KOZIER & ERB’S Fundamentals of NURSING NINTH EDITION Concepts, Process, and Practice CHAPTER 48 Urinary Elimination Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Elimination from the urinary tract is usually taken for granted. Only when a problem arises do most people become aware of their urinary habits and any associated symptoms. • A person’s urinary habits depend on social culture, personal habits, and physical abilities. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Figure 48-1 Anatomic structures of the urinary tract. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Process of Urination • Depends on effective functioning of – Upper urinary tract (kidneys, ureters) – Lower urinary tract (bladder, urethra, pelvic floor) – Cardiovascular system – Nervous system Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Figure 48-2 The nephrons of the kidney are composed of six parts: the glomerulus, Bowman’s capsule, proximal convoluted tubule, loop of Henle, distal convoluted tubule, and collecting duct. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Urination Micturition, voiding, and urination all refer to the process of emptying the urinary bladder. Urine collects in the bladder until pressure stimulates special sensory nerve endings in the bladder wall . This occurs when the adult bladder contains between 250 and 450 mL of urine. In children, a considerably smaller volume, 50 to 200 mL, stimulates these nerves. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. The stretch receptors 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. If the time and place are appropriate for urination, the conscious portion of the brain relaxes the external urethral sphincter muscle and urination takes place. If the time and place are inappropriate, the micturition reflex usually subsides until the bladder becomes more filled and the reflex is stimulated again Urine is eliminated through urethra. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Factors Affecting Voiding • Developmental factors (enuresis( a repeated inability to control urination), nocturnal enuresis(is involuntary urination that happens at night while sleeping) , nocturnal frequency( condition that causes you to wake up during the night to urinate) ) • Psychosocial factors These factors include privacy, normal position, sufficient time, and, occasionally, running water…. • Fluid and food intake the amount of fluid intake increases, therefore, the output normally increases. • Medications (especially diuretics) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Muscle tone Good muscle tone is important to maintain the stretch and contractility of the muscle of the bladder . • Pathologic conditions Some diseases and pathologies can affect the formation and excretion of urine such as the kidneys disease • Surgical and diagnostic procedures The urethra may swell following a cystoscopy, and surgical procedures on any part of the urinary tract may result in some postoperative bleeding; as a result, the urine may be red or pink tinged for a time. • Spinal anesthetics can affect the passage of urine because they decrease the client’s awareness of the need to void. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 1. Altered Urine Production • Polyuria (or diuresis) refers to the production of abnormally large amounts of urine by the kidneys, often several liters more than the client’s usual daily output. • Polyuria can follow excessive fluid intake, a condition known as polydipsia, or may be associated with diseases such as diabetes mellitus and chronic nephritis. • Polyuria can cause excessive fluid loss, leading to intense thirst, dehydration, and weight loss Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • The terms oliguria and anuria are used to describe decreased urinary output. • Oliguria is low urine output, usually less than 500 mL a day or 30 mL an hour for an adult. • Although oliguria may occur because of abnormal fluid losses or a lack of fluid intake, it often indicates impaired blood flow to the kidneys or impending renal failure and should be promptly reported to the primary care provider Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Anuria refers to a lack of urine production. • Anuria (requires dialysis) • Dialysis a technique by which fluids and molecules pass through a semipermeable membrane • The two most common methods of dialysis are : • Hemodialysis :the client’s blood flows through vascular catheters, passes by the dialysis solution in an external machine, and then returns to the client • Peritoneal dialysis. In peritoneal dialysis, the 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 the catheter. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 2. Altered Urinary Elimination • Urinary frequency: is voiding at frequent intervals, that is, more than four to six times per day. An increased intake of fluid causes some increase in the frequency of voiding. Conditions such as UTI, stress, and pregnancy can cause frequent voiding of small quantities (50 to 100 mL) of urine. • Nocturia is voiding two or more times at night. Like frequency, it is usually expressed in terms of the number of times the person gets out of bed to void, for example, “nocturia × 4.” Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Urgency is the sudden, strong desire to void. There may or may not be a great deal of urine in the bladder, but the person feels a need to void immediately. • Urgency accompanies psychological stress and irritation of the urethra. It is also common in people who have poor external sphincter control and unstable bladder contractions. It is not a normal finding Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Dysuria means voiding that is either painful or difficult. It can accompany a stricture of the urethra, urinary infections, and injury to the bladder and urethra. • Often clients will say they have to push to void or that burning accompanies or follows voiding. • The burning may be described as severe, like a hot sensation , like a sunburn. • Often, urinary hesitancy(a delay and difficulty in initiating voiding) is associated with dysuria. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Enuresis is involuntary urination in children beyond the age when voluntary bladder control is normally acquired, usually 4 or 5 years of age. • Nocturnal enuresis often is irregular in occurrence and affects boys more often than girls. • Diurnal (daytime) enuresis may be persistent and pathologic in origin. It affects women and girls more frequently Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Altered Urinary Elimination (cont’d) • Urinary incontinence (UI), or involuntary leakage of urine or loss of bladder control, is a health symptom, not a disease. It is only normal in infants. • The four main types of UI are stress urinary incontinence, urge urinary incontinence, mixed urinary incontinence, and overflow incontinence . 1. Stress urinary incontinence (SUI) occurs because of weak pelvic floor muscles and/or urethral hypermobility, causing urine leakage with such activities as laughing, coughing, sneezing, or any body movement that puts pressure on the bladder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 2. URGE URINARY INCONTINENCE: an urgent need to void and the inability to stop micturition (passage of urine). The urine leakage can range from a few drops to soaking of undergarments. 3.MIXED URINARY INCONTINENCE it is diagnosed when symptoms of both stress UI and urgency UI are present. It is very common among middle-age and older women. 4. OVERFLOW INCONTINENCE it is “continuous involuntary leakage or dribbling of urine that occurs with incomplete bladder emptying. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Urinary retention: When emptying of the bladder is impaired, urine accumulates and the bladder becomes overdistended. Overdistention of the bladder causes poor contractility of the muscle, further impairing urination. • The bladder is firm and distended on palpation and may be displaced to one side of the midline Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. • Neurogenic bladder: An impaired neurologic function that can interfere with the normal mechanisms of urine elimination . • The client with a neurogenic bladder does not perceive bladder fullness and is therefore unable to control the urinary sphincters. • The bladder may become flaccid and distended or spastic, with frequent involuntary urination Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Assessing • • • • Nursing history Physical assessment and hydration status Examination of urine Related data from diagnostic tests and procedures Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Nursing History • • • • • • Normal voiding patterns Appearance of urine Recent changes Past or current problems Presence of ostomy Factors influencing elimination pattern Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Physical Assessment • Percussion of kidneys to detect tenderness • Palpation and percussion of bladder • Inspection of urethral meatus for swelling, discharge, inflammation • Inspect skin for color, texture, turgor, signs of irritation, edema • Assessing Urine Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Assessing Urine • • • • • • Volume Color, clarity Odor Sterility pH Specific gravity Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Assessing Urine (cont’d) • • • • • • Glucose Ketone bodies Blood Measure urinary output Measure residual urine Diagnostic tests – Blood urea nitrogen (BUN) – Creatinine clearance Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Nursing Diagnoses • Impaired Urinary Elimination • Readiness for Enhanced Urinary Elimination • Functional Urinary Incontinence • Overflow Urinary Incontinence • Reflex Urinary Incontinence Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Nursing Diagnoses (cont'd) • • • • Stress Urinary Incontinence Urge Urinary Incontinence Risk for Urge Urinary Incontinence Urinary Retention Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Urinary Elimination May Become Etiology • • • • • Risk for Infection Situational Low Self-Esteem Risk for Impaired Skin Integrity Toileting Self-Care Deficit Risk for Deficient Fluid Volume or Excess Fluid Volume • Disturbed Body Image Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Urinary Elimination May Become Etiology (cont'd) • Deficient Knowledge • Risk for Caregiver Role Strain • Risk for Social Isolation Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Planning • Maintain or restore a normal voiding pattern • Regain normal urine output • Prevent associated risks such as infection, skin breakdown, fluid and electrolyte imbalance, and lowered self-esteem • Perform toilet activities independently with or without assistive devices Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Planning (cont'd) • Contain urine with the appropriate device, catheter, ostomy appliance, or absorbent product Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing • Maintaining normal urinary elimination – Promoting fluid intake – Maintaining normal voiding habits – Assisting with toileting • Preventing urinary tract infections Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing (cont’d) • Teaching to prevent UTIs – Drink eight 8-oz glasses of water per day – Practice frequent voiding (every 2 - 4 hours) – Avoid harsh soaps, bubble baths, powder or sprays in perineal area – Avoid tight-fitting clothing – Wear cotton, not nylon, underclothes Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing (cont’d) • Teaching to Prevent UTIs (cont’d) – (Girls and women) - always wipe perineal area from front to back following urination or defecation – Take showers rather than baths if recurrent urinary infections are a problem Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing (cont’d) • Managing urinary incontinence – Providing continence training (bladder training, habit training, prompted voiding) – Pelvic muscle exercises – Maintaining skin integrity – Applying external urinary drainage devices (Skill 48-1) • Managing urinary retention (flaccid bladder, Crede’s maneuver) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing (cont’d) • Condom catheter preferred because less risk of UTI • Methods to apply vary by manufacturer; follow instructions provided Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 1 An external or condom catheter. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 3 The condom rolled over the penis. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Figure 48-11 A three-way Foley catheter often used for continuous bladder irrigation. (Courtesy of Bard Medical Division.) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 1A Catheter insertion kits: A, indwelling; B, straight. (Courtesy of Bard Medical Division.) A Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 1B Catheter insertion kits: A, indwelling; B, straight. (Courtesy of Bard Medical Division.) B Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 2 To expose the urinary meatus, separate the labia minora and retract the tissue upward. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 3 When cleaning the urinary meatus, move the swab downward. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 4A Placement of indwelling catheter and inflated balloon in A, female client and B, male client. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 4B Placement of indwelling catheter and inflated balloon in A, female client and B, male client. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 5 Secure the catheter to the thigh of a female client. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 6 Secure the catheter to the upper thigh or lower abdomen of a male client. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 7 A catheter securement device. (Courtesy of Dale Medical Products, Inc.) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 8 Correct position for urine drainage bag and tubing. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Catheterization and Infection • Insertion of urinary catheters is one of most common causes of hospital-acquired (nosocomial) infections Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Nursing Care for Clients with Indwelling Catheters • Encourage large amounts of fluid intake • Provide foods that create acidic urine • Give routine perineal care; prevent contamination with feces in incontinent clients • Change catheter and tubing when necessary (sediment, impaired drainage) • Maintain sterile closed-drainage system Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Nursing Care for Clients with Indwelling Catheters (cont’d) • Remove catheter as soon as possible after purpose achieved • Provide bladder retraining if needed • Follow good handwashing techniques Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Ongoing Assessments of Clients with Indwelling Catheters • Ensure tubing is free of obstructions • Ensure there is no tension on catheter or tubing • Ensure gravity drainage is maintained, with no loops in tubing below entry to drainage bag • Ensure system is well sealed or closed Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Ongoing Assessments of Clients with Indwelling Catheters (cont’d) • Keep drainage receptacle below level of client’s bladder • Observe flow of urine q 2 - 3 hours • Note color, odor, abnormal constituents • If sediment is present, check more often Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Removing Indwelling Catheter • Obtain receptacle for catheter; place client in supine position; remove cathetersecuring device • Insert syringe into injection port and withdraw fluid from balloon • After all fluid removed, withdraw catheter and place in receptacle • Dry perineal area • Remove gloves Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Implementin Removing Indwelling Catheter (cont’d) • Measure and record amount of urine in drainage bag • Document removal of catheter • Provide urinal, commode, or collection device • Monitor for first voiding and amount voided in first 8 hours; monitor I&O • Observe for dysfunctional voiding behaviors Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Teaching Clean Intermittent Self-Catheterization • Performed by clients with neurogenic bladder dysfunction • Clean or medical aseptic technique • Before teaching, establish – Client voiding pattern, volume voided, fluid intake, residual amounts Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Bladder Irrigations • Bladder irrigation – To wash out bladder – To provide medication to bladder lining • Catheter irrigation – To maintain or restore patency of catheter • Closed method preferred; open method occasionally required but adds risk for infection Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 1 A continuous bladder irrigation (CBI) setup. Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. 2 An irrigation set. (Courtesy of Bard Medical Division.) Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Suprapubic Catheter Care • Inserted surgically through abdominal wall above symphysis pubis • Care includes – Regular assessment of urine, fluid intake, and comfort – Maintaining patent system – Maintaining skin around site, trimming pubic hair as needed – Periodic clamping preparatory to removal Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Urinary Diversions • Incontinent – Ureterostomy – Nephrostomy – Vesicostomy – Ileal conduit • Continent – Kock pouch – Neobladder Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Implementing: Nursing Care for Clients with Urinary Diversions • Assess intake and output • Note any changes in urine color, odor, or clarity (mucus shreds are commonly seen in urine of clients with ileal diversion) • Frequently assess condition of stoma and surrounding skin • Consult with wound ostomy continence nurse (WOCN) as needed Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved. Evaluating • Nurse collects data to evaluate the effectiveness of nursing activities • If desired outcomes not achieved, explore the reasons before modifying the care plan – Client perception and understanding, access to toilet, ability to manipulate clothing, Kegel exercises – Review schedule for voiding, fluid intake (including caffeine, etc.), diuretics – Lighting, mobility aids, continence aids Kozier & Erb’s Fundamentals of Nursing: Concepts, Process, and Practice, Ninth Edition Audrey Berman • Shirlee Snyder Copyright ©2012 by Pearson Education, Inc. All rights reserved.