1. URINARY ELIMINATION & Catheters
TO PEE OR NOT TO PEE, WHAT IS THE COLOR?
Jennifer Bettag RN, BSN

2. Objectives
Demonstrate correct technique for inserting indwelling and straight catheters
Recognizes signs and symptoms of infection related to urinary catheters
Demonstrate aseptic routine care of a patient with an indwelling catheter
Demonstrate correct technique for removing an indwelling catheter.
Demonstrate correct procedure for application of condom catheter
Document and report to RN care related to urinary drainage

3. Urinary Elimination System

4. Anatomy
Kidney - Urine production Ureters - Tubes which connect the kidneys to the bladder. Bladder - Reservoir for urine until the urge to void takes place. Urethra - Tube from the bladder to the outside of the body in normal anatomy. Male = 20 cm long Female = 4 cm long

5. Anatomy Facts
A continuous layer of mucous membrane lines the kidney pelvis, ureters, urethra & bladder
Because there is no break in this lining, bacteria introduced into this normally sterile environment can quickly spread throughout the entire system
When the bladder is empty it falls into folds which provide pockets where bacteria can multiply
Because this membrane layer is highly vascular, bacteria can easily enter the blood stream & cause septicemia

6. Normal Urination The amount of fluid intake Personal habits
The healthy adult excretes about 1500 milliliters (ml) (3 pints) of urine a day.
Factors affecting urine production include:
Age
Disease
The amount and kinds of fluid ingested
Dietary salt
Body temperature
Perspiration
Drugs
Urination, micturition, and voiding mean the process of emptying urine from the bladder.
Certain factors affect frequency, including:
The amount of fluid intake
Personal habits
People usually void at bedtime, after getting up, and before meals.
Some people void every 2 to 3 hours. .

7. What is your color?

8. Urine observations Normal urine:
Is pale yellow, straw colored, or amber
Is clear with no particles
Has a faint odor
Observe urine for color, clarity, odor, amount, and particles.
Some foods affect urine color and odor.
Certain drugs change urine color.
Report the following to the nurse:
Any urine that looks or smells abnormal
Complaints of urgency, burning on urination, or painful or difficult urination .

9. 20 Shades of Urine What does your urine say?
What does your urine smell like?

10. Urinary Incontinence
Urinary incontinence is the involuntary loss of urine from the bladder.
It may be temporary or permanent.
Basic types of incontinence (review page 382)
Stress
Urge
Overflow
Functional
Reflex
Mixed

11. Effects of incontinence:
Incontinence is embarrassing.
Skin irritation, infection, and skin breakdown can occur.
Falling is a risk.
The person’s pride, dignity, and self-esteem are affected.
Loss of independence, social isolation, and depression are common. .

12. Effects of Incontinence
Incontinence is linked to abuse, mistreatment, and neglect.
Caring for persons with incontinence is stressful.
Remember, incontinence is beyond the person’s control.
Be patient.
If you become short-tempered and impatient, talk to the nurse at once.
The person has the right to be free from abuse, mistreatment, and neglect. .

13. Persons with Dementia may void in the wrong places.
Some persons remove incontinence products and throw them on the floor or in the toilet.
Some resist staff efforts to keep them clean and dry.
Check with the nurse and the care plan for measures to help the person. .

14. Assistance devices for urination:
Bedpans used by persons who cannot get out of bed.
Women use bedpans for voiding and bowel movements.
Men use them for bowel movements.
Made of plastic or metal.
Metal bedpans are warmed with water and dried before use. .

15. Fracture Pans Fracture pans
A fracture pan has a thin rim and is approximately 1/2 inch deep at one end.
Fracture pans are used:
By persons with casts
By persons in traction
By persons with limited back motion
After spinal cord injury or surgery
After a hip fracture
After hip replacement surgery
Fracture pans provide more comfort for persons with osteoporosis and those with painful joints from arthritis.

16. Urinals . Men use urinals to void.
The urinal hooks to the bed rail within the man’s reach.
Some agencies do not use bed rails.
Follow agency policy for where to place urinals.
Men stand, sit on the side of the bed, or lie in bed to use the urinal.
Some men need support when standing.
You may have to place and hold the urinal for some men.
After voiding, the cap is closed.
Remind men:
To hang urinals on bed rails, or place them according to agency policy
To signal when urinals need emptying
Not to place urinals on overbed tables and bedside stands .

17. Commodes
A commode is a chair or wheelchair with an opening for a bedpan or container.
Persons unable to walk to the bathroom often use commodes.
Commodes allow a normal position for elimination.
Some commodes are wheeled into bathrooms and placed over toilets.
The container is removed if the commode is used with the toilet.
Wheels are locked after the commode is positioned over the toilet.
Review ~ Helping the Person to the Commode p381 .

18. Catheterization - Reasons
Collect a sterile specimen
Check residual urine
Inability to void related to post-op complications
Before, during or after surgery to empty bladder
Temporary/Permanent Incontinence:
a. Total- continuous loss of urine from bladder
b. Stress- leakage of small amounts of urine with
physical stress i.e. coughing or sneezing

19. Catheterization - Reasons
Urge - Involuntary passage of urine after feeling strong need to void. Unable to stop urinating and can’t get to bathroom on time. Seen in the elderly, with UTIs and tumors.
Functional - Involuntary, unpredictable passage of urine related to no call light or immobility, etc.

20. Alternative to Catheterization
Bladder Scan
Estimates residual urine
Increased use over straight catheterization
90% accuracy
Decreases risk of infection and discomfort to patient

21. PRIOR to Catheterization
Know and Confirm
Doctor’s order
Last void
Patient’s level of consciousness and understanding
Mobility, physical limitations, ability to cooperate
Sex, age, catheter size
Kids 6-10
Female 14-16
Male 16-18)
Allergies to antiseptics, tape, rubber, latex
Adverse conditions
Impaired passage such as enlarge prostate

22. Catheter Types - Condom
Condom Catheter
(External, Texas, Urinary Sheath)
Incontinent men
Soft rubber, latex, silicone
Slides over Penis
Tubing connects to tip of condom and flows into collection bag.

23. Catheter Types - Condom
Remove for thirty minutes each day,
clean and dry penis, re-apply new catheter.
Elastic tape may be used to secure catheter in place. This tape will expand when the penis changes size.
Never use adhesive tape- cuts off blood flow which causes injury.

24. Catheter Types - Straight
Straight Catheter
Removes urine from bladder aseptically due to
1. Incontinence
2. Post void residuals
3. Sterile specimen
Does not attach to a collection bag
Considered a sterile procedure

25. Straight Catheter

26. Catheter Types - Indwelling
Indwelling Catheter (Foley)
To remove urine aseptically
Sterile procedure
Has urinary collection bag
May be used for extended periods of time

27. Catheter Types - Suprapubic
Catheter inserted into the bladder through an opening in the lower abdomen (about 1 inch above the symphysis pubis)
Placed under anesthesia
May be left in place for long periods of time
Sutured into place.

28. Subrapubic Catheter
Reasons for infections???

29. Rules for Catheterization
Wash hands, use gloves
Tubing without kinks/obstructions
Drainage bag below bladder
Attach to non-movable bed part
Secure with leg strap
Check system for leaks
Perform perineal care BID, after all BMs &with cath care
Watch I&O closely
Report complaints of discomfort to nurse (pain, burning, irritation)
Record amount, color, clarity, odor, particles

30. Insertion/Application - Condom
Condom Catheter
Clean gloves to remove old catheter
Wash and dry penis
Apply skin prep to penis shaft
Remove protective backing from condom exposing adhesive strip

31. Insertion/Application - Condom
Hold penis firmly. Roll condom onto penis leaving 1inch space between penis and end of catheter.
Secure condom with elastic strip in
spiral manner not completely on penis
Connect condom to drainage bag
Check penis for redness and excoriation

32. Insertion Tips – Straight/Foley
Have patient relax by taking slow deep
breaths
Lubricate catheter well
To find female meatus
Look for the wink
Betadine pools in the meatus
Ask patient to bear down as if to void
If catheter enters the vagina, leave it

33. Catheter Insertion Video
Please take notes as this will be a check off this year

34. Insertion of Indwelling Catheter
If indwelling catheter, GENTLY tug on catheter until resistance is met to insure placement in bladder
Do peri care and apply leg band to secure catheter to patient’s leg
Remove gloves and discard supplies properly

35. Other Considerations When performing straight cath
Know policy & procedure for maximum amount of urine allowed to be withdrawn.
To place catheter in an uncircumcised man
Carefully pull back foreskin before cleansing

36. Documentation Document Type of procedure Size of catheter and balloon
Amount of fluid actually instilled into balloon
Amount of urine returned
Characteristics of urine (color, odor, sediment)
Specimen sent if applicable
How patient tolerated procedure

37. Problems During Insertion
Catheter inserted into Vagina 1. Leave in place 2. Reposition fingers to re-visualize meatus 3. Use new catheter 4. Repeat procedure

38. Problems During Insertion
Unable to insert into female
1. Ask patient or other team member to hold legs apart
2. Observe urethral opening (before cleansing) for
movement when pressure is applied
3. Improve lighting
4. Repeat insertion procedure

39. Problems During Insertion
Unable to insert catheter into male 1. Notify nurse 2. Repeat procedure but change the angle of the penis 3. Try an a coude catheter

40. Benign Prostatic Hyperplasia
BPH
Benign Prostatic Hyperplasia

41. Problems During Insertion
Catheter comes out with balloon inflated
1. Check with nurse
2. Check for urethral trauma (pain, bleeding)
3. Monitor urine output for bleeding
4. Obtain new catheter kit & reinsert with
10 ml balloon per nurse’s instruction

42. Care of Patient with a Catheter
Keep catheter bag below level of bladder
Attach drainage bag to bed frame (not side rails)
Secure tubing onto bed – urine should flow freely from catheter to bag (coil tubing on bed)
Empty catheter bag every 8 hours or prn
Provide catheter care & pericare as needed
Do not allow the drain on the bag to touch any surface
Keep drainage bag off the floor

43. Catheter Removal Physician’s order
Gather supplies- 10cc syringe, gloves, chux
Deflate balloon- note amount withdrawn
Avoid pubic hair
Pinch catheter; pull out on exhalation steadily & gently
Measure output
Discard catheter bag properly
Provide peri care
Monitor patient for output
If not voided in 4-6 hours, notify nurse

44. Drainage system disconnected, what do you do?
Tell_________________
Do not______________
Practice_____________
Wipe_______________
Connect_____________
Discard______________
Remove______________

45. Following Catheter Removal
Patient to void within 4-6 hours
Urine amount ml (or per policy)
Observe bladder for distention
Monitor patient for any complaints of painful urination
Monitor patient for hematuria

46. Catheter Removal Documentation
Size of catheter removed
Size and amount of fluid in balloon
Patient tolerance
Output in catheter bag
Description of urine
Peri care
Time of removal

47. Voiding Following Catheter Removal
Hints to assist patient to void after catheter removal
Encourage oral fluids
Proper position to urinate
Sound of running water
Sitz bath

48. Catheter Specimen - Syringe

49. Urinary Diversions Definition
Removal of bladder (cancer, bladder injuries) and making a new pathway for urine to exit the body.
Two Categories
1. Continent
2. Noncontinent (incontinent)

50. Continent Urinary Diversions
Surgery creates an internal pouch where urine
is stored (Kock or Indiana Pouch)
Do not need to wear an appliance
Taught to insert catheter into
the stoma several times a day
to drain the urine

51. Noncontinent Urinary Diversions
Patient cannot control urine
Must wear an external urinary ostomy pouch
Types of non-continent urinary diversions
1. Ureterostomy

52. Ureterostomy Ureterostomy
The surgical creation of an artificial opening between the ureter and the abdomen.
Both ureters may be brought through the skin onto the abdomen
Drains urine

53. Measuring Urinary Output