Urinary Elimination

Disease Conditions: Disease processes that affect urine elimination affect renal function (changes in urine volume or quality), the act of urine elimination, or both. Conditions that affect urine volume and quality are generally categorized as prerenal, renal, or postrenal in origin.

Decreased blood flow to and through the kidney (prerenal), disease conditions of the renal tissue (renal) and obstruction in the lower urinary tract that prevents urine flow from the kidneys (postrenal) sometimes alter renal function. Conditions of the lower urinary tract, including narrowing of the urethra, altered innervation of the bladder, or weakened pelvic and/or perineal muscles, affect urinary elimination.

Diabetes mellitus and neuromuscular diseases such as multiple sclerosis cause changes in nerve functions that can lead to possible loss of bladder tone, reduced sensation of bladder fullness, or inability to inhibit bladder contractions. Older men often suffer from benign prostatic hyperplasia (BPH), which makes them prone to urinary retention and incontinence. Some patients with cognitive impairments, such as Alzheimer’s disease, lose the ability to sense a full bladder or are unable to recall the procedure for voiding. Diseases that slow or hinder physical activity interfere with the ability to void. Degenerative joint disease and Parkinsonism are examples of conditions that make it difficult to reach and use toilet facilities.

Diseases that cause irreversible damage to kidney tissue result in end-stage renal disease (ESRD). Eventually the patient has symptoms resulting from uremic syndrome. An increase in nitrogenous wastes in the blood, marked fluid and electrolyte abnormalities, nausea, vomiting, headache, coma, and convulsions characterize this syndrome. As the uremic symptoms worsen, aggressive treatment is indicated for survival (Box 45-1). These treatments are renal replacement therapies.

Dialysis and organ transplantation are two methods of renal replacement. Dialysis takes one of two forms, peritoneal dialysis or hemodialysis. Patients can use both dialysis modalities for a short or long term, but they require specialized equipment and nurses with specialized education.

Peritoneal dialysis is an indirect method of cleaning the blood of waste products using osmosis and diffusion, with the peritoneum functioning as a semipermeable membrane. This method removes excess fluid and waste products from the bloodstream when a sterile electrolyte solution (dialysate) is instilled into the peritoneal cavity by gravity via a surgically placed catheter. The dialysate remains in the cavity for a prescribed time interval and then is drained out by gravity, taking accumulated wastes and excess fluid and electrolytes with it.

Hemodialysis requires a machine equipped with a semipermeable filtering membrane (artificial kidney) that removes accumulated waste products and excess fluids from the blood. In the dialysis machine dialysate fluid is pumped through one side of the filter membrane (artificial kidney) while a patient’s blood passes through the other side. The processes of diffusion, osmosis, and ultrafiltration clean the patient’s blood. Then the blood returns through a specially placed vascular access device (Gore-Tex graft, arteriovenous fistula, or hemodialysis catheter).

Organ transplantation is the replacement of a patient’s diseased kidney with a healthy one from a living or cadaver donor of compatible blood and tissue type. The new organ is surgically implanted into the abdomen. Special medications (immunosuppressives) are administered, often for life, to prevent the body from rejecting the transplanted organ. Unlike the other treatments, successful organ transplantation offers patients the potential for restoration of normal kidney function.

Sociocultural Factors: The degree of privacy needed for urination varies with cultural norms. North Americans expect toilet facilities to be private, whereas some European cultures accept communal toilet facilities. Social expectations (e.g., school recesses) influence the time of urination.

Psychological Factors: Anxiety and emotional stress cause a sense of urgency and increased frequency of urination. Anxiety often prevents a person from being able to urinate completely; as a result, the urge to void returns shortly after voiding. Emotional tension makes it difficult to relax abdominal and perineal muscles. Attempting to void in a public restroom sometimes results in a temporary inability to void. Privacy and adequate time to urinate are usually important to most people.

Fluid Balance: The kidneys primarily maintain the balance between retention and excretion of fluids (see Chapter 41). If fluids and the concentration of electrolytes and solutes are in equilibrium, an increase in fluid intake causes an increase in urine production. This amount varies with food and fluid intake. The volume of urine formed at night is about half of the volume formed during the day because both intake and metabolism decline. Nocturia (awakening to void one or more times at night) is often a sign of renal alteration. In a healthy person the intake of water in food and fluids balances the output of water in urine, feces, and insensible losses in perspiration and respiration. An excessive output of urine is polyuria. A urine output that is decreased despite normal intake is called oliguria. Oliguria often occurs when fluid loss through other means (e.g., perspiration, diarrhea, or vomiting) increases. It also occurs in early kidney disease. Often in severe kidney disease no urine is produced (anuria).

Ingestion of certain fluids directly affects urine production and excretion. Coffee, tea, cocoa, and cola drinks that contain caffeine promote increased urine formation (diuresis). Alcohol inhibits the release of antidiuretic hormone (ADH), also resulting in increased water loss in urine.

Febrile conditions affect urine production. A patient with excessive perspiration loses a large amount of fluids through insensible water loss, which decreases urine production. Fever causes an increase in body metabolism and accumulation of body wastes. Although urine volume is reduced, it is highly concentrated.

Surgical Procedures: The stress of surgery initially triggers the general adaptation syndrome (see Chapter 37). Preoperative orders of nothing-by-mouth or an underlying disease condition affect fluid balance before surgery, which reduces urine output. In addition, the stress response releases an increased amount of ADH, which increases water resorption. Stress also elevates the level of aldosterone, causing retention of sodium and water. Both of these substances reduce urine output in an effort to maintain circulatory fluid volume.

Anesthetics and narcotic analgesics slow the glomerular filtration rate, reducing urine output. These pharmacological agents also impair sensory and motor impulses traveling among the bladder, spinal cord, and brain. Patients are often unable to sense bladder fullness and initiate or inhibit micturition. Spinal anesthetics, in particular, create the risk of urinary retention because of an inability to sense the need to void and a possible inability of the bladder muscles and urethral sphincters to respond (Lewis et al., 2011).

Surgery of lower abdominal and pelvic structures sometimes impairs urination because of local trauma to surrounding tissues. After returning from surgery involving the ureters, bladder, and urethra, patients routinely have urinary catheters.

Medications: Many medications directly or indirectly contribute to urinary dysfunction. Antipsychotics, antidepressants, alpha-adrenergic agonists, and calcium channel blockers can cause urinary retention and overflow incontinence. Alpha-antagonists, diuretics, sedative hypnotics, opioid analgesics, angiotensin-converting enzyme (ACE) inhibitors, and antihistamines can cause urinary incontinence. Antiparkinson medications may cause urinary urgency and subsequent incontinence. Always consider these medications as the cause of new-onset urinary incontinence, especially in older adults.

Some medications change the color of urine. For example, phenazopyridine (Pyridium) colors the urine a bright orange to rust; amitriptyline causes a green or blue discoloration, whereas levodopa discolors the urine to brown or black. Cancer chemotherapy drugs also color the urine and are often toxic to the bladder and/or kidneys. Patients with impaired kidney function require dosage adjustments in medications excreted by the kidneys.

Diagnostic Examination: Examination of the urinary system influences micturition. Some procedures such as an intravenous pyelogram (IVP) require patients to limit fluids before the test. A restriction in fluid intake commonly lowers urine output. Diagnostic examinations (e.g., cystoscopy) involving direct visualization of urinary structures cause localized edema of the urethral passageway and spasm of the bladder sphincter. After the procedure, a patient may have difficulty voiding or have red or pink urine because of trauma to the urethral or bladder mucosa.

Urinary Retention: Urinary retention is an accumulation of urine resulting from an inability of the bladder to empty properly. Normally urine production slowly fills the bladder and prevents activation of stretch receptors until it distends to a certain level of stretch. The micturition reflex occurs, and the bladder empties. In urinary retention the bladder is unable to respond to the micturition reflex and thus is unable to empty. Urine continues to collect in the bladder, stretching its walls and causing feelings of pressure, discomfort, tenderness over the symphysis pubis, restlessness, and diaphoresis (sweating).

As retention progresses, retention with overflow develops. Pressure in the bladder builds to a point at which the external urethral sphincter is unable to hold back urine. The sphincter temporarily opens to allow a small volume of urine (25 to 60 mL) to escape. As urine exits, the bladder pressure falls enough to allow the sphincter to regain control and close. With retention a patient may void small amounts of urine 2 or 3 times an hour with no real relief of discomfort or may continually dribble urine. Be aware of the volume and frequency of voiding to assess for urinary retention. Assess the abdomen for evidence of bladder distention and tenderness.

In acute retention key signs are bladder distention and absence of urine output over several hours. A patient under the influence of anesthetics or analgesics often feels only pressure, but the alert patient has severe pain as the bladder distends beyond its normal capacity. In severe urinary retention the bladder holds as much as 2000 to 3000 mL of urine. Retention occurs as a result of urethral obstruction, surgical or childbirth trauma, and alterations in motor and sensory innervation of the bladder such as occurs with neuropathy secondary to diabetes. It may occur after removal of an indwelling catheter. Medication side effects or anxiety may also result in urinary retention. If a patient cannot void or completely empty the bladder, he or she must be catheterized because a UTI, kidney stones, and hyperreflexia can occur.

Retained or residual urine, also referred to as postvoid residual (PVR), occurs if a patient has urinary retention or cannot empty the bladder completely. You can use a portable noninvasive bladder ultrasound device (bladder scanner) or the technique of straight/intermittent catheterization to assess for PVR. Bladder scanners are often not readily available for nurses to use in all clinical settings, and straight/intermittent catheterization may be the only means to determine bladder urine volume. Regardless of the method used to determine PVR, assess the amount of urine left in the bladder within 10 to 15 minutes after a patient voids (Altschuler and Diaz, 2006). Instruct the patient not to void again before measurement. At least two residuals should be obtained since a patient may empty well one time and not the next. Spastic bladders and some medications and problems such as using a bedpan or not sitting upright to void cause inconsistent emptying. In normal micturition or in a normal void the bladder should empty completely.

Urinary Tract Infections: UTI is the most common health care–acquired infection; 80% of these infections result from the use of an indwelling urethral catheter (Lo et al., 2009). Catheterization results in over 1 million UTIs each year in the United States (Matteucci and Walsh, 2011). Infection frequently occurs after placement of urinary catheters, and each day a catheter is in place there is a 5% increase in bacteria in the urine (Saint et al., 2009). Catheter-associated UTIs (CAUTIs) are associated with increased hospitalizations, increased morbidity and mortality, longer hospital stay, and increased hospital costs (Newman, 2007). Each episode of CAUTI and ensuing complications are estimated to cost between $600 and $2800 (Saint et al., 2009). Because a CAUTI is common, costly, and believed to be reasonably preventable, as of October 1, 2008, the Centers for Medicare and Medicaid Services (CMS) chose it as one of the complications for which hospitals no longer receive additional payment to compensate for the extra cost of treatment (Saint et al., 2009). Consequently there has been a shift in reimbursement practices from its traditional focus on early recognition and prompt treatment to one of prevention (Wilson et al., 2009).

Although several different microorganisms cause CAUTIs, the patient’s own colonic flora, including Escherichia coli, remains the most common causative pathogen (Ksycki and Namias, 2009). Bacteriuria (bacteria in the urine) leads to the spread of organisms into the kidneys and possibly to bacteremia or urosepsis (bacteria in the bloodstream) (Lewis et al., 2011). Microorganisms commonly enter the urinary tract through the ascending urethral route. Bacteria inhabit the distal urethra and external genitalia in men and women and the vagina in women. Organisms enter the urethral meatus easily and travel up the inner mucosal lining to the bladder. Women are more susceptible to infection because of a short urethra and the proximity of the anus to the urethral meatus. In men prostatic secretions containing an antibacterial substance and the length of the urethra reduce the susceptibility to UTIs. However, men are at increased risk for infection-related renal disease. Older adults and patients with progressive underlying disease or decreased immunity are also at increased risk.

In a healthy person with good bladder function, organisms are flushed out during voiding. Residual (retained) urine in the bladder becomes more alkaline and is an ideal site for microorganism growth. Any condition resulting in urinary retention such as a kinked, obstructed, or clamped catheter increases the risk of a UTI.

Poor perineal hygiene is another cause of UTIs in women. Inadequate handwashing, failure to wipe from front to back after voiding or defecating, and frequent sexual intercourse predispose women to infection.

Patients with lower UTIs have pain or burning during urination (dysuria) as urine flows over inflamed tissues. Fever, chills, nausea, vomiting, and malaise develop as an infection worsens. An irritated bladder (cystitis) causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa results in blood-tinged urine (hematuria). The urine appears concentrated and cloudy because of the presence of white blood cells (WBCs) or bacteria. If infection spreads to the upper urinary tract (kidneys—pyelonephritis), flank pain, tenderness, fever, and chills are common.

Another common cause of infection is the introduction of instruments into the urinary tract. For example, the introduction of a catheter through the urethra provides a direct route for microorganisms (Nazarko, 2008). With an indwelling catheter bacteria ascend along the outside of the catheter on the urethral wall or travel up its lumen. Local irritation to the urethra or bladder predisposes tissues to bacterial invasion.

Urinary Incontinence: Urinary incontinence is the involuntary leakage of urine that is sufficient to be a problem. It can be either temporary or permanent, continuous or intermittent. Urinary incontinence related to urinary causes is called either stress or urge urinary incontinence (Palmer and Newman, 2007). Urge incontinence is more common in younger women and may be caused by local irritating factors such as UTIs (Ebersole et al., 2008). Individuals sense the urge to urinate but cannot keep from urinating long enough to reach a toilet. Stress incontinence occurs more often in older women when intraabdominal pressure exceeds urethral resistance. Muscles around the urethra become weak; thus even a small amount of urine may leak spontaneously (Ebersole et al., 2008). Some patients may have a mixed form of incontinence that has features of both stress and urge urinary incontinence. Table 45-5 on p. 1060 describes the types of urinary incontinence, their symptoms, and treatment interventions. Hyperactive or overactive bladder (OAB) is associated with individuals of all ages, but older adults are more likely to have incontinence associated with it following physical and cognitive decline associated with aging and effects of medications (Stewart, 2010). OAB results from sudden, involuntary contraction of the muscles of the urinary bladder, resulting in an urge to urinate (urge incontinence). Common abnormalities of the nervous system that cause OAB include cerebrovascular accident (CVA) and other head injuries, spinal cord injury, and diabetic neuropathy. Other causes include UTI and anxiety.

Approximately 15% to 30% of adult women experience urinary incontinence. It is present in as many as 30% to 70% of nursing home residents and in 30% of adults living at home (Touhy and Jett, 2010). Incontinence can impair body image and often leads to a loss of independence. Clothing becomes wet with urine, and the accompanying odor adds to the embarrassment. As a result, patients with this problem often avoid social activities. They often fail to discuss this condition with health care providers or nurses, and as a result urinary incontinence is underreported and undertreated. Resources for information about continence care, patient education, and treatment are available at the following websites: the Society for Urological Nurses and Associates (http://www.suna.org), the National Association for Continence (http://www.nafc.org), and the Simon Foundation (http://www.simonfoundation.org).

Physical limitations and environmental barriers are risks for incontinence. People with restricted mobility have greater chances of being incontinent because of their inability to reach toilet facilities in time. Low-set chairs and beds raised well above the floor are obstacles for people who must get up to reach a toilet. Some patients often lack the energy to walk very far at one time. The toilet is sometimes too far away for patients with urge incontinence. Patients who have difficulty undoing buttons or manipulating zippers face another obstacle.

Continued episodes of incontinence is a risk for impaired skin integrity. The character of urine changes when it remains in contact with skin, causing skin breakdown. The immobilized patient with frequent incontinence is especially at risk for pressure ulcers (see Chapter 48). Additional health care and patient education resources are available at the websites for the American Geriatrics Society (http://www.americangeriatrics.org) or the American Urogynecologic Society (http://www.augs.org).

Urinary Diversions: Conditions such as bladder cancer, radiation injury to the bladder, or chronic urinary infections may necessitate a urinary diversion to drain urine from a diseased or dysfunctional bladder. There are two types of continent urinary diversions (Fig. 45-4, A). One is a continent urinary reservoir that is created from a distal portion of the ileum and proximal portion of the colon. The ureters are embedded in the reservoir. This reservoir is situated under the abdominal wall and has a narrow ileal segment brought out through the abdominal wall to form a small stoma. The ileocecal valve creates a one-way valve in the pouch through which a catheter is inserted to empty the urine from the pouch. Patients must be willing and able to catheterize the pouch 4 to 6 times a day for the rest of their lives.

The second continent urinary diversion is an orthotopic neobladder that also uses an ileal pouch to replace the bladder. Anatomically the pouch is in the same position where the bladder was before removal, allowing patients to void normally.

Incontinent urinary diversions are less commonly performed. The surgery involves connecting the ureters to a section of the intestinal ileum with formation of a stoma on the abdominal wall (Fig. 45-4, B). Urine drains continuously because a patient has no sensation or control over urinary output, requiring the application of a collection pouch at all times.

Some patients need urinary drainage directly from one or both kidneys. In this case a tube is placed directly into the renal pelvis. This procedure is called a nephrostomy.

Any urinary diversion poses threats to a patient’s body image. The patient must learn how to manage the diversion, and those who do not have a continent urinary diversion must wear an artificial device at all times. However, most patients are able to wear normal clothing, engage in physical activity, travel, and have sexual relations. Care must be taken not to pull on tubing, especially in a nephrostomy, since it can be pulled out, causing tissue and organ damage and infection. Most nephrostomies are sutured into the kidney.

Refer patients with a urinary diversion to an ostomy nurse (a nurse with specialized education in this area). This specialist is a valuable resource for assisting a patient and family with matters pertaining to all aspects of care. The ostomy nurse often meets with the patient and family before surgery. In addition, refer the patient to the United Ostomy Associations of America (http://www.uoaa.org). This organization provides information about support groups to enhance coping and adaptation to lifestyle and body-image changes.

Pattern of Urination: Ask the patient about daily voiding patterns, including frequency and times of day, normal volume at each voiding, and any recent changes. Frequency varies among individuals and with intake and other types of fluid losses. The common times for urination are on awakening, after meals, and before bedtime. Most people void an average of 5 or more times a day. Some patients who void frequently during the night may have renal disease, prostate enlargement, or cardiac disease. Information about the pattern of urination establishes a baseline for comparison.

Symptoms of Urinary Alterations: Certain symptoms specific to urinary alterations may occur in more than one type of disorder. During assessment ask the patient about any symptoms related to urination (Table 45-1). Also assess whether the patient is aware of conditions or factors that precipitate or aggravate symptoms and determine what the patient does when any of these symptoms occur.

Note the presence of an indwelling catheter. It places a patient at risk for infection, catheter blockage, or skin-care problems. Monitor fluid balance through regular intake and output (I&O) measurements (see Chapter 41). Patients with a urinary diversion sometimes need special assistance to maintain adequate urine elimination and skin care integrity.

Skin and Mucosal Membranes: Observe the condition of the skin and mucosal membranes. Problems with urinary elimination are frequently associated with fluid and electrolyte disturbances. By assessing skin turgor and the oral mucosa you gather data about the patient’s hydration status. Urinary incontinence increases the risk for skin breakdown. Observe the perineum for rashes, blistering, irritation, and breakdown.

Kidneys: Nurses with advanced examination skills learn to palpate the kidneys during abdominal examination. The position, shape, and size of the kidneys reveal problems such as tumors; whereas tenderness indicates inflammation. Auscultation is sometimes performed to detect the presence of a renal artery bruit (sound resulting from turbulent blood flow through a narrowed artery).

Bladder: In adults the bladder rests below the symphysis pubis. When it is distended, it rises above the symphysis pubis at the midline of the abdomen and often extends to just below the umbilicus. On inspection you may note a swelling or convex curvature of the lower abdomen. Gently palpate the lower abdomen. The partially filled bladder normally feels smooth and rounded. Gentle palpation on a distended bladder causes the patient to feel the urge to urinate, tenderness, or even pain. Percussion of a full bladder yields a dull percussion note.

Urethral Meatus: Observe the urinary meatus for any discharge, inflammation, and lesions. To examine the female, a dorsal recumbent position provides full exposure of the genitalia. While wearing clean gloves, retract the labial folds to see the urethral meatus. Normally it is pink, it appears as a small slitlike opening below the clitoris and above the vaginal orifice, and there is no discharge; if discharge is present, obtain specimens of urethral discharge before the patient voids.

Women with vaginal infections are susceptible to UTIs because it is easy for the drainage to travel to the urethral meatus. If yeast (candidiasis) is found in urine, it is important to inspect the vagina, in the groin area, under the breasts, and in the mouth for the source. It needs to be treated to keep UTI from yeast recurring. Older women may have vaginitis as a result of estrogen deficiency. Inspect the vaginal orifice carefully for signs of inflammation and describe any drainage.

A man’s urethral meatus is normally a small opening at the tip of the penis. Inspect the meatus for discharge, inflammation, and lesions. It is necessary to retract the foreskin in uncircumcised men to see the meatus. Wear clean gloves when retracting the foreskin. Be sure to replace it after the examination is complete to prevent swelling of the tissue around the glans of the penis.

Intake and Output: Assess the patient’s average daily fluid intake. If you need an accurate measurement of fluid intake from the patient who is at home, ask him or her to estimate his or her intake by showing a measurement on a commonly used glass or cup.

In a health care setting measure a patient’s fluid intake either when the health care provider orders I&O measurements or when you judge that measurement is needed (see Chapter 41). A change in urine volume is a significant indicator of fluid alterations or kidney disease. While caring for the patient, use a graduated receptacle to measure urinary output from a bedpan or urinal after each voiding. Special receptacles (urimeters) that attach between indwelling catheters and drainage bags are a convenient means of accurately measuring urine volume. A urimeter holds 100 to 200 mL of urine. After measuring urine from a urimeter, drain the cylinder into the urinary drainage bag or into a receptacle for disposal. Use urimeters when precise hourly measurements of urine are necessary.

When you measure urine from a drainage bag, the use of a separate plastic graduated measuring receptacle obtains a more precise measurement of urine output (Fig. 45-6). Each patient needs to have a graduated receptacle for his or her exclusive use to prevent potential cross-contamination. Label each container with patient name. The container needs to be rinsed after emptying, and the tubing that drains the bag securely clamped and cleaned with alcohol before putting it back in the holder.

Report any extreme increase or decrease in urine volume. An individual’s daily output generally ranges from 1200 to 1500 mL of urine (Hall, 2011). An hourly output of less than 30 mL for more than 2 consecutive hours is cause for concern. Similarly, you need to report consistently high volumes of urine (polyuria) (i.e., over 2000 to 2500 mL daily).

Characteristics of Urine: Inspect the patient’s urine for color, clarity, and odor.

Urine Testing: Nurses often collect urine specimens for laboratory testing. The type of test determines the method of collection. Label all specimens with the patient’s name, date, and time of collection. Transport specimens to the laboratory in a timely fashion to ensure accuracy of test results. Agency infection control policies require the adherence to standard precautions by all personnel during specimen handling (see Chapter 34).

Common Urine Tests:

• Obtain a signed consent (check agency policy)

• Assess patient for history of any allergies and whether they have had a previous reaction to a contrast agent (Schabelman and Witting, 2010). Allergic individuals in general (including individuals with asthma) are at mildly increased risk for developing adverse reactions to radiocontrast media (Beaty, Lieberman, and Slavin, 2008).

• Administer bowel-cleaning medications as ordered (check agency policy)

• Ensure that patient receives appropriate pretest diet (clear liquids) or nothing by mouth (NPO) as needed

• Assessing I&O

• Observing characteristics of urine (color, clarity, presence of blood)

• Encouraging fluid intake, especially if using radiopaque dye

• Patient will void within 4 hours.

• Urinary output of 300 mL or greater will occur with each voiding.

• Patient’s bladder is not distended to palpation.

Patient Education: Success of therapies aimed at eliminating or minimizing urinary elimination problems depends in part on successful patient education (Box 45-6). Although many patients need to learn about all aspects of urinary elimination, first focus the teaching on their specific elimination problems. For example, patients who practice poor hygiene benefit most from learning about normal sterility of the urinary tract and how frequent handwashing and proper perineal hygiene reduce the risks for infection. Patients also learn the significance of symptoms of urinary alterations so they can initiate early preventive health care.

You can easily incorporate teaching when giving nursing care. For example, a good time to discuss the benefits of increasing fluid intake is while giving fluids with medications or meals. Often you are more successful in teaching about perineal hygiene while giving a bath or performing catheter care.

Promoting Normal Micturition: Maintaining normal urinary elimination helps to prevent many urination problems. Many nursing measures promote normal voiding in patients at risk for urination difficulties and in those with established urination problems. Some of these measures are independent nursing interventions.

Maintaining Elimination Habits: Many patients follow routines to promote normal voiding. In a hospital or long-term care facility health care routines often conflict with those of patients. Integrating patients’ habits into the care plan fosters normal voiding and helps prevent problems related to urination.

Maintaining Adequate Fluid Intake: A simple method of promoting normal micturition is maintaining optimal fluid intake. A patient with normal renal function who does not have heart or kidney disease needs to drink 2200 to 2700 mL of fluid daily. However, a minimal daily intake of 1200 to 1500 mL of fluids is usually adequate unless the patient has a history of UTI.

Increasing fluid intake helps flush out solutes or particles that collect in the urinary system. Because some patients are unwilling to drink 2500 mL of water daily, encourage fluids that the patient prefers. Many vegetables and fruits also have a high fluid content. At home it helps to set a schedule for drinking fluids (e.g., with meals or medications). To minimize nocturia, avoid fluids 2 hours before bedtime.

Promoting Complete Bladder Emptying: Under normal conditions a small amount of a patient’s urine remains in the bladder after voiding (residual urine). Encouraging patients to wait until urine stops flowing or to attempt to void again (double voiding) can improve bladder emptying (Table 45-5). Urinary retention care includes scheduled toileting (Lewis et al., 2011). In addition, Credé’s method or manual compression of the bladder walls with each attempted void may be used (Madineh, 2008). Instruct the patient to place both hands flat on the abdomen below the umbilicus and above the symphysis pubis with the fingers pointed down toward the bladder dome. Have him or her compress the hands downward against the walls of the bladder while tightening the perineum, contracting the abdominal wall, and holding the breath. The maneuver promotes bladder emptying by relaxing the urethral sphincter.

Preventing Infection: One of the most important considerations is to prevent infection of the urinary system. Good perineal hygiene that includes cleaning the urethral meatus after each voiding or bowel movement is essential. A minimal daily fluid intake of 1200 to 1500 mL dilutes urine, promotes regular micturition, and flushes the urethra of microorganisms. Voiding after intercourse; not using excessive soap or taking bubble baths; wearing cotton underwear; and drinking enough fluids, especially fluids high in acid ash such as apple or cranberry juice help prevent UTI.

Maintaining Elimination Habits: Patients usually require time to void. Requesting a urine specimen on demand does not contribute to relaxation and normal voiding habits. Give patients at least 30 minutes to provide a specimen. Patients normally void on awakening or before meals; therefore offer the opportunity to use toilet facilities then. Also important is the need to respond to and anticipate patients’ urges to urinate. For example, many older-adult falls are related to the urge to urinate. Anticipate the need and provide for scheduled bathroom visits to help reduce the fall risk in these patients.

Many patients need privacy for voiding. If a patient cannot reach the bathroom and uses a bedside commode or bedpan, make sure that the bedside curtain is closed. Patients who are debilitated and live at home often prefer using a bedside commode screened by a partition or room divider. Young children are often unable to void in the presence of persons other than their parents.

When possible encourage the continued use of special measures that the patient uses to void. Some patients are able to relax and void more easily while reading or listening to music. Having a cup or glass of fluids also promotes urination.

Medications: Drug therapy given alone or with other therapies often helps problems of incontinence or retention. The bladder is innervated by the parasympathetic nervous system. Drugs that block the muscarinic receptors suppress bladder contractions and reduce incontinence caused by bladder irritation. Examples include solifenacin (Vesicare) and oxybutynin chloride (Ditropan). These medications can cause constipation, dry mouth, and skin irritation (Lehne, 2010). Irritants present in the urine such as caffeine or alcohol may cause uncontrolled bladder contractions, and thus patients should avoid them.

When the bladder empties, the detrusor muscle contracts in response to parasympathetic stimulation. Incomplete bladder emptying results from impaired innervation or weakness of the detrusor muscle. The patient experiences retention and possible overflow incontinence. Cholinergic drugs increase contraction of the bladder and improve emptying. Bethanechol (Urecholine) stimulates parasympathetic nerves to increase bladder wall contraction and relax the sphincter. You can administer bethanechol by subcutaneous or oral routes. Cholinergic drugs often cause diarrhea as a side effect (Lehne, 2010).

The dribbling or overflow incontinence seen in men with prostatic enlargement can be treated with an alpha₁-adrenergic blocker such as tamsulosin (Flomax). Tamsulosin is given orally and relaxes prostatic smooth muscle, thus relieving obstructive symptoms. This drug has few side effects and does not cause transient hypotension as other alpha-adrenergic blockers do (Lehne, 2010).

Catheterization: Catheterization of the bladder involves introducing a latex or plastic tube through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients unable to control micturition or those with obstructions. It also provides a means of assessing urine output in hemodynamically unstable patients. Because bladder catheterization carries the risk of UTI, blockage, and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence.

Catheter Irrigations and Instillations: To maintain the patency of indwelling urinary catheters, it is sometimes necessary to irrigate or flush a catheter with sterile solution. If a catheter becomes plugged with pus or sediment, it is best to change it rather than irrigate because irrigation washes the pus and sediment back into the bladder, creating a worse infection. Change the catheter as needed. It is appropriate to use irrigation after surgery for blood clots and short-term catheter use; but for long-term use irrigation can create a chronic sediment and pus problem, requiring lifelong irrigation in long-term indwelling catheters. For patients with bladder infections, a health care provider often orders antiseptic or antibiotic bladder irrigations to wash out the bladder or treat local infection. In both irrigations follow sterile aseptic technique.

Before performing irrigation assess the catheter for blockage. If the amount of urine in the drainage bag is less than the patient’s intake or output during the previous shift, expect some blockage. If urine does not drain freely, milk the tubing. Milk the tube by squeezing and then releasing it, starting at a point close to the patient and then out to the drainage bag so a clot or sediment is not forced back into the catheter. Many times this takes care of the problem without irrigation.

Maintenance of a closed system is recommended during intermittent irrigations or instillations. This technique is effective for irrigating a partially blocked catheter or for bladder instillations. One method of closed-bladder irrigation provides for frequent intermittent irrigations or continuous irrigation without disruption of the sterile catheter system through use of a three-way catheter (Skill 45-4 on pp. 1081-1084). This method is used most often in patients who have had genitourinary surgery and are at risk for blood clots and mucus fragments occluding the catheter. The other method involves accessing the closed drainage system to instill bladder irrigations (see Skill 45-4). This method is often used for unanticipated irrigation or intermittent instillations.

Removal of Indwelling Catheter: When removing an indwelling catheter, promote normal bladder function and prevent trauma to the urethra. Removing a catheter requires a clean, disposable towel; a trash receptacle; and a sterile syringe the same size as the volume of solution within the inflated balloon of the catheter. Perform hand hygiene and put on clean gloves before removing the catheter. The end of each catheter contains a label that denotes the volume of solution (5 to 30 mL) within the balloon. If a different volume was used, there should be a notation on the patient record.

Position the patient in the same position as during catheterization. Some institutions recommend collecting a sterile urine specimen at this time or sending the catheter tip for culture and sensitivity tests. After removing the tape, place the towel between a female patient’s thighs or over a male patient’s thighs. Insert the syringe into the balloon injection port. Most ports are self-sealing and require that only the tip of the syringe be inserted. Slowly withdraw all of the solution to deflate the balloon totally. If a portion of the solution remains, the partially inflated balloon traumatizes the urethral canal as the catheter is removed. After deflation, explain that the patient will feel a burning sensation as the catheter is withdrawn. Then pull the catheter out smoothly and slowly.

It is normal for the patient to experience some dysuria, especially if the catheter has been in place several days or weeks. Until the bladder regains full tone, some patients also experience frequency of urination or urinary retention.

Assess the patient’s urinary function by noting the first voiding after catheter removal and documenting the time and amount of voiding for the next 24 hours. If amounts are small, frequent assessment of bladder for distention is necessary. If 4 hours have elapsed without voiding or the patient experiences discomfort, it often becomes necessary to reinsert the catheter.

Alternatives to Urethral Catheterization: To avoid the risks associated with urethral catheters, two alternatives are available for urinary drainage.

Strengthening Pelvic Floor Muscles: Patients who have stress or urge urinary incontinence and difficulty starting and stopping urination may benefit from pelvic floor exercises. Pelvic floor exercises, also known as Kegel exercises, improve the strength of pelvic floor muscles and consist of repetitive contractions of muscle groups. These exercises have demonstrated effectiveness in treating stress incontinence, OAB, and mixed cause of urinary incontinence. A patient begins these exercises during voiding to learn the technique. They are then practiced at nonvoiding times. Improvement is usually gradual. Patients need to be alert and motivated to perform the exercises. They need to continue to use them to maintain effectiveness (see Box 45-6). The exercises are noninvasive and carry a low risk of adverse effects.

Bladder Retraining: The goal of bladder retraining is to reduce the voiding frequency and perhaps the bladder capacity (Doughty, 2006). This method is a specific program for patients who have a decreased urge to void or have stress incontinence since it keeps the bladder from getting full; thus there is less dribbling. Ultimately the overall goal of this retraining is to restore a normal pattern of voiding by teaching patients to keep the patient continent. Initially patients keep a bladder diary or log noting times, volumes, fluid intake, and any other related symptoms. This provides a baseline for comparison during the retraining. For bladder retraining to be successful, patients must agree to it and be alert and physically able to follow a training program. Bladder retraining is very important in long-term care and rehabilitation facilities. Remember that keeping a patient with a severely spastic bladder from frequent toileting causes pain for the patient. Nurses should never refuse to toilet a patient. Urological consultation can be helpful; and, if treated properly, bladder capacity will increase.

Assess the patient’s current pattern of urination. This information allows the nurse to plan a program that often takes 2 weeks or more to learn. Although patients may start the program in the hospital or in rehabilitation, they may need to continue it in an extended care facility or at home. Generally the patient is asked to suppress urination for each voiding and increase time by increments of 15 minutes every week. The goal is to void every 3 to 4 hours in volumes of 240 to 500 mL. If the patient has an underlying UTI, treat this at the same time.

As part of restorative and rehabilitative care, patients with different types of incontinence may benefit from specific measures that address particular continence issues. These guidelines help patients control factors that affect the number of incontinence episodes.

The following measures may help patients with stress urinary incontinence to gain control over urination:

Habit Training: A patient with functional incontinence benefits from habit training, which helps patients improve voluntary control over urination. A patient establishes a flexible toileting schedule based on his or her pattern. Have the patient establish the pattern by documenting episodes of incontinence and scheduling voiding opportunities just before the urge time interval. The goal is to keep the patient dry. Help him or her to the bathroom before the urge usually occurs. Time fluids and medications to prevent interference with the toileting schedule. Patients with moderate or severe mental or physical dysfunction and those who have normal bladder function or overflow reflex incontinence benefit from habit training. When combined with positive reinforcement to reward successful voiding, this approach is also called prompted voiding.

Self-Catheterization: Some patients with chronic disorders such as spinal cord injury learn to perform self-catheterization. A patient must be able to physically manipulate equipment and assume a position for successful catheterization. You teach the patient the structures of the urinary tract, clean-versus-sterile technique, the importance of adequate fluid intake, and the frequency of self-catheterization. Generally the goal is to have patients perform self-catheterization 4 to 6 times a day with volumes of 400 to 500 mL; but be sure to individualize the schedule.

Maintenance of Skin Integrity: The normal acidity of urine is irritating to skin. Urine allowed to remain in contact with the skin becomes alkaline, causing encrustations or precipitates to collect on it, fostering breakdown. Washing with mild soap and warm water is the best way to remove urine from skin. Body lotion keeps skin moisturized, and petroleum-based ointments provide a barrier to the urine. Patients who wet their clothing need to receive partial baths and dry clothing after voiding. Continuous exposure of the perineal area or skin around an ostomy leads to gradual maceration and excoriation (see Chapter 48) requiring special care.

When the skin becomes irritated or inflamed, often the health care provider prescribes a cream or spray containing steroids (e.g., Kenalog) to reduce inflammation. If fungal growth develops, the antifungal drug nystatin (Mycostatin), available in cream or powder, is effective.

Promotion of Comfort: Patients with urinary alterations become uncomfortable as a result of the symptoms of urinary problems. Frequent or unpredictable voiding, dysuria, and painful distention are sources of discomfort.

The incontinent patient gains comfort from having clean, dry clothing. When stress incontinence is the problem, a protective pad offers protection against soiling. Wet clothing adheres to the skin and can cause rubbing and irritation.

Urinary analgesics that act on the urethral and bladder mucosa (e.g., phenazopyridine) relieve dysuria. Often you combine this drug with sulfonamide antibiotics in preparations such as Azo-Gantanol and Azo-Gantrisin. Patients taking drugs with phenazopyridine need to be aware that their urine will be orange. They must drink large amounts of fluids to prevent toxicity from the sulfonamides and maintain optimal flow through the urinary system (Lehne, 2010).

If the patient has local discomfort from an inflamed urethra, an iced sitz bath provides pain relief. The patient is often relaxed after a sitz bath; thus voiding occurs easily. Patients cannot relieve pain of distention unless they are able to empty the bladder. Interventions that stimulate micturition or intermittent catheterization may be the only sources of pain relief.

• “Tell me, how frequently are you voiding now?”

• “Do you continue to have the feeling of urgency every time you void?”

• “Have the symptoms of urgency decreased since you changed your caffeine intake?

• “Do you still have burning when you pass urine?

• “Do you still feel uncomfortable over your lower abdomen?”

Unexpected Outcomes and Related Interventions:

Recording and Reporting:

Home Care Considerations:

Unexpected Outcomes and Related Interventions:

Recording and Reporting:

Home Care Considerations:

Unexpected Outcomes and Related Interventions:

Recording and Reporting:

Home Care Considerations:

Unexpected Outcomes and Related Interventions:

Recording and Reporting:

Home Care Considerations:

1. She has recently begun Kegel exercises to attempt improvement in her urinary control. She doesn’t see any improvement. She has been trying to deal with the problem by using an absorbent pad in her underwear, but she feels as though everyone knows her problem. What additional teaching does Mrs. Grayson need?

2. Two months after your first encounter with Mrs. Grayson, she has been seen by her primary health care provider for burning on urination with increased frequency and urgency. She has also noted blood in her urine for a week. What is Mrs. Grayson experiencing and what can you teach her to minimize her symptoms?

3. Mrs. Grayson says she is not satisfied with her current state of urinary control and has decided on a more permanent solution to her stress incontinence. She opts for a minimally invasive procedure that will provide support for the urethra. She will be going home with an indwelling catheter. She asks how to care for the catheter while she is home. She does not want another urinary tract infection. What do you tell her about measures at home to remain infection free?

1. A female patient reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. The probable cause of these symptoms and findings is:

2. A male patient returned from the operating room 6 hours ago with a cast on his right arm. He has not yet voided. Which action would be the most beneficial in assisting the patient to void?

3. Elimination changes that result from inability of the bladder to empty properly may cause which of the following? (Select all that apply.)

4. An older male patient states that he is having problems starting and stopping his stream of urine and he feels the urgency to void. The best way to assist this patient is to:

5. Since removal of the patient’s Foley catheter, the patient has voided 50 to 100 mL every 2 to 3 hours. Which action should the nurse take first?

6. To minimize the patient experiencing nocturia, the nurse would teach him or her to:

7. A patient with a Foley catheter carries the collection bag at waist level when ambulating. The nurse tells the patient that he or she is at risk for: (Select all that apply.)

8. The patient is incontinent, and a condom catheter is placed. The nurse should take which action?

9. After a transurethral prostatectomy a patient returns to his room with a triple-lumen indwelling catheter and continuous bladder irrigation. The irrigation is normal saline at 150 mL/hr. The nurse empties the drainage bag for a total of 2520 mL after an 8-hour period. How much of the total is urine output? __________________________________

    10. The nurse directs the NAP to remove a Foley catheter at 1300. The nurse would check if the patient has voided by:

    11. The postoperative patient has difficulty voiding after surgery and is feeling “uncomfortable” in the lower abdomen. Which action should the nurse implement first?

    12. The patient is to have an intravenous pyelogram (IVP). Which of the following apply to this procedure? (Select all that apply.)

    13. The nurse assesses that the patient has a full bladder, and the patient states that he or she is having difficulty voiding. The nurse would teach the patient to:

    14. The patient states that she “loses urine” every time she laughs or coughs. The nurse teaches the patient measures to regain urinary control. The nurse recognizes the need for further teaching when the patient states:

    15. The nurse notes that the patient’s Foley catheter bag has been empty for 4 hours. The priority action would be to: