URINARY ELIMINATION ▪ 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 URETERS ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ 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 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 ▪ ▪ ▪ KIDNEYS ▪ ▪ Aldosterone: Na & H2O are reabsorbed in greater quantities, increase blood volume and decreasing urinary output. ▪ ▪ ▪ ▪ 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) (II) Hemodialysis ▪ The client’s blood flows through a vascular catheter ▪ Passes by the dialysis solution in an external machine then returns to the client. 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. - 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. 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. - NEUROGENIC BLADDER - Does not perceive bladder fullness therefore unable to control urinary sphincters. Bladder become flaccid and distended or spastic, with frequent involuntary urination. - 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. 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 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. 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. URINARY RETENTION - Bladder is impaired, urine accumulates and the bladder becomes overdistended. 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. DIAGNOSTIC TESTS MEASURING URINARY OUTPUT Nurse catheterizes or scan the bladder after voiding and then document. An indwelling catheter may be inserted if residual urine exceeds a specific amount. 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. 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. 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. 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) (ii) (iii) (iv) (v) (vi) (vii) Drink 8-glasses of water a day. Practice frequent voiding. Void after intercourse. Avoid use of harsh soaps, bubble bath, or sprays in the perineal area. Avoid tight-fitting pants or clothes that can irritate urethra & prevents ventilation of perineal area. Wear cotton rather than nylon underclothes. Always wipe the perineal area from front to back. 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. ▪ Purposes: 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 ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ ▪ 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 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. 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. Purpose: SUPRAPUBIC CATHETER ▪ 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. Maintain the patency or urinary catheter & tubing To free a blockage in a urinary catheter or tubing, ▪ 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?
