NF2 Module 5

Urinary Elimination
Organs of the urinary system (renal system)
- Kidneys
o Remove waste from the blood to form urine
- Ureters
o Transport urine from the kidneys to the bladder
- Bladder
o Reservoir for urine until the urge to urinate
develops
- Urethra
o Urine travels from the bladder and exits through
the urethral meatus

Urine – waste product of the renal system

What is it?
Characteristics? – clear, pale yellow to yellowish waste
What’s normal/abnormal? – cloudy, red to brown colors

Colour = pale straw to amber

Odour = ammonia like
Clarity = transparent
Amount = Min 30mL/hr

Terminology
- Micturation
o Urination; act of passing urine voluntarily through the urethra
- Oliguria
o Diminished capacity to form and pass urine
- Anuria
o Cessation of urine production
- Polyuria
o Excretion of an abnormally large volume of urine
- Dysuria
o Painful or difficult urination
- Hematuria
o Abnormal presence of blood in the urine
- Nocturia
o Urination at night
- Cystitis
o Inflammation of the urinary bladder characterized by pain, urgency,
and frequency of urination
It is means inflammation an means missing hemat means presence of
of bladder poly means a lot blood
ia means abnormal dys means difficult Noct means night
olig means very little Cyst means bladder

Urinary retention
What is it? What causes urinary retention?
- An accumulation of urine in the bladder due to bladder’s inability to empty.
o Overflow incontinence may occur (urethral sphincter is unable to hold back urine
due to built-up pressure).
o Bladder could be firm and distended upon assessment. In severe cases, the
bladder may hold as much as 2-3L of urine.
- What are some factors that can affect a person’s ability to urinate?
Illness; malfunction of an organ that affects the urinary system
- How do you know your patient is retaining urine?
Inflation of the abdomen
- Complications of urinary retention?
Bladder may burst if urine is not emptied in the bladder

Catheterization: What is it?

- Introducing a narrow tube through the urethra
and into the bladder to allow a continuous flow
of urine intro a drainage receptacle

How might we explain this procedure to a patient?

Catheterization: Indications
- Collect sterile urine specimen
- Intermittent or continuous bladder drainage and/or irrigation
An intervention to manage
• Incontinence
• Surgery
• Persistent residual urine volume after voiding
• Feeling of discomfort (patient's subjective feeling of fullness,
symptoms secondary to a UTI, etc.)

Super pubic catheter – surgeons create a pathway through the

pubic area and a catheter is placed inside the bladder
Catheterization: Types
Straight, Intermittent, “in & out”
• Insertion followed by immediate removal
• Single lumen catheter
• No balloon
Indications?
Nocturia

Indwelling, continuous, Foley

• Balloon to secure in situ
• Double or triple-lumen catheter
Indications?

Coude tip catheter

• Type of indwelling catheter
• Curved and rigid tip for ease of passing
enlarged prostate
• Easier to control/stiff
• Less traumatic insertion
Indications?

Catheter materials and sizes (Check for allergies)

1. Catheter Materials
• Latex, silicone, teflon, plastic

2. Catheter Size (lumen size)

• Determined by size of patient's urethral canal
• Presence of clots/debris
• French (Fr) system
o Child 8 Fr to 10 Fr
o Adults 14 Fr to 16 Fr
o Urological procedure 20 Fr to 24 Fr

3. Balloon Size (how much to instill?)

• From 3mL (peds) to 30mL prostatectomies)
• Commonly 5mL in adults for optimal drainage
*Check packaging for manufacturer's recommendation of volume to instill*

Closed drainage systems

 o What is a closed drainage system?
- Another port for draining
- Clamp it the tube first
o Consider position of the bag
- No opening
- Drainage tube in the bag
- Open it to drain the bag
o How can you maintain asepsis?

o When would a urometer drainage system be required?

o What might the Luer lock port be used for?

Catheterization: Assessments
*Physician order is required to insert a catheter*
Indications for the procedure
• Consider any pathological condition that may impair the passage of the catheter (i.e.,
enlarged prostate)
Allergies – allergic to latex?
Gather data from your head-to-toe assessment
• Intake and output
• time of last void
• assess output for colour, odour, consistency, amount (COCA)
• Palpate bladder for distension, pain, etc.
• Bladder scan to determine the amount of urine retained or post-void residual
• May need a doctor’s order to use
• Skin integrity at the perineum
• redness, edema, ecchymosis, drainage, approximation (REEDA)
• provide peri-care before (and after) the procedure
• Subjective data from patient
• feeling of fullness, frequency, painful voiding, etc.
Mobility/physical limitations which might impede procedure and post-care
Consider cultural, gender, age, and mental capacity
• determine catheter size, approach, teaching, and post-care

Catheter Associated Urinary Tract Infections (CA-UTIs)

Nursing interventions and evaluation:
• Promote infection prevention (teaching and assessments)
• Ensure unobstructed urine flow (bag below the height of the bladder)
• Encourage hydration
• Proper peri-care
Aseptic catheter insertion techniques
• 75% of nosocomial UTIs are CA-UTIs

Routine Catheter Care is to promote bladder health- page 1198.

Catheterization: Adverse outcomes

• Leakage due to obstruction or bladder spasms
• Obstructions (kinks/loops in tubing)
• Bleeding
• Chronic renal inflammation
• Urethral erosion, strictures
• Bladder spasms
• Encrustations
• Kidney stones
• Prostatitis, Orchitis
• UTI/Urosepsis
To catheterize or not to catheterize
Guideline for Prevention of Catheter-Associated Urinary Tract Infections (CA-UTIs; CDC, 2019)
Best Practice Guidelines:
• Risk/benefit must be weighed for each patient
• Must be indicated for initiation
• Must be indicated for continuing use
• Must be assessed and reassessed

Catheterization: Documentation
• Date and time
• Relevant data from your assessment
• The indication for the procedure
• Type and size of Foley inserted (# Fr.) and balloon (size/inflated volume) (so the next
nurse will know how much fluid will they remove from the catheter)
• Patient teaching provided
• If specimen obtained
• Assessment of the drainage (COCA)
• Patient reaction, adverse outcomes

Discussion
1. What are the symptoms of an UTI?
Burning sensation Cystitis
Hematuria WBC in urine
Frequent urination Sediments in urine
fever Dysuria
Foul odor Urinary retention
Urine color may differ from normal urgency
 2. Why are UTIs the leading cause of hospital acquired infections?
Unsterile techniques for urinary catheters
Interventions
Immobility issues
Poor hygiene

3. What patient teaching should take place?

Drink of a lot of water
Maintain good hygiene
Do not hold your pee
Complete your medications

Patient teaching are:

• Hygiene
• Fluids
• Positioning
• Reporting

Indwelling catheter removal (Clean technique)

Do pericare after
*Need physician order to remove catheter*
• Clean technique, wear clean gloves
• Short-term dysuria is normal, especially if the catheter was in situ for several days or
weeks
• The patient may experience urinary frequency or retention until the bladder
regains full tone
• Assess urinary system function
• Document first void after removal, time and amount of voiding during the next
24 hours
Body is very relax when catheter is in
Couple of days: spasms or may mimic symptoms of UTI (burning feeling in the urethra)

Bladder irrigation
Purpose
o Maintain catheter patency
o Medication administration
o Indications?
Intermittent – two lumens; bladder irrigation kit
Flush it, clamp it, and drain ml according to the
doctor’s order
Continuous – three lumens; set up like an iv bag
Irrigate bladder – flushing to see if there is n0o blood clot after surgery

Prior to bladder irrigation

1. Assess client
• History of catheter changes (frequency,
bypassing, blocking, spasms)
• Ensure no kinks, clothing restricting, etc.
• Bag below level of bladder
• Intake and output
• Pain assessment (OPQRSTUV)
• Last bowel movement (can impede
bladder emptying)
• Presence of debris/film in tubing
• Activity and mobility
2. Investigate cause of catheter blockage
• Mucosal occlusion
• Encrustation - primary reason for
blockage
Bacteria build-up >> Biofilm in catheter and tubing >>
encrustation of catheter
Maintenance solutions
• Normal saline
• Wash debris from catheter through mechanical action
• Will not dissolve encrustation (crystalline material)
• Acetic Acid
• Evidence that mineral deposits can be dissolved with acetic acid but not
preventative measure

Intermittent bladder irrigation:

Open system
• Urine collection bag has no ports on drainage bag therefore must disconnect drainage
bag (open the system) to instill fluid
• MUST maintain sterility
• Catheter tip - bulb or piston syringe
• Greater risk of infection

Alcohol swabs – can make the cap sterile after irrigation; 30 seconds to clean

Intermittent bladder irrigation:

Closed system
• Urine collection bag has a port in place
• Collection bag is clamped prior to initiating irrigate
BE SURE TO UNCLAMP when finished
 • Continuous infusion of a sterile solution into the bladder
• Use a 3-way irrigation closed system with a triple-lumen catheter
One lumen is used to drain urine; another is used to inflate the catheter balloon; the final lumen
carries the irrigation solution
• Usually indicated in patients with complications such as gross hematuria or after
a urological surgery

Bladder irrigation: Documentation

• Assessment of patient prior, during, and post irrigation
• Type of irrigation performed and irrigate solution used (as per physician order)
• Amount instilled & amount returned as drainage
• Character of the drainage (COCA)
• Any indicators of issues during irrigation:
• Inability to instill, presence of clots or sudden bleeding
• Changes to drainage
• Retaining solution
• Pain/bladder distention
• Bladder spasms
• Bypassing