Kidneys

The kidneys are reddish-brown, bean-shaped organs, one on either side of the vertebral column, posterior to the peritoneum and lying against the deep muscles of the back. The kidneys extend to the twelfth thoracic and third lumbar vertebrae. Normally, the left kidney is 1.5–2 cm higher than the right because of the anatomical position of the liver on the right side of the abdomen. Each kidney typically measures approximately 12 × 7 cm and weighs 120–150 g. Each kidney is covered by a tough capsule and surrounded by a cushion of fat.

The kidneys filter the waste products of metabolism that collect in the blood. Blood reaches each kidney by a renal artery that branches from the abdominal aorta. The renal artery enters the kidney at the hilum. Approximately 20–25% of the cardiac output circulates each minute through the kidneys. The nephron, the functional unit of the kidney, forms the urine. The nephron is composed of the glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal tubule and collecting duct (Figure 38-2).

FIGURE 38-2 Renal nephron.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Blood reaches nephrons through the afferent arterioles. A cluster of these blood vessels forms the capillary network of the glomerulus, which is the initial site of filtration of the blood and the beginning of urine formation. The glomerular capillaries are porous and permit filtration of water and substances such as glucose, amino acids, urea, creatinine and major electrolytes into the Bowman’s capsule. Large proteins and blood cells do not normally filter through the glomerulus. The presence of large proteins in the urine (proteinuria) is one sign of glomerular injury. The glomerulus filters approximately 125 mL of filtrate per minute. Initially the filtrate closely approximates the composition of blood plasma minus the large proteins.

Only a small amount of the glomerular filtrate is excreted as urine. About 99% of the filtrate is reabsorbed into the plasma, with the remaining 1% excreted as urine. Thus the kidneys play a key role in fluid and electrolyte balance (see Chapter 39). Although urine output does depend on intake, the normal adult 24-hour output of urine is about 1500–1600 mL. An output of less than 0.5 mL/kg per hour may indicate alterations in renal function.

The kidneys also produce several hormones vital to production of red blood cells (RBCs), blood pressure regulation and bone mineralisation. The kidneys are responsible for maintaining a normal RBC volume by producing erythropoietin. As a hormone, erythropoietin functions within the bone marrow to stimulate RBC production and maturation (McCance and Huether, 2010). Erythropoietin also prolongs the life of mature RBCs. People with chronic alterations in kidney function cannot produce sufficient quantities of this hormone and are, therefore, prone to anaemia.

Renin is another hormone produced by the kidneys. Its major role is the regulation of the systemic circulation in times of renal ischaemia (decreased blood supply to the kidneys). Renin is released from juxtaglomerular cells (Figure 38-3).

FIGURE 38-3 Physiological effects of the renin–angiotensin mechanism.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Renin functions as an enzyme to convert angiotensinogen (a plasma substance synthesised by the liver) into angiotensin I. As angiotensin I circulates through the lungs, it is converted to angiotensin II and angiotensin III. Angiotensin II exerts its effect on vascular smooth muscle to cause vasoconstriction and stimulates aldosterone release from the adrenal cortex. Aldosterone causes retention of water, which increases blood volume. Angiotensin III exerts similar effects, but to a lesser degree. The net effect of both these mechanisms is an increase in arterial blood pressure and renal blood flow (McCance and Huether, 2010).

The kidneys also play a role in calcium and phosphate regulation. They are responsible for producing a substance that converts vitamin D into its active form. People with chronic alterations in kidney function do not make sufficient amounts of the active vitamin D metabolite. They are therefore prone to developing renal bone disease resulting from the demineralisation of bone secondary to impaired intestinal calcium absorption unless the active form of vitamin D is supplied.

Ureters

Urine enters the renal pelvis from the collecting ducts. A ureter joins each renal pelvis to the urinary bladder. Ureters are tubular structures measuring 25–30 cm in length and 0.5 cm in diameter in the adult (Getliffe and Dolman, 2007). They extend retroperitoneally to enter the urinary bladder in the pelvic cavity at the ureterovesical junction. Urine draining from the ureters to the bladder is usually sterile.

Three layers of tissue form the wall of the ureter. The inner layer is a mucous membrane continuous with the lining of the renal pelvis and urinary bladder. The middle layer consists of smooth muscle fibres that transport urine through the ureters by peristaltic waves stimulated by distension with urine. An outer layer of fibrous connective tissue supports the ureters.

Peristaltic waves cause the urine to enter the bladder in spurts, rather than steadily. The ureters enter obliquely through the posterior bladder wall. This arrangement normally prevents the reflux of urine from the bladder into the ureters during the act of micturition by the compression of the ureter at the ureterovesical junction (the juncture of the ureters with the bladder). An obstruction within a ureter, such as a kidney stone (renal calculus), results in strong peristaltic waves that attempt to move the obstruction into the bladder. These strong peristaltic waves result in pain often referred to as renal colic.

Bladder

The urinary bladder is a hollow, distensible, muscular organ that is both a reservoir for urine and the organ of excretion. The size and shape of the bladder will vary depending on its state of fullness. When empty, the bladder lies in the pelvic cavity behind the symphysis pubis. In men the bladder lies against the anterior wall of the rectum and in women it rests against the anterior wall of the uterus and vagina.

The bladder expands as it becomes filled with urine. Pressure within the bladder is usually low, even when partly full, a factor that protects against reflux of urine back up the ureters into the kidneys. In a healthy adult, bladder capacity is approximately 500 mL and when the bladder is emptied there is no residual urine volume. Both men and women will void at 3- to 5-hour intervals during the day and usually do not need to void at night (Getliffe and Dolman, 2007). Keep in mind, however, that the habits of individuals will vary. When the bladder is full, it expands and extends above the symphysis pubis. A greatly distended bladder may reach the umbilicus. In a pregnant woman the developing fetus pushes against the bladder, causing a feeling of fullness and reducing the bladder’s capacity. This effect is more likely to occur in the first and third trimesters.

The trigone (a smooth, triangular area on the inner surface of the bladder) is at the base of the bladder. An opening exists at each of the trigone’s three angles. Two are for the ureters, and one is for the urethra. This area does not change shape very much during bladder filling and is very sensitive to stretch due to the large number of sensory nerve endings it contains (Getliffe and Dolman, 2007).

The wall of the bladder has four layers: an inner mucous coat, a submucous layer of connective tissue, a muscular layer and an outer serous coat. The muscular layer has bundles of muscle fibres that form the detrusor muscle. Parasympathetic nerve fibres stimulate the detrusor muscle during urination. In the male, the bladder neck provides a powerful sphincter mechanism. It also prevents retrograde ejaculation into the bladder during orgasm. The male internal urethral sphincter is made of a ring-like band of muscle which has a rich nerve supply. In the female the bladder neck is a far weaker structure than in the male (Getliffe and Dolman, 2007): the smooth muscle fibres extend longitudinally along the urethra; there are no circular muscles.

Urethra

Urine travels from the bladder through the urethra and passes outside the body through the urethral meatus. Normally, the turbulent flow of urine through the urethra washes it free of bacteria. Mucous membrane lines the urethra, and urethral glands secrete mucus into the urethral canal. The mucus is believed to be bacteriostatic and forms a mucous plug to prevent entrance of bacteria. Thick layers of smooth muscle surround the urethra. In addition, the urethra descends through a layer of skeletal muscle called the pelvic floor muscles. When these muscles are contracted, it is possible to prevent urine flow through the urethra (McCance and Huether, 2010).

In women the urethra is approximately 4–6.5 cm long. The external urethral sphincter, located about halfway down the urethra, permits voluntary flow of urine. The short length of the urethra predisposes women to ascending infection. Bacteria can easily enter the urethra from the perineal area. In men the urethra, which is both a urinary canal and a passageway for semen, is 18–22 cm long. The male urethra has three sections: the prostatic urethra, the membranous urethra and the cavernous or penile urethra. The prostate gland encircles the male urethra at the base of the bladder. In a female the urinary meatus (opening) is located between the labia minora, above the vagina and below the clitoris. In a male the meatus is located at the distal end of the penis.

Growth and development

Infants and young children cannot effectively concentrate urine. Their urine thus appears light yellow or clear. In relation to their small body size, infants and children excrete large volumes of urine. For example, a 6-month-old infant who weighs 6–8 kg excretes 400–500 mL of urine daily.

A child cannot control micturition voluntarily until 18–24 months old. A child must be able to recognise the feeling of bladder fullness, to hold urine for 1–2 hours and to communicate the sense of needing to void to an adult. The young child needs parents’ understanding, patience and consistency. A child may not gain full control of micturition until age 4 or 5 years. Daytime control of micturition is easier to accomplish than night-time control and occurs earlier in the child’s development, usually by 2–3 years of age (see Working with diversity).

The adult normally voids 1500–1600 mL of urine daily. The kidney concentrates urine, normally producing amber-coloured urine. A person does not normally wake to void during sleep because of reduction of renal blood flow during rest and the kidneys’ ability to concentrate urine.

Changes in kidney and bladder function also occur with ageing. The glomerular filtration rate declines, but the kidneys’ ability to concentrate urine also declines. Thus the older adult often experiences nocturia (urination at night). The bladder loses its muscle tone and capacity to hold urine, resulting in increased urinary frequency. Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). Older men may also suffer from benign prostatic hypertrophy, which makes them prone to urinary retention and incontinence. These changes increase the risk for bacterial growth and development of urinary tract infections (UTIs). Another factor related to urinary elimination difficulties is constipation. Constipation and resulting bowel fullness may put external pressure on the bladder, reducing the effective capacity and causing frequency or even incontinence (see Chapter 37).

In the female, childbearing and/or the hormonal changes of menopause may cause changes that lead to urinary difficulties. During a pregnancy, urinary frequency is common and susceptibility to UTIs is increased. Temporary or permanent changes that result from repeated vaginal deliveries or hormonal changes may result in decreased pelvic floor muscle tone, leading to urgency and stress incontinence (see Chapter 22). The changes in the urethral mucosa associated with loss of oestrogen during and after menopause also contribute to increased susceptibility to infection (McCance and Huether, 2010).

Fluid balance

The kidneys maintain a sensitive balance between retention and excretion of fluids (see Chapter 39). If fluids and the concentration of electrolytes and solutes are in equilibrium, an increase in fluid intake causes an increase in urine production. Ingested fluids increase the body’s circulating plasma and thus increase the volume of glomerular filtrate and urine excreted.

This amount varies with food and fluid intake. The volume of urine formed at night is about half that formed during the day, because both intake and metabolism decline. This results in a reduction in the volume of renal blood flow. In a healthy person, the intake of water in food and fluids balances the output of water in urine, faeces and insensible losses in perspiration and respiration. An excessive output of urine is known as polyuria.

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), resulting in increased water loss in urine. Foods that contain a high fluid content, such as fruits and vegetables, may also increase urine production.

Febrile conditions affect urine production. The patient who becomes diaphoretic loses a large amount of fluids through insensible water loss, which decreases urine production. However, the increased body metabolism associated with fever increases accumulation of body wastes. Although urine volume may be reduced, it is highly concentrated.

Changes to renal function

Disease processes that primarily affect renal function (changes in urine volume or quality) are generally categorised as prerenal, renal or postrenal in origin (Box 38-1). Prerenal alterations in urinary elimination decrease circulating blood flow to and through the kidneys, with subsequent decreased perfusion to renal tissue. In other words, the alterations are outside the urinary system. The decrease in renal perfusion leads to oliguria (diminished capacity to form urine) or, less commonly, anuria (inability to produce urine). Renal alterations result from factors that cause injury directly to the glomerulus or renal tubule, interfering with their normal filtering, reabsorptive and secretory functions. Postrenal alterations result from obstruction to the urinary collecting system anywhere from the calyces (drainage structures within the kidney) to the urethral meatus (i.e. outside the kidney but within the urinary system). Urine is formed by the urinary system but cannot be eliminated by normal means.

Changes to bladder function

Several diseases can affect the ability to void normally. Any lesion of peripheral nerves leading to the bladder causes loss of bladder tone, reduced sensation of bladder fullness and difficulty in controlling urination. For example, diabetes mellitus and multiple sclerosis cause neuropathic conditions that alter bladder function.

Illness and frailty

Reduced mobility or disability sometimes makes it difficult for a person to reach a toilet in time or to manage clothing or hygiene requirements. Rheumatoid arthritis, degenerative joint disease and Parkinson’s disease are examples of conditions that make it difficult to reach and use toilet facilities. A person with rheumatoid arthritis often cannot sit on or rise from a toilet without an elevated seat or handrails.

Any alteration in cognitive function can impair a person’s perception of the need to void or impair their ability to get themselves to the toilet and complete toileting activities. This is particularly relevant when a person who has dementia is admitted to an acute care hospital or moves from home to residential care. The change in environment can increase the person’s confusion and make episodes of urinary incontinence more likely. A major goal when caring for a person in this situation is to reduce the impact of the change in environment by close observation of the person’s responses, so that the nurse can anticipate the cues that the person needs to go to the toilet, reinforce the location of the toilet and provide frequent reassurance.

Psychological and environmental factors

Anxiety and emotional stress may cause a sense of urgency and increased frequency of urination. An anxious person may have the urge to void even after voiding only a few minutes earlier. Anxiety may also prevent a person from being able to urinate completely. Emotional tension makes it difficult to relax abdominal and pelvic floor muscles. If the external urethral sphincter is not completely relaxed, voiding may be incomplete and urine is retained in the bladder.

When people are hospitalised they are often reluctant to void in a shared ward environment or to use a bedpan or urinal. Where possible the person should be assisted to the toilet to void. Men may need assistance to stand to void. Staying close by and leaving the person with a call bell may encourage a more normal environment in which they feel comfortable for voiding to occur.

Surgical procedures

The stress of surgery initially triggers the general adaptation syndrome (see Chapter 42). The posterior pituitary gland releases an increased amount of ADH, which increases water reabsorption and reduces urine output. The surgical patient is often in an altered state of fluid balance before surgery due to the disease process or preoperative fasting, which aggravates the reduction in urine output. The stress response also elevates the level of aldosterone, resulting in reduction of urine output in an effort to maintain circulatory fluid volume.

Anaesthetic and narcotic analgesics may slow the glomerular filtration rate, reducing urine output. These pharmacological agents also impair sensory and motor impulses between the bladder, spinal cord and brain. Patients recovering from anaesthesia and deep analgesia are often unable to sense bladder fullness and are unable to initiate or inhibit micturition. Spinal anaesthetics, 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 sphincters to respond (Brown and Edwards, 2011).

Surgery of lower abdominal and pelvic structures can impair voiding because of local trauma to surrounding tissues. Pain can interfere with relaxation of pelvic floor and sphincter muscles and make voiding difficult or painful. After returning from surgery involving the ureters, bladder and urethra, patients routinely have an indwelling urinary catheter.

Medications

Diuretics prevent reabsorption of water and certain electrolytes to increase urine output. Urinary retention may be caused by use of anticholinergics (e.g. atropine), antihistamines (e.g. pseudoephedrine), antihypertensives (e.g. methyldopa) or beta-adrenergic blockers (e.g. propranolol). Some medications change the colour of urine. Amitriptyline causes a green or blue discolouration, while levodopa may discolour the urine to brown or black (Bryant and Knights, 2010). Cancer chemotherapy drugs may also colour the urine and be toxic to the kidneys or the bladder. Patients with alterations in kidney function require dosage adjustments of medications excreted by the kidneys.

Lower urinary tract infections

Urinary tract infections are very common throughout the life span but are more prevalent in older people. It is estimated that 1 in 3 women and 1 in 20 men will develop a UTI during their lifetime. Approximately 1 in 3 women will have a UTI requiring treatment before the age of 24 years (Masson and others, 2009). When the infection is confined to the bladder and urethra it is termed a lower urinary tract infection. Bacteria in the urine (bacteriuria) may lead to the spread of organisms into the kidneys (upper urinary tract infection).

The most common organisms that cause UTIs in otherwise healthy people are Escherichia coli (85%), Staphylococcus saprophyticus (10%), Enterococcus faecalis and other enterobacteriacae (Gray and Robinson, 2010). Microorganisms most commonly enter the urinary tract through the urethral route. Bacteria inhabit the distal urethra, external genitalia and vagina in women. Organisms enter the urethral meatus easily and travel up the inner mucosal lining to the bladder. Risk factors for developing a UTI include being a postmenopausal woman, sexual activity in women, pregnancy, and underlying anatomical abnormality (vesico-ureteric reflux, history of recurrent UTI, urinary obstruction, presence of renal calculi). Older adults and people with progressive underlying disease or decreased immunity are also at increased risk (Gray and Moore, 2009).

Most children and adults with lower UTIs have pain or burning during urination (dysuria) as urine flows past inflamed tissues. An irritated bladder causes a frequent and urgent sensation of the need to void. Irritation to bladder and urethral mucosa can result in blood-tinged urine (haematuria). The urine can appear concentrated and cloudy because of the presence of white blood cells (WBCs) or bacteria. The signs and symptoms of UTI in older adults can be less obvious. Often the first symptoms may be confusion and dehydration. An infection in the upper urinary tract (kidneys—pyelonephritis) can cause more-severe symptoms such as (commonly) flank pain, tenderness, nausea, vomiting, fever and chills.

The most common cause of infection in hospitalised patients 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. Catheter-associated urinary tract infections (CAUTIs) are common. The incidence of bacteriuria increases with the duration that the catheter is in situ. According to Gray and Moore (2009:105), nearly all people with an indwelling urinary catheter will have bacteriuria within 30 days. Hence, a goal of care is to remove the urinary catheter as soon as possible. Bacteria ascend along the outside of the catheter on the urethral wall or travel up the catheter’s lumen. The catheter interferes with the normal voiding mechanism that acts as a defence against organisms entering the urethra. Local irritation to the urethra or bladder further predisposes tissues to bacterial invasion. The majority of CAUTIs do not cause generalised symptoms and are generally not treated with antibiotics. Use of antibiotics in this situation can result in bacterial resistance.

Urinary incontinence

Urinary incontinence is defined as the complaint of any involuntary loss of urine (Abrams and others, 2009). It may be temporary or permanent. Urinary incontinence can be further defined according to the person’s symptoms: stress incontinence, urge incontinence, mixed incontinence (a mix or stress and urge symptoms), nocturnal enuresis, post-micturition dribble, continuous urinary leakage, overactive bladder and functional incontinence (Abrams and others, 2009; Newman and Wein, 2009a) (see Table 38-1 for definitions, risk factors and defining characteristics).

TABLE 38-1 TYPES OF URINARY INCONTINENCE

Adapted from: Abrams P, Cardozo P, Khoury S and others, editors, 2009 Incontinence, ed 4. Paris, Health Publications Ltd, Paris; Gray M, Moore KN 2009 Urologic disorders: adult and paediatric care. St Louis, Mosby; Newman DK, Wein A 2009 Managing and treating urinary incontinence. Baltimore: Health Professionals Press.

Urinary incontinence affects up to 13% of Australian men and up to 37% of Australian women (Australian Institute of Health and Welfare, 2006). In New Zealand, 17% of adult women have bothersome urinary incontinence. The prevalence is even higher in adult Māori women, at 47% (New Zealand Continence Association 2011).

Urinary incontinence significantly affects a person’s quality of life, including the person’s daily activities, sexuality, body image and self-esteem. Efforts to cope with the problem may lead to the person reducing their fluid intake, increasing the frequency of voiding and avoiding social contact (Newman and Wein, 2009a; St John and others, 2010). There is also evidence in the literature that continence problems have significant impact on family caregivers, including depression (Gotoh and others, 2009; Hayder and Schnepp, 2008).

Prostatic hypertrophy and prostate cancer

Benign enlargement of the prostate gland that can occur with ageing can obstruct the urethra and make voiding difficult. Benign prostatic hypertrophy (BPH) is a common condition affecting men from the age of approximately 50 years. According to Gray and Moore (2009:50), 50% of 60-year-old men and 80% of 80-year-old men will experience some bothersome lower urinary tract symptoms (LUTS). The typical symptoms are decreased urinary stream, hesitancy, intermittent stream, nocturia, frequency and urgency (see Table 38-2 for a description of common types of lower urinary symptoms). Some men may develop an acute or chronic urinary retention (see below). Treatment for men who have symptomatic BPH include medications which aim to relax the smooth muscles at the bladder neck (alpha-blockers) or to reduce the size of the prostate gland (5-alpha-reductase inhibitors), or surgery—for example trans-urethral resection of the prostate (Bright and Abrams, 2010).

TABLE 38-2 COMMON LOWER URINARY TRACT SYMPTOMS

Adapted from Newman DK, Wein A 2009 Managing and treating urinary incontinence. Baltimore: Health Professionals Press.

Prostate cancer is the most common cancer that occurs in men. The risk of developing prostate cancer to age 75 years is 1 in 8 for Australian men (Australian Institute of Health and Welfare, 2008). There are similar rates of prostate cancer in New Zealand men (Ministry of Health, 2011). Prostate cancer is essentially a disease of older men, with 85% diagnosed after 65 years of age (Cancer Council Australia 2011). Prostate cancer is rare before the age of 40 years and its incidence rises rapidly after age 60 years. The cause of prostate cancer is unknown. Apart from advancing age and being male, the strongest established risk factor is a family history of the disease (Bright and Abrams, 2010). Part of the concern for men and for healthcare workers is the non-specific nature of the typical presenting signs and symptoms associated with prostate cancer. In the early stages they are likely to be asymptomatic. Differential diagnosis involves a health assessment and will include a prostatic-specific antigen (PSA) test, digital rectal examination (DRE) and transrectal ultrasound and biopsy. Treatment options for prostate cancer include surgery (radical prostatectomy), androgen deprivation therapy and radiation therapy.

Urinary retention

Urinary retention is defined as the inability to fully empty the bladder after voiding or a complete inability to urinate (Gray and Moore, 2009). Urinary retention can be acute or chronic. In acute retention, key signs are bladder distension and absence of urine output over several hours. The bladder may hold as much as 2000–3000 mL of urine. The person may experience significant discomfort, tenderness over the symphysis pubis, restlessness and diaphoresis (sweating). Acute retention is most common in men due to obstruction of the urethra as a result of benign enlargement of the prostate gland. It is a medical emergency that requires immediate intervention.

Chronic retention results from incomplete bladder emptying over a period of time. It results from either a partial obstruction of the urethra (e.g. urethral stricture, enlarged prostate, chronic constipation) and/or from reduced ability of the detrusor (bladder) muscle to contract during voiding (e.g. spinal cord injury, nerve damage from diabetes mellitus) (Gray and Moore, 2009). As retention progresses, retention with overflow may develop. Pressure in the bladder builds to a point where the external urethral sphincter is unable to hold back urine. The person may have an urge to void but is only able to void small amounts. Some people may experience intermittent episodes of incontinence, and others constant dribbling of urine. Depending on the cause of the chronic retention, the person may or may not be aware of the incomplete bladder emptying. Chronic retention caused by partial obstruction can result in increased pressures within the urinary tract causing damage to the kidneys (postrenal obstruction). Incomplete bladder emptying can predispose the person to UTIs.

Chronic kidney disease

Diseases that cause irreversible damage to the glomerulus or tubules result in permanent alterations in renal function. Chronic kidney disease (CKD—formally known as chronic renal failure) or end-stage kidney disease (ESKD) are the terms used to describe the resulting decline in kidney function from these processes. CKD is damage to the kidneys or reduced renal function lasting more than 3 months (Australian Institute of Health and Welfare, 2009). It is estimated that 13% of Australians are living with CKD (Australian Institute of Health and Welfare, 2009). Aboriginal and Torres Strait Islander people, especially those living in remote communities, are at high risk of developing CKD and the incidence is increasing (Australian Institute of Health and Welfare, 2011). There is a similar incidence of CKD in New Zealand, with 16% of New Zealanders having some form of kidney damage, and a higher incidence in Māori and Pacific Islanders (Joshy and others, 2010). A major risk factor for developing CKD is diabetes. Other risk factors include hypertension, cigarette smoking, obesity, family history of CKD and being over 50 years of age (Kidney Health Australia, 2011).

The person with ESKD manifests numerous metabolic disturbances that require treatment for survival. The associated symptoms experienced by the patient occur as a result of the uraemic syndrome. This syndrome is characterised by an increase in nitrogenous wastes in the blood, altered regulatory functions (causing marked fluid and electrolyte abnormalities), nausea, vomiting, headache, coma and convulsions. Treatment options include methods to correct these biochemical derangements. The problem may be managed conservatively with medications and a regimen of dietary and fluid restrictions. However, as worsening of the uraemic symptoms becomes evident, more-aggressive treatment is indicated. These treatments are known as renal replacement therapies. Dialysis (see Box 38-2) and organ transplant are the two methods of renal replacement; the two methods of dialysis are haemodialysis and peritoneal dialysis. Both dialysis methods can be applied for a short or a long time, and they require specialised equipment and appropriately qualified nurses.

Haemodialysis involves using a machine equipped with a semipermeable filtering membrane (artificial kidney) that removes accumulated waste products from the blood. In the dialysis machine, dialysate fluid is pumped through one side of the filter membrane (artificial kidney) while the patient’s blood passes through the other side. The processes of diffusion, osmosis and ultrafiltration clean the patient’s blood, and it is returned through a specially placed vascular access device (LaRocco, 2011).

An organ transplant is the replacement of the patient’s diseased kidney with a healthy one from a living or cadaveric donor of compatible blood and tissue type. After the patient (recipient) is deemed medically and psychosocially suitable, the organ is surgically implanted. Immunosuppressive medications are administered for life to prevent the body rejecting the transplanted organ. Unlike the other treatments, a successful organ transplant offers the patient the potential for restoration of normal kidney function for varying periods of time.

Promotion of normal voiding patterns

Many nursing measures have been designed to promote normal voiding in patients at risk of urination difficulties and in patients with established urination problems. The nurse can initiate many of these interventions independently.

STIMULATING MICTURITION REFLEX

It is often difficult for hospitalised patients to void due to the effects of surgery, an anaesthetic, pain or medications. The patient’s ability to void depends on feeling the urge to urinate, being able to control the urethral sphincter and being able to relax during voiding. You can help a patient learn to relax and stimulate the reflex to void by assuming the normal position for voiding. A woman is better able to void in a sitting position, leaning forward with feet flat on the floor. This position promotes contraction of the pelvic and intra-abdominal muscles that assist in sphincter control and bladder contraction. If the patient is unable to use toilet facilities, assist the person to position themselves in a squatting position on a bed pan (see Chapter 37) or bedside commode. A man voids more easily in the standing position. If the man cannot reach the toilet, he may stand at the bedside and void into a urinal (a metal or plastic receptacle for urine) (Figure 38-9). At times it may be necessary for one or more nurses to assist a man to stand.

FIGURE 38-9 Types of male urinals.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Other measures that promote relaxation and the ability to void include sensory stimuli. The sound of running water may help the patient void through the power of suggestion. If the patient is confined to bed the nurse can also pour warm water over their perineum and create the sensation to urinate. If urine output is to be measured, the nurse must first measure the volume of water to be poured over the perineal area. Offering fluids the patient will drink may also promote voiding.

CATHETERISATION

Catheterisation of the bladder involves introducing a tube, usually made of silicone- or hydrogel-coated latex, through the urethra and into the bladder. The catheter provides a continuous flow of urine in patients unable to control voiding or those with urethral obstructions. It also provides a means of assessing hourly urine outputs in haemodynamically unstable patients. Because bladder catheterisation carries the risk of UTI and trauma to the urethra, it is preferable to rely on other measures for either specimen collection or management of incontinence.

WORKING WITH DIVERSITY FOCUS ON CULTURAL CARE

The Victorian Continence Resource Centre conducted a project titled ‘Awareness of incontinence in ethnic communities’. The aim of the project was to explore the awareness of people from different ethnic communities in relation to the prevention, treatment and management of incontinence.

Twenty focus groups were undertaken in selected ethnic communities in Victoria. Participants (n = 218) included older men and women, and middle-aged women (167 female and 52 male). The communities represented included Arabic-speaking, Chinese, Greek, Italian, Polish, Vietnamese, Macedonian, Russian, Spanish-speaking and Turkish. Interpreters were used when needed.

Key findings included:

• Knowledge of incontinence was low across all ethnic groups.

• Not all languages have a term to describe ‘incontinence’ or the translated term often has a negative or detrimental meaning.

• Limitation to social participation was a common impact of incontinence.

• Incontinence could lead to religious restriction for Muslim men and women.

• Cultural and religious influences were expressed in relation to preferences for information in a specific language and for healthcare professionals who spoke their language or were a specific gender.

• Communication and language barriers were perceived to limit access to information and support services.

REFERENCE

Continence Foundation Australia (Victoria Branch). Awareness of incontinence in ethnic communities. Kew: CFA (Vic Branch). Online. Available at: www.continencevictoria.org.au/node/138, 2011. 27 Feb 2012.

OTHER RESOURCES

Incontinence information for supporting ethnic communities available at: www.continencevictoria.org.au/node/138.

METHODS OF ACHIEVING DRAINAGE OF THE URINARY TRACT

There are several methods for achieving drainage of the urinary tract:

• An indwelling or Foley catheter has a small inflatable balloon that encircles the catheter just below the tip. When inflated, the balloon rests against the bladder outlet to anchor the catheter in place. The indwelling retention catheter also has two or three lumens within the body of the catheter (Figure 38-10B). One lumen drains urine through the catheter to a collecting tube. A second lumen carries sterile water to and from the balloon when it is inflated or deflated. A third (optional) lumen may be used to instil fluids or medications into the bladder. It is easy to determine the number of lumens by the number of drainage and injection ports at the catheter’s end. An indwelling catheter is used when constant drainage is required, for example when there has been surgery to the abdomen or pelvic area, or when accurate measurement of urine is required. Indwelling catheters can be left in for long periods of time. It is necessary to change indwelling catheters periodically—usually every 6–8 weeks.

• Intermittent catheterisation. With the intermittent technique, a straight single-use catheter (Figure 38-10A) is introduced long enough to drain the bladder (5–10 minutes). When the bladder is empty, the catheter is withdrawn. The straight single-use catheter has a single lumen with a small opening about 1.3 cm from the tip. Urine drains from the tip, through the lumen, to a receptacle. Intermittent catheterisation can be repeated as necessary, usually several times per day. Some people require intermittent catheterisation for many months or years and are taught to catheterise themselves; this is termed intermittent self-catheterisation (ISC).

• Suprapubic catheterisation. A suprapubic catheter is surgically inserted into the bladder via a puncture wound on the lower abdomen. These are used in patients who have chronic retention of urine, neurological disease (such as spinal cord injury or multiple sclerosis), prior pelvic or gynaecological surgery, urethral trauma or those who require long-term drainage of urine (Harrison and others, 2010). They can be more comfortable for people who require long-term urinary drainage. Suprapubic catheters are self-retaining—they have a balloon at the catheter tip. Suprapubic catheters need to be changed the same way that indwelling urethral catheters are changed. Registered nurses who have had appropriate training are able to change these catheters.

• Other methods to achieve drainage from the urinary tract. There are several other devices that can be used to drain urine from the upper urinary tract. Nephrostomy tubes are inserted in the flank region straight into the pelvis of the kidney. These are used when there is obstruction in the upper ureter from urinary calculi or tumours or resulting from oedema when there has been surgery to the upper tract. A sterile drainage bag is applied to the person’s skin and urine can drain freely. Stents can also be inserted into the ureter so that drainage is maintained. These fine tubes are inserted via a cystoscope in an operating room.

FIGURE 38-10 Types of urinary catheters. A, Non-retaining or straight catheter. B, Self-retaining indwelling (Foley) catheter.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

Catheters come in many diameters to fit the size of a patient’s urethral canal. Suggestions on catheter selection are provided in Box 38-4.

BOX 38-4 GUIDELINES FOR APPROPRIATE CATHETER SELECTION

• The catheter size should be determined by the size of the person’s urethral canal. When the French system (Charriére or French Gauge) is used, the larger the gauge number, the larger the catheter size. One Charriére is ⅓ of a millimetre. Generally, children require an 8–10 FG, women require a 12–14 FG and men require a 16–18 FG. To prevent trauma, the smallest effective catheter size is preferred.

• The expected time required for the catheterisation will determine the catheter material selection.

— PVC catheters are suitable only for intermittent use due to their inflexibility.

— Silicone-coated latex catheters are recommended for use up to 1 month—although these are usually only used for short periods (1 week).

— Hydrogel-coated catheters are recommended for use up to 3 months; these are comfortable for the person as they cause little friction in the urethra.

— Pure silicon catheters are best suited for long-term use (2–3 months), as they cause less encrustation at the urethral meatus. They have a large lumen as they are not coated.

• Balloon size is also important in selecting an indwelling catheter. Use the smallest balloon size possible, as a large balloon can cause irritation at the bladder neck.

— Balloon sizes range from 3 mL for babies and children to 5–30 mL for adults. In adults, the 10 mL is the most common. A 30 mL size is used after prostate surgery to provide haemostasis of the prostatic bed.

• Only sterile water should be used to inflate the balloon as saline may crystallise, resulting in incomplete deflation of the balloon at the time of removal.

Adapted from Australian and New Zealand Urological Nurses Society 2009 Catheterisation guidelines. Online. Available at www.anzuns.org/?page_id=105 22 May 2012; Turner B, Dickens N 2011 Long-term urethral catheterisation. Nurs Stand 25(24):49–56.

INDICATIONS FOR CATHETERISATION

Catheterisation may be indicated for many reasons. When catheterisation time will be short and minimising infection is a priority, the intermittent method is best. Intermittent catheterisation is also preferred for people who have chronic retention of urine (without urethral obstruction), such as a person with diabetes who has developed an atonic bladder. By intermittently draining the bladder on a routine basis, these patients have fewer infections (Newman and Wilson, 2011). Indwelling catheterisation is used when long-term bladder emptying is necessary. Box 38-5 outlines specific indications for catheterisation.

BOX 38-5 INDICATIONS FOR CATHETERISATION

• Relief of acute or chronic urinary retention.

• Measurement of urinary output in acutely ill patients:

— to bypass an obstruction (e.g. enlarged prostate, tumour or clot)

— to assist with drainage of urine in patients with neurogenic bladder dysfunction who cannot manage intermittent self-catheterisation

— to empty the bladder prior to procedures or surgery.

• Following surgery on the bladder, urethra and surrounding structures:

— to permit continuous or intermittent bladder irrigation or instil medication

— to protect skin from urine (e.g. serious decubitus ulcers of the buttocks, burns to thighs)

— to alleviate discomfort in terminally ill patients

— to determine residual urine volume in the absence of ultrasound equipment (bladder scanner)

— to manage intractable incontinence (only a last resort).

Adapted from Australian and New Zealand Urological Nurses Society 2009 Catheterisation guidelines. Online. Available at www.anzuns.org/?page_id=105 22 May 2012; Turner B, Dickens N 2011 Long-term urethral catheterisation. Nurs Stand 25(24):49–56.

CATHETER INSERTION

Urethral catheterisation may require a medical prescription. Aseptic technique is used to minimise the risk of introducing microorganisms into the bladder (see Chapter 29). The steps for inserting indwelling and single-use straight catheters are basically the same. The difference lies in the procedure taken to inflate the indwelling catheter balloon and secure the catheter. Skill 38-2 lists steps for performing female and male urethral catheterisation.

SKILL 38-2 Inserting a straight or indwelling catheter

DELEGATION CONSIDERATIONS

Catheterisation requires the problem-solving and knowledge application skills of registered nurses. Insertion of a urinary catheter normally requires a medical request.

EQUIPMENT

• Catheterisation kit containing the following sterile items:

— Gloves (extra pair optional)

— Drapes, one fenestrated

— Lubricant (usually water-based for women and xylocaine gel (2%) in a pre-filled syringe for men)

— Antiseptic cleaning solution (aqueous chlorhexidine or Normal saline)

— Gauze swabs

— Forceps

— Syringe with sterile water to inflate the balloon of indwelling catheter

— Catheter of correct size and type for procedure (i.e. intermittent or indwelling)

— Sterile urinary bag

— Catheter strap or other catheter-securing device

— Receptacle or basin (usually bottom of disposable catheterisation tray)

• Blanket/large towel to cover patient

STEPS			RATIONALE
1. Assess status of patient:
	a. Time of last urination; ask patient, check fluid balance chart or palpate bladder		Bladder fullness may be detected with deep palpation above the symphysis pubis.
	b. Level of awareness or developmental stage		Reveals the patient’s ability to cooperate and level of explanation needed.
	c. Mobility and physical limitations of patient		Affect way the nurse positions patient.
	d. Patient’s gender and age		Determines catheter size: see Box 38-4.
	e. Distended bladder		Causes pain. Can indicate need to insert catheter if patient is unable to void independently.
	f. Perineum erythema, drainage and odour		Determines condition of the perineum.
	g. Any pathological condition that may impair passage of catheter (e.g. enlarged prostate in men)		Obstruction prevents passage of catheter through urethra into the bladder.
	h. Allergies		Determines allergy to antiseptic, tape, latex and lubricant. Betadine allergies are common; if the patient is unaware of allergy, ask if allergic to shellfish.
2. Review patient’s medical record, including medical request and nurses’ notes.			Determines purpose of inserting catheter. Assess for previous catheterisation, including catheter size, response of patient and time of last catheterisation.
3. Assess patient’s knowledge of the purpose of catheterisation.			Reveals need for patient instruction.
4. Explain procedure to patient.			Promotes cooperation.
5. Arrange for extra nursing personnel to help as necessary.			Patient may be unable to assume positioning for procedure.
6. Begin monitoring fluid balance.			Catheterised patients are at risk of urinary complications.
7. Perform hand hygiene.			Reduces transmission of microorganisms.
8. Close curtain or door.			Offers privacy, reduces embarrassment and aids in relaxation during procedure.
9. Raise bed to appropriate working height.			Promotes use of proper body mechanics.
10. Facing patient, stand on left side of bed if right-handed (on right side of bed if left-handed). Clear the bedside table and arrange equipment.			Successful catheter insertion requires nurse to assume comfortable position with all equipment easily accessible. The materials in the kit are arranged in sequence of use.
11. Raise side rail on opposite side of bed, and put side rail down on working side.			Promotes patient safety.
12. Place waterproof pad under patient.			Prevents soiling of bedclothes.
13. Position patient.			Provides good view of perineal structures.
	A. Female patient
		(1)Help into dorsal recumbent position (supine with knees flexed). Ask patient to relax thighs so the hips can be externally rotated.	Legs may be supported with pillows to reduce muscle tension and promote comfort.
		(2)Position female patient in side-lying (Sims’) position with upper leg flexed at hip if unable to be supine. Support patient with pillows if necessary to maintain position.	This position is used if patient cannot abduct leg at hip joint (e.g. if patient has arthritic joints). Also, this position may be more comfortable for patient.
	B. Male patient
		(1)Help into supine position with thighs slightly abducted.	Comfortable position for patient that gives good view.
14. Drape patient.			Avoids unnecessary exposure of body parts and maintains patient’s comfort.
	A. Female patient (see illustration) Drape with bath blanket. Place blanket diamond-fashion over patient, with one corner at patient’s neck, side corners over each arm and side, and last corner over perineum.
	B. Male patient (see illustration) Drape upper trunk with bath blanket, and cover lower extremities with bed sheets, exposing only genitalia.
Step 14A Draping technique (female).			Step 14B Draping technique (male).
15. Position lamp to illuminate perineal area. (When using torch, have an assistant hold it.)			Permits accurate identification and good view of urethral meatus.
16. Wearing non-sterile gloves, wash perineal area with soap and water as needed; dry.			Reduces microorganisms near urethral meatus and allows further opportunity to see perineum and landmarks.
17. For men: take pre-filled syringe of xylocaine gel (2%). Insert tip of syringe into the urethral meatus, holding the penis firmly and straight. Gently instil the gel into the urethra. Ask the man to hold the end of his penis to stop the gel coming out.			Wait several minutes before inserting the catheter so that the anaesthetic agent has time to take effect.
18. Remove and discard gloves; perform hand hygiene.			Prevents transmission of microorganisms from table or work area to sterile supplies.
19. Open package containing drainage system; place drainage bag over edge of bottom bed frame, and bring drainage tube up between side rails and mattress (indwelling catheter only).
20. Perform hand hygiene. Open catheterisation kit according to directions, keeping bottom of container sterile.
21. Put on sterile gloves (see Chapter 29).			Allows nurse to handle sterile supplies without contamination.
22. Organise supplies on sterile field. Open inner sterile package containing catheter. Pour sterile antiseptic solution into correct compartment containing sterile gauze squares. Open sterile packet containing lubricant.			Maintains principles of surgical asepsis and organises work area.
23. Lubricate 2-5 cm of catheter for women and 12-18 cm for men.
24. Apply sterile drape:
	A. Female patient
		(1)Allow top edge of drape to form a cuff over both hands. Place drape down on bed between patient’s thighs. Slip cuffed edge just under buttocks, taking care not to touch contaminated surface with gloves.	Outer surface of drape covering hands remains sterile. Sterile drape against sterile gloves is sterile.
		(2)Pick up fenestrated sterile drape, and allow it to unfold without touching an unsterile object. Apply drape over perineum, exposing labia, and being sure not to touch contaminated surface.	Maintains sterility of work surface.
	B. Male patient
		(1)Two methods are used for draping depending on preference. First method: apply drape over thighs and under penis without completely opening fenestrated drape. Second method: apply drape over thighs just below penis. Pick up fenestrated sterile drape, allow it to unfold and drape it over penis with fenestrated slit resting over penis.	Maintains sterility of work surface.
25. Place sterile tray and contents on sterile drape.			Provides easy access to supplies during catheter insertion. Maintains aseptic technique during procedure.
26. Clean urethral meatus:
	A. Female patient
		(1)With non-dominant hand, carefully retract labia to fully expose urethral meatus. Maintain position of non-dominant hand throughout procedure.	Full view of urethral meatus is provided. Full retraction prevents contamination of urethral meatus during cleaning.
		(2)Using forceps in sterile dominant hand, pick up gauze square saturated with antiseptic solution/sterile water and clean perineal area, wiping from front to back from clitoris towards anus. Using a new gauze square for each area, wipe along the far labial fold, near labial fold and directly over centre of urethral meatus (see illustration).	Cleaning reduces number of microorganisms at urethral meatus. Use of a single gauze square for each wipe prevents transfer of microorganisms. Cleaning proceeds from area of least contamination to that of most contamination. Dominant hand remains sterile.
Critical decision point: Closure of labia during cleaning requires that the cleaning procedure be repeated because the area has become contaminated.
	B. Male patient
		(1)If patient is not circumcised, retract foreskin with non-dominant hand. Grasp penis at shaft just below glans. Retract urethral meatus between thumb and forefinger. Maintain non-dominant hand in this position throughout procedure.	Accidental release of foreskin or dropping of penis during cleaning requires process to be repeated because area has become contaminated.
		(2)With dominant hand, pick up gauze square with forceps and clean penis. Move in a circular motion from urethral meatus down to base of glans. Repeat cleaning three more times, using a clean gauze square each time (see illustration).	Reduces number of microorganisms at urethral meatus and moves from area of least to most contamination. Dominant hand remains sterile.
Step 26A(2) Cleaning female perineum.			Step 26B(2) Cleaning male urinary meatus.
27. Pick up catheter with gloved dominant hand 8-10 cm from catheter tip. Hold end of catheter loosely coiled in palm of dominant hand (optional: may grasp catheter with forceps).
28. Insert catheter:
	A. Female patient
		(1)Slowly insert catheter through urethral meatus (see illustration).
		(2)Advance catheter a total of 5-8 cm in adult or until urine flows out of catheter’s end. When urine appears, advance catheter another 2-5 cm. Do not force against resistance.	Female urethra is short. Appearance of urine indicates that catheter tip is in bladder or lower urethra. Advancement of catheter ensures bladder placement.
Critical decision point: If no urine appears, check that catheter is in vagina. If misplaced, leave catheter in vagina as landmark indicating where not to insert, and insert another (you will need to start the procedure again unless you have another nurse attending who can open another sterile catheter onto the sterile field).
		(3)Release labia, and hold catheter securely with non-dominant hand. Inflate balloon if retention catheter is used (see illustration). Only put in the amount of sterile water that is indicated on the catheter.	Bladder or sphincter contraction may cause accidental expulsion of catheter.
	Over-inflation of the balloon may cause it to burst or block off the drainage holes of the catheter. Under-inflation can result in the catheter falling out.
Step 28A(1) Inserting catheter.			Step 28A(3) Inflating balloon of retention catheter.
	B. Male patient
		(1)Lift penis to position perpendicular to patient’s body and apply light traction (see illustration).	Straightens urethral canal to ease catheter insertion.
		(2)Slowly insert catheter through urethral meatus.
		(3)Advance catheter 18-23 cm in adult or until urine flows out catheter’s end. If resistance is felt, withdraw catheter; do not force it through urethra. When urine appears, advance catheter another 2-5 cm.	The adult male urethra is long. It is normal to meet resistance at the prostatic sphincter. When resistance is met, nurse should hold catheter firmly against sphincter without forcing catheter. After a few seconds, the sphincter relaxes, and the catheter is advanced. Appearance of urine indicates catheter tip is in bladder or urethra. Further advancement of catheter ensures proper placement.
		(4)Lower penis and hold catheter securely in non-dominant hand. Place end of catheter in urine tray. Inflate balloon if retention catheter is used. Only put in the amount of sterile water that is indicated on the catheter.	Catheter may be accidentally expelled by bladder or urethral contraction. Collection of urine prevents soiling and provides output measurement.
	Over-inflation of the balloon may cause it to burst or block off the drainage holes of the catheter. Under inflation can result in the catheter falling out.
		(5)Reduce (or reposition) the foreskin.	Paraphimosis (retraction and constriction of the foreskin behind the glans penis) secondary to catheterisation may occur if foreskin is not reduced.
Step 28B(1) Positioning penis prior to catheter insertion.
29. Remove straight, single-use catheters when drainage ceases. Withdraw catheter slowly but smoothly until removed.
Step 29 Drainage bag attached to lower bed frame.
	For indwelling catheterisation—attach end of catheter to tube of drainage bag system (see illustration). Make sure drainage port at the base of the drainage bag is closed. Drainage bag must be below level of bladder; attach bag to bed frame, do not place bag on side rails of bed.		Establishes a closed system for urine drainage.
30. Pack up equipment and leave it on the trolley so that it can be easily disposed of shortly.
31. Remove gloves and perform hand hygiene.			Reduces transmission of microorganisms.
32. Anchor catheter:
	A. Female patient
		(1)Secure catheter tubing to inner thigh with a catheter strap or other catheter-securing device. Allow for slack so movement of thigh does not create tension on catheter.	Anchoring catheter to inner thigh reduces pressure on urethra, thus reducing possibility of tissue injury and reduces risk of urinary tract infection.
	B. Male patient
		(1)Secure catheter tubing to top of thigh or lower abdomen (with penis directed towards chest). Allow slack in catheter so movement does not create tension on catheter.	Anchoring catheter to lower abdomen reduces pressure on urethra at junction of penis and scrotum, thus reducing possibility of tissue injury.
33. Help patient into comfortable position. Wash and dry perineal area as needed.			Maintains comfort and security.
34. Dispose of equipment, drapes and urine in proper receptacles. Perform hand hygiene.			Reduces transmission of microorganisms.
35. Palpate bladder.			Determines whether distension is relieved.
36. Ask about patient’s comfort.			Determines whether patient’s sensation of discomfort or fullness has been relieved.
37. Observe character and amount of urine in drainage system.			Determines whether urine is flowing adequately.
38. Determine that there is no urine leaking from catheter or tubing connections.			Prevents injury to patient’s skin.
39. Perform hand hygiene when leaving the patient’s bed area.

RECORDING AND REPORTING

HOME CARE CONSIDERATIONS

• Report and record type and size of catheter inserted, amount of water used to inflate the balloon, characteristics of urine, amount of urine, reasons for catheterisation, specimen collection if appropriate and patient’s response to procedure and teaching concepts. • Initiate fluid balance chart. • If catheter is definitely in bladder and no urine is produced within an hour, absence of urine should be immediately reported to a medical practitioner.

• Patients who are at home may use a leg bag during the day and attach a large-volume bag at night so sleep can be uninterrupted. • Patients may catheterise themselves at home using a clean technique.

CLOSED DRAINAGE SYSTEMS

After inserting an indwelling catheter, a closed urinary drainage system is maintained to minimise the risk of infection. Urinary drainage bags are plastic and can hold about 1000–1500 mL of urine. The bag should hang on the bed frame or wheelchair without touching the floor. When the patient moves about, the nurse or patient carries the bag below the patient’s waist. The drainage bag should never be raised above the level of the patient’s bladder, so that urine does not flow back from the tubing into the bladder.

Most drainage bags contain an anti-reflux valve to prevent urine in the bag from re-entering the drainage tubing and contaminating the patient’s bladder. A valve at the base of the bag provides a means for emptying the bag. The valve should always be closed, except during emptying, and tucked into the protective pouch on the side of the bag. To keep the drainage system patent, frequently check for kinks or bends in the tubing, avoid positioning the patient on the drainage tubing and observe for clots or sediment that may occlude the collecting tubing.

For the person who will go home from hospital with an indwelling urinary catheter, a smaller leg bag is connected to the catheter. Leg bags are designed to be strapped to the person’s leg so that they can carry on their usual daily activities without having to carry a large urine bag. Because the leg bag only holds approximately 500 mL of urine, the leg bag will need to be emptied frequently throughout the day. This can easily be done into a toilet or plastic jug. A larger overnight bag is connected (at the base of the leg bag) before the person goes to sleep so that their sleep is not interrupted by the need to empty the smaller leg bag.

ROUTINE CATHETER CARE

Patients with indwelling catheters have a number of special care needs. Nursing measures are directed at preventing infection and maintaining an unobstructed flow of urine through the catheter drainage system.

Perineal hygiene

Build-up of secretions or encrustation at the catheter insertion site is a source of irritation and potential infection. The person can shower normally with a catheter, and they should be encouraged to use mild soap and water to wash their genital area at least daily (Turner and Dickens, 2011). If the patient is unable to shower on their own they will need assistance with their personal hygiene either in the shower or during a bed bath.

Fluid intake

All patients with catheters should have a daily intake of 2000–2500 mL of fluid if not contraindicated. This can be achieved through oral intake or intravenous infusion. A high fluid intake produces a large volume of urine that flushes the bladder and keeps the catheter tubing free of sediment.

Bowel care

As mentioned previously, constipation can affect urinary elimination. Promotion of normal bowel elimination is also important in catheterised patients. Assessment of bowel function should be conducted daily.

Ongoing assessment

A patient who has a urinary catheter needs focused assessment at least three times per day (once per shift). The assessment should include:

• daily inspection of the urethral meatus for signs of inflammation and leakage of urine

• checking of the closed drainage system for patency

• inspection of the urine for colour and clarity

• abdominal palpation for bladder distension

• checking that the catheter is secured to the upper thigh or lower abdomen with an appropriate device such as a catheter strap.

PREVENTING INFECTION

Infection can develop in a catheterised patient in many ways. A CAUTI is defined as a symptomatic UTI in a person with a urinary catheter (Gray and Moore, 2009). The longer the catheter is left in situ, the higher the likelihood of developing a CAUTI. According to Hameed and others (2010), there is a 5% risk of developing a CAUTI each day that the catheter is in situ and this rate increases over time. After 30 days of catheterisation nearly all patients will have bacteriuria, although not all will have symptomatic infection (Gray and Moore, 2009). Bacteria can enter the bladder at several points. Sites at risk are the site of catheter insertion, the drainage bag, the spigot, the tube junction and the junction of the tube and the bag. Maintaining a closed urinary drainage system is important in infection control, as a break in the system can lead to introduction of microorganisms.

Pooling of urine in the drainage bag tubing should also be avoided. Urine in the drainage bag is an excellent medium for microorganism growth. Bacteria can travel up drainage tubing to grow in pools of urine in the tubing. If this urine flows back into the patient’s bladder, an infection is likely to develop. Suggestions for ways to prevent infections in catheterised patients are provided in Box 38-6.

BOX 38-6 TIPS FOR PREVENTING INFECTION IN CATHETERISED PATIENTS

• Follow hand hygiene guidelines (see Chapter 29).

• Maintain a closed system—catheter, drainage tubing and drainage bag.

• Do not open the drainage system at connecting points to collect specimens.

• If the drainage tube becomes disconnected, do not touch the ends of the catheter or tubing. Wipe the end of the tubing and catheter with an antimicrobial solution before reconnecting.

• Prevent pooling of urine in the tubing and reflux of urine into the bladder:

— avoid raising the drainage bag above the level of the bladder

— avoid allowing large loops of tubing to lie on the bed

— provide for drainage of urine from the tubing to the bag by positioning the tubing

— before exercise or walking, drain urine from the tubing into the drainage bag.

• Do not allow the drainage port on the drainage bag to touch the floor.

• Empty the drainage bag at least every 8 hours. If large outputs are noted, empty more frequently.

• Remove the catheter as soon as clinically warranted.

• Secure the catheter appropriately for the patient (see Skill 38-2).

REMOVAL OF INDWELLING URETHRAL CATHETER

The aim when removing an indwelling catheter is to prevent trauma to the urethra. Following catheter removal, time to first void and volume of first void are assessed as well as return to normal voiding patterns.

The equipment required to remove a catheter is a disposable towel or plastic bed protection pad; a rubbish receptacle; and a sterile syringe the same size as the volume of the catheter balloon. The distal end of each catheter contains a label that denotes the volume of solution (5–30 mL) within the balloon. Standard infection-control precautions are also recommended.

• Explain the procedure to the patient. The removal of the catheter is likely to cause minor discomfort but is unlikely to be painful.

• Position the patient in the same position as during catheterisation.

• After removing catheter-securing devices such as a catheter strap, place the towel/bed protection pad between a female patient’s thighs or over a male patient’s thighs.

• Insert the syringe into the balloon port. Slowly withdraw all of the solution to deflate the balloon totally. If a portion of the solution remains, the partially inflated balloon will traumatise the urethral canal as the catheter is removed.

• When all of the solution from the balloon has been aspirated, pull the catheter out smoothly and slowly. If the balloon does not deflate or you have trouble removing the catheter, do not cut the tubing. Refer the problem to a specialist clinical nurse (for example a urology or continence nurse) or a medical practitioner.

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

Assesses the patient’s urinary function by noting the time of first voiding after catheter removal, and document the time and amount of voiding for the next 24 hours. Encourage the patient to drink water. If the voided amounts are small (less than 100 mL), frequent assessment for retention of urine is necessary. Most hospitals use ultrasonic bladder scanners to assess post-void residual urine volumes. Guidelines vary on the amount of residual urine that is considered acceptable. The post-void residual volume is compared with the actual amount voided. If over 8 hours elapse without voiding in a patient who is drinking good amounts, it may become necessary to reinsert a catheter.

Interventions to promote continence

All of the interventions mentioned previously that promote normal voiding patterns are also used to promote continence. There are a number of interventions that are used to treat urinary incontinence. The treatment plan can only be developed after careful assessment of the problem. Implementing toileting programs without a detailed assessment and identification of the specific continence issue is not likely to result in an improvement in the person’s continence.

CONTINENCE AIDS AND APPLIANCES

Aids and appliances form the key to achieving social continence. Social continence refers to the use of continence aids and appliances to keep urinary leakage and odour contained, enabling the person to engage in normal daily activities. Continence aids and appliances are an important part of active treatment plans for many people because they give the person the confidence they need to engage in normal daily activities and social interactions. For some people, social continence may be the goal of treatment. There are various continence aids and appliances available. These include continence pads and pants, absorbent bed sheets and chair covers, and other products that assist with voiding such as bed pans, urinals, commode chairs, raised toilet seats and chairs; most hospitals and healthcare agencies will have a selection in stock. Some of these products can be misused. A study by Zisberg (2011) found that continent adult women, especially those with impaired mobility, were being given continence pads in the acute care setting. Zisberg makes the point that using continence pads for these people is likely to result in reduced self-esteem and quality of life, increased risk of skin problems and urinary tract infections and may increase the risk of urinary incontinence in frail older people. It is not acceptable practice to give a patient a continence pad when they do not have any urinary incontinence.

A person with an ongoing continence problem should be referred to a continence nurse specialist for assessment and management of their continence problem. Continence nurse specialists are registered nurses who have postgraduate qualifications and experience in promoting continence and managing incontinence. A continence nurse specialist can provide expert advice on appropriate continence aids and appliances and can assist the person to access government funding schemes. Individual needs must be taken into account when selecting continence products. These include the amount of urine that the pad needs to contain, rate of loss of urine, gender, size of the person, cognitive function, manual dexterity and strength, the person’s lifestyle, access to laundry and/or disposal facilities, and the personal preference of the person (Cottenden and others, 2009).

URINARY SHEATH

The urinary sheath (or the ‘condom’ in condom drainage) is a non-invasive soft, pliable, silicone or latex sheath that slips over the penis (Skill 38-3). It is suitable for men who have urinary incontinence but still have complete and spontaneous bladder emptying. It may be worn continuously or at night only, depending on the person’s needs. The success of the urinary sheath relies on correct choice of size of the device and correct application of the device to the penis. Urinary sheaths come in varying lengths and diameters. Each brand of sheath will come with a sizing guide; care must be taken to ensure that whatever type or size is used, blood supply to the penis is not impaired. Each sheath has adhesive on the inside so that the sheath is comfortably fitted and stays in place without leaking. The penis needs to be clean and dry for the adhesive to stick properly. Some men may need to reduce the amount of pubic hair (using a personal trimmer) so that the adhesive sticks properly.

SKILL 38-3 Applying a sheath/condom drainage device

DELEGATION CONSIDERATIONS

Applying a sheath/condom can be delegated to enrolled nurses, the person if he is able or a family carer in the home context.

• Ensure that person/caregiver knows standard precautions guidelines relating to body fluids.

• Clarify that skin of penile shaft is intact and free of swelling, redness or open lesions before sheath/condom drainage device is applied.

• Clarify the person’s/caregiver’s understanding of how to apply the adhesive strip that secures the sheath/condom drainage device.

EQUIPMENT

• Sheath/condom drainage device kit

— Latex/silicone condom sheath (proper size) (check for possible rubber or latex allergy)

— Skin preparation solution or swab (may be required)

• Urinary collection bag with tubing or leg bag with straps

• Basin with warm water and soap

• Towels and washcloths

• Non-sterile disposable gloves

• Bath blanket

• Scissors and/or personal trimmer (patient’s own)

STEPS	RATIONALE
1. Assess urinary elimination patterns, patient’s ability to voluntarily urinate and continence.	Patients who are incontinent are at high risk of skin breakdown.
2. Provide privacy by closing door or bed curtains.	Maintains patient’s self-esteem.
3. Assess mental status of patient so appropriate teaching related to sheath device can be implemented.	Some male patients may be incontinent only at night. Teaching can be implemented to instruct patient on self-application.
4. Assess condition of penis.	Provides a baseline to compare changes in condition of skin after condom application.
5. Assess patient’s knowledge of the purpose of a sheath device.	Reveals need for patient instruction.
6. Explain procedure to patient.	Reduces anxiety and promotes cooperation.
7. Perform hand hygiene.	Reduces transmission of microorganisms.
8. Raise bed to appropriate working height. Raise side rail on opposite side of bed, and lower rail on working side.	Promotes patient safety and proper use of body mechanics by nurse.
9. Help patient into supine position. Place bath blanket over upper torso. Fold bed sheets so that lower extremities are covered; only genitalia should be exposed.	Promotes patient comfort and prevents unnecessary exposure of body parts.
10. Prepare urinary drainage collection for connection to sheath/condom. Clamp off all drainage exit ports. Secure collection bag to bed frame; bring drainage tubing up through side rails onto bed. Prepare leg bag for connection to sheath/condom if necessary.	Provides easy access to drainage equipment after sheath/condom is applied.
11. Put on non-sterile gloves. Assess the required size of the sheath/condom using the manufacturer’s guide.	Sheath/condoms come in a variety of sizes (circumference and length). It is very important to use the correct size for comfort and so that the sheath/condom remains in place for the required period of time.
12. Wash area with soap and water or ask the patient to do this for himself if he is able (see Skill 38-2), and dry thoroughly.	Removes irritating secretions. Rubber/latex sheath rolls onto dry skin more easily. The adhesive will adhere to dry skin. Be aware of possible latex allergy.
13. Clip hair at base of penis. In some cases, shaving the hair at the base of the penis may be necessary.	Hair adheres to sheath/condom and is pulled during sheath/condom removal or may get caught as sheath/condom is applied.
14. Roll sheath/condom onto penis—try to keep the glans centrally within the sheath. You may need to put gentle tension on the penis to keep it straight within the sheath. As the adhesive is on the inside of the sheath/condom, you need to gently press the sheath onto the shaft of the penis as you unroll it (see illustrations).	Make sure that the foreskin remains over the glans to protect the glans from the adhesive on the inside of the sheath/condom. Gentle pressure and the heat from your hand will help make sure that the adhesive is well applied to the penile shaft.
Critical decision point: Allow 2-5 cm of space between tip of glans penis and end of sheath/condom (see illustration, Step 14).
Step 14 Technique for rolling sheath/condom onto penis.
15. Connect drainage tubing to end of sheath/condom. Be sure sheath/condom is not twisted. The sheath/condom can be attached to large-volume bag or leg bag (see illustrations).	Allows urine to be collected and measured. Keeps patient dry. Twisted sheath/condom obstructs urine flow.
Step 15 Attaching sheath/condom to large-volume or leg bag.
16. Place excess coiling of tubing on bed, and secure to bottom sheet.	Promotes free drainage of urine.
17. Place patient in a safe, comfortable position. Lower bed, and place side rails accordingly.	Promotes safety and comfort.
18. Dispose of contaminated supplies. Remove gloves, and wash hands.	Reduces spread of microorganisms.
19. Observe urinary drainage.	Determines whether normal voiding is occurring.
20. Inspect penis with sheath/condom in place within 30 minutes after application. Look for swelling and discolouration, and ask patient if there is any discomfort.	Determines whether sheath/condom has been applied correctly.
21. Remove and change sheath/condom and inspect skin on penile shaft for signs of breakdown or irritation at least daily when hygiene is performed and when the sheath/condom is reapplied.	Indicates whether sheath/condom or urine is causing irritation. Frequent assessment of good blood circulation to glans penis is important to determine whether sheath/condom has been applied too tightly.

RECORDING AND REPORTING

HOME CARE CONSIDERATIONS

• Record and report pertinent information: sheath/condom application, condition of skin, voiding pattern. • Monitor fluid balance chart as indicated.

• If leg bag is used, assess leg for circulatory impairment. Switch to a large-volume drainage bag at night. • Teach patient that a collection bag that fills completely may put unnecessary tension on the catheter and contribute to problems keeping the sheath/condom intact. • Some men have difficulty in getting the adhesive to stick to their skin. These men may benefit from the use of skin preparation wipes to the shaft of penis (these can be purchased from the sheath/condom manufacturer). These remove skin oils and adhesive from previous applications and may assist the adhesion of the sheath.

The distal end of the sheath fits into plastic drainage tubing. A drainage bag can be attached to the side of the bed, or a leg bag can be strapped to the patient’s leg. The sheath itself poses little risk of infection. Infections with urinary sheaths usually result from a build-up of secretions around the urethra, trauma to the urethral meatus or a build-up of pressure in the outflow tubing.

The man (or their carer) should be advised to gently remove and discard the sheath daily. This provides a good opportunity to check the skin of the penis for irritation and inflammation. Normal personal hygiene can be attended to, such as showering, and a new sheath fitted.

For a man with a retracted penis, maintaining a conventional urinary sheath may prove difficult. Special devices are available to help alleviate this problem (Figure 38-11). Manufacturers’ guidelines for product application should be consulted.

FIGURE 38-11 Retracted penis pouch external urinary device.

From Potter PA, Perry AG 2013 Fundamentals of nursing, ed 8. St Louis, Mosby.

• CRITICAL THINKING

Mr Miller is a 75-year-old widower who has had prostate surgery for benign prostatic hypertrophy. He thought his problems would be over, but now he is experiencing continual dribbling of urine. He has been trying to deal with the problem by using an absorbent pad in his underwear, but he feels as though everyone knows his problem. The embarrassment of having an odour often keeps him at home. He has given up attending his senior citizens centre.

1. Outline the areas for further assessment of his problem.

2. Describe a pelvic floor exercise program that would be suitable for this man.

Maintenance of skin integrity

The normal acidity of urine is irritating to skin. Urine allowed to be in contact with the skin becomes alkaline, causing encrustations or precipitates to collect on the skin, fostering breakdown. Continuous exposure of the perineal area leads to gradual maceration and excoriation (see Chapter 30). Washing with mild soap and warm water is the best way to remove urine from skin. A non-perfumed body lotion keeps skin moisturised, and skin barriers (for example zinc and castor oil cream) provide a barrier to the urine.

If the skin becomes inflamed, the doctor may prescribe a cream containing a corticosteroid such as hydrocortisone. If a fungal infection develops, a topical antifungal containing an agent such as nystatin or clotrimazole is effective.

Voiding programs

Voiding programs should not be commenced until a detailed assessment has been undertaken and the specific continence problem(s) identified. Bladder training programs aim to increase bladder capacity by gradually increasing the interval between voids, for example in a person with urge incontinence who may be voiding frequently. These programs consist of an educational program about how the bladder works and how continence is maintained; a voiding program based on the person’s current voiding pattern (determined by a voiding diary); and an ongoing support program as the program is likely to take several months to achieve the desired increase in voiding frequency (Newman and Wein, 2009b).

Habit training, timed voiding and prompted voiding are methods of bladder re-education aimed at re-establishing a normal voiding pattern. These programs are used for people with stress, urge and mixed incontinence and are often used with frail or cognitively impaired people to reduce incontinence episodes (Newman and Wein, 2009b). Habit training involves identification of the person’s usual voiding pattern and pre-empting incontinence episodes by decreasing voiding intervals, while keeping these intervals as long as possible. Timed voiding is a program of voiding according to a schedule that is determined from a voiding diary (Ostaszkiewicz and others, 2010a). Prompted voiding is a program in which the nurse (or carer) checks the person at regular intervals to see if they are wet or dry, provides feedback to the person about their own perception of being wet or dry and offers assistance with toileting. Positive responses are praised and incontinent episodes are managed without comment. This type of voiding program is most suited to people with mild to moderate cognitive impairment or with functional incontinence due to immobility (Eustice and others, 2009). While these programs are extensively used in practice, there is very little published evidence on their efficacy and patient outcomes (Eustice and others, 2009; Ostaszkiewicz and others, 2010a, 2010b).

Patient expectations

If the nurse has developed a relationship of trust with a patient, indications of the patient’s degree of satisfaction with the care will be evident. However, the nurse needs to confirm whether the patient’s expectations have been met to full satisfaction. The nurse may need to ask specifically about the patient’s degree of urinary control and comfort. Keep in mind that it may take several months before any measurable improvement in urinary incontinence can be determined. These people need ongoing support so that their treatment goals can be realised. The nurse can also assist the patient in redefining unrealistic patient goals when impairment in function is not likely to be altered as completely as the patient might like.