07.05 Urinary Elimination

Overview

  1. Urinary Elimination
    1. Nursing care priorities
    2. External aids
    3. Internal aids
    4. Surgical interventions

Nursing Points

General

  1. Nursing care priorities
    1. Dignity
      1. Provide comfort
      2. Provide privacy
    2. Safety
      1. Reduction of infection
      2. Skin care
    3. Measure output
      1. Measure every device
    4. Urine output output
      1. Check for consistent urine output
      2. Some drugs can change the color of urine
      3. Address concerns with providers as necessary and promptly
  2. External aids
    1. Bedside toilet
      1. Use for ambulatory patients
      2. Check for safety
        1. Reduce fall risk
    2. Urinals
      1. For difficult mobility
      2. Available for male and female
    3. Bedpan
      1. Available for female patients to urinate
      2. Use fracture pans for ortho patients
    4. Condom cath
      1. When to use
      2. Orders are sometimes necessary
      3. Check for skin integrity and seal
  3. Internal aids
    1. Foley (indwelling urinary catheter)
      1. Coudé
        1. Male insertion with prostate problems
      2. 3-way Foley
        1. Use for continuous bladder irrigation
      3. Use sterile technique for insertion and catheter care
      4. CAUTI (Catheter Associated Urinary Tract Infection
        1. Perform cath care regularly
        2. Remove as soon as possible
    2. In-and-Out Catheter
      1. Single pass to insert and drain bladder
      2. Provider order necessary
      3. Use same care for in-and-out as Foley
  4. Surgical interventions
    1. Suprapubic catheter
      1. Used when voiding can’t occur below the level of the bladder
        1. Ex: urethral injury
      2. Sometimes can leak
        1. Check skin integrity
    2. Nephrostomy tube
      1. Used when voiding can’t occur below the level of the kidney
        1. Typically inserted in the back
    3. Ileal conduit
      1. Used when removal of the bladder is necessary
      2. Creates stoma
        1. Provide stoma care
        2. Monitor similar to Foley

Assessment

  1. Assess for patient knowledge regarding elimination aids
  2. Assess output based on the type of device used
  3. Check skin integrity frequently
  4. Determine if device is still necessary

Nursing Concepts

  1. Elimination
  2. Safety
  3. Functional Ability
  4. Comfort

Patient Education

  1. Educate patient on the type of device necessary for care
  2. Educate patient on need to notify the nurse for elimination needs
    1. Provide call light, and educate patient on use
    2. Observe patient using call light appropriately
  3. Educate patient on long term use of devices such, as ostomies.
    1. Provide teaching for ostomy and stoma management
    2. Utilize teaching methods such as the teach back in reducing the probability of complication

Reference Links

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Video Transcript

In this lesson, we’re going to cover urinary elimination. There’s a ton of info, so get ready.

Okay we’re going to hit a lot of topics today but I want to focus on some real important parts right up front.

The two really important things that you need to focus are dignity and safety. Using the restroom can be awkward for them and you need to make sure that you’re giving them with privacy. The other thing that you need to do is focus on your patient safety. When I say safety I’m talking about removing or reducing the risk of infection. You reduce risk of infection by doing good catheter care and inserting catheters steriley.

You also need to remember the you’re in charge of the patient’s urine output and the device that they use. Be sure to measure your patient’s urine output, and always address concerns with your provider if you think something’s wrong with your patient’s urine or device. But if you have a real concerns don’t hesitate in contacting provider. Now let’s get started.

As you go further into your nursing career, you’re going to use these devices, so make sure you familiarize yourself with them.

The two most common ones that you’re going to use are your urinals and your bed pans. They have both male and female urinals. I’ve actually found bedpans to be more beneficial for female patients, and I have never seen a female urinal in real life. But just know that they do exist and if that’s what your patient wants to use, then you give it to them. One thing you need to be mindful of though is making sure you’re using the right bed pan. If you have a patient has an orthopedic injury or a pelvic injury, they can’t sit on a regular bed pan correctly or it’s painful so make sure that use a fracture bedpan for these patients.

If your patient can get up and you have a bedside toilet available, they’re really helpful too. They provide your patient a little bit more autonomy and Independence, especially if they’re connected to a bunch of stuff like tubes or lines or monitors. Just know that it gives him a little bit more independence.

Another urinary aid that you may end up seeing if something called condom catheter. It literally is what it sounds like. It’s a condom attached to a tube of the drainage bag. These are great for patients that are urinary incontinent. Just be aware that sometimes they slip off and sometimes they leak. So be sure to practice due diligence and making sure that patient has it on and that if it does leak, make sure that you clean your patient up quickly because you don’t want your patient getting skin breakdown.

Now when we talk about internal devices or internal urinary aids, what were literally talking about is placing a tube into the patient, but not surgically. The most common type that you’re going to see is a Foley catheter, which is a long tube that has a balloon that you fill with saline when it’s in the bladder to keep it from coming out. So in the bladder fills up, the urine drains into a drainage bag. One other one that you’re going to see is an in and out catheter. The biggest thing with that one is that you inserted into the patient once, you drain a bladder, and then you remove it. It’s not an indwelling catheter.

There are two things I want to hit real quick, but they’re important. Because the Foley catheter has a balloon, the last thing you want to do is just pull that thing out when the balloon is full. So when you insert it, make sure it’s all the way in before you fill it, and make sure it’s completely deflated before you pull it out. If you don’t, you can damage the urethra, it’s going to be painful, and it could complicate their situation.

Another really important point is that we need to make sure that we try to keep our patient’s from getting catheter associated urinary tract infections or CAUTIs. Make sure that when you’re inserting the catheters that you’re using sterile technique, and make sure that you’re doing your peri care and catheter care at least once a shift if not more. But check with your facility policy for how often you have to do that. The last thing we want is for our patients to have complicated stays because they got some sort of urinary tract infection because the nurses weren’t being diligent and making sure that their catheters were clean.

Sometimes our patients need some surgical help in order to urinate. And there’s three big ones that we look at. These are not all-encompassing so just know that you may see more or variances of these.

The first one is called a suprapubic catheter. It’s a literally a tube inserted through the abdomen into the urinary bladder. The reason we do these is because the patient can’t void below the level of the bladder, usually with something like urethral trauma. so the patient can make urine and the kidneys it can hold it in the bladder but it can’t get out. So that’s why you would use a suprapubic catheter.

Another one that you may see is something called a nephrostomy tube. If a patient has a problem with the ureters, and they can’t get the urine from the kidney to the bladder and then out of the patient, providers can insert tubes directly into the kidney to allow the patient to urinate that way. Is usually a drain inserted their back of their side, and drains into a drainage bag. one thing that you need to be considerate of it’s just because the patient has a nephrostomy tube other kidney isn’t working. So you need to make sure that your patient is voiding normally if they can.

The last one is called an ileal conduit. You’re going to see this in your patients that have had like total bladder removals or their bladder can’t hold urine appropriately. So what they do is a redirect urine from the kidneys and the ureters into the ilium, and then they create a stoma on the abdomen. So be sure that you continue to monitor that output. There’s some really good information on stomas in the bowel elimination lesson, so be sure to check that out.

Today we really focused on our nursing concepts of elimination and functional ability, and we really want to drive home that idea of safety by reducing the risk of infection.

Okay, so let’s recap.

Your patient may not always be able to eliminate on their own, so if they have a device make sure that that device is staying clean and free of infection.

External devices are great for your patients that have the ability to get up and move, so we don’t have to use any sort of internal devices.

Only use your internal devices when you absolutely need to and make sure that you take them out as soon as possible.

Surgical interventions are last resort, but sometimes they are absolutely necessary. So make sure that you know what kind of device your patient has and to make sure that is absolutely necessary.

Always let your providers know if there are changes to the device, or if there is concern so then we can protect our patients and make sure they don’t have any real complications.

That’s it for our lesson on urinary elimination. Make sure you check out all the resources attached to this lesson. Now, go out and be your best selves today. And, as always, happy nursing!!

Read more

  • Question 1 of 6

A 56-year-old patient has been diagnosed with stress incontinence and has frequent episodes of leaking urine. The nurse has given this patient a nursing diagnosis of Altered Urinary Elimination related to her condition. Which of the following nursing interventions are most appropriate in this situation? Select all that apply.

  • Question 2 of 6

Which of the following changes in elimination would most likely occur in a patient who is unable to get out of bed and is immobile? Select all that apply.

  • Question 3 of 6

A client in a long-term care facility is having elimination problems and suffers from incontinence. Which nursing intervention would most likely help to prevent skin breakdown in this client?

  • Question 4 of 6

A 67-year-old client has been given a nursing diagnosis of Altered Patterns of Urinary Elimination related to stress incontinence. Which of the following most accurately explains this condition?

  • Question 5 of 6

Your patient has two IV’s, one of which has Cardizem infusing at 5mg/hr, and the other has a heparin drip infusing at 11 units/kg/hr. The patient has already removed their Foley catheter (with the balloon still intact), their sequential compression devices and blood pressure cuff multiple times. You have reoriented her, moved her closer to the nurse’s station, implemented fall precautions, and increased rounding, but you are very worried she will remove these IV’s. It was incredibly difficult to obtain these two access points and you are concerned that if you lose access from her removing them herself, you may not be able to get an additional IV. What would be the next most appropriate intervention for this patient to ensure her safety?

  • Question 6 of 6

You have an order to insert a Foley catheter on your male patient with an enlarged prostate with urinary retention. You have attempted to advance the catheter up the urethra, however you cannot advance any further. What would be your next step in addressing this?

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