ATI Urinary Elimination PDF

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ATI Urinary Elimination Basic Anatomy • • •

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Filtration, reabsorption, and excretion Maintain fluid and electrolyte balance while filtering and excreting water-soluble wastes Primary organs: KIDNEY o Retroperitoneal space below ribcage on back o Left higher than right bc right lies beneath liver o Pelvis, medulla, cortex o Blood supply arrives via renal arteries (branch from abdominal aorta) o Innervated by sympathetic component of ANS Nephrons perform most parts of filtering, reabsorb, and excreting o Contain glomerulus, proximal convoluted tubule, descending loop of Henle, ascending loop of Henle, and collecting tubule Filter 7 L/hr (99% reabsorbed) Produce 1-3 L urine a day Produce erythropoietin, contribute to RBC production in activation of Vit D Hormones in kidney: o Renin: regulates blood flow, glomerular filtration, BP (closely related to filtration) ▪ Activates angiotensin 1 --> ACE --> angiotensin 2 (inc blood vol and BP) o Antidiuretic hormone (volume of urine that produced ▪ High levels: limit urine production ▪ Low levels: large amounts urine ▪ Produced in posterior pituitary gland Action of urinating called micturition

INSERTING INDWELLING RETENTION CATHETER • • • • •

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Introduce self Confirm 2 identifiers Verify orders (allergies) Assess the perineum for redness, rashes, sores (provide cleaning) Gather supplies o Correct side catheter o ****Latex free for clients who have allergies o ****Iodine allergy? Use antiseptic solution Privacy Supplies near bedside Hand hygiene Explain procedure Bath blanket on top Withdraw linens to end of bed Position client Waterproof pad underneath Surgical asepsis Open away, side, side, toward you Place sterile drape between legs on bottom Don sterile gloves Drape over client Indwelling has balloon Open iodine solution Apply lubricant to tray Clean area Use non dom hand to spread Dom hand, clean top toward back, side, side, center Hold cath with dom Bear down while inserting Advance until you see flash of urine Then 2 more inches Then inflate balloon Release labia, hold on to catheter with non dom hand Pull to make sure balloon is in proper position Let client know she can relax Hand hygiene Don gloves Secure cath to thigh and attach drainage system Put band around thigh Place below bladder on bedside (immovable part) Dispose equip and supplies

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Note urine quantity and quality Remove bath blanket Lower bed to original position Remove gloves/hand hygiene Routinely changed as defined in facilities protocol

REMOVING INDWELLING CATH • • • • • • • • • • • • • • • • • • • • • • • • • •

Introduce yourself Confirm client Verify orders (allergies) Assess perineum Gather supplies Privacy Hand hygiene Don gloves Explain procedure Position in supine w/ knees flex Residual urine in tubing: drain in bag Remove thigh thing Drape under client Remove fluid in balloon Remove tubing Towel to collect drainage Look for blood, mucus, signs of infection Remove/dispose supplies and gloves Hand hygiene Don gloves Pull covers up and lower bed Always assess skin quality Intervene appropriately Remove gloves HH Document quantity and quality

INSERTING AND REMOVING A STRAIGHT CATHETER • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Introduce self Confirm client Verify orders Assess penis Cleanse perineum w/ soap and water Gather supplies **allergies Enlarged prostate: use coude tip Privacy Hh Explain procedure Bath blanket over patient Withdraw linens Waterproof pad under client Hh Surgical asepsis Place wrap on top of legs Don gloves Drape over penis Pour iodine Lubricant to prepare catheter Clean penis hold with non dom Use sterile hand to pick up catheter Lubricate Take a deep breath Insert cath Advance till flash Then another ½ in Drain urine while holding cath into tray until flow stops Deep breath Remove cath slowly Client can relax Dispose equip and supplies

APPLYING CONDOM CATHETER • • • • • • • • • • • • • • • • • • • • • • • • • • • • •

Introduce self Confirm client Verify orders Assess penis Measure shaft Gather supplies Allergies Confirm privacy Hh Explain procedure Bath blanket over patient Hh Gloves Supine position, thighs slightly abducted Cloth in warm soapy water and wrap around hand like a mit Wash tip of penis Different wipe to wash remainder of penis Rise soap off completely Same thing with just water Pat dry Retracted foreskin--> make sure you release it Don clean gloves Apply adhesive, wait a moment for it to dry Secure condom to penis Apply pressure for 10-15 sec Connect cath to drainage tubing and then to drainage bag Attach leg strap Perform assessments and perineal care frequently Blood supply to penis adequate

Equipment Types of catheters • • •

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Straight catheters o One time use Indwelling o Short term closed drainage system Retention o Post op o Multiple lumens to drain urine, irrigation of bladder and instillation of meds into bladder Coude cath o Prostatic hyperplasia (enlargement) o Curved tip for easier insertion Suprapubic cath o Placed through surgical opening in abdomen rather than urethra o Similar to indwelling Condom cath o Latex sheath over penis

Types of drainage

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Standard collection bag o Most common o Large capacity o Do not wait till full o Every 8 hrs empty o Free flowing drainage or one way valve at top o Port for emptying o Pour into urinal, measuring container, then flush Non movable part of bed Leg bag o Smaller and attach to client o Bag attached to leg o Smaller, easily concealed o One way valve o Empty more often o Difficult with clients who are confused/non ambulatory

Insertion • • • •

Assess before and after Allergies, mental status, urine quality, voiding patterns, vital signs, skin assessment, abdominal assessment Urine assess: color, Odor, blood and amount Vital signs

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Skin: hydration status and skin breakdown Abdominal: bladder distention in clients who cannot urinate

Urinary Specimen Collection • • • • • • • • •

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Used for infection, hydration status Never take urine from collection bag Cath have small port located on cath tubing area near the end of the cath that is attached to bag Cleanse port using swab Use syringe, withdraw sample from tubing Transfer to sterile cup Labe with name, dob, date/time Transport to lap immediately Urine dipstick o Immediate information o Identify ph, specific gravity (hydration status), wbc, blood Urinalysis o In depth about a lot o Cannot determine type of bacteria o Often ordered with culture and sensitivity Culture and sensitivity o Provide valuable info for treating infection o Bacteria identified o Grows sample of bacteria to determine type o Grown sample used to determine which antibiotics kill bacteria o Wait until results before prescribing antibiotic therapy

PERINEAL CARE (FEMALE) • • • • • • • • • •

Supine position Bath blanket Waterproof drape under client Warm soapy water, wrap like a mit One side with non dom Then other side Clean around urethra from front to back Dispose washcloth New cloth rinse soap off each side Pat dry

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Always requires dr order Inc risk for UTI because of prolonged time they are in place Female: higher risk for UTI bc they have shorter urethra and shorter distance from urethra to anus than male clients o Shorter urethra--> increases risk of infection bc distance for bacteria to travel into bladder shorter o Advanced age and prolonged indwelling cath use inc risk of UTI Manifestation of UTI o Elevated WBC o Pungent odor o Sediment in urine o Confusion o Urination pattern o Fever Autonomic dysreflexia o Affects clients with Spinal cord injuries above thoracic level o Stimulus from ANS causes hypertension, bradycardia, headaches, pallor, flushing above level of injuries, pallor below o Causes: constipation and full bladders due to clamping o Treatment: removal of stimulus o Medications stabilize client Causes of hematuria (blood in urine) o Mechanical injury of urethra o Urinary calculi (stones) o Genitourinary cancers o UTI o Pyelonephritis (infection of kidney) o Glomerulonephritis (infection of glomerulus structure in kidney) Documentation o Date and time o Type o Size o Amount of fluid used to inflate balloon o Urinary output o Catheter patency o Urine quality, quantity, odor o Clients' alertness, orientation, abdominal assessment, skin assessment o Teaching done

Urinary Elimination Practice Assessment • • • • • • • •

73-year-old female pale, thin, tremors, diaphoretic, not alert to place/time 102.3 F Pulse: irregular 124 Resp 18 Bp 94/62 Mild bladder distention PHYSICIAN ORDERS: urinalysis, c&s, indwelling cath NURSE: cleans, inserts, client repositions and labia close over urethra

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What should you do next? o Restrain client, start procedure over o AP to help and apply sterile gloves, recleans meatus o Quickly insert cath before further contamination can occur ▪ Contents have not been contaminated only meatus ▪ Meatus has become contaminated, na can orient client and cleanse again ▪ Any contamination to meatus can introduce bacteria into bladder

After inserting catheter, you do not observe any return of urine, abdominal palpation suggests that client's bladder remains distended •

Which of the following actions should you take next? o Remove cath and repeat with sterile, larger diameter catheter o Slowly advance catheter tip while gently rotating tubing o Apply pressure to distended abdomen and observe for urine return ▪ Lack of urine related to placement not size ▪ No urine appears continue to advance ▪ Appling pressure will increase client's discomfort and will not result in urine output if cath is not placed correctly

Now you have inserted cath into bladder and inflated balloon, you must obtain a urine sample and send to lab for urinalysis, c&s •

Correct steps for obtaining urine sample from a closed system o Disconnect collection bag, cleanse end of tube, allow urine to flow from tube into bottle o Collect 5-10mL of urine from collection bag into sterile specimen container before emptying urine from collection bag into commode o Allow urine to collect in bag and empty bag and collect urine from collection port ▪ Disconnecting bag will open system, contaminating bag and tube ▪ Collection bag new: sterile and uncontaminated. First sample can be collected by collection bag, other samples obtained from collection tube ▪ Do not need to discard urine as it is in a closed system and sterile

Provide routine cath care for 2 days. Area is wet and erythematous. Urine is leaking around catheters insertion site, some bladder distension •

What actions do you take next? o Deflate balloon and remove catheter o Call provider and notify charge nurse of findings o Examine cath and drainage tube along their entire path ▪ Not first action to take ▪ Not first action to take ▪ Least invasive and do first; may be due to obstructions in kinks or tubing

Clients' provider orders daily bladder irrigation to clear urine of bacterial debris and blood clots, follow protocol and attach a Y tube to cath and start bladder irrigation. Irrigate solution flows easily into bladder but shortly after you begin, client reports of lower abdominal pain and cramping •

What should you do next? o Slow irrigate solution and continue o Stop and evaluate for occlusion o Assure client that some discomfort is expected o Hasten procedure by inc rate of flow of irrigant ▪ Bladder distension due to outlet occlusion is most likely cause ▪ Clients history and possible development of clots, assess that cath has not become obstructed ▪ Client uncomfortable, intervene ▪ Will feel even more discomfort

Today you are working on medical surgical unit. Each of your four clients has an indwelling cath •

Which clients should you manage first? o Client with spinal cord injury who has sediment in urinary drainage bag o Client newly admitted to unit after kidney surgery with bloody urine output o Client reporting pressure around bladder o Discharged home today with leg bag ▪ Not highest priority ▪ Post op patient at risk for hemorrhage due to possibility of injury to large vessels surrounding kidney (aorta, inferior vena cava)

Go to post op client first, enter room, immediately client reports severe abdominal pain •

Which of the following nursing assessments should you perform ▪ Obtain orthostatic bp ▪ Palpate bilateral pedal pulses ▪ Auscultate and palpate abdomen ▪ Measure client's jugular venous pressure • Orthostatic is for dehydration/fluid status • Pedal pulses: detect ischemia • Dec bowel sounds, palmate for firmness • Jugular venous pressure: right atrium

Clients' abdomen distended and firm without active bowel sounds. Suspect internal hemorrhage and call surgeon immediately Client with bladder pressure: •

Observe client's urinary output and remove barriers to flow of urine. Cath was kinked. Client reports signs of relief

Client with spinal cord injury who has sediment in urinary drainage bag (most likely due to dehydration or immobility, assess fluid and recognize need for rehydration o

He has high sodium levels, BUN levels which indicate mild dehydration

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Which client should you manage first? o 1 day post op and needs cath removed o Condom cath and reports pain when urinates o Dementia who pulled off condom cath o Green exudate seeping from urethra ▪ Not highest priority ▪ Possible kidney stones, not highest ▪ Tissue damage can result and can impair circulation to penis. threat to airway, breathing, circulation ▪ Discharge can be infection, not highest

Skin barrier around cath is loose, no tissue damage •

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Before replacing, which should you do? o Cleanse glans penis with povidone-iodine o Apply bacitracin ointment to meatus o Provide perineal care with soap and water ▪ Not necessary when applying external condom cath ▪ Antibiotic ointment ▪ Appropriate to perform perineal care while condom cath is off Who will you see next? o Post op o Pain when urination o Exudate seeping ▪ Not highest priority ▪ Dysuria (painful urination) likely due to infection or stones, collect specimen ▪ Infection but not highest

You perform a clean catch specimen Who will you see next? Green exudate No signs of irritation, provider asks to obtain specimen for gram stain and culture Pain client has large number of wbc due to uti •

In light of clients gram stain results, it is appropriate for you to notify provider and o Local state health department o Spouse o Health care team members who had contact ▪ Health department must know every case of gonorrhoeae so sexual relation with client can be identified and treated

Post Test A nurse is preparing to remove a client indwelling urinary catheter. Which of the following should the nurse take? • • • •

Pull catheter out as quickly as possible Deflate balloon completely before removal Cut inflation port to deflate balloon Tell client to expect to feel a tugging sensation on removal

Identify correct sequence of steps that the nurse should take 1. 2. 3. 4. 5.

Wipe port with alcohol swab Attach a syringe to collection port of indwelling catheter Withdraw 3-30mL of urine Transfer urine to sterile specimen container Transport specimen to laboratory

A nurse is applying a condom catheter for a client who is uncircumcised. Which of the following actions should the nurse take? • • • •

Stretch sheath portion of condom catheter along length of penis Secure sheath portion with adhesive tape Leave a space between penis and sheath portion tip Reposition foreskin after application

A nurse is preparing to insert an indwelling catheter for a client. Which of the following actions should the nurse instruct client to perform during insertion procedure • • • •

Bear down Take deep breaths Sip water Tighten perineum

A nurse is preparing a male client for intermittent urethral catheterization. Which of the following actions should the nurse take? • • • •

Grasp penis at base Lift penis perpendicular to body Hold penis parallel to clients body Lift penis 45 angle to clients body

A nurse is providing perineal care for female client who has indwelling urinary cath. Which of the following areas should nurse cleanse last? • • • •

Urethral meatus Labia minora Perineum Anus

A nurse is caring for a group of newly admitted clients. For which of the following clients should the nurse expect to receive a prescription for urinary catherterization? • • • •

Frequent UTI Urge incontinence ICU for gastrointestinal bleed Inc due to cognitive decline

Nurse assessing indwelling urinary cath drainage at end of shift and notes output is less then fluid intake. Which of the following actions should nurse take? • • • •

Irrigate catheter Assess for peripheral edema Palpate for ladder distension Check catheter for kinks...