Bladder

Penile Sheath Rationale: A penile sheath is a containment device that directs urine into a drainage bag. Pessaries are anticontinence intravaginal support devices. A urethral plug is an anticontinence intraurethral occlusive device. Bladder neck support prostheses are intravaginal support devices that are used to control incontinence in patients.

Urethral surgery Rationale Suprapubic catheterization is used in urethral, prostate, and bladder surgery; it provides an alternate route for elimination to promote healing. Spinal cord injuries, neurologic diseases, and bladder outlet obstruction utilize intermittent catheterization to reduce the risk of injury and infection.

Urge incontinence Rationale Interstitial cystitis is a bladder disorder that causes urge incontinence. Stress incontinence is caused by prostate surgery for benign prostate hyperplasia. A herniated disc and diabetic neuropathy cause overflow incontinence. Problems affecting balance and mobility in older adults cause functional incontinence.

Enlarged prostate Rationale An enlarged prostrate is a common cause of bladder outlet obstruction. Overdistention, diabetes mellitus, and chronic alcoholism are common causes of deficient detrusor contraction.

Stress incontinence Rationale Stress incontinence occurs when the patient coughs or sneezes. In stress incontinence, the leakage is in small amounts and may not be daily. Overflow incontinence occurs when the pressure of urine in an overfull bladder overcomes sphincter control. This usually occurs frequently throughout the day and night. Reflex incontinence is a condition that occurs when no warning or stress precedes periodic involuntary urination. Urination is frequent, is moderate in volume, and occurs equally during the day and night. Trauma incontinence occurs when a fistula develops as result of trauma or surgery.

Urge incontinence Rationale Conditions resulting in interference with spinal inhibitory pathways such as spondylosis cause urge incontinence. Prostrate surgery or multiple pregnancies cause stress incontinence. Spinal cord lesions above S2 cause reflex incontinence. Herniated disc and diabetic neuropathy cause overflow incontinence.

Cough triggering stress urinary incontinence (UI) Rationale Angiotensin-converting enzyme (ACE) inhibitors result in chronic dry cough leading to stress urinary incontinence (UI). Alcohol and diuretics cause polyuria. Methylxanthines cause bladder irritation. α-adrenergic receptor agonists cause urinary retention in males.

Intravaginal support devices Rationale Intravaginal support devices include pessaries and bladder neck support prostheses. These devices relieve minor organ prolapse. External collection devices such as penile sheaths help to direct the urine into a drainage bag. Penile compression devices are applied to the penis to prevent leakage through the urethra. Intraurethral occlusive devices include urethral plugs that provide mechanical obstruction to prevent urine leakage.

Brain tumor Carcinoma in situ Rationale Central nervous system disorders such as a brain tumor, and bladder disorders such as carcinoma in situ are causes of urge incontinence. Cystoscopy, neurogenic bladder, and diabetic neuropathy cause overflow incontinence.

Contract muscles around rectum Rationale To teach pelvic floor, or Kegel, exercises, the nurse should instruct the patient (without contracting the legs, buttocks, or abdomen) to contract the muscles around the rectum (pelvic floor muscles) as if stopping a stool, which should result in a pelvic lifting sensation. Squeezing the thighs together, tightening buttocks together, and lying on the back and lifting legs do not strengthen the pelvic floor muscles.

Intravaginal support device An intravaginal support device is an antiincontinence device used to relieve minor pelvic organ prolapse. An external collection device is a containment device used to direct urine into a drainage bag. A penile compression device is applied to the penis to prevent any flow or leakage via the urethra. An intraurethral occlusive device is worn in the urethra to provide mechanical obstruction to prevent urine leakage.

Mirabegron

Irrigation must be done under strict aseptic precautions. The catheter should not be kinked, compressed, or clamped. Attention should be given to any complaints of excessive pain in the area. Rationale Irrigation must be done under strict aseptic precautions to avoid any contamination and infection to the kidneys. The catheter should not be kinked, compressed, or clamped, as this can affect the passage of urine through the catheter. If the patient complains of any excessive pain in the area, the nurse should check the catheter for patency. During irrigation, no more than 5 mL of sterile saline solution should be instilled at once to prevent renal damage. If there is excessive drainage around the tube, the nurse should check the catheter for patency.

It conveys urine from the ureters to a stoma opening on the abdomen. Rationale An ileal conduit is a permanent urinary diversion in which a portion of the ileum is surgically resected with one end of the segment closed. The ureters are surgically attached to the segment of the ileum, and the open end of the ileum is brought to the skin surface on the abdomen to form a stoma. The patient must wear a pouch to collect the urine, which continuously flows through the conduit. An ileal conduit is a permanent urinary diversion procedure. An ileal conduit does not divert urine into the sigmoid colon or create an opening in the bladder allowing urine to drain into an external pouch.

Paralytic ileus Thrombophlebitis Small bowel obstruction Rationale Pelvic surgery involves the removal of part of the bowel. It increases the risk of paralytic ileus, thrombophlebitis, and small bowel obstruction. Periurethral abscess is the complication of intermittent catheterization. Insertion of a nephrostomy tube is associated with secondary stone formation.

Deficient detrusor contraction Rationale Deficient detrusor contraction results in urinary retention when the muscle is no longer able to contract with enough force or for a sufficient time to completely empty the bladder. Deficient detrusor contraction occurs due to neurologic diseases affecting the 2, 3, and 4 sacral segments. Reflex incontinence occurs when spinal cord lesions above S2 interfere with central nervous system inhibition. Functional incontinence occurs due to problems affecting balance and mobility. Bladder outlet obstruction occurs due to enlarged prostate.

The patient will not have burning pain in the bladder. Rationale Verapamil is a calcium channel blocker that is used in the treatment of voiding dysfunction to reduce burning pain in the urinary bladder. Antibiotics are used in the treatment of hematuria (blood in the urine). Acetohydroxamic acid is used in the treatment of kidney stones. Nystatin is used in the treatment of inflammation of the urethra.

"If the bag is not reused immediately, wash it with soap and water." Rationale When the collection bag is not reused immediately, it should be filled with 1/2 cup of vinegar, and drained to prevent microorganisms and to avoid odors. If there is a need for frequent irrigation, a triple-lumen catheter is used. In women, the catheter is anchored to the upper thigh. The catheter is changed based on patient assessment, and not on a routine changing schedule.

Oxybutynin Rationale Urine leakage with a suprapubic catheter results when the patient experiences bladder spasms. Oxybutynin is an antispasmodic, which reduces the bladder spasms. Fosmicin and nitrofurantoin are the antibiotics used to treat urinary tract infections. Sulfamethoxazole is used to treat acute pyelonephritis.

Identifying type of incontinence Rationale It is a registered nurse's responsibility to assess and identify the type of incontinence and to consult with the primary health care provider on the appropriate interventions for treatment. Catheterization is within the scope of practice of any nurse. A registered nurse or a licensed practical nurse with the consent of healthcare provider can administer medications via bladder instillation. A registered nurse or a licensed practical nurse can use a bladder scanner to measure postvoid residual volume (PRV).

The patient will not have leakage of small amounts of urine during the day and night. Rationale Tamsulosin is an α-adrenergic blocker used in the treatment of overflow incontinence. Overflow incontinence results in leakage of small amounts of urine frequently throughout the day and night. Absence of leakage of small amounts of urine throughout the day and night indicates effectiveness of the therapy. Diazepam or baclofen therapy results in preventing periodic urination without warning. No involuntary urination with urinary urgency indicates the effectiveness of anticholinergic therapy. Pelvic floor muscle exercises result in no leakage of urine during coughing and sneezing.

Record it as a normal observation Rationale After the surgery, mucus may be present in the drainage tube for few days; this is a normal observation. The nurse should irrigate the drainage bag only with an order from the primary health care provider. Lotions or creams should never be applied, because they increase the risk of infection around the surgical area. Notifying the primary health care provider is not an appropriate intervention, because the mucus is a normal finding.

Cutaneous ureterostomy Rationale Cutaneous ureterostomy is a urinary diversion surgery that involves the excision of ureters from bladder through abdominal wall, and creation of a stoma. Cutaneous ureterostomy has the possibility of stoma stenosis, which involves the narrowing of the lumen of stoma. Ileal conduit is an incontinent urinary diversion procedure in which the ileum is converted into a conduit for urinary drainage. Nephrostomy has a high risk of renal infection. Laparoscopic nephrectomy is not a type of urinary diversion surgery.

Inserting a nasogastric tube Rationale With the removal of part of the bowel, there is an increased incidence of small bowel obstruction and paralytic ileus. Therefore a nasogastric tube is inserted for few days. The urine should be acidic to prevent alkaline encrustations. Stoma shreds into the drainage bag and mucus in the urine are common in first few days after the surgery.

"Perform light exercises to prevent constipation." Rationale Constipation is a frequent complication associated with urinary incontinence (UI). Therefore patients should be taught to exercise lightly, increase intake of dietary fiber, and ensure adequate fluid intake. Lotions and sprays may irritate the skin causing skin infection and should be avoided. The patient should urinate regularly on a scheduled basis every two to three hours to empty the bladder. Coffee is a bladder irritant, which should be avoided or should be consumed in smaller amounts by patients who have UI.

Bladder decompression Rationale Reflex incontinence occurs due to detrusor hyperreflexia resulting in ureteral reflex and hydronephrosis. Bladder decompression helps to prevent urethral reflux and hydronephrosis. Insertion of a pessary will help to support prolapse in overflow incontinence. Urinary diversion surgery bypasses urethra and bladder incontinence after trauma. Administration of diazepam will help to relax the external sphincter in reflex continence.

Deficient detrusor contraction strength Rationale Inability to urinate with pain in the lower abdomen indicates urinary retention. If the postvoid residual (PVR) volume is above 100 mL, it indicates urinary retention. The cause of urinary retention is deficient detrusor contraction strength, in which the muscle no longer contracts with enough force to void the bladder. Obstruction with urinary stasis can be seen in patients with stress incontinence due to prostate cancer. Interference of urethral sphincter control causes urinary incontinence (UI). Colonization and infection of the upper urinary tract cause acute pyelonephritis. p. 1060

Diltiazem Verapamil Imipramine Rationale Calcium channel blockers such as diltiazem and verapamil reduce smooth muscle contraction and help reduce burning pain. Tricyclic antidepressants such as imipramine reduce burning pain in the bladder. Alfuzosin reduces urethral sphincter resistance to urinary outflow. Phenylpropanolamine is an α-adrenergic agonist that increases urethral resistance. p. 1059

Stress incontinence Rationale Injecting autologous stem cells into the rhabdosphincter and urethral submucosa is a recent surgical technique done for stress urinary incontinence (UI) to increase the closure pressure and periurethral electromyography activity. Reflex incontinence is cured by surgical sphincterotomy. Overflow incontinence can be cured by urinary or intermittent catheterization. Incontinence after trauma or surgery is treated by placing an artificial implantable sphincter. pp. 1057-1058

Use urethral inserts. Reduce excess weight. Practice Kegel exercises. Rationale Urethral inserts should be used to support and correct the underlying problem causing stress incontinence. Reducing excess weight can help in reducing the pressure on and relaxation of the pelvic floor muscles. Practicing pelvic floor muscle (Kegel) exercises can decrease stress incontinence, because the condition is caused by relaxed pelvic floor muscles. Oxybutynin is an anticholinergic drug, which should be used to treat central nervous system disorders such as urge incontinence. Bladder decompression should be done to prevent ureteral reflux and hydronephrosis in the case of reflex incontinence.

Milking the tube Turning the patient side to side Preventing tube kinking by coiling the excess tubing Rationale A suprapubic catheter is prone to poor drainage, because of mechanical obstruction of the tip of the catheter by clots and sediments. Milking the tube will help to prevent tube obstruction. To ensure the proper functioning of the tube and to check whether the catheter is properly inserted, the patient should be turned side to side. Preventing tube kinking by coiling the excess tubing also prevents obstruction in the tube. Lubricating the catheter is not an appropriate intervention to ensure patency of the tube. Instilling 5 mL of sterile saline solution is performed in patients with a nephrostomy tube to prevent overdistention of the kidney pelvis.

Terazosin Doxazosin Rationale Terazosin and doxazosin are α-adrenergic antagonists that are used to reduce urethral sphincter resistance to urinary outflow. They cause smooth muscles in the bladder neck to relax and improve urine flow rate. Finasteride is a 5 alpha reductase inhibitor that suppresses androgen, which contributes to prostate disease. Mirabegron is a β 3-adrenergic agonist that improves the bladder storage capacity by relaxing the bladder muscle during filling. Propantheline is a muscarinic receptor antagonist and anticholinergic that reduces overactive urinary contractions in urge urinary incontinence (UI). p. 1059

Finasteride Bethanechol Rationale The feeling of incomplete passage of urine and frequent leakage of small amounts of urine indicates overflow incontinence, which commonly occurs after a patient undergoes surgery or anesthesia. Finasteride is used to decrease outlet resistance and bethanechol is used to enhance bladder contractions; both are beneficial for the patient's condition. Diazepam is used to relax the external sphincter. Oxybutynin and trospium chloride are used in the treatment of urge incontinence. p. 1056

Pubovaginal sling placement Rationale Urinary incontinence (UI) is the involuntary passage of urine. Surgical therapy is performed based on the type of incontinence. Bladder perforation is a complication resulting from pubovaginal sling placement. Urinary diversion surgery is associated with complications such as stoma stenosis. Laparoscopic nephrectomy may cause abdominal distension. Retropubic colposuspension is associated with vaginal prolapse, postoperative voiding dysfunction, and urgency. p. 1056

Observe color and consistency of urine. Measure urine output at least every one or two hours. Measure the drainage from the catheters and on the dressing. Rationale Observing the color and consistency of urine is important, because urine with increased amounts of mucus, blood, or sediment may occlude the drainage tubing or catheter. Measuring and recording urine output is important, because the total urine output should be at least 0.5 mL/kg/hr. It is important to assess for urine drainage from the catheters and on the dressings to estimate the minimum amount of urine output. Never clamp the catheter unless ordered to do so by a health care provider. There is no stoma after a nephrectomy; the stoma and its care are integral part of procedures such as ileal conduit.

Containment devices Accidental loss of urine, urgency, and increased frequency of urination at night are experienced by patients with urge incontinence; this is due to overactivity of the detrusor muscle. This condition can be treated by using containment devices. Surgical sphincterotomy is used in the treatment of reflex incontinence. Intermittent catheterization is performed for treating the overflow incontinence. Bladder neck support devices are used in the treatment of stress incontinence.

175 Rationale The total urine output should be 0.5 mL/kg/hr. Because the weight of the patient is 70 kg, 70 × 0.5 = 35 mL/hr. The urine output for 1 hour is 35 mL/hr and for 5 hours 175 mL/hr. p. 1063

To choose the appropriate type and size of catheter Rationale The registered nurse chooses the type and size of the catheter during catheterization. Anchoring the catheter in place is the role of unlicensed assistive personnel (UAP). A licensed practical/vocational nurse irrigates the catheter if obstruction is suspected and inserts an indwelling catheter for uncomplicated patients.

Terazosin Rationale Leakage of small amounts of urine throughout the day and night indicates overflow incontinence. Overflow incontinence is a condition in which the pressure of urine in an overfull bladder overcomes sphincter control. The bladder remains distended and is palpable in patients with overflow incontinence. Terazosin is an alpha-blocker, which relaxes the smooth muscles around the bladder and relieves the need of frequent or urgent urination even during the night. Oxybutynin (Oxytrol) is an anticholinergic medication used in the treatment of urge incontinence. Baclofen is effective in patients with reflex incontinence. Solifenacin, an anticholinergic medication, is used to treat urge incontinence. p. 1059

To provide mechanical obstruction to prevent urine leakage Rationale A urethral plug is an intraurethral occlusive device, which is worn in the urethra to provide mechanical obstruction to prevent urine leakage. Pessaries and bladder neck support prostheses are devices that help to support the bladder neck. Urine is directed into a drainage bag through external catheter systems. Penile compression devices are applied to the penis to prevent leakage through the urethra. p. 1057

Pelvic floor muscle exercises Rationale The involuntary passage of urine while coughing, laughing, and sneezing indicates stress incontinence. These issues may occur due to prostate surgery for benign prostate hyperplasia, or prostate cancer; atrophy of the structures of the female urethra; and relaxed pelvic floor musculature. Pelvic floor muscles relax after prostate surgery. Pelvic floor muscle exercises such as Kegel exercises help to strengthen the pelvic muscles. Reductase inhibitors decrease the outlet resistance in overflow incontinence. Vaginal estrogen creams are used to treat females with urge incontinence. Urinary diversion surgery is performed to bypass the urethra and cure bladder incontinence after trauma or surgery in males and females.

The patient with a herniated disc Rationale Overflow incontinence occurs when the pressure of urine in an overfull bladder overcomes sphincter control. It is due to an underactive detrusor muscle, caused by myogenic or neurogenic factors such as a herniated disc. Therefore, the patient with a herniated disc would have overflow incontinence. Central nervous system disorders such as Parkinson's disease and Alzheimer's disease lead to urge incontinence. A patient who has had multiple pregnancies experiences relaxation of the pelvic floor muscles, which can cause stress incontinence. Retropubic prostatectomy causes incontinence after trauma or surgery.

"I should keep the drainage pouch on same side of the bed as the stoma." Rationale Ileal conduit is a urinary diversion procedure in which ureters are implanted into the part of the ileum or colon that has been resected from the intestinal tract and an abdominal stoma is created. The ureters anastomose into one end of the conduit, and the other end of the bowl is brought out through the abdominal wall to form a stoma. There is no valve and no voluntary control over the stoma; this causes drops of urine to flow from the stoma every few seconds. As a result, the drainage pouch should be attached on same side of the bed as the stoma. The area should be washed with warm water. The area around the stoma should be dry and the bag should lie towards the side of the body if the patient is in bed.

Diaphoresis Blurred vision GastrointestinaI cramping Rationale Tolterodine is an anticholinergic medication. Anticholinergics are medications that block acetylcholine in the brain. Overdose of anticholinergics causes decreased sweating (diaphoresis), blurred vision, and gastrointestinal cramping. Delirium occurs as a side effect of opioids and alcohol. Urethral constriction is a side effect of α-adrenergic receptor agonists. p. 1057

Checking the catheter for patency Rationale When the patient with a nephrostomy tube experiences excessive drainage around the tube or pain, the nurse should check for patency of the catheter. Changing the tube may also help in reducing excessive drainage, but it should be done only on the order of the primary health care provider. Documenting the observation is also useful; however, it is not the most appropriate in this situation. The nurse should document the findings and appropriate actions only after notifying the primary health care provider. The nurse should notify the primary health care provider after checking the patency of the urinary catheter.

Vaginal prolapse Postoperative voiding dysfunction Rationale Retropubic colposuspensions are periurethral injectables used in the treatment of urinary incontinence (UI). This procedure is performed through low transverse incisions, and may lead to complications such as vaginal prolapse, postoperative voiding dysfunction, and urgency. Infection, urinary retention, and bladder perforation occur due to the placement of a suburethral sling.

"I am doing it right when I release the muscle to urinate." Rationale When there is strong urge for urination, the patient should tighten the pelvic muscle quickly and squeeze hard several times until the urge passes. Pelvic floor muscle exercises should be performed in a sitting or lying down position. To perform long squeezes, the pelvic muscle should be tightened for 5 to 10 seconds before relaxing. Short squeezes require tightening the muscle quickly, squeezing for two seconds, and then relaxing. p. 1058

Bethanechol Rationale Overflow incontinence occurs when the pressure of the urine in an overfull bladder overcomes sphincter control. Bethanechol enhances bladder contraction by increasing detrusor muscle tone in the bladder wall. Baclofen and diazepam are used to relax the external sphincter in reflex incontinence. Finasteride is a reductase inhibitor used to decrease outlet resistance in overflow incontinence. p. 1056

Instructing the patient to tolerate pelvic pain Rationale The patient should not be encouraged to tolerate pelvic pain. Adequate pain management is necessary for healing. The nurse should check the drainage from the ureteral catheter every one or two hours to prevent complications associated with the ureteral catheter. The catheter should be checked frequently to avoid tension on the catheter. The nurse should not clamp the ureteral catheter. p. 1062

Decreasing urinary stasis Rationale A patient with benign prostatic hypertrophy may have urinary retention due to lower urinary tract obstruction. Urinary stasis may increase the risk of infections in the patients. Therefore urinary catheterization should be performed in these patients to decrease urinary retention. Because the patient does not have an infection, bladder irrigation does not need to be performed. Therefore this could not be the reason for urinary catheterization in this patient. Urinary catheterization for collecting a sterile urine sample would not be appropriate in this patient. Facilitating medication instillation is not necessary in this patient. p. 1060

The patient will not experience bladder spasms. Rationale The patient with suprapubic catheterization may have urine leakage due to bladder spasms. An opium suppository is administered to decrease the bladder spasms. Acute pyelonephritis involves flank pain and administration of ciprofloxacin reduces the flank pain. Administration of trimethoprim will help to reduce urine loss after voiding in a urinary tract infection. Overdistention of the kidney pelvis is a complication associated with nephrostomy tubes. Instilling 5 mL of sterile saline solution will help to prevent overdistention of the kidney pelvis.