URINARY ELIMINATION
▪ Aldosterone: Na & H2O are reabsorbed in greater
Course Outline
ANATOMY & PHYSIOLOGY OF URINARY ELIMINATION
FACTORS AFFECT VOIDING
ALTERED URINE PRODUCTION
ALTERED URINARY ELIMINATION
NURSING MANAGEMENT
▪ Urinary elimination is important to health
▪ Elimination from the urinary tract is usually taken for
granted.
▪ A person’s urinary habits depend on social culture,
personal habits, and physical abilities.
ANATOMY & PHYSIOLOGY OF URINARY
ELIMINATION
KIDNEYS
▪ Adult: 12 cm long, 6cm wide and 3cm thick
▪ Lie against the dorsal body wall in a retroperitoneal
position (behind the parietal peritoneum) in the
superior lumbar region
▪ Extends from the T12 to L3 vertebra thus receive
protection from the ribcage.
▪ Right kidney is slightly lower than the left because it is
crowded by the liver.
▪ Primary regulators of fluid and acid-base balance.
▪ NEPHRONS: functional unit of kidney that filters the
blood and remove metabolic wastes.
▪ BOWMAN’S CAPSULE: the filtrate moves into the
tubule of the nephron
▪ PROXIMAL CONVOLUTED TUBULE: water and
electrolytes are reabsorbed. Solutes [glucose], are
reabsorbed in the loop of Henle. Other subs are
secreted in the same area resulting into urine
concentration.
▪ DISTAL CONVOLUTED TUBULE: additional water
and sodium are reabsorbed under ADH and
aldosterone. This allows fine regulation of fluid and
electrolyte balance in the body.
▪ When fluid intake is low/ solute concentration in the
blood is high, ADH in the posterior pituitary is
released, more water is reabsorbed in the distal tubule
so less urine is excreted.
▪ No ADH or less ADH = distal tubule is impermeable =
more excreted urine
quantities, increase blood volume and decreasing
urinary output.
URETERS
▪ Moves through the collecting ducts into the calyces of
the renal pelvis and from there into the ureters.
▪ Adult: 25 to 30cm [10 to 12 inches] long and 1.25cm
[0.5inches] in diameter.
▪ Upper end: funnel shape as it enters the kidney.
▪ the junction between the
▪ ureter and the bladder, a flaplike fold of mucous
membrane acts as a valve to prevent reflux (backflow)
of urine up the ureters.
BLADDER
▪ Serves as the reservoir of urine and organ of excretion
▪ Empty: lies between the symphysis pubis
▪ Men: lies in front of the rectum and above the
prostate gland.
▪ Women: lies in front of the uterus and vagina.
▪ Detrusor Muscle [smooth muscle layers] allows the
bladder to expand when it is filled by urine and
contract to release urine to the outside of the body
during voiding.
▪ Full bladder: may extend above the symphysis pubis
and in extreme situations, it may extend to the
umbilicus
▪ Normal Capacity: 300mL to 600mL
URETHRA
▪ Extends from the bladder to the urinary meatus
▪ Male: 20cm and passageway of urine and semen
▪ Female: 3 to 4cm and located behind symphysis pubis,
anterior to the vagina and serves only as passageway
of urine.
▪ Women are particularly prone to urinary tract
infections (UTIs) because of their short urethra and
the proximity of the urinary meatus to the vagina and
anus.
PELVIC FLOOR
▪ Vagina, urethra, and rectum pass through the pelvic
floor that consists of sheets of muscle and ligaments
that provide support to the viscera of the pelvis.
▪ Specific sphincter muscles contribute to the
continence mechanism: (1) internal sphincter muscle
(2) external sphincter muscle
▪ Internal sphincter muscle: located in the proximal
urethra and bladder neck that is composed of smooth
 muscle under involuntary control. It provides active
tension to closed the urethral lumen.
▪ External sphincter muscle: composed of skeletal
muscle under voluntary control that allow us to
choose when to urinate.
URINATION
▪ Micturition/voiding/urination refers to emptying the
bladder.
▪ Stretch receptors are special sensory nerves that
transmit impulses to the spinal cord, specifically to the
voiding reflex center located at the level of the second
to fourth sacral vertebrae, causing the internal
sphincter to relax and stimulating the urge to void.
▪ Stimulates when the adult bladder contains 250mL to
450mL of urine and in children, 50 to 200mL of urine.
▪ Voluntary control of urination is possible only if the
nerves supplying the bladder and urethra, the neural
tracts of the cord and brain, and the motor area of the
cerebrum are all intact
▪ Injury to any parts of these nervous system results in
intermittent involuntary micturition.
▪ Cognition impaired may not be aware of the need to
urinate or able to respond to urge of seeking toilet
facilities.
FACTORS AFFECT VOIDING
1. DEVELOPMENTAL FACTORS
(a) Infants
- Gradually increases to 250 to 500mL a day during
first year.
- May urinate as often as 20 times a day.
- Colorless and odorless and has a specific gravity
of 1.008.
- Unable to concentrate urine very effectively.
- Born without urinary control and will develop this
between the ages of 2 to 5 years old.
(b) Preschoolers
- Able to take responsibility for independent
toileting
- Parents or guardians need to realize that
accidents do occur and they should not be
punished.
- Need to instruct them to wash their hands, flush
the toilet and wipe themselves.
- From front to back to avoid contamination.
- Teach not to hold urine and go to bathroom as
soon as possible.
(c) School-Age Children
- Urinates 6 to 8 times a day
- Enuresis: the involuntary passing of urine when
control should be stablished [about 5 years of
age]
- Nocturnal Enuresis: bedwetting; involuntary
passing of urine during sleep.
- Nocturnal enuresis may refer to as “primary”
when the child hasn’t achieved night-time urinary
control.
- Secondary enuresis appears after the child
achieve dryness for a period of 6 consecutive
months. Related to problem such as constipation,
stress, or illness and may resolve when the cause
is eliminated.
- Both primary and secondary nocturnal enuresis
may both be related to poor daytime voiding
habits.
(d) Older Adults
- Excretory function diminishes with age.
- Blood flow can be reduced by arteriosclerosis
that impairs renal function.
- With age, nephrons decrease to some degree
that leads to impairing kidney’s filtering abilities.
- Having influenza or surgery can alter the I&O of
normal fluid that can compromise kidney’s ability
to filter, maintain acid-base balance, and
maintain electrolyte balance.
- Decrease in kidney function places them at
higher risk for toxicity from medications if
excretion rates are longer.
- Complaints of urinary urgency and urinary
frequency are common.
- Men: enlarged prostate gland can inhibit
complete emptying bladder resulting into urinary
incontinence.
- Women: weakened muscles supporting the
bladder or weakness of the urethral sphincter
due to low levels of estrogen that leads to
urgency, UTI and stress incontinence.
- Stiffness & joint pain, previous joint injury and
neuromuscular problems impair mobility that
makes difficult to get in the bathroom.
- Dementia, prevents the person from
understanding of urinating because of cognitive
impairment.
2. PSYCHOSOCIAL FACTORS
- Privacy, normal position, sufficient time, and,
occasionally, running water helps to stimulate
micturition reflex.
- Time pressure can suppress the urination
- Nurses often ignore the urge to void until they
are able to break and this behavior can increase
risk of UTIs.
3. FLUID INTAKE & OUTPUT
- When amount of fluid intake increases, the
output normally increases.
- Alcohol increases fluid output by inhibiting
production of ADH.
- Caffeine also increases urine output.
- Foods and fluids high in sodium can cause fluid
retention because water is retained to maintain
the normal concentration of electrolytes,
- Foods containing carotene can cause urine to
appear yellower than usual.
4. MEDICATIONS
- Diuretics can increase urine formations by
preventing the reabsorption of water and
electrolytes from the tubules of the kidney into
the bloodstream.
- Medications that cause urinary retention:
o Anticholinergic
o Antidepressant and antipsychotic drugs
o Antihistamine
o Antihypertensive
o Antiparkinsonism drugs
o Beta-adrenergic drugs
o Opioids
5. MUSCLE TONE
- Good muscle tone maintains the elasticity &
contractility of detrusor muscle so that the
bladder can fill adequately and empty
completely.
- Catherization for a long period of time will lead to
poor bladder muscle tone
- Pelvic muscle tone also contributes to the ability
to store and empty urine.
6. PATHOLOGIC CONDITION
- Diseases of the kidney may affect the ability of
nephrons to produce urine.
- Proteinuria or blood cells may be present in the
urine, or the kidneys stop producing urine
altogether, a condition known as renal failure.
- Heart failure, shock, or hypertension can affect
blood flow to the kidneys, interfering with urine
production.
- Abnormal amounts of fluid are lost through
another route [vomiting/hyperthermia], water is
retained and urine output falls
- Calculus [urinary stone], obstruct ureter that
blocks the urine flow from kidney to the bladder.
- Hypertrophy of prostate gland may obstruct the
urethra that impairs micturition.
7. SURGICAL & DIAGNOSTIC PROCEDURES
- After cystoscopy the urethra may swell.
- Surgical procedures on any part of the urinary
tract may result in to postop bleeding; as a result,
the urine may be red or pink tinge.
- Spinal anesthetics can affect the passage of urine
because they decrease the client’s awareness of
the need to void.
ALTERED URINE PRODUCTION
POLYURIA/DIURESIS
- Abnormally large amounts of urine by the kidneys.
- Can follow excessively fluid intake [polydipsia]
- Associated with diseases such as diabetes mellitus,
diabetes insipidus, and chronic nephritis,
- Can cause excessive fluid loss that leads to intense thirst,
dehydration, and weight loss.
OLIGURIA
- Low urine output
- Less than 500mL a day or 30mL an hour
- May occur due to abnormal fluid loss, lack of fluid intake
that often indicates impaired blood flow to the kidneys
or impending renal failure.
ANURIA
- Lack of urine production
The kidneys become unable to adequately function, some
mechanism of filtering the blood is necessary to prevent illness
and death. Dialysis, a technique by which fluids and molecules
pass through a semipermeable membrane according to the
rules of osmosis.
(I) Hemodialysis
▪ The client’s blood flows through a
vascular catheter
▪ Passes by the dialysis solution in an
external machine then returns to the
client.
(II) Peritoneal Dialysis
▪ Dialysis solution is instilled into the
abdominal cavity through a catheter
▪ Allowed to rest there while the fluid and
molecules exchange and then removed
through a catheter.
ALTERED URINARY ELIMINATION
Frequency, nocturia, urgency, and dysuria often are
manifestations of underlying conditions such as a UTI. Enuresis,
incontinence, retention, and neurogenic bladder may be either
a manifestation or the primary problem affecting urinary
elimination.
FREQUENCY AND NOCTURIA
Urinary Frequency
- Voiding at frequent intervals, that is more than 4 to 6
times per day.
- UTI, stress, and pregnancy can cause frequent voiding of
small quantities of urine. [50 to 100mL]
Nocturia
- Voiding two or more times at night.
URGENCY
- Sudden, strong desire to void.
- Accompanies psychological stress and irritation of the
trigone and urethra.
- Common in people who have poor external sphincter
control and unstable bladder contractions.
DYSURIA
- Painful or difficult voiding
- Accompany a stricture of the urethra, urinary infections,
and injury to the bladder and urethra,
- Feeling of they have to push to void or there’s a
presence of burning sensation.
- Urinary hesitancy [delay and difficult in initiating
voiding] is associated with dysuria.
ENURESIS
- Involuntary urination in children beyond the age when
voluntary bladder control is normally acquired.
URINARY INCONTINENCE
- involuntary leakage of urine or loss of bladder control.
- Health symptom not a disease.
- Facts that make women more likely to experience UI
include shorter urethras, the trauma to the pelvic floor
associated with childbirth, and changes related to
menopause.
- Common causes: UTIs, urethritis, pregnancy,
hypercalcemia, volume overload, delirium, restricted
mobility, stool impaction, and psychological causes.
- Can be transient or established.
URINARY RETENTION
- Bladder is impaired, urine accumulates and the bladder
becomes overdistended.
- Overdistention of bladder causes poor contractility of
detrusor muscle that impairs urination.
- Common causes: prostatic hypertrophy, surgery, and
some medications.
- Overflow voiding or incontinence, eliminating 25 to 50
mL of urine at frequent intervals.
- Firm bladder and distended on palpation; may be
displaced to one side of the midline.
NEUROGENIC BLADDER
- Does not perceive bladder fullness therefore unable to
control urinary sphincters.
- Bladder become flaccid and distended or spastic, with
frequent involuntary urination.
NURSING MANAGEMENT
ASSESSING
Complete assessment of patient’s urinary function:
▪ Nursing history
▪ Physical assessment of genitourinary system
▪ Hydration status
▪ Urine examination
▪ Relating data obtained to results of diagnostic tests &
procedures
NURSING HISTORY
 Normal voiding pattern
 Frequency
 Appearance of urine or any recent changes
 Past or current problems with urination
 Presence of ostomy
 Factors influencing elimination pattern
PHYSICAL ASSESSMENT
 Percussion of kidneys to detect tenderness.
 Palpation & percussion of bladder.
 Urethral meatus is inspected as indicated for swelling,
discharge, and inflammation.
 Assess skin for color, texture, and tissue turgor as well
as the presence of edema.
 If continence, dribbling, or dysuria is noted in the
history, skin of perineum should be inspected for
irritation because contact with urine can excoriate the
skin.
ASSESSING URINE
 Normal urine: 96% water 4% solutes
  Organic Solutes: urea, ammonia, creatinine, and uric
acid
 Inorganic solutes: sodium, chloride, potassium, sulfate,
magnesium, and phosphorus
 Urea is the chief organic solute
 Sodium chloride is the most abundant inorganic salt.
MEASURING URINARY OUTPUT
 Normal: 60mL per hour or 1500mL per day
 Urine is affected by fluid intake, body fluid losses
through other routes, cardio/renal status of the
patient.
 Below 30mL per hour may indicate low blood volume
or kidney malfunction.
To measure fluid output:
✓ Wear gloves to avoid contact with microorganisms
✓ Ask patient to void in clean urinal, bed pan, commode
or toilet collection device.
✓ Instruct to keep urine separated from feces and toilet
paper in the urine container,
✓ Pour voided urine into calibrated container
✓ Hold the container, eye level, then read the amount in
the container.
✓ Record the amount on the fluid intake & output sheet
✓ Rinse the urine collection & measuring with cool water
& store appropriately
✓ Remove gloves & perform hand hygiene
✓ Calculate & document the total output at the end of
each shift & at the end of 24hr on the client’s chart
Measuring urine from a client who has urinary catheter:
✓ Apply clean gloves
✓ Take calibrated container to the bedside
✓ Place container under urine collection so that the
spout is above the container but not touching it.
✓ Open the spout & permit the urine to flow into the
container
✓ Close the spout, then proceed as described in the
previous list.
MEASURING RESIDUAL URINE
 Residual urine is normally 50 to 100mL
 Bladder outlet obstruction or loss of bladder muscle
tone may interfere with complete emptying the
bladder during urination.
 Residual urine is measured to assess the amount of
retained urine after voiding & determine the need for
interventions.
 Nurse catheterizes or scan the bladder after voiding
and then document.
 An indwelling catheter may be inserted if residual
urine exceeds a specific amount.
DIAGNOSTIC TESTS
 Urea & creatinine are routinely used to evaluate renal
function
 Urea: end product or protein metabolism & measured
as BUN
 Creatinine: produced in relatively constant quantities
by the muscles.
 Creatinine clearance test uses 24-hour urine & serum
creatinine levels to determine the GFR, a sensitive
indicator of renal function.
DIAGNOSING
❖ Impaired Urinary Elimination
❖ Readiness for Enhanced Urinary Elimination
❖ Functional Urinary Incontinence
❖ Overflow Urinary Incontinence
❖ Reflex Urinary Incontinence
❖ Stress Urinary Incontinence
❖ Urge Urinary Incontinence
❖ Risk for Urge Urinary Incontinence
❖ Urinary Retention
❖ Risk for infection
❖ Situational Low Self-Esteem
❖ Risk for Impaired Skin Integrity
❖ Toileting Self-Care Deficit
❖ Risk for Deficient Fluid Volume
❖ Excess Fluid Volume
❖ Disturbed body Image
❖ Deficient Knowledge
❖ Risk for Caregiver Role Strain
❖ Risk for Social Isolation
PLANNING
PLANNING FOR HOME CARE
▪ Provide continuity of care
▪ Nurse needs to consider the patient’s needs for
teaching & assistance with care in the home.
▪ Home Care Assessment outlines an assessment of
home care capabilities related to urinary elimination
problems.
▪ Many patients have increased fluid requirements,
necessitating higher daily fluid intake.
▪ Clients who are at risk for UTI/ urinary calculi should
consume 2000 to 3000mL of fluid daily.
 ▪ Increased fluid intake may be contraindicated for
patient with renal or heart failure.
MAINTAINING NORMAL VOIDING HABITS
▪ Prescribed medications interfere with client’s normal
voiding
▪ Nurse helps the client adhere to normal voiding habits
as much as possible.
ASSISTING WITH TOILETING
▪ Physically impaired should require assistance when
toileting.
▪ Clients need to be encouraged to use handrails placed
near the toilet.
▪ Nurse can provide urinary equipment close to the
bedside & provide necessary assistance to use them.
PREVENTING URINARY TRACT INFECTIONS
▪ UTI is the most common type of nosocomial infection
found in long-term care facilities.
▪ Most UTIs are caused by bacteria common in the GI
tract.
Guidelines to prevent UTI:
(i) Drink 8-glasses of water a day.
(ii) Practice frequent voiding. Void after intercourse.
(iii) Avoid use of harsh soaps, bubble bath, or sprays in
the perineal area.
(iv) Avoid tight-fitting pants or clothes that can irritate
urethra & prevents ventilation of perineal area.
(v) Wear cotton rather than nylon underclothes.
(vi) Always wipe the perineal area from front to back.
(vii) Take showers rather than baths.
MANAGING URINARY INCONTINENCE
▪ UI is not normal part of aging & often treatable.
▪ Independent nursing interventions with UI:
(a) a behavior-oriented continence training program
that may consist of bladder training, habit
training, prompted voiding, pelvic muscle
exercises, and positive reinforcement.
(b) Meticulous skin care
(c) Application of external drainage device
Stress incontinence in women may be successfully treated by
insertion (under local anesthesia) of a transvaginal tape (TVT)
sling to support the urethra.
CONTINENCE (BLADDER) TRAINING
▪ Requires involvement of nurse, client, and support
people.
▪ The client postpones voiding, resist or inhibit the
sensation of urgency, and void according to a
timetable rather than according to the urge to void.
▪ Goal: lengthen the intervals between urination to
correct the client’s frequent urination, stabilize the
bladder, and diminish urgency.
▪ Instruct the client to practice deep, slow breathing
until diminish or disappears.
▪ Habit training also known as timed voiding or
scheduled toileting.
▪ Can be effective in children who are experiencing
urinary dysfunction.
▪ Prompted voiding supplements habit training by
encouraging to try to use toilet & reminding when to
void.
PELVIC MUSCLE EXERCISE
▪ Kegel exercises
▪ Help to strengthen the pelvic floor.
▪ Reduce or eliminate episodes of incontinence
▪ Tightening the anal sphincter as if to hold bowel
movement.
▪ Contraction of the buttocks & thigh muscles are
avoided.
MAINTAINING SKIN INTEGRITY
▪ Moist skin is risk for maceration.
▪ Accumulation of urine in the skin is converted into
ammonia.
▪ Skin irritation & maceration predispose the client to
skin breakdown & ulceration.
▪ Nurse washes the perineal area with mild soap &
water or commercially no-rinse cleanser after episodes
of incontinence.
▪ Clean, dry clothing or bed linen should be provided.
▪ Apply barrier ointments or creams to protect the skin
from contact with urine.
▪ Nurse should use products that absorb water & leave
dry surface in contact with skin.
▪ Incontinence drawsheets are used to provide
significant advantages over standard drawsheets for
incontinent patients confined to bed.
▪ It is like drawsheet but double layered.
▪ Quilted upper layer nylon or polyester surface.
▪ Absorbent viscose rayon layer below.
▪ This absorbent sheet helps to maintain skin integrity;
does not stick to skin when wet, decreases risk of
bedsores & reduces odor.
EXTERNAL URINARY DEVICE
The application of condom catheter connected to urinary
drainage system used for incontinent males. It is preferable to
insertion of retention catheter due to minimal risk for UTI. The
nurse should determine when the client experiences
incontinence.
Purpose:
 To collect urine & control UI
 To permit the patient physical activity while controlling
UI
 To prevent from skin irritation as a result of UI
MANAGING URINARY RETENTION
▪ If interventions that maintains normal voiding pattern
are unsuccessful, primary health care provider will
prescribe cholinergic drug [bethanechol chloride] to
stimulate bladder contraction & facilitate voiding.
▪ Flaccid bladder: manual pressure or Crede’s Maneuver
to promote bladder emptying.
▪ Used only for clients who lost or not expected to
regain their voluntary bladder control,
▪ Fail to initiate voiding, urinary catheterization may be
necessary to empty the bladder.
▪ Foley catheter may be inserted until the underlying
cause is treated.
URINARY CATHETERIZATION
▪ Introduction of catheter into the urinary bladder,
▪ Clients who have lowered immune resistance are at
the greatest risk.
▪ Strict sterile technique is used for catheterization.
▪ Urinary catheters are one of the most common causes
of nosocomial infections.
▪ Trauma is also common particularly in male client,
whose urethra is longer & more tortuous.
▪ The size of diameter of the lumen using the French (Fr)
scale
▪ The larger the number, the larger the lumen.
▪ Straight catheters: inserted to drain bladder &
immediately removed.
▪ Retention catheters: remain in the drain urine.
▪ Coudé catheter is a variation of straight catheter and
has a tapered, curved tip. This catheter used for men
with prostatic hypertrophy because it is easily
controlled and less traumatic on insertion.
▪ Foley catheter is a double lumen catheter. The larger
lumen drains the urine while the small one is used to
inflate the balloon to hold the catheter in place within
the bladder.
▪ Clients who require continuous or intermittent bladder
irrigation may have a three-way Foley catheter.
▪ Pretesting silicone balloons is not recommended
because the silicone can form a cuff or crease at the
balloon area that can cause trauma to the urethra
during catheter insertion
Purposes:
 To relieve discomfort due to bladder distention or to
provide gradual decompression of a distended bladder
 To assess the amount of residual urine if the bladder
empties incompletely
 To obtain a sterile urine specimen
 To empty the bladder completely prior to surgery
 To facilitate accurate measurement of urinary output
for critically ill clients whose output needs to be
monitored hour
 To provide for intermittent or continuous bladder
drainage and/or irrigation
 To prevent urine from contacting an incision after
perineal surgery
 To manage incontinence when other measures have
failed
NURSING INTERVENTIONS
Encouraging large amounts of fluid intake, accurately recording
the fluid intake and output, changing the retention catheter
and tubing, maintaining the patency of the drainage system,
preventing contamination of the drainage system, and teaching
these measures to the client.
FLUIDS
▪ Should drink up to 3000mL per day if permitted
▪ Large amount fluid keeps the bladder flushed out and
decreases the risk for infection and urinary stasis.
▪ Also minimizes the sediment or other particles
obstructing the drainage tubing.
DIETARY MEASURES
▪ Acidifying the urine with retention catheter may
reduce the risk for UTI & calculus formation.
▪ Eggs, cheese, meat & poultry, whole grains,
cranberries, plums and prunes, and tomatoes can
increase the acidity of urine.
PERINEAL CARE
▪ Routine hygienic care is necessary for clients with
retention catheters.
CHANGING THE CATHETER & TUBING
▪ Routine changing of catheter & tubing is not
recommended.
▪ Collection of sediment in the catheter/tubing or
impaired urine drainage are indicators for changing
the catheter & drainage system.
REMOVING INDWELLING CATHETERS
▪ Indwelling catheters are removed after their purpose
has been achieved,
▪ Clients who have had a retention catheter for a
prolonged period may require bladder retraining to
regain bladder muscle tone.
▪ A few days before removal, the catheter may be
clamped for specified periods of time (e.g., 2 to 4
hours), then released to allow the bladder to empty.
▪ This allows the bladder to distend and stimulates its
musculature.
CLEAN INTERMITTENT SELF-CATHETERIZATION
▪ Mostly performed by patients who have some
neurogenic bladder dysfunction,
▪ Clean or medical aseptic technique is used.
▪ Similar to that used by the nurse to catheterize a
client.
▪ The procedure requires physical and mental
preparation, client assessment is important.
▪ Prior teaching CISC, establish client’s voiding pattern,
volume voided, fluid intake, residual amounts.
▪ CISC is easier for males to learn due to visibility of
urinary meatus.
URINARY IRRIGATION
▪ Flushing with specified solution.
▪ To wash out the bladder & sometimes apply
medication to the bladder lining,
▪ It also performs to maintain or restore the patency of
the catheter.
▪ Closed method: preferred technique due to low risk
for acquiring UTI. Often used for clients who have had
genitourinary surgery. The continuous irrigation helps
prevent blood clots from occluding the catheter
▪ Open method: necessary to restore the catheter
patency. Strict precautions must be taken to maintain
the sterility of both the drainage tubing connector and
the interior of the indwelling catheter. Necessary for
clients who develop blood clots & mucous fragments
that occlude the catheter or undesirable to change the
catheter.
Purpose:
 Maintain the patency or urinary catheter & tubing
 To free a blockage in a urinary catheter or tubing,
SUPRAPUBIC CATHETER
▪ Inserted surgically through abdominal wall above the
symphysis pubis into the urinary bladder,
▪ Can be temporary or permanent device.
▪ It is secured in place with sutures if retention balloon
isn’t used & then attached to closed drainage system.
▪ Regular assessment of client’s urine, fluid intake,
comfort, patency of drainage system, skin care around
insertion site, and clamping of catheter preparatory to
removing it.
▪ Dressings around the newly placed suprapubic
catheter are changed whenever they are soiled with
drainage to prevent bacterial growth around the
insertion site and reduce the potential for infection.
▪ For catheters that have been in place for an extended
period, no dressing may be needed and the healed
insertion tract enables removal and replacement of
the catheter as needed.
▪ Nurse assesses the insertion area at regular intervals.
If pubic hair invades the insertion site, it may be
carefully trimmed with scissors. Any redness or
discharge at the skin around the insertion site must be
reported.
URINARY DIVERSIONS
It is a surgical rerouting of urine from the kidneys to a site other
than the bladder.
INCONTINENT
▪ Incontinent diversions clients have no control over the
passage of urine and require the use of an external
ostomy appliance to contain the urine.
▪ The stomas provide direct access for microorganisms
from the skin to the kidneys, the small stomas are
difficult to fit with an appliance to collect the urine,
and they may narrow, impairing urine drainage.
CONTINENT
▪ Entails creation of a mechanism that allows the client
to control the passage of urine either by intermittent
catheterization of the internal reservoir [Kock Pouch]
or by strained voiding [neobladder].
EVALUATING
Nurse collects data to evaluate the effectiveness of nursing
activities. If desired outcomes are not achieved, formulate
questions that need to be considered.

✓ What is the client’s perception of the problem?

✓ Does the client understand and comply with the health
care instructions provided?
✓ Is access to toilet facilities a problem?
✓ Can the client manipulate clothing for toileting?
✓ Are there adjustments that can be made to allow
easier disrobing?
✓ Are scheduled toileting times appropriate?
✓ Is there adequate transition lighting for night-time
toileting?
✓ Are mobility aids such as a walker, elevated toilet seat,
or grab bar needed? If currently used, are they
appropriate or adequate?
✓ Is the client performing pelvic floor muscle exercises
appropriately as scheduled?
✓ Is the client’s fluid intake adequate? Does the timing of
fluid intake need to be adjusted (e.g., restricted after
dinner)?
✓ Is the client restricting caffeine, citrus juice,
carbonated beverages, and artificial sweetener intake?
✓ Is the client taking a diuretic? If so, when is the
medication taken? Do the times need to be adjusted
(e.g., taking second dose no later than 4 PM)? Should
continence aids such as a condom catheter or ab
sorbent pads be used?