URINARY ELIMINATION

OBJECTIVES
• Describe common physiological alterations of urinary elimination.
• Demonstrate procedures and techniques in providing nursing skills in the GUT.

COMMON ALTERATIONS
1. URGENCY- feeling of need to void immediately
2. DYSURIA- painful or difficult urination
3. FREQUENCY- voiding at frequent intervals (<2 hr)
4. HESITANCY- difficulty initiating urination
5. POLYURIA- voiding large amounts of urine
6. OLIGURIA- diminished urinary output relative to intake (usually 400 ml/24 hr)
7. NOCTURIA- urination, particularly excessive or frequent, at night.
8. BRIBBLING- leakage of urine despite voluntary control of urination
9. INCONTINENCE- involuntary loss of urine
10. HEMATURIA- blood in the urine
11. RETENTION- accumulation of urine in the bladder, with inability of bladder to empty fully
12. RESIDUAL URINE- volume of urine remaining after voiding (>100 ml)

URINARY CATHETERIZATION
This is the introduction of a rubber or plastic tube through the urethra and into the bladder.

TYPES:
 INTERMITTENT CATHETERIZATION
- a straight single-use catheter is introduced long enough to drain the bladder (5-10 mins) then
immediately withdrawn by the nurse.
- can be repeated as necessary but with caution since repeated use increases the risks of trauma and
infection.

 INDWELLING CATHETERIZATION(FOLEY)
- remains in place for a longer period until a client is able to void completely and voluntarily or as long as
accurate measurements are needed.

INDICATIONS:
1. INTERMITTENT CATHETERIZATION
- relief of comfort of bladder distention, provision of decompression.
- obtaining sterile urine specimen.
- assessment of residual urine after urination.
- long-term management of clients with spinal cord injuries, neuromuscular degeneration, or incompetent
bladders.
2. SHORT-TERM CATHETERIZATION
- obstruction to urine flow (e.g., prostate enlargement).
- surgical repair of bladder, urethra, and surrounding structures.
- prevention of urethral obstruction from blood clots.
- measurement of urinary output in critically ill clients.
- continuous or intermittent bladder irrigations.

3. LONG-TERM INDWELLING CATHETERIZATION

- severe urinary retention with recurrent episodes of UTI.
- skin rashes, ulcers, or wounds irritated by contact with urine.
- terminal illness when bed linen changes are painful for client.

PRINCIPLES:
 Catheters come in many diameters to fit the client’s urethral canal.
Guidelines for appropriate catheter selection:
 the catheter size should be determined by the size of the client’s urethral canal.
Children: 8-10 Fr
Women: 14-16 Fr
Men: 16-18 Fr
 The smallest effective catheter size is preferred to prevent trauma.
 The expected time required for the catheterization will determine the catheter material selection.
 Plastic catheters are suitable only for intermittent use due to their inflexibility.
 Latex and rubber catheters are recommended for use up to 3 weeks. Be aware of allergies to either
of these materials.
 Pure silicon r Teflon catheters are recommended for long-term use (2-3 mos) because they cause
less encrustation of the urethral meatus.
 Balloon size:
 3ml(pediatric)
 5ml(adult)- for optimal drainage
 30ml(adult)- to provide hemostasis of the prostatic bed.
 75ml(large post-op volumes)
• Only sterile water should be used to inflate the balloon because saline may crystallize, resulting in
incomplete deflation of the balloon a the time of removal.
 If leakage should occur around the catheter, a change in lumen size or use of antispasmodic
medication may be warranted.
 Urethral catheterization requires a physician’s order.
 Organize first all equipment before the start of the procedure to prevent interruptions.
 Prevention of infection and Maintenance of the patency of the drainage system.
 Strict Aseptic technique
 Closed drainage system
 Routine catheter care
 Perineal hygiene
• Provision of comfort to the patient.

NURSING RESPONSIBILITIES
1. Catheter insertion
 Check first the client’s chart.
 Observe strict aseptic technique.

Special Considerations
 Female Patient - thorough and careful cleaning of the perineum is very important before catheter
insertion to reduce the incidence of infection.
 Elderly and Physically Challenged Patient - Will require additional time and careful handling,
especially if lower extremities are contracted
 Pediatric Patient- Provide age-appropriate instructions.
- For infants and children, allow parents to participate in comforting patient.
 Home Health Patient- Patients may need careful monitoring and additional education about
catheter care for indwelling and straight catheterization.

2. Prevent infection and maintain patency of the drainage system.

 Closed drainage system
 Perineal Hygiene
 Routine catheter care

EQUIPMENT
1.Catheterization kit containing the ff. sterile items:
- gloves (extra pair-optional)
- drapes, one fenestrated
- lubricant
- antiseptic cleansing solution
- cotton balls
- forceps
- prefilled syringe with sterile water Catheter of correct size and type for procedure
- sterile drainage tubing with collection bag and multipurpose tube holder or tape, safety pin and elastic
band for securing tubing to bed if client is bed bound (for indwelling catheter)
- receptacle or basin(usually bottom of catheterization tray)
- specimen container
- blanket.

*TYPES OF CATHETER
1. Straight single-use catheter
- has a single lumen with a small opening about 1.3cm (1/2 inch) from the tip.

2. Indwelling Foley catheter

- has small inflatable balloon that encircles the catheter just above the tip.
May have 2 or 3 lumens within the body of the catheter.

PROCEDURE
ASSESSMENT:
1.Assess the need for catheterization and the type of catheterization ordered.
2. Assess for the need for peritoneal care prior to catheterization.
3. Assess the urinary meatus for signs of infection or inflammation. Ask the client for any history of
difficulty with prior catheterizations, anxiety, or urinary strictures.
4. Assess the client’s ability to assist with the procedure.
5. Assess the light.
6. Assess for an allergy to povidone -iodine and/or latex.
7. Watch for indications of distress or embarrassment. Explore further if indicated.

PLANNING
Expected Outcomes:
1. The catheter will be inserted without pain, trauma, or injury to the client.
2. The client’s bladder will be emptied without complication.
3. The nurse will maintain the sterility of the catheter during insertion.
IMPLEMENTATION:
1. Wash hands.
2. Gather the equipment needed. Read the label on the catheterization kit. Note if the catheter is included
in the kit and, if so, what type it is. Gather any supplies you will need that are not in the prepackaged kit.

3. Provide for privacy and explain procedure to client.

a. Explain the procedure to client, and describe anticipated sensations of burning and urgency that occur
when the catheter is placed.
b. Explain the need for the catheter.
c. Explain the basics of aseptic technique and the need not to touch or contaminate the sterile field.
4. Set the bed to a comfortable height to work, and raise the side rail on the side opposite you.
5. Position your client.
 FEMALE: Assist the client to a supine position with legs spread and feet together or to a side-lying
position with upper leg flexed.
 MALE: Assist the client to a supine position with legs slightly spread.
6. Drape your patient.
 FEMALE: Drape the client’s abdomen and thighs for warmth if needed.
 MALE: Drape the client’s abdomen and thighs if needed.
7. Ensure adequate lighting of the genitals and perineal area.
8. Apply disposable gloves, and wash the perineal area.
9. Remove gloves and wash hands.
10. Open the catheterization kit, using aseptic technique. Use the wrapper to establish a sterile field
11. If the catheter is not included in the kit, carefully drop the sterile catheter onto the field using aseptic
technique. Add any other items needed.
12. Apply sterile gloves. These may be included in the kit.
13. Place the fenestrated drape from the catheterization kit over the client’s perineal area with the penis
extending through the opening.
14. If inserting a retention catheter, attach the syringe filled with sterile water to the Luer-Lok tail of the
catheter. Inflate and deflate the retention balloon. Detach the water-filled syringe
15. Attach the catheter to the urine drainage bag if it is not pre-connected.
16. Generously coat the distal portion of the catheter with water-soluble, sterile lubricant and place it
nearby on the sterile field.
17. With your non-dominant hand cleanse the genitalia and perineal area with povidone-iodine.
 FEMALE: a. Gently spread the labia minora with the fingers of your nondominant hand and
visualize the urinary meatus
b. Holding the labia apart with your non-dominant hand, use the forceps to pick up a
cotton ball soaked in povidone-iodine, and cleanse the periurethral mucosa.Use one downward stroke for
each cotton ball and dispose. Keep the labia separated with your non-dominant hand until you insert the
catheter.
 MALE: a. With your non-dominant hand, gently grasp the penis and retract the foreskin (if
present). With your dominant hand, cleanse the glans penis with a povidone-iodine solution or
other antimicrobial cleanser
b. Hold the penis perpendicular to the body and pull up gently.
c. Inject 10 ml sterile, water-soluble lubricant (use a 2% Xylocaine lubricant whenever
feasible) into the urethra.
18. Insert the catheter.
 FEMALE: Holding the catheter in the dominant hand, steadily insert the catheter into the meatus
until urine is noted in the drainage bag or tubing.
  MALE: Holding the catheter in the dominant hand, steadily insert the catheter about 8 inches,
until urine is noted in the drainage bag or tubing.
19. If the catheter will be removed as soon as the client’s bladder is empty, insert the catheter another
inch, place the penis in a comfortable position (for male) and hold the catheter in place as the bladder
drains.
20. If the catheter will be indwelling with a retention balloon,
 FEMALE: continue inserting another 1 to 3 inches.
 MALE: Continue inserting until the hub of the catheter (bifurcation between drainage port and
retention balloon arm) is met. Continue inserting the catheter until the bifurcation between the
drainage port and the retention balloon reaches the end of the penis. This ensures the retention
balloon will be fully in the bladder prior to inflation.
21. Reattach the water-filled syringe to the inflation port.
22. Inflate the retention balloon with sterile water per manufacturer’s recommendations or the physician’s
or qualified practitioner’s orders.
23. Instruct the client to immediately report discomfort or pressure during balloon inflation; if pain occurs,
discontinue the procedure, deflate the balloon, and insert the catheter farther into the bladder. If the client
continues to complain of pain with balloon inflation, remove the catheter and notify the client’s qualified
practitioner.
24. Once the balloon has been inflated, gently pull the catheter until the retention balloon is restingsnug
against the bladder neck (resistance will be felt when the balloon is properly seated).
25. Secure the catheter according to institutional policy.
 FEMALE: Tape the catheter to the abdomen or thigh snugly, yet with enough slack so it will not
pull on the bladder.
 MALE: Securing it to either the client’s thigh or abdomen is generally acceptable.
26. Place the drainage bag below the level of the bladder. Do not let it rest on the floor. Secure the
drainage tubing to prevent pulling on the tubing and the catheter.( Place the drainage bag tubing over the
leg. Place the drainage bag below the level of the bladder, but do not rest it on the floor.)
27. Remove gloves, dispose of equipment, and wash hands.
28. Help client adjust position. Lower the bed.
29. Assess and document the amount, color, odor, and quality of urine.

EVALUATION:
 The catheter was inserted without pain, trauma, or injury to the client.
 The client’s bladder was emptied without complication.
 The nurse maintained the sterility of the catheter during insertion.

DOCUMENTATION:
 Document and report date and time of catheterization and specimen collected if ordered. Initiate
I&O record.
 Characteristics of urine and signs of possible urinary infection.
 Disposition of specimen if ordered.

COLLECTING URINE SPECIMEN

INDICATION
1. To evaluate urine content or renal function
2. To determine if the catheter needs to be removed or if antibiotic therapy is indicated
3. Random- routine urinalysis
4. Clean-voided or midstream- culture and sensitivity
5. Sterile specimen- culture and sensitvity.
6. Timed urine specimens – for measuring levels of adrenocortical steroids or hormones, creatinine
clearance, or protein quantity tests.
PRINCIPLE

 Aseptic technique
 Privacy
 Safety
 Correct Procedure
 Accuracy
 Timeliness and Consistency

NURSING RESPONSIBILITIES
1. Provide client comfort, privacy and safety.
2. Explain the purpose of the specimen collection and the procedure for obtaining the specimen.
3. Use the correct procedure for obtaining a specimen or ensure that the client or staff follows the correct
procedure.
4. Note relevant information on the laboratory requisition slip that may affect the results.
5. Transport the specimen to the laboratory promptly.
6. Report abnormal laboratory findings to the health care provider in a timely manner consistent with the
severity of the abnormal results.

OBTAINING URINE SPECIMEN FROM INDWELLING CATHETER

ASSESSMENT
1. Identify the purpose of the urine test to determine the amount of urine needed and the proper container
to collect it in.
2. Assess the client’s ability to understand purpose of the test to determine amount of instruction needed.
3. Identify the type of collecting tubing attached to the indwelling catheter to determine if you will need to
disconnect the catheter from the system or can obtain the specimen from a closed system.
 Equipment Needed
1. Nonserrated clamp or rubber band
2. Nonsterile gloves
3. Syringe with needle (1 inch), 10 cc
4. Specimen container, plastic bag, and labels
5. Povidone-iodine swab
IMPLEMENTATION
1. Check physician’s or qualified practitioner’s order.
2. Wash hands.
3. Gather the necessary equipment.
4. Explain procedure to the client and provide privacy.
5. Put on clean gloves.
6. Check for urine in the tubing. Urine from the collection bag should not be used for sterile specimens.
7. If more urine is needed, clamp the tubing using a non-serrated clamp or a rubber band for 10 to 15
minutes (30minutes). Collects 10 cc of urine, which is needed for most urinalysis.
8. Clean sample port with a povidone-iodine swab or wipe the area where the needle will be inserted. The
site should be distal to the tube leading to the balloon to avoid puncturing the tube.
9. Insert sterile needle and syringe into the sample port or catheter at a 30°- 45° angle and withdraw the
required amount of urine.
10. Put urine into sterile container and close tightly, taking care not to contaminate the lid of the container.
11. Remove clamp and rearrange tubing avoiding dependent loops.
12. Do after care of the equipment. Discard syringe and needle in an appropriate sharps container.
13. Label specimen container, put it in a plastic bag, and send to the laboratory immediately or
refrigeration.
14. Wash hands.
15. Document. Record collection of the specimen and any pertinent observations of the urine on the
appropriate records.

Nurses’Notes
• Record the date and time the specimen was sent to the laboratory.
• Note the test(s) ordered.

Laboratory Requisition
• Record the date, time, client name and room number.
• Note the test(s) ordered.

Intake and Output Record

• Record the amount of urine collected for the specimen.
BLADDER TRAINING
-This is used to gradually increase the interval between voiding and to decrease frequency during
both waking and sleeping hours.

INDICATION:
 Restoring the normal pattern of voiding.

PRINCIPLES:
 Client’s involvement: must be alert and physically able to follow training programs.
 Education
 Scheduled voiding
 Positive reinforcement.

GOAL:
To break the cycle of urgency and frequency using consistent, incremental voiding schedules.

IMPORTANT FEATURE:
Dissociates voiding from urgency (voiding by the clock rather than in response to urgency weakens the
urge-void response)

INSTRUCTIONS FOR BLADDER TRAINING

STEP 1
Review voiding diary with the patient. Note the voiding intervals and their variability.
STEP 2
With the patient select the longest voiding interval with which the patient finds comfortable.
STEP 3
Instruct the patient to:
 Empty his/her bladder:
 First thing in the morning.
 Every time his/her voiding interval passes during the day.
 Just before he/she goes to bed.
STEP 4
Teach patient techniques for coping with the urge to void that occurs before the interval has passed:
 Distraction to another task that is mentally but not physically engaging.
 Deep breathing and relaxation.
 Self Statements
 Urge suppression strategy: using pelvic floor muscle contraction to keep bladder relaxed.
STEP 5
Gradually increase the voiding interval:
 When the patient is comfortable on the voiding schedule for at least 3 days.
 By 15-30 minutes interval as determined by the patient’s confidence and clinical judgement.
MEASURES THAT CAN HELP INCONTINENT CLIENT GAIN CONTROL OVER URINATION
AND ARE PART OF RESTORATIVE AND REHABILITIVE CARE:

1. Learning exercises to strengthen the pelvic floor.

2. Initiating a toileting schedule on awakening, at least every 2 hours during the day and evening, before
getting into bed, every 4 hours at night (individualizing the time frame as needed)
3. Using methods to initiate voiding.
 Never ignoring the urge to void.
 Minimizing tea, coffee, other caffeine drinks and alcohol.
 Taking prescribed diuretic medication or fluids that increase diuresis (such as tea or coffee) early
in the morning.
 Progressively lengthening or shortening periods between voiding as appropriate for control of
specific cause of incontinence.
 Offering protective undergarments to contain urine and reduce the client’s embarrassment (not
diapers)
 Following a weight-control program if obesity is a problem.
 Providing positive reinforcement when continence is maintained.