Ch: 36 Urinary Elimination

caffeine intake. Fluids or food containing alcohol or caffeine, such as coffee, tea, cola, or chocolate, irritate the bladder and contain a diuretic that can increase urine output when ingested in large amounts.

Daytime continence is normal in a 3-year-old child. Children who are able to remain dry for a few hours at a time may be signaling readiness for toilet training. Children old enough to undress themselves will have increased abilities to toilet train. Beginning sometime between 2 and 3 years of age, parents should to watch for signs that a child may be ready for toilet training. These signs include staying dry for two hours at a time or dry after naps, as well as being able to walk to the bathroom and ability to undress themselves. Most children will achieve daytime urinary control by 3 to 4 years of age. Sometimes, toddlers need to experience outdoor playtime without diapers to see what happens when they experience bladder fullness, followed by urethral relaxation and bladder emptying. They begin to understand the relationship between bladder fullness and voluntary bladder emptying and are ready for toilet training. Nighttime continence may not occur until 4 or 5 years of age.

The nurse should lubricate 1 to 2 inches (2.5-5 cm) of the catheter tip and, using the dominant hand, hold the catheter 2 to 3 inches (5-7.5 cm) from the tip and insert slowly into the urethra. The nurse should then advance the catheter until there is a return of urine (approximately 2 to 3 inches [5 to 7.5 cm]) and, once urine drains, advance catheter another 2 to 3 inches (5 to 7.5 cm).

"Void a small amount, stop, and discard it." When collecting a midstream urine specimen, the client voids a small amount, stop, and discards it; the first small amount helps to flush away organisms near the urinary meatus. The midstream urine specimen is a sterile specimen so it is not collected in the hat in the toilet bowl. The client will not need to be catheterized. It is a one-time specimen, so urine will not be collected for 24 hours.

the first voiding of the day The nurse would discard the first void of the day. The bladder has collected urine that has been produced by the kidneys overnight. The first voided urine of the day is usually more concentrated than other urine excreted during the day. Because the first urine of the day is not fresh, but rather an accumulation of a number of hours of kidney output, this urine may or may not be used as a specimen for certain tests.

Burning and frequency The nurse anticipates that the client has a urinary tract infection (UTI), which is characterized by cloudy, foul-smelling urine, burning, and frequency.

Withdraw several milliliters of urine from the port on the collection tubing, using a syringe and needle.

Limiting fluid intake is not a healthy practice, and clients should be encouraged not to use fluid restriction as an incontinence management strategy. Promoting fluid intake is beneficial for most clients who do not possess a contraindication, and it is appropriate and useful to take diuretics in the morning to avoid nocturia. Even though it may involve work for both the client and the nurse, clients who want to use a bathroom or commode rather than an adult absorbent brief should be encouraged to do so.

greater than normal urinary volume Polyuria means greater than normal urinary elimination. It may accompany minor dietary variations. For example, consuming higher than normal amounts of fluids, especially those with mild diuretic effects (e.g., coffee, tea), or taking certain medications actually can increase urination. Other definitions: Oliguria is inadequate elimination of urine. Anuria means the absence of urine. Dysuria is difficult or uncomfortable voiding.

Nephron The functional unit of the kidney is called the nephron. Each kidney has more than 1 million nephrons, and each nephron is capable of forming urine. The nephron consists of the glomerulus, Bowman's capsule, proximal convoluted tubules, loop of Henle, distal tubule, and collecting duct. The glomerulus is a network of blood vessels, surrounded by Bowman's capsule, where urine formation begins. The tubules, loop of Henle, and collecting ducts are passageways that permit urine to flow to the renal pelvis and then to the ureters.

Provide instruction to the client. Clean the area surrounding the urinary meatus with the provided cloth. Void a small amount into stool. Void into the provided collection device. Secure the lid on the specimen container. Submit collected specimen to the health care professional.

Boys may take longer for daytime continence than girls. Children in North American cultures usually achieve daytime urinary continence by 3 years of age; boys may take longer than girls. Nighttime continence may not occur until 4 or 5 years of age.

Burns The water saving, to regulate the concentration of solutes in the ECF, results in decreased urine output. Increased loss of body fluids can occur with vomiting, diarrhea, excessive diaphoresis (sweating) secondary to fever or exercise, excessive wound drainage, extensive burns, or blood loss from trauma or surgery.

void following sexual intercourse Factors that increase the incidence of urinary tract infections include incorrect wiping of the anal area after bowel movements; sexual intercourse, which can bring perineal microorganisms into closer contact with the urethral meatus; and any procedure that places an object in the urethra or bladder for diagnostic procedures or therapeutic reasons.

True

Reddened perineal skin The presence of reddened perineal skin is an abnormal finding. The healthy skin should be moist and noninflamed with no discharge present. Smegma, an accumulation of white, odorous secretions from sebaceous glands found under the labia minora in women and under the foreskin in men, is considered a normal finding.

"Void a small amount, stop, and discard it.

The nurse gently palpates the client's symphysis pubis. The nurse places a generous amount of ultrasound gel or gel pad midline on the client's abdomen, about 1 to 1.5 in (2.5 to 4 cm) above the symphysis pubis. The nurse aims the scanner head toward the bladder (points the scanner head slightly downward toward the coccyx). The nurse adjusts the scanner head to center the bladder image on the crossbars.

The appearance of urine streaked with blood is always abnormal. Urine may appear cloudy, dark reddish-brown, or streaked with blood when a woman is menstruating.

24-hour specimen

first thing in the morning While the specimen can be collected at any time during the day, the first urine voided in the morning is preferred. The first urine is usually more concentrated because the client does not usually consume fluid during the night and the effects of diet and activity are minimized.

bedside commode

stress Stress incontinence is associated with a raise in intra-abdominal pressure related to activities such as sneezing, coughing, or laughing

Kegel exercises should be performed by tightening the internal muscles used to prevent or interrupt urination for 10 seconds, followed by a period of 10 seconds of relaxation. The client should be instructed to perform this regimen 3-4 times daily for 2 weeks to 1 month.

Inform the client that the health care provider can be contacted to discuss other catheter options. The nurse will tell the client that another type of catheter, such as a condom catheter, may be ordered at the discretion of the health care provider. The nurse should not implement bathroom privileges or straight catheterization without a health care provider's order. It is unethical and inappropriate to continue to place the catheter without the client's consent.

"Bend forward and apply pressure over your bladder."

Anuria

The catheter can be connected to a smaller leg bag for ambulation. Educational points related to an indwelling urinary catheter include instructions on connecting the catheter to a smaller leg bag for ambulation; maintaining adequate fluid intake; keeping the catheter free of kinks (avoid clamping the catheter tubing); emptying the drainage bag at regular intervals; and avoiding a full drainage bag that may lead to reflux of urine.

Blood A reddish-brown urine sample is indicative of the presence of blood. The urine appears dark amber in color due to dehydration. Infection and stasis would cause the urine to appear cloudy.

Stress

neurogenic bladder.

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The client has an enlarged prostate. Enlargement of the prostate gland is commonly seen in men over age 50 and may interfere with urinary catheterization.

Leave the catheter in place as a marker and attempt to insert a new sterile catheter directly above the misplaced catheter. Start the procedure over and attempt to place the new catheter directly above misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Never remove a catheter from the vagina and insert it in the urethra as this action can cause cross-contamination.

intermittent urethral catheter An intermittent urethral catheter (straight catheter) is a catheter inserted through the urethra into the bladder to drain urine for a short period of time (5 to 10 minutes). With an indwelling urethral catheter (retention or Foley catheters), a catheter (tube) is inserted through the urethra into the bladder for continuous drainage of urine; a balloon is then inflated to ensure that the catheter remains in the bladder once it is inserted.

The client is dehydrated. The BUN test measures the amount of urea nitrogen in the blood. Urea, the major nitrogenous end-waste product of metabolism, is formed in the liver. The bloodstream carries urea from the liver to the kidneys for excretion. When the kidneys are diseased, they are unable to excrete urea adequately, and urea begins to accumulate in the blood, causing BUN to rise. Normal BUN is 8 to 25 mg/100 mL. Because other factors, such as high dietary intake of protein, fluid deficit, infection, gout, or excessive breakdown of protein stores, can also elevate BUN, it is not a highly sensitive indicator of impaired renal function.

"How frequently do you urinate each day?" The client with frequent urinary tract infections may have infrequent urination, which can lead to stagnation of urine in the bladder; this potentially leads to growth of bacteria.

urinary retention

straight catheter Intermittent urethral catheters, or straight catheters, are used to drain the bladder for shorter periods. If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters

Functional Incontinence Definitions of Different Incontinence episodes: Functional incontinence is the inability of a normally continent person to reach the bathroom in time to avoid the unintentional loss of urine. Stress Incontinence is a state where the client loses small amounts of urine with increased pressure on the abdomen. laughs & coughs Urge Urinary Incontinence is when a client experiences an involuntary loss of urine when a specific bladder volume is reached. Total Urinary Incontinence is when a client experiences continuous, unpredictable loss of urine.

cloudy, foul odor

After the initial stream is initiated, collect the sample. A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.

"Let's review your medication history and whether you consume bladder irritants." Urge incontinence can be aggravated by bladder irritants such as caffeine or alcohol, and can take place if diuretics are taking in the morning. The nurse will start by reviewing these factors. The nurse should not discount this as an isolated event without further assessment. It is too soon to refer the client to the healthcare provider, or to recommend incontinence undergarments.

urinal The client with weakness who has been ordered to stay on bed rest will benefit from use of a urinal. The client should not be moved to the bedside commode or regular bathroom. A fracture pan may be useful for bowel movements.

"Let's review the types of fluids that your child drinks in the morning." Bladder irritants such as caffeine can cause urge incontinence; it is appropriate to determine whether the child is consuming fluids that contain caffeine. The child's urge incontinence is not extremely abnormal, and this physiological response is not related to gender. It is too soon to refer the client to the healthcare provider without taking a history, and it is impractical to simply recommend incontinence undergarments.

dark brown, cloudy

Clean each labial fold, then the area directly over the meatus. Insert the lubricated catheter into the urethra. Advance the catheter until there is a return of urine. Inflate the balloon with the correct amount of sterile saline. Discard used supplies.

Document the findings as normal, recognizing that they have been caused by an accumulation of uric acid crystals.

Check electronic health record for medical order.

dehydration The nurse anticipates that the client may be dehydrated, which is characterized by strongly aromatic, dark amber urine.

Request an order for catheter discontinuation from the health care provider.

The rounded shelf of a regular bedpan should be placed under the client's buttocks.

one or both of the ureters are surgically implanted elsewhere The nurse should understand that in a urinary diversion, one or both of the ureters are surgically implanted elsewhere. This procedure is done for various life-threatening conditions. Incontinence is the inability to control either urinary or bowel elimination. Catheter care means the hygiene measures used to keep meatus and adjacent area of the catheter clean. In order to collect a catheter specimen, the nurse uses a catheter to collect a sample of urine in a sterile environment.

Urinal

Catheterized clients should drain a minimum of 30 mL of urine per hour.

It collects urine into a drainage bag without the risk of infection associated with indwelling urinary catheters.

The nurse would suspect the client had decreased bladder contractility, which lead to the client having issues with urinary retention.

A clean-catch specimen is collected in mid-stream. It is not reasonable, nor necessary, to collect the entire urinary output. It is not correct to collect the first urine expelled or to wait until the void is almost over.

dark brown, cloudy

Document the finding. A PVR of less than 50 mL indicates the bladder is adequately emptying, so the nurse should document the findings. Since this normal there is no need to encourage more fluids, re-catheterize the client, or perform a bladder scan.

Contact the health care provider to decrease furosemide. Voiding over 3000 mL/day is considered abnormal. The client may benefit from a reduction in the amount of furosemide that is prescribed. Therefore, it is appropriate to contact the healthcare provider to decrease furosemide. Documenting the finding as normal, increasing IV fluids, and administering an additional dose of furosemide are not appropriate nursing actions.

stress

urinal The client with weakness who has been ordered to stay on bed rest will benefit from use of a urinal. The client should not be moved to the bedside commode or regular bathroom. A fracture pan may be useful for bowel movements.

The birth can cause perineal swelling. Trauma from vaginal birth causes swelling in the perineal area, which can obstruct the flow of urine and cause urinary retention during the early postpartum period.