SKILLS II LAS PINAS COLLEGE CATHETERIZATION Objectives: 1. 2. 3. 4. Describe the process of urination, from urine formation through micturition.

Identify factors that influence urinary elimination. Identify common causes of selected urinary problem. Describe nursing assessment of urinary function including subjective and objective data. 5. Identify normal and abnormal characteristics and constituent of urine. 6. Explain the care of clients with retention catheters or urinary diversions.

I. a. b. c. d. e. II.

PHYSIOLOGY OF URINARY ELIMINATION Kidneys Ureters Bladder Urethra Urination FACTORS AFFECTING VOIDING

a. Developmental factors 1. 2. 3. 4. b. c. d. e. f. g. Infant Pre-schooler School-age children Elders Psychosocial factors Fluid and food Intake Medications Muscle Tone Pathologic conditions Surgical and Diagnostic Procedures

III.

ALTERED URINE PRODUCTION

a. Polyuria b. Oliguria c. Anuria IV. a. b. c. d. e. f. g. V. a. b. c. d. VI. VII. ALTERED URINARY ELIMINATION Frequency and nocturia Urgency Dysuria Enuresis Urinary Incontinence Urinary Retention Neurogenic Bladder ASSESSMENT Nursing History Physical assessment Assessing urine Diagnostic Tests DIAGNOSING PLANNING

a. Planning for Home Care VIII. IMPLEMENTING a. b. c. d. e. f. g. h. IX. Maintaining Normal Urinary Elimination Maintaining Normal Voiding Habits Preventing Urinary Tract Infections Managing Urinary Incontinence Maintaining skin Integrity Applying External urinary Drainage Devices Managing Urinary Retention Catheterization EVALUATION

I.

PHYSIOLOGY OF URINARY ELIMINATION

A. KIDNEYS Situated on either side of the spinal column, behind the peritoneal cavity. Primary regulators of fluid and acid-base balance in the body. Functional units are Nephrons filters the blood and remove metabolic wastes. 21 % of cardiac output passes through the kidneys/minute.

*Each Nephron has a glomerulus* a tuft capillaries surrounded by Bowmans capsule. Bowmans Capsule Proximal Convuluted tubules Loop of Henle Distal Convuluted tubules

B. URETERS 25 to 30 cm ( 10 to 12 inches) long in the adult and 1.25 cm( o.5 in) in diameter. The upper end of each of the ureters is funnel shaped as it enters the kidney. The lower ends of the ureters enter the bladder at the posterior corners of the floor of the bladder

C. BLADDER a. b. c. d. It is a hollow, muscular organ that serves as a reservoir for urine and as the organ of excretion. When empty, it lies behind the symphysis pubis. In men, the bladder lies in front of the rectum and above the prostate gland In women, it lies in front of the uterus and vagina The wall of the bladder is made up of four layers: An inner mucous layer A connective tissue layer Three layers of smooth muscle fibers An outer serous layer

*The smooth muscle layers are collectively called the detrusor muscle. The Trigone at the base of the bladder is a triangular area marked by the ureter openings at the posterior corners and the opening of the urethra at the anterior inferior corner*

- It is capable of considerable distention because of the rugae (folds) in the mucous membrane lining and because of the elasticity of its walls. D. URETHRA It extends from the bladder to the urinary meatus ( opening). In women, the urethra lies directly behind the symphysis pubis, anterior to the vagina, and is about 3.7 cm ( 1.5 inches) long. Serves only a s a passageway for the elimination of urine. The urinary meatus is located between the labia minora, in front of the vagina and below the clitoris. In men, urethra is about 20 cm. (8 inches) long and serves as a passageway for semen as well as urine. The meatus is located at the distal end of the penis. The internal sphincter muscle situated at the base of the urinary bladder is under involuntary control. The external sphincter is under voluntary control, allowing the individual to choose when urine is eliminated. Women are particularly prone to urinary tract infections because of their short urethra and the proximity of the urinary meatus to the vagina and anus.

E. URINATION Micturition, voiding and urination refer to the process of emptying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall called stretch receptors, this occurs when the adult bladder contains between 250 and 450 mL of urine. In children a considerably smaller volume, 50 to 200 mL stimulates these nerves. The stretch receptors transmit impulses to the spinal cord, specifically to the voiding reflex center located at the level of the second to fourth sacral vertebrae, causing the internal sphincter to relax and stimulating the urge to void.

II.

FACTORS AFFECTING VOIDING 1. Developmental Factors

a. Infants Urine output varies according to fluid intake but gradually increases to 250 to 500 mL a day during the first year May urinate as often as 20 times a day Colorless, odorless, specific gravity 1.008

Because of immature kidneys, unable to concentrate urine effectively Born without urinary control, most will develop between 20 to 5 yrs old.

b. Pre-schoolers Able to take responsibility for independence toileting Girls should be taught to wipe from front to back to prevent contamination of the urinary tract by feces

c. School-age Children elimination system maturity kidneys double in size from 5 to 10 yrs. Old child urinate 6 to 8 times a day

*Enuresis* Involuntary passage of urine when control should be established* *Nocturnal Enuresis* also called bed-wetting, it is the involuntary passing of urine during sleep. d. Elders excretory function of the kidney diminishes Number of functioning nephrons decreases Places the elderly at higher risk for toxicity of medication Complaints of urinary urgency and urinary frequency are common, in men due to enlarged prostate in women, weakened muscles supporting the bladder. 2. PSYCHOSOCIAL FACTOR A set of conditions helps stimulate the micturition reflex. It includes privacy, normal position, sufficient time, and occasionally running water. Anxiety and muscle tension may result to unable to relax abdominal and perineal muscles and the external urethral sphincter and voiding is inhibited. Time pressure, for example a nurse often ignore the urge to void until they are able to take a break. 3. FLUID AND FOOD INTAKE Amount of fluid intake increase, the output normally increases Certain fluids such as alcohol, increase fluid output by inhibiting the production of antidiuretic hormone. Foods high in sodium can cause fluid retention, because water is retained to maintain the normal concentration of electrolytes.

4. MEDICATIONS Medications affecting the autonomic nervous system, interfere with the normal urination process and may cause retention. *Diuretics* Increase urine formation by preventing the reabsoprtion of water and electrolytes from the tubules of the kidney into the bloodstream. 5. MUSCLE TONE Good muscle tone is important to maintain the stretch and contractility of the detrusor muscle so the bladder can fill adequately and empty completely. Clients who require a retention catheter for a long period may have poor bladder muscle tone because continuous drainage of urine prevents the balder from filling and emptying normally. Pelvic muscle tone is a factor being able to retain urine voluntarily once the urge to urinate is perceived. 6. PATHOLOGIC CONDITIONS Diseases of the kidneys may affect the ability of the nephrons to produce urine. Abnormal amounts of protein or blood cells may be present in the urine Kidneys may virtually stop producing urine altogether, a condition known as kidney failure. Processes that interfere with the flow of urine from the kidneys to the urethra affect urinary excretion. A urinary stone ( calculus) may obstruct a ureter, blocking urine flow from the kidney to the bladder. 7. SURGICAL AND DIAGNOSTIC PROCEDURES The urethra may swell following a cystoscopy Surgical procedures on any part of the urinary tract may result in some postoperative bleeding, as a result the urine may be red or pink tinged for a time.

III.

ALTERED URINE PORDUCTION

1. Polyuria or diuresis refers to the production of abnormally large amount of urine by the kidneys, often several liters more than the clients usual daily output. Can follow excessive fluid intake a condition known as Polydipsia or excessive thirst. 2. Oliguria Is low urine output, usually less than 500 mL a day or 30 mL an hour. It may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure and should be promptly reported to the primary care provider. 3. Anuria refers to a lack of urine production. -Should the kidneys become unable to adequately function, some mechanism of filtering the blood is necessary to prevent illness and death, Renal dialysis a technique by which fluids and molecules pass through a semipermeable membrane according to the rules of osmosis. a. Hemodialysis the clients blood flows through vascular catheters, passes by the dialysis solution in an external machine, and then returns to the client. b. Peritoneal Dialysis the dialysis solution is instilled into the abdominal cavity through a catheter, allowed to rest there while the fluid and molecules exchange, and the removed through the catheter. IV. ALTERED URINARY ELIMINATION

Despite normal urine production, a number of factors or conditions can affect urinary elimination. a. Urinary frequency is voiding at frequent intervals, that is more often than usual. An increased intake of fluid causes some increase in the frequency of voiding. b. Nocturia Is voiding two or more times at night. It is usually expressed in terms of the number of times the person gets out of bed to void, for example, nocturia x 4 c. Urgency Is the feeling that the person must void. It accompanies psychologic stress and irritation of the trigone and urethra. Common in young children who have poor sphincter control. d. Dysuria Means voiding that is either painful or difficult. I can accompany a stricture of the urethra, urinary infections, and injury to the bladder and urethra. Urinary hesitancy a delay and difficult in initiating voiding. e. Enuresis Is involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age. Irregular in occurrence and affects boys more often than girls. Diurnal enuresis may be persistent and pathologic in origin, it affects women and girls more frequently.

f. Urinary Incontinence Or involuntary urination, is a symptom not a disease. It can have significant impact of the clients life, creating physical problems such as skin breakdown and possibly leading to psychosocial problems such as embarrassment, isolation and social withdrawal. g. Urinary Retention A condition in which the urinary accumulates and bladder become overdistended because the balder is impaired. Overdistention of the bladder causes poor contractility of the detrusor muscle, further impairing urination. Common causes of urinary retention imclude prostatic hypertrophy, surgery and some medications. h. Neurogenic bladder interfere with the normal mechanism of urine elimination because of impaired neurologic function. Does not perceive bladder fullness and is unable to control the urinary sphincters. The bladder may become flaccid and distended or spastic, with frequent involuntary urination. NURSING MANAGEMENT V. ASSESSMENT

1. Nursing History the nurse determines the client;s normal voiding pattern and frequency, appearance of the urine and any recent changes, any past or current problems with urination, the presence of an ostomy and factors influencing the elimination pattern. 2. Physical Assessment Complete physical assessment of the urinary tract usually includes percussion of the kidneys to detect areas of tenderness. Palpation and percussion of the bladder are also performed. If the clients history or current problems indicate a need for it, the urethral meatus of both male and female clients is inspected for swelling, discharge, and inflammation. 3. Assessing Urine Normal urine consists of 96% water and 4% solutes. Organic solutes include urea, ammonia, creatinine and uric acid. Urea is the chief organic solutes include sodium, chloride, potassium, sulfate, magnesium and phosphorus. Sodium chloride is the most abundant inorganic salt. Measuring urinary output -Normally the kidneys produce urine at a rate of approximately 60 mL per hour or about 1,500 mL per day. Urine output below 30 mL per hour may indicate low blood volume or kidney malfunction and must be reported. a. Wear clean gloves to prevent contact with microorganisms or blood in urine. b. Ask the client to void in a clean urinal, bedpan, commode or toilet collection device c. Instruct the client to keep urine separate form feces and to avoid putting toilet paper in the urine collection container. d. Holding the container at eye level, read the amount in the container. Containers usually have a measuring scale on the inside

e. Record the amount on the fluid intake and output sheet, which may be at the bedside or in the bathroom f. Rinse the urine collection and measuring containers with cool water and store appropriately. g. Remove gloves and wash hands h. Calculate and document the total output at the end of each shift and at the ends of 24 hours on the clients chart. Measuring clients with indwelling catheter: a. Don clean gloves b. Take the calibrated container to the bedside c. Place the container under the urine collection bag so that the spout of the bag is above the container but not touching it. d. The calibrated container is not sterile, but the inside of the collection bag is sterile. e. Open the spout and permit the urine to flow into the container f. Close the spout Measuring Residual Urine *Residual Urine* Urine remaining in the bladder followed by voiding. Is normally present or consists of only a few milliliters. Diagnostic Tests Blood levels of two metabolically produces substances, urea and creatinine, are routinely used to evaluate renal function. Both are normally eliminated by the kidneys through filtration and tubular secretion. Urea the end product of protein metabolism, is measured as blood urea and nitrogen (BUN). The creatinine clearance test uses 24 hour urine and serum creatinin levels to determine the glomerular filtration rate, a sensitive indicator of renal function. VI. 1. 2. 3. 4. 5. DIAGNOSING

Impaired Urinary Elimination: disturbance in urine elimination Functional Urinary Incontinence Reflex urinary Incontinence Stress Urinary Incontinence Risk for infection If the client has urinary retention or undergoes an invasive procedures such as catheterization or cystoscopic examination. 6. Low self-esteem or Social Isolation If the client is incontinent. Incontinence can be physically and emotionally distressing to clients because it is considered socially unacceptable.

7. Risk for Impaired skin integrity If the client is incontinent. Bed linens and clothes saturated with urine irritate and excoriate the skin. Prolonged skin dampness leads to dermatitis and subsequent formation of decubitis ulcer.

VII.

PLANNING

The goals established will vary according to the diagnosis and defining characteristics. Examples of overall goals for clients with urinary elimination problems may include the following: 1. maintain or restore a normal voiding pattern 2. Regain normal urine output 3. Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem 4. Perform toilet activities independently with or without assistive devices. VIII. IMPLEMENTING 1. Maintaining Normal Urinary Elimination Most interventions to maintain normal urinary elimination are independent nursing functions. These includes: a. Promoting Fluid Intake Increasing fluid intake increases urine production, which in turn stimulates the micturition reflex. A normal daily intake averaging 1,500 mL of measurable fluids is adequate for most adult clients. b. Maintaining Normal Voiding Habits prescribe medical therapies often interfere with a clients normal voiding habits. When a clients urinary elimination pattern is adequate, the nurse helps the client adhere to normal voiding habits as much as possible. c. Assisting with toileting Clients who are weakened by a disease process or impaired physically require assistance to toilet. The nurse should stay with the client to prevent risk of falling.

d. Preventing Urinary Tract Infections Most UTIs are caused by bacteria common to the intestinal environment (eg. E Coli). These gastrointestinal bacteria can colonize the perineal area and move into the urethra, especially when there is urethral trauma, irritation, or manipulation. Women are particularly at risk because of the short urethra and its proximity to the anal and vaginal areas. For women who have experienced a UTI, nurses need to provide instructions about ways to prevent a recurrence: 1. Drink eight ounce glasses of water per day to flush bacteria out of the urinary system. 2. Practice frequent voiding ( every 2 to 4 hours) to flush bacteria out of the urethra and prevent organisms from ascending into the bladder. Void immediately after intercourse. 3. Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal area. These substances can be irritating to the urethra and encourage inflammation and bacterial infection. 4. Avoid tight-fitting pants or other clothing that creates irritation to the urethra and prevents ventilation of the perineal area. 5. Wear cotton rather than nylon underclothes. Accumulation of perineal moisture facilitates bacterial growth and cotton enhances ventilation of the perineal area. 6. Girls and women should always wipe the perineal area from front to back following urination or defecation in order to prevent introduction of gastrointestinal bacteria into the urethra. 7. If recurrent urinary infections are a problem, take showers rather than baths. Bacteria present in bathwater can readily enter the urethra. 8. Increase the acidity of urine through regular intake of vitamin C and drinking two to three glasses of cranberry juice daily.

A. Managing Urinary Incontinence Independent nursing interventions for clients with urinary incontinence: a. A behavior oriented continence training program that may consist of balder training, habit training, prompted voiding, pelvic muscle exercises and positive reinforcement b. Meticulous skin care c. For males, application of an external drainage device (condom-type catheter device)

Continence Training A continence training program requires the involvement of the nurse, the client, and support people. a. Education of the client and support people b. Bladder training, which requires the client postpone voiding, resist or inhibit the sensation of urgency, and void according to timetable rather than according to the urge of the void. c. Habit training also referred to as timed voiding or scheduled toileting, attempts to keep clients dry by having them void at regular intervals. d. Prompted voiding it supplements habit training by encouraging the client to delay voiding if the urge occurs. 1. Pelvic Muscle Exercise referred to as kegel exercises, strengthen pelvic floor muscles in women and can reduce episodes. 2. Maintaining Skin integrity Skin that is continually moist becomes macerated (softened). Urine that accumulates on the skin is converted to ammonia, which is very irritating to the skin. The nurse washes the clients perineal area with soap and water after episodes of incontinence, rinse it thoroughly, dries it gently and thoroughly and provides clean, dry clothing or bed linen. 3. Applying external Urinary Drainage Devices The application of a condom or external catheter to a urinary drainage system is commonly prescribed for incontinent males. B. Managing Urinary Retention *Credes Maneuver* manual pressure on the bladder to promote bladder emptying. It is not advised without a physician or nurse practitioners order and is used only for clients who have lost and are not expected to regain voluntary bladder control. When all measures fail to initiate voiding, urinary catheterization may be necessary to empty the bladder completely. URINARY CATHETERIZATION Is the introduction of a catheter through the urethra into the urinary bladder. This is usually performed only when absolutely necessary, because the danger exists of introducing microorganisms into the bladder. Clients who have lowered immune resistance are at the greatest risk. Once an infection is introduced into the bladder, it can ascend the ureters and eventually involve the kidneys. The hazard of infection remains after the catheter is in place, thus strict sterile technique is used for catheterizations. Another hazard is trauma, particularly in the male client, whose urethra is longer and more tortous. It is important to insert a catheter along the normal contour of the urethra.

Damage to the urethra can occur if the catheter is forced through the strictures or at an incorrect angle. Catheters are commonly made of rubber or plastics although they may be made from latex, silicone, or polyvinyl chloride (PVC). They are sized by the diameter of the lumen using the French (Fr) scale. The larger the number, the larger the lumen. Either straight catheters, inserted to drain the bladder and then immediately removed, or retention catheters, which remain in the bladder to drain urine, may be used. a. Straight Catheter Is a single lumen tube with a small eye or opening about 1 cm ( in.) from the insertion tip. b. Coude catheter Is a variation of the straight catheter. It is more rigid than other straight catheters and has tapered. This catheter may be used fro men with prostatic hypertrophy because it is more easily controlled and less traumatic on insertion. c. Retention or Foley Catheter Is a double lumen catheter, the larger lumen drains urine from the bladder. A second, smaller lumen is used to inflate a balloon near the tip of the catheter to hold the catheter in place with the bladder. d. Three-way Foley Catheter has a third lumen through which sterile irrigating fluid can flow into the bladder. The fluid then exits the bladder through the drainage lumen, along with the urine. The balloons of retention catheters are sized by the volume of fluid used to inflate them. The two commonly used sizes are 5 mL and 30 mL balloons. The size of the balloon is indicated on the catheter along with the diameter, for example, #18 Fr-5mL. PERFORMING URINARY CATHETERIZATION Purposes: a. To relieve discomfort due to bladder distention or to provide gradual decompression of a distended bladder. b. To assess the amount of residual urine if the bladder empties incompletely c. To obtain urine specimen d. To empty the bladder completely prior to surgery e. To facilitate accurate measurement of urinary output for critically ill clients whose output needs to be monitored hourly

Equipments: 1. Sterile catheter of appropriate size ( an extra catheter should also be at hand) 2. Catheterization kit: 1-2 pair sterile gloves, Waterproof drapes, antiseptic solution, cleansing balls, water soluble lubricant, urine receptacle, specimen container. 3. For indwelling catheter: syringe pre-filled with sterile water in amount specified by catheter manufacturer, collection bag and tubing, 2% xylocaine gel ( if agency permits), disposable clean gloves, bath blanket or sheet for draping the client, adequate lighting ( obtaina flashlight or lamp is necessary). Procedure: 1. Explain to the client what you are going to do, why it is necessary, and how he or she can cooperate. Explain that catheter insertion causes the sensation of voiding and possibly a burning feeling. 2. Wash hands and observe appropriate infection control procedures 3. Provide for client privacy 4. Place the client in the appropriate position and drape all areas except the perineum: a. Female : Supine with knees flexed and externally rotated b. Male: Supine, legs slightly abducted 5. Establish adequate lighting. Stand on the clients right if you are right handed, on the clients left if you are left-handed. 6. If using a collecting bag and it is not contained within the catheterization kit, open the drainage package and place the end of the tubing within the reach.