1. Terms and Definitions
• Bladder – a muscular sac that stores the urine in the body
• Incontinent – in ability to control the passage of urine
• Indwelling urinary catheter (foley) – a sterile tube inserted through the urethra into the bladder to drain urine; held in place by a small inflated balloon
• Kidneys – filtering system of the body
• Nocturia – the need to urinate at night
• Retention – inability to empty the bladder
• Sphincter muscles – circle of muscle fibers around the outlet of the urethra and rectum that is normally closed but can be relaxed to allow passage of urine and stool
• Ureters – tubes that carry urine from kidneys to urinary bladder

2. Terms and Definitions
• Urethra – the small passage from the bladder through which urine leaves the body
• Urinate – to pass urine (void)

3. Urinary System (See Figure 1.1.)
• Organs
Kidneys
Ureters
Bladder
Urethra
• Functions
Produces urine
Removes waste products from the blood
Maintains a stable balance of water and minerals in the body (homeostasis)

4. Figure 1.1 – The Urinary System

5. Urinary System • Aging process
Bladder opening weakens; may result in urinary incontinence and dribbling.
Decrease in bladder muscle tone occurs that may result in urinary retention and infections.
The kidneys’ ability to filter wastes and concentrate urine decreases.
• Related health problems
Urinary retention
Urinary incontinence
Urinary tract infection (UTI) – infection of any organ in the urinary tract. The organs most commonly affected are the bladder and kidneys.

6. Urinary System • Nursing care
Monitor bladder habits, frequency, and amount of urine voided.
Observe for the following:
• Fever
• Elevated pulse and respiration
• Confusion
• Midback or lower abdominal pain
• Burning sensation when urinating
• Cloudy or bloody urine
• Foul smelling urine
• Frequent voiding

7. Urinary System • Small quantities of urine
• Sudden onset of incontinence, which may be an indication of infection
Give 2,000-3,000 cc of fluid to resident per day.
Provide good peri care for resident who is dependent.
Assist resident to the bathroom when requested.

8. Factors That Maintain Urine Elimination
• Fluids
The body needs an adequate intake of fluids so the urinary system can function properly.
Nursing responsibilities
• Ensure adequate intake of 2,000-3,000 cc of fluid per 24 hours (2-3 quarts).
• Most fluids should be given between 7 a.m. and 7 p.m. to prevent resident from having to get up during the night to void.
• Habits/pattern
Nursing responsibilities
• Determine where and how often the resident usually voids.
• Try to follow established routine and respect privacy.
• Assist resident to the bathroom when requested.

9. Normal Urine Characteristics
• Color – straw yellow
• Clarity – clear, free of sediment and mucus
• Amount – The usual amount voided is cc five to six times a day, or 1,000 to 1,500 cc every 24 hours; however, this amount varies with the individual.
• Odor – none, except with certain liquids such as coffee or some medications
• Frequency – depends on fluid intake; most people void at least every 3 hours

10. Conditions That May Cause Abnormal Urine Elimination
• Infection of kidney or bladder
Symptoms
• Confusion
• Incontinence/dribbling
• Frequency
• Blood in urine – dark red or bright red
• Change in normal characteristics of urine – dark yellow, foul odor, or cloudy from sediment or mucus
• Resident complains of burning upon urination.
• Resident complains of pain, e.g., pain in midback or bladder area. (Location depends on where infection is.)
• Change in vital signs (Temperature, pulse, and respirations may be normal or increased.)

11. Conditions That May Cause Abnormal Urine Elimination
Nurse assistant’s responsibilities
• Report any of the above to the charge nurse.
• Give adequate fluids, especially water and fruit juices.
• Assist resident to the bathroom at least every 2 to 3 hours while he/she is awake.
• Ensure proper hygiene of perineal area; provide daily washing and proper wiping from front to back.

12. Conditions That May Cause Abnormal Urine Elimination
• Retention – inability to empty bladder caused by poor muscle tone of bladder, obstruction of urethra, or damage to certain areas of nervous system
Symptoms
• Resident complains of difficulty passing urine.
• Resident complains of feeling of fullness in the bladder.
• Resident urinates in very small amounts and frequently.

13. Conditions That May Cause Abnormal Urine Elimination
Nurse assistant’s responsibilities
• Report any of the above to the charge nurse.
• Report lack of output or voiding for more than 4 hours.
• Try triggering mechanisms to help resident relax and allow the sphincter muscle to open and release urine.
Sound of running water
Pouring warm water over the perineal area
Putting resident’s hand in warm water
• Assist the charge nurse with catheterization procedure if indicated.
• Incontinence – inability to stop or control the passage of urine.

14. Factors That Can Lead to Incontinence
• Confusion – Resident is unable to understand where or when he/she is urinating.
• Poor fluid intake – Concentrated urine is irritating.
• Sphincter muscle weakness causes bladder to release urine unexpectedly.
• Damage to nerves in bladder prevents stimulation of a full bladder from signaling the brain.
• Damage to brain prevents person from feeling urge to urinate.
• Due to irritation and reduction in the size of the bladder, dribbling occurs after catheter is removed.
• Resident has limited mobility, uses a restraint, and lacks assistance in getting to the bathroom.
• Overmedication
• Bladder infection

15. Factors That Can Lead to Incontinence
• Nurse assistant’s responsibility is to ensure adequate fluid intake. Some residents may be candidates for bladder retraining. See Unit VI, Lesson Plan 3, Bladder & Bowel (B&B) Retraining, for further information.

16. Special Measures for Abnormal Urinary Function
• Indwelling catheter (foley) – a sterile tube inserted through the urethra into the bladder to drain urine; held in place by a small inflated balloon. (See Figure 1.2.)
Must be ordered by physician and inserted only by a licensed nurse.
Figure 1.2 – Indwelling Catheter
Relief of a partial obstruction in the urethra causing urinary retention requires catherization.

17. Special Measures for Abnormal Urinary Function
Important points about indwelling catheters:
• The bladder is considered sterile. The catheter and drainage tube and bag are a sterile system. Do not open this system except when the catheter or bag must be changed. If the system is opened, germs may enter, which could lead to an infection.
Drainage tubing/bags must not touch the floor; always hook to unmovable part of the bed frame or chair.
When the bad is emptied, put on gloves. The drainage tube must not touch the rim of the graduate container, floor, or left out of its pouch after the container is emptied. Hands must be washed and gloves must be used every time a catheter bag is emptied.
NOTE: Change gloves after changing the resident’s drainage bag.

18. Special Measures for Abnormal Urinary Function
Drainage bag must be changed as directed by the charge nurse.
Check urine in the bag and tubing every 2 hours.
NOTE: Immediately report lack of urine output.
Drainage bag must be emptied when it starts getting full or at the end of a shift. Record amount emptied.

19. Special Measures for Abnormal Urinary Function
• The urine drains by the principle of gravity.
The catheter and tubing should always be free of bends or kinks.
Tubing should always be coiled or looped instead of hanging loosely. Prevent tubing from hanging below the level of the drainage bag.
The drainage bag should always be below the level of the bladder. If moved above, urine could flow back into the bladder.
When the resident is positioned on his/her side, the tubing should be positioned between the resident’s legs toward the side he/she is facing.

20. Special Measures for Abnormal Urinary Function
• Never pull on the catheter tubing.
Taping it loosely to inner thigh or using a leg band helps prevent pulling.
When transferring resident from bed to chair, always move drainage bag over to the chair before moving resident. Do not step on tubing.
When transferring resident out of the room, place catheter inside a cloth drainage bag cover (sometimes called a dignity bag).

21. Special Measures for Abnormal Urinary Function
• Suprapubic catheter
A sterile tube is inserted into the bladder through the abdominal wall above the pubis. (See Figure 1.3.)
The nurse assistant should:
Figure 1.3 – Suprapubic Catheter
• Monitor the catheter.
• Monitor skin at insertion point.
• Empty drainage bag.

22. Special Measures for Abnormal Urinary Function
Important points about suprapubic catheters:
• Observe the catheter for patency (draining properly).
• Maintain a closed drainage system.
• Observe for signs of urinary tract infection (color, odor, sediment).
• Observe the dressing for drainage.
• If the resident is on a clamp/release protocol, check with the charge nurse for specific instructions.

23. Special Measures for Abnormal Urinary Function
• Texas/external catheter may be used only for male residents. A condom-type device is attached to the penis with a drainage bag. (See Figure 1.4.)
Figure 1.4 – External Catheter
Nurse assistant may apply or assist resident. This is not a sterile system; use clean techniques.
Various types are available. Follow directions that come with external catheter for applying catheter.

24. Special Measures for Abnormal Urinary Function
Resident requires peri care every shift.
Frequently check area around catheter for proper circulation, skin breakdown; white, slippery, cheesy substance on penis; and position of tubing.

25. Helping the Resident Use the Bedpan or Urinal
• Bedpans (See Figure 1.5.)
Always keep bedpans covered when carrying them. Identify bedpans with the resident’s name.
Putting powder on a bedpan prevents it from sticking to the resident’s skin.
Keep bedpan clean.
Never put bedpans on the floor because there are germs on the floor.
Never put the bedpan on the overbed table or bedside stand. Put it on the bed.
Always pull curtains and/or close the door to provide privacy for the resident.
Using the bedpan is easier with head of bed elevated.

26. Figure Bedpans

27. Helping the Resident Use the Bedpan or Urinal
Figure Urinal
• Urinal (See Figure 1.6.)
Always use a urinal cover. Identify urinals with the resident’s name.
Check the color and odor of urine before emptying the urinal.
Some men have difficulty urinating while lying down. If the resident cannot stand, let him sit on the side of the bed.
Never place urinal on the bedside stand. Pull the curtains and/or close the door to provide privacy for the resident.
Always answer call signals without delay.

28. Helping the Resident Use the Bedpan or Urinal
• Bedside commode (See Figure 1.7.)
A resident who can be out of bed but is unable to use the bathroom may use a bedside commode.
Remove the bucket and clean after each use.
Always pull curtains and/or close door to allow for privacy.
Always make sure the call signal is within reach when the resident is on the commode.
Answer call signal without delay.
Replace the seat cushion or cover the seat with a towel when not in use.

29. Figure 1.7 – Bedside Commode

30. Conclusion
It is our goal to properly maintain the basic bodily functions for each of our residents. Incontinence should not be assumed when referring to the elderly. Many of our residents just need guidance and support in regaining control of this function. Keep in mind the importance of your observation skills. It may be up to your senses to detect a problem.

31. Steps of Procedure for Giving Peri Care with Catheter
1. Gather necessary equipment.
2. Wash your hands. Put on gloves.
3. Identify and greet resident. Identify self.
4. Explain what you are going to do.
5. Provide privacy.
6. Resident should be in supine position with legs apart; place bed protector under buttocks.
7. Cover resident with bath blanket then remove top sheet.
8. Check catheter and drainage bag for leaks, kinks, level of bag, color and character of urine; ensure that it is securely attached to bed frame.

32. Steps of Procedure for Giving Peri Care with Catheter
9. Expose the perineal area.
Separate the labia of the female resident and gently wash around the opening of the urethra with soap and warm water.
b. If the male resident is uncircumcised, gently pull back the foreskin and wash around the opening of the urethra with soap and warm water.
10. Wash the catheter tubing from the opening of the urethra outward 4 inches or farther if needed. Do not pull on the catheter.
11. Using a fresh washcloth, continue washing and rinsing the peri area. Dry the perineal area. (Follow procedure in Unit V, Lesson Plan 5, Perineal Care.)
12. Remove bed protector and bath blanket. Place soiled linen in appropriate container and close lid tightly.

33. Steps of Procedure for Giving Peri Care with Catheter
13. Remove and clean equipment per facility policy.
14. Remove gloves and dispose of in appropriate container. Wash hands.
15. Store equipment per facility policy.
16. Make the resident comfortable; place call signal within reach.
17. Record observations and report anything unusual to the charge nurse.

34. Steps of Procedure for Changing Urinary Drainage Bag
1. Gather necessary equipment.
2. Wash your hands. Put on gloves.
3. Identify and greet resident. Identify self.
4. Explain what you are going to do.
5. Provide privacy.
6. If applying a reusable leg bag, swab the end to be connected with alcohol and place on sterile gauze in alcohol packet. Do not allow it to touch anything else.
7. Crimp with your fingers or clamp the catheter tubing so urine does not flow.
8. Disconnect catheter tubing from drainage bag. Apply cap over end of tubing if reusing that drainage bag.

35. Steps of Procedure for Changing Urinary Drainage Bag
9. Swab end of catheter tube with alcohol before connecting to leg bag.
10. Connect leg bag to catheter.
11. Unclamp catheter. Check to see that urine is flowing (may take a few minutes).
12. If placing a leg bag or applying new tape, allow enough slack so there is no pull on the catheter.
13. If drainage bag is to be reapplied later, remove the cap, swab the end of the connection with alcohol, and replace cap.
14. Remove and clean equipment per facility policy.
15. Remove gloves and dispose of in appropriate container. Wash hands.

36. Steps of Procedure for Changing Urinary Drainage Bag
16. Store equipment per facility policy.
17. Make the resident comfortable; place call signal within reach.
18. Record observations and report anything unusual to the charge nurse.

37. Steps of Procedure for Emptying Urinary Drainage Bag
1. Gather necessary equipment.
2. Wash your hands. Put on gloves.
3. Identify and greet resident. Identify self.
4. Explain what you are going to do.
5. Provide privacy.
6. Place graduate under the drain at the bottom of the bag.
7. Open the drain and allow the urine to drain into the graduate, making sure the drain does not touch the inside of the container or the floor. Be careful not to splash.
8. Close the drain and replace it in the holder on the bag. If you accidently touch the inside of the measuring container with the tip of the drain, then cleanse the tip of the drain with an alcohol swab and replace it in the holder.

38. Steps of Procedure for Emptying Urinary Drainage Bag
9. Note the color, clarity, and amount of the urine.
10. Empty the urine into the toilet and flush. (Notify the charge nurse of any abnormalities before emptying the urine.)
11. Document the amount on the I&O sheet.
12. Clean, dry, and replace the equipment.
13. Remove gloves; wash hands.

39. Steps of Procedure for Assisting Resident in Using Urinal
1. Wash your hands. Put on gloves.
2. Gather necessary equipment.
3. Identify and greet resident. Identify self.
4. Explain what you are going to do.
5. Provide privacy.
6. Turn back top bedding, except for top sheet. Expose the peri area.
7. Place the resident’s penis in the urinal and lay the urinal between his legs. Make sure there is no pressure on the resident’s scrotum.
8. Make sure urinal is placed at an angle to keep urine from spilling out. Flat edge should be lying on bed.
9. Remove gloves and dispose of in appropriate container.

40. Steps of Procedure for Assisting Resident in Using Urinal
10. Wash your hands.
11. Place signal cord within reach and leave the room. Do not allow the urinal to remain in place for more than 10 minutes.
12. Return to room promptly when resident signals.
13. Wash hands. Put on gloves.
14. Remove and cover urinal; take it to the bathroom.
15. Measure urine if on I&O and empty into toilet.
16. Clean equipment and cover.
17. Remove gloves and dispose of in appropriate container. Wash hands.
18. Store equipment out of sight (per facility policy).

41. Steps of Procedure for Assisting Resident in Using Urinal
19. Give resident a clean, wet washcloth to wash his hands. Make resident comfortable and place call signal within reach.
20. Record observations and repot anything unusual to the charge nurse.

42. Steps of Procedure for Assisting Resident in Using Bedpan
1. Wash your hands. Put on gloves.
2. Gather necessary equipment.
3. Identify and greet resident. Identify self.
4. Explain what you are going to do.
5. Provide privacy.
6. Resident should be in supine position (lying on his/her back); turn back top bedding.
NOTE: Sprinkle powder on bedpan to prevent sticking.
7. Resident is able to assist
Have resident flex his/her knees and lift buttocks off mattress. Assist by slipping hand under lower part of his/her back. If resident is wearing pajamas or underwear, lower it to his/her knees.
b. With your other hand, slip the bedpan under the resident’s hips and adjust.

43. Steps of Procedure for Assisting Resident in Using Bedpan
Resident is unable to assist
Turn resident on his/her side away from you.
b. Expose the buttocks and position bedpan firmly against buttocks.
c. Place small pillow/rolled towel at top of bedpan at the small of the resident’s back.
d. Turn resident toward you and onto the bedpan.
8. Raise the head of bed (if allowed) and side rails for resident’s comfort and safety as per care plan. Place toilet tissue and call signal within reach.
9. Remove gloves and dispose of in appropriate container.
10. Wash your hands and leave the room.

44. Steps of Procedure for Assisting Resident in Using Bedpan
11. Return to room promptly when the resident signals or check on him/her after 5 minutes.
NOTE: Do not leave resident on bedpan over 10 minutes. This may lead to extreme discomfort and result in skin breakdown.
12. Wash hands. Put on gloves.
13. Lower the head of bed and side rail of side you are on.
14. Resident is able to assist – Place one hand under the small of the back and assist resident to lift his/her hips. Hold bedpan with other hand.
Resident is unable to assist – Hold bedpan with one hand and roll resident off pan with other hand. This prevents contents of bedpan from spilling.

45. Steps of Procedure for Assisting Resident in Using Bedpan
15. Remove bedpan and then cover it.
16. Wipe, wash, and dry perineal area from front to back.
17. Take bedpan to bathroom; measure urine if on I&O and empty into toilet.
18. Clean equipment.
19. Remove gloves and dispose of in appropriate container. Wash hands.
20. Store equipment.
21. Give resident a clean, wet washcloth to wash his/her hands, make resident comfortable, and place call signal within reach.
22. Record observations and report anything unusual to the charge nurse.