Nursing Study Guide/Care of Uro-Renal Needs

woman using bedpan

Using a bedpan or urinal

bed pan

Plastic has largely replaced other materials in manufacture of bedpans. Staimless steel is easy to decontaminate, but plastic has the advantage of a more desirable temperature against the clients skin. Some agencies have started using recycled cardboard inserts which are liquified in a macerator device or disposable liners empied into the clients toliet before discarding, to reduce the amount of waste and consider the environmental footprint. Bedpans and portable urine bottles were once routinely covered with tissue paper. This elegance signalled that the receptacle was clean, but is largely disregarded now as quaint. Some clients feel more able to relax their sphincter and pelvic muscles in the upright position, and this can be accomplished by placing the bedpan on a chair beside the bed, or accommodating the client with a commocde (night chair) to minimize the distance travelled to evacuate the bladder and bowel. Nurses can help clients to micturate by providing privacy. Children are sometimes helped by the sound of running water. Men with very low flow due to enlarged prostate may require gentle suprapubic massage to initiate urination. Many wheeled shower/commode chairs fit over a regular toilet pedestal, so the client can be manouvred into position more easily.

Applying a Condom Catheter

(Compiled by Siti & Shelby)
Read the manufacturers directions before applying.

Urine Sheath

Equipment

Condom Catheter Kit: rubber condom sheath (appropriate size), strip of elastic adhesive, skin preparation.
Urinary collection bag with drainage tubing or leg bad and straps
Basin with warm water and soap
Towels and washcloths
Bath blanket
Non-sterile disposable glove
Scissors or safety razor

Assessment

Assess urinary patterns, ability to do so themselves and continence
Asses mental status on patient so appropriate teaching related to condom catheter can be implemented
Assess condition of penis
Assess clients knowledge of the purpose of a condom catheter

Nursing Diagnosis

Risk for impaired skin integrity
Knowledge deficit regarding application of condom catheter
Toileting self-care deficit
Total incontinence

Planning

Explain rationale and expected outcomes to client (e.g. dry night).
Explain the procedure.
Arrange for extra nursing personnel to assist with moving dependent client
Read the instruction on the condom catheter kit before use

Implementation

Wash hands
Provide privacy
Raise bed to appropriate working height
Assist client into supine position
Prepare urinary drainage collection bag and tubing
Apply disposable gloves
Clip hair at base of penis (shave around penis if necessary)
Apply skin preparation to penis and allow to dry (or apply adhesive tape in a spiral fashion. Devices differ and some require the adhesive be placed outside the sheath).
With non-dominant hand grasp penis along shaft (hold condom sheath at tip of penis and smoothly roll sheath onto penis)
Spiral wrap penile strip of elastic adhesive.
Connect drainage tubing to the end of condom catheter
Place excess coiling of tubing on bed and secure to bottom sheet
Place client in safe, comfortable position (bed rails could be raised)
Dispose of contaminated supplies and wash hands

Evaluation

Observe urinary drainage
Inspect penis with condom catheter in place within 30 minutes after application (look for swelling, discoloration and ask client if any discomfort
Remove and change condom and inspect skin on penile shaft for signs of breakdown or irritation at least daily when hygiene is preformed and when condom is reapplied
Unexpected outcomes (may occur) include: skin around penis is reddened and excoriated, urination is reduced in amount and frequency, urine leaks from tubing, penile swelling or discoloration

Female Catheter Insertion

1. Assemble equipment in the workroom.
2. Take the drape sheet, protective sheet, and floor lamp to the patient unit.
3. If the patient is weak or irrational, arrange to have an assistant, since vigilant support is needed if the patient cannot cooperate or respond to instructions.
4. Explain the procedure briefly to the patient; state that there will be no pain, only a slight discomfort.
5. Screen the unit.
6. Put patient in supine position. Place the drape sheet in a diamond shape over her, with the top corner at her chin and the bottom corner toward the foot of the bed. Fold the top bed clothes to the foot of the bed.
7. Place patient in dorsal recumbent position (knees flexed, thighs separated, feet flat on the mattress). Drape her thighs and legs with the right and left corners of the sheet, tucking the free edges under her feet.

NOTE Do not fold back the bottom corner to expose the vulva until ready to start the catheterization.

8. Place the lamp on the far side of the bed, adjusting light to shine on the perineal area.
9. Provide a convenient work area toward the foot of bed. This may be the bedside stand or, if no other alternative is possible, the foot of the bed.
10. Go back to the workroom. Wash hands.
11. Maintaining aseptic technique, uncover the sterile tray. Use hands for the corners of the outer wrapper ; use transfer forceps for handling all inner contents.
12. Pour the prescribed detergent-disinfectant solution over four cotton balls in the solution bowl. (If surgical soap is used, pour sterile water into the solution cup or medicine glass.)
13. Squeeze a liberal amount of water based lubricant on a 4- by 4-inch gauze sponge.
14. Maintaining aseptic technique, recover the tray.
15. Carry the prepared tray, transfer forceps, sterile glove package, and the emesis basin to the patient unit. Place this equipment on the prepared work area.
16. Fold back the drape sheet to expose the vulva. Encourage patient to relax and to breathe regularly and slowly to relax tension.
17. Adjust the light.
18. Place the unsterile emesis basin on the protective sheet on the operator's side of the near leg away from the sterile field.
19. Uncover the tray. Using transfer forceps, remove the sterile folded towel. Grasping one corner in each hand, open the towel. Place the sterile towel between the patient's thighs, pulling the top edge just under the buttocks. Use care to protect the exposed sterile surface.
20. Put on sterile gloves.
21. With the gloved non-dominant hand, separate the labia to expose the urinary meatus. Keep left hand in position, holding the labia apart until the catheter has been inserted. Remember, the left gloved hand is no longer sterile.

NOTE If there is edema of the vestibule, the meatus may be difficult to identify; it should be visible as a small opening about 1 cm above the vagina. During childbirth, the urethral orificie may be taken up into the vaginal mucosa by the advance of the babies head.

22. With the right gloved hand, pick up the forceps from the tray. Using the forceps, pick up a saturated cotton ball from the other balls in the solution basin and with no retracing, cleanse the meatus and vestibule from above downward. Discard each cotton ball in the waste basin. Discard forceps into the basin following use of the last cotton ball.
23. With the gloved right hand, pick up the sterile basin and place it on the sterile towel, close to the buttocks and below the separated labia.
24. Consider catching a specimen or Inflate balloon with 8 or 30 ml sterile solution to retain catheter in place.
25. connect urine draiage system.

Catheter Care

Catheter Removal

Wash hands, don gloves, assemble equipment. Explain procedure to client.
place waterproof drape over sheet, under clients buttocks (unnecessary if client on toilet)
Deflate the balloon with a luer slip syringe (Usually 8 or 30 mls).
Gently withdraw catheter, stop and summon assistance if there is any resistance. It is not necessary to visualize the urethral meatus.
Some pinkness on the catheter from urethral trauma is usual. Any amount of bright frank blood should be reported. Consider sample or measurement of urine specimen.
Dispose waste appropriately and wash hands.

Specimen Collection

Urinary tract infection is the second most common type of human sepsis after respiratory conditions. Therefore, the general principle is to obtain a specimen not contaminated by skin or bowel flora. Various methods can be used, such as catheter or mid-stream urine collection. Cleanliness may be less critical in collection over longer periods, such as 24 hour collection for protein urea and creatinine assay, in which case general hygiene should be observed.

Client health education - how to obtain a midstream specimen.

Wash hands before sitting on toilet.
Part labia with one hand and irrigate genital area with normal saline or sterile towellette.
Start urinating and catch a few drops from the middle of the stream.
Recap specimen jar and wash hands.
Ensure label and laboratory request paperwork complete before despatch.
Document collection (e.g. to save the cost of unplanned repetition).

In difficult nursing situations, attempt the following alternatives Catheter specimen - Once the connection between a catheter and collection bag has been broken, the urinary system is exposed to environmental microbes. Care should be taken to keep the procedure as clean as possible. Some collection bags have luer lock connectors for use as aspiration ports. Some nurses even collect specimens using a needle and syringe taking care to avoid puncturing the balloon inflation tube. Paediatric collection may be attempted with a self-adhesive collection pouch after swabbing the skin to avoid contamination. Neonatal collection may be attempted by placing a specimen collection jar in the open nappy. Stimulate the baby's bladder stretch-receptors by very gentle rhythmic patting with finger pad over the supra-pubic area. This technique requires patience and the clients parents may be better motivated to achieve a result. Urgent collection may require bladder tap by a doctor using a needle.

Ward Urinalysis

(Compiled by Maddie and Kayla)
Do not use drinking cups to collect urine specimens as they may be mistaken for consumables. Disposable cups marked as biohazard specimens should be used, ideally yellow to indicate a body fluid. Commercial all-in-one dip-stick tests are available, saving time over the use of hydrometer or separate chemical tests. Ensure the test strips are stored correctly and within the use-by date to guarantee accuracy. Specific Gravity varies from 1.000 (as dilute as water) to 1.310 (concentrated, indicating dehydration or pyuria). In cases of uncomplicated symptomatic urinary tract infection, a positive value for nitrites and leukocyte esterase by urine dipstick can be treated without the need for a urine culture. Young & Soper Other typical findings on a ward urinalysis include.

Billirubin and Urobilinogen - indicating hepatic or biliary jaundice or incomplete haemoglobin metabolism.
ketones -from lipid metabolism indicating starvation or diabetes.
pH- ranges from acidosis 7.2 to alkylosis 7.6
Protein in the presence of blood or infection as well as renal failure.
Sugar-relating to diabetes or gestational diabetes.
Nitrates-present during systemic or bladder infection.
Blood-always an abnormal finding. Consider specimen contamination or glomerular infection.

Mid stream urine collection

Empty urine drainage device

References

Army 1970 Handbook of Nursing