubic and external catheter considerations

    • Suprapubic catheters require ongoing site care and monitoring; less common and require surgical placement

    • External catheters (condom, PureWick) reduce skin contact with urine and are chosen based on patient needs and anatomy

Urinary irrigation: indications and methods

  • Continuous bladder irrigation (CBI)

    • Often used after urinary procedures (e.g., TURP) to prevent clot formation

    • Uses a three-lumen catheter with an irrigation solution flowing into the bladder and out to the drainage bag

    • Monitor for pink-tinged urine; initial bright pink may occur and should trend toward clearer urine

  • Intermittent bladder irrigation

    • Sterile technique using a 60 mL syringe and sterile saline; syringe connected to bladder via catheter; after irrigation, the solution drains back into the drainage bag

  • Open irrigation (uncommon and higher risk)

    • Involves disconnecting the system; generally avoided due to infection risk

Education, delegation, and scope of practice in urinary care

  • Delegation and scope of practice

    • Nurses: can administer medications and perform most catheter-related procedures with sterile technique

    • CNAs/PCAs: can assist with basic care activities (hygiene, feeding, positioning) and report observations, but cannot perform sterile catheter insertions, irrigation, specimen collection, or interpret data to change treatment

  • Examples of appropriate nursing education topics

    • Pelvic floor exercises (Kegels) and lifestyle modifications for incontinence

    • Hydration and urinary health, recognizing UTI signs and when to notify a clinician

    • Privacy, dignity, and environmental controls to promote normal urinary patterns

    • Bladder training and timed voiding to promote emptying

    • Avoid irritants (caffeine, certain artificial sweeteners) and encourage healthy fluids (water and appropriate beverages)

  • Evidence-based practice (EBP) in catheter care

    • Sterile technique reduces infection risk during insertion

    • Remove catheter as soon as clinically feasible to reduce infection risk

    • Use the smallest effective catheter size

    • Maintain a closed drainage system and prevent disconnections

    • Proper periurethral hygiene and routine catheter care are supported by evidence to reduce infections

Clinical scenario: nursing process and evidence-based care planning

  • Case example: Miss Grayson, a 75-year-old female with suspected UTI and worsening incontinence

    • Cues: fever, dysuria, frequency; postmenopausal; prior vaginal births; diabetes; increasing incontinence; social impact

    • Problem prioritization: stress incontinence related to weakened pelvic floor; risk for infection; risk for impaired skin integrity due to incontinence

    • Expected outcomes: patient will learn and demonstrate pelvic floor exercises; patient will verbalize steps for pelvic exercises; patient will report fewer than two episodes of daily incontinence after initiating exercises; maintain absence of urinary tract infection; resist urge to void for at least 15 minutes without leaking

    • Interventions: educate on Kegel exercises; hydration and hygiene; signs/symptoms of UTI and when to call the clinician; bladder training and lifestyle changes; dietary adjustments to reduce irritants; social and psychosocial support to reduce isolation

Summary of key concepts and practical takeaways

  • Always assess self-care abilities and adapt communication to health literacy and cultural context

  • Use accurate but understandable terms when discussing urinary issues with patients

  • Monitor I&O meticulously; know normal ranges and action thresholds (e.g., <30 mL/h for 2 consecutive hours requires notification)

  • Understand sample collection methods, including the limitations of catheter bag samples and the proper use of sterile vs clean containers

  • Recognize the differences between sample types (random, midstream, sterile, catheter) and the appropriate use for each

  • Master catheter types, insertion techniques, and maintenance to prevent infections (closed system, appropriate sizing, minimal catheter duration)

  • Be aware of imaging and diagnostic options (KUB, CT with/without contrast, IVP, ultrasound, cystoscopy) and pre-test considerations (allergies, hydration, consent)

  • Apply evidence-based practices to reduce catheter-associated urinary tract infections (CAUTIs) and promote patient dignity and comfort

  • Use a structured nursing process approach in urinary care scenarios, including assessment, diagnosis, planning/outcomes, implementation, and evaluation