1. Chapter 21 Urinary Elimination
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2. Waste and Balance The urinary system:
Removes waste products from the blood
Maintains the body’s water balance
Eliminating waste is a physical need.
The respiratory, digestive, integumentary, and urinary systems remove body wastes.
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3. Normal Urination
The healthy adult produces about 1500 mL (milliliters) or 3 pints of urine a day.
Factors affecting urine production include:
Age
Disease
Amount and kinds of fluid ingested
Dietary salt
Body temperature and perspiration
Drugs
Frequency of urination is affected by:
The amount of fluid intake, habits, and available toilet facilities
Activity, work, and illness
People usually void at bedtime, after sleep, and before meals. Some people void every 2 to 3 hours.
Some persons need help getting to the bathroom. Others use bedpans, urinals, or commodes.
Urination, micturition, and voiding mean the process of emptying urine from the bladder.
Review Box 21-1 on page 352 and the person’s care plan.
Review Focus on Communication: Normal Urination on page 352.
Review Teamwork and Time Management: Normal Urination on page 352.
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4. Elimination The person’s elimination needs are assessed. Normal urine:
A care plan is developed to ensure that these needs are met.
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.
Bedpans are used by:
Persons who cannot be out of bed
Women for voiding and bowel movements
Men for bowel movements
Some foods affect urine color. Red food dyes, beets, blackberries, and rhubarb cause red-colored urine. Carrots and sweet potatoes cause bright yellow urine. Certain drugs change urine color. Asparagus causes a urine odor.
Ask the nurse to observe urine that looks or smells abnormal. Report oliguria (voiding less than 500 mL [milliliters] in 24 hours), polyuria, urinary frequency, hematuria (blood in the urine), and complaints of urinary urgency, burning on urination, and painful or difficult urination (dysuria).
Both the standard and fracture bedpans are shown in Figure 21-2 on page 353.
Review Table 21-1 on page 353.
Review Delegation Guidelines: Bedpans on page 353.
Review Promoting Safety and Comfort: Bedpans on page 353.
Review the Giving the Bedpan procedure on page 354.
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5. Fracture Pan 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
A fracture pan has a thin rim. It is only about ½-inch deep at one end (see Fig p. 353).
The smaller end is placed under the buttocks (see Fig p. 353).
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6. Urinals Men use urinals to void.
The man stands if possible.
Some sit on the side of the bed.
The man may lie in bed.
Some men need support when standing.
You may have to place and hold the urinal for some.
Persons unable to walk to the bathroom often use commodes.
Some commodes are wheeled into bathrooms and placed over toilets.
Plastic urinals (see Fig on p. 356) have caps and hook-type handles. The urinal hooks to the bed rail within the man’s reach.
After voiding, the urinal cap is closed to prevent urine spills.
Remind men to hang urinals on bed rails and to use the call light after using them. Remind them not to place urinals on over-bed tables and bedside.
Some beds may not have bed rails. Follow center policy for where to place urinals.
Review Focus on Communication: Urinals on page 356.
Review Delegation Guidelines: Urinals on page 356.
Review Promoting Safety and Comfort: Urinals on page 356.
Review the Giving the Urinal procedure on pages
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7. Commode Persons unable to walk to the bathroom often use commodes.
The commode allows a normal position for elimination.
The commode arms and back provide support and help prevent falls.
Some commodes are wheeled into bathrooms and placed over toilets; they are useful for persons who need support when sitting.
The container is removed if the commode is used with the toilet. Wheels are locked after the commode is positioned over the toilet.
A commode is a chair or wheelchair with an opening for a container (Fig. 21-8) on p. 357.
Review Delegation Guidelines Commodes on p. 358.
Review Promoting Safety and Comfort: Commodes on p. 358.
Review the Helping the Person to the Commode procedure on pp
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8. Urinary Incontinence The basic types of incontinence are:
Stress
Urge
Over-flow
Functional
Reflex
Mixed incontinence
Transient
If incontinence is a new problem, tell the nurse at once.
Urinary incontinence is the involuntary loss or leakage of urine.
Although it occurs in some older persons, it is not a normal part of aging.
Older persons are at risk for incontinence because of changes in the urinary tract, medical and surgical conditions, and drug therapy.
Incontinence may be temporary or permanent.
Sometimes incontinence results from intestinal, rectal, and reproductive system surgeries.
Incontinence may result from a physical illness or drugs.
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9. Caring for the Person with Incontinence
The following may be needed:
Good skin care and dry garments and linens
Promoting normal urinary elimination
Bladder training
Catheters
Incontinence products to help keep the person dry
Incontinence is linked to abuse, mistreatment, and neglect.
Remember, incontinence is beyond the person’s control.
If you find yourself becoming short-tempered and impatient, talk to the nurse at once.
The person has the right to be free from abuse, mistreatment, and neglect.
The Centers for Medicare and Medicaid Services (CMS) requires appropriate treatment and services for persons who are incontinent. The goals are to prevent UTIs (urinary tract infections) and restore as much normal bladder function as possible.
Incontinence is embarrassing and uncomfortable. Pride, dignity, and self-esteem are affected. Social isolation, loss of independence, and depression are common.
Review Box 21-2 on p. 360.
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10. Dementia and Incontinence
Persons with dementia may:
Void in the wrong places.
Remove incontinence products and throw them on the floor or in tahe toilet.
Resist staff efforts to keep them clean and dry.
Review Residents with Dementia: Urinary Incontinence on p. 360.
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11. Catheters
Inserted through the urethra into the bladder, a urinary catheter drains urine into a drainage bag.
A straight catheter drains the bladder and then is removed.
An indwelling catheter (retention or Foley catheter) is left in the bladder.
Catheterization is the process of inserting a catheter.
In an indwelling catheter, a balloon near the tip is inflated with sterile water after the catheter is inserted. The balloon prevents the catheter from slipping out of the bladder (see Fig on p. 361).
Catheterization is done by a doctor or nurse. With the proper education and supervision, some states and centers let nursing assistants insert and remove catheters.
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12. Catheters (Cont’d) Catheters are used:
Before, during, and after surgery
For people too weak or disabled to use the bedpan, urinal, commode, or toilet
To protect wounds and pressure ulcers from contact with urine
To allow hourly urinary output measurements
As a last resort for incontinence
For diagnostic purposes
You will care for persons with indwelling catheters.
Catheters keep the bladder empty and thereby reduce the risk of bladder injury during surgery. After surgery, a full bladder causes pressure, which can lead to pain or discomfort. A bladder scanner is a piece of equipment that can help tell the amount of urine that is in the bladder (see Fig , p. 361).
Catheters do not treat the cause of incontinence.
Catheters are also used to collect sterile urine specimens.
Measure the amount of urine left in the bladder after the person voids. This is called the post void residual urine.
The risk of urinary tract infection (UTI) is high with indwelling catheters.
Review Box 21-3 on p. 362 to promote safety and comfort.
Review Delegation Guidelines: Catheters on p. 362.
Review Promoting Safety and Comfort: Catheters on p. 362.
Review the Giving Catheter Care procedure on pp
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13. Catheter Drainage Systems
A closed drainage system is used for indwelling catheters.
Nothing can enter the system from the catheter to the drainage bag.
Some people wear leg bags, which attach to the thigh or calf, when up.
The drainage bag is always kept lower than the bladder to prevent urinary tract infections (UTIs).
The urinary system is sterile.
The drainage system has drainage tubing and a drainage bag (Fig on p. 363). Tubing attaches at one end to the catheter, and at the other end, to the drainage bag.
The bag hangs from the bed frame, chair, lower part of an intravenous (IV) pole, or wheelchair. It must not touch the floor.
Microbes can grow in urine.
If the drainage bag is higher than the bladder, urine can flow back into the bladder. A UTI can occur.
Do not hang the drainage bag on a bed rail. Otherwise when the bed rail is raised, the bag is higher than bladder level.
When the person walks, the bag is held lower than the bladder.
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14. Accidental Disconnect
If a drainage system is disconnected accidentally:
Tell the nurse at once.
Do not touch the ends of the catheter or tubing.
Practice hand hygiene and put on gloves.
Wipe the end of the tube with an antiseptic wipe.
Wipe the end of the catheter with another antiseptic wipe.
Do not put the ends down.
Do not touch the ends after you clean them.
Connect the tubing to the catheter.
Discard the wipes into a biohazard bag.
Remove the gloves and practice hand hygiene.
Be sure to know what to do if a drainage system is disconnected accidentally.
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15. Drainage Bags
Leg bags are changed to drainage bags when the person is in bed.
You open the closed drainage system.
Prevent microbes from entering the system.
Drainage bags are emptied and measured:
At the end of every shift
When changing from a leg bag to a drainage bag
When changing from a drainage to a leg bag
When the bag is becoming full
The drainage bag stays lower than bladder lever.
Review Delegation Guidelines: Drainage Systems on p. 365.
Review Promoting Safety and Comfort: Drainage Systems on p. 365.
Review the Changing a Leg Bag to a Drainage Bag procedure on p. 366.
Review Emptying a Urinary Drainage Bag procedure on p. 367.
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16. Condom Catheters
To apply condom catheters (external catheters, Texas catheters, urinary sheaths):
Follow the manufacturer’s instructions.
Thoroughly wash the penis with soap and water.
Dry the penis before applying the catheter.
Condom catheters are self-adhering or applied with elastic tape.
Never use adhesive tape to secure catheters.
A condom catheter is a soft sheath that slides over the penis (see Fig p. 368). Tubing connects the condom catheter and the drainage bag. Many men prefer leg bags (see Fig on p. 370).
Condom catheters are changed daily after perineal care.
Use the elastic tape packaged with the catheter. Elastic tape expands when the penis changes size. This allows blood flow to the penis.
Review Delegation Guidelines: Condom Catheters on p. 368.
Review Promoting Safety and Comfort: Condom Catheters on p. 369.
Review the Applying a Condom Catheter procedure on pp
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17. Bladder Training Control of urination is the goal.
The normal position for urination is assumed if possible.
Privacy is important.
Four methods:
Bladder retraining—resist the urge, follow a schedule instead
Prompted voiding—the person uses the toilet, commode, bedpan, or urinal at certain times.
Habit training/scheduled voiding—voiding is scheduled usually every 3 to 4 hours based on the person's normal voiding pattern.
Catheter clamping—catheter is clamped for increasing periods of time, increasing tolerance.
Bladder training helps some persons with urinary incontinence. Some persons need bladder training after indwelling catheter removal.
Bladder control promotes comfort and quality of life. It also increases self-esteem.
You assist with bladder training as directed by the nurse and the care plan.
Successful bladder retraining may take several weeks. The person’s care plan may contain one or more of the four methods.
Bladder restraining (bladder rehabilitation) requires the person to resist or ignore a strong desire to urinate, postpone or delay voiding, and urinate following a schedule rather than the urge to void.
Prompted voiding the person is taught to recognize when the bladder is full, recognize the need to void, ask for help, and void when prompted.
Habit training (scheduled voiding) requires that the person not delay or resist voiding. The schedule is created around the person’s usual voiding pattern while awake.
Catheter clamping (Fig on p. 367) usually starts for 1 hour. Over time it is clamped for 3 to 4 hours. When the catheter is removed, voiding is encouraged every 3 to 4 hours or as directed by the nurse or care plan.
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18. Quality of Life Empty urinals, bedpans, and commodes promptly.
Illness, disease, and aging can affect the private act of voiding.
Residents often depend on the nursing staff to assist with elimination needs.
Promote dignity, comfort, and respect when assisting with elimination needs.
You must protect the person’s privacy.
If you must stay in the room, allow as much privacy as possible.
Empty urinals, bedpans, and commodes promptly.
Promote independence. Keep devices within reach for persons who use them without help.
Leaving urine-filled devices in the person’s room does not respect the person’s right to a neat and clean setting.
Privacy and confidentiality are important for persons who are incontinent.
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