14. Urinal Elimination

Urinal Elimination

Elimination patterns are essential to maintain health. The urinary and gastrointestinal systems together provide for the elimination of body wastes. The urinary system filters and excretes urine from the body, thereby maintaining fluid, electrolyte, and acid-base balance. Normal bowel function provides for the regular elimination of solid wastes. During periods of stress and illness, clients experience alterations in elimination patterns. Nurses assess for changes, identify problems, and intervene to assist clients with maintaining proper elimination patterns. The nurse’s role encompasses teaching clients self-care activities to promote independence and health.

PHYSIOLOGY OF ELIMINATION

The urinary system is composed of the kidneys, ureters, bladder, and urethra. The kidneys form the urine, the ureters carry urine to the bladder, the bladder acts as a reservoir for the urine, and the urethra is the passageway for the urine to exit the body.

The gastrointestinal tract is composed of the stomach, small intestine, large intestine, and rectum. The small intestine absorbs nutrients, the large intestine absorbs fluids and the remaining nutrients, and the distal portion of the large intestine collects and stores the remaining solid waste until elimination occurs.

Urinary Elimination

The physiological mechanisms that govern urinary elimination are complex and not yet completely understood. Continence in the adult requires anatomic integrity of the urinary system, nervous control of the detrusor muscle, and a competent sphincter mechanism. Urinary incontinence occurs when abnormalities of one or more of these factors causes an uncontrolled loss of urine that produces social, physiological, or hygienic difficulties for the client.

Structures of the Urinary Tract

The urinary system is typically divided into upper and lower tracts. The upper urinary tract includes the kidneys, renal pelves, and ureters; the lower urinary tract includes the urinary bladder, urethra, and pelvic muscles (Figure 39-1).

Upper Urinary Tract

The kidneys are a pair of reddish brown, bean-shaped organs located in the retroperitoneal space, adjacent to vertebral bones T-12 to L-2. The right kidney lies slightly lower than the left because of the presence of the liver. The periphery of the kidney contains approximately 1 million nephrons; collectively this aspect of the organ is called the parenchyma. The hilus of the kidney (its convex surface) contains the renal pelvis and the ureters, which connect the kidneys and the bladder. The primary function of the kidney is to maintain internal homeostasis through filtration of the blood and production of urine. In addition, the kidney is an endocrine organ (producing erythropoietin, a hormone that aids in the production of red blood cells), and it plays a role in vitamin D synthesis.

After production within the nephron, urine passes through the calyceal system of the kidneys into the renal pelvis. The renal pelvis is shaped like a funnel, holds approximately 15 ml of urine, and serves as a temporary storage area for urine before transport to the lower urinary tract. The ureter is a long tube, shaped like an inverted S, that begins at the renal pelvis, passes under the psoas muscle of the back, and enters the pelvis near the sacroiliac junction. When entering the pelvis, the ureters curve medially to end in the base of the bladder. The union between bladder and ureter is called the ureterovesical junction.

Both the renal pelvis and ureters consist primarily of smooth muscle, and they move urine from the upper to the lower urinary tract by muscular contraction. This process is called peristalsis, and it is similar to the peristaltic waves of the gastrointestinal system used to digest food and produce fecal waste. The process of peristalsis occurs during the prolonged phases of bladder filling and storage, but it is temporarily interrupted during micturition.

Lower Urinary Tract

The bladder is a hollow, muscular organ located in the pelvis. It has a fixed base and a distensile upper portion composed of multiple bundles of smooth muscle. Collectively, the smooth muscle bundles are called the detrusor muscle.

The urethra is a tube that is a conduit for urinary elimination. The urethra differs significantly in women and men. In women, the urethra exits the bladder base and travels at a 16° angle to the external meatus located at the vestibule. The female urethra is approximately 3.5 to 5.5 cm long, and the distal third is histologically fused with the vaginal wall (Figure 39-1). The entire length of the urethra forms a sphincter mechanism with elements of compression and elements of tension.

In men, the urethra is approximately 23 cm long. It begins at the bladder base, pierces the anterior portion of the prostate, and turns to exit the body through the penis.

The proximal third of the male urethra forms a sphincter mechanism comparable to the female urethra. The distal two-thirds is a conduit for the expulsion of urine or semen.

The pelvic muscles connect the anterior and posterior aspects of the bony pelvis, support the organs of the true pelvis, and contribute to the urethral sphincter mechanism in both women and men. The pelvic muscles contain primarily slow-twitch fibers that are physiologically suited for prolonged periods of tone. In addition, fast-twitch fibers within the pelvic muscles respond rapidly to sudden increases in abdominal pressure, although they soon fatigue. Fibers from the pelvic muscles surround the membranous urethra of the male and the proximal two-thirds of the female urethra. In both sexes, the urethra pierces the muscular diaphragm of the pelvic muscles.

Nervous Control of the Detrusor Muscle

The detrusor muscle, the smooth muscle of the bladder, is under indirect voluntary control, allowing the continent adult to postpone urination until a “socially approriate” time and location for bladder evacuation is identified. Specific areas of the brain, spinal cord, and peripheral nervous system modulate the reflex activity of the detrusor muscle. Central nervous control of the bladder begins in several modulatory centers in the brain. A neurologic lesion affecting one or more of these areas causes hyperactive detrusor contractions and a loss of bladder control. The primary areas in the brain that modulate the detrusor muscle are located in the frontal lobes, the thalamus, hypothalamus, basal ganglia, and cerebellum.

The limbic system, which controls many aspects of autonomic nervous function, also influences continence.

A micturition center, located near the base of the brain has two groups of neurons that mark the origin of the urination (micturition), the evacuation of urine from the

bladder. In the infant, urinary elimination is controlled entirely by the micturition center, which evacuates the bladder when a specific “threshold” volume is reached or when the bladder is stimulated in another way. In the adult, however, the micturition center is controlled by the multiple centers of the brain, and urination usually occurs when the individual wishes to empty the bladder. Reticulospinal tracts in the spinal cord transmit messages from the brain and brain stem to the peripheral nerves of the bladder. Bladder filling and urinary storage are promoted by excitation of the sympathetic nervous system via efferent, sympathetic spinal nuclei at spinal segments T-10 to L-2. Excitation of these neurons relaxes the detrusor muscle and contracts the muscular elements of the sphincter mechanism. Urinary evacuation is accomplished through the parasympathetic nervous system. Excitation of neurons located at segmentsS-2 to S-4 causes voiding (urination) by contraction of the detrusor muscle and relaxation of muscular elements of the sphincter mechanism.

Two peripheral nerves transmit messages from the central nervous system to the detrusor muscle. The pelvic plexus transmits parasympathetic impulses to the smooth muscle of the detrusor. Nervous excitation of the parasympathetic nerves causes release of a neurotransmitter, acetylcholine, which produces contraction of detrusor muscle cells. Other substances also affect contraction of the detrusor muscle, but all act under the influence of the central nervous system.

The inferior hypogastric nerves provide the majority of sympathetic tone to the bladder wall and sphincter mechanism. In the detrusor muscle, excitation of β-adrenergic receptors causes release of norepinephrine, which inhibits detrusor muscle contraction. In addition, stimulation of α-adrenergic (excitatory) receptors at the bladder neck, proximal urethra, and in the prostatic urethra in men causes contraction of muscular components of the sphincter mechanism, promoting urethral closure and continence.

Urethral Sphincter Mechanism

The urethral sphincter is traditionally divided into two muscles, an internal (smooth muscle) and external (striated) sphincter. Unfortunately, this schema leads to more confusion than it addresses, and it should be discarded for a conceptualization of the sphincter as a single mechanism, comprising elements of compression and elements of tone, with essential supportive structures.

Urethral compression relies on three components:

urethral mucosa softness, mucous secretions, and a vascular cushion. During bladder filling and urinary storage, the epithelium must fill in the gaps of the collapsed (closed) urethral lumen, creating a watertight seal through which no urine can escape. Coaptation requires a pliable, soft, and nonscarred urethra, with adequate mucous secretions to reduce surface tension and to fill in the microscopic gaps left by the epithelium. These elements of compression are supplemented by a rich network of vascular connections in the submucosal space. This vascular network promotes urethral closure by nourishing the epithelium and mucous production cells and by serving as a cushion for the transmission of force exerted by the muscular elements of the sphincter mechanism. In women, all the elements of compression are directly influenced by the presence of estrogens. Elements of urethral tension protect the individual from urinary leakage during physical exercise or exertion. Smooth muscle bundles at the bladder neck and proximal urethra (and prostatic urethra of the male) close the urethra during bladder filling and urinary storage. The urethral wall also contains a set of highly specialized, triple-innervated striated muscle fibers that form a rhabdosphincter. It is crucial for maintaining continence during normal exertion. Striated muscle fibers from the pelvic muscle surround the urethra and contribute to the sphincter. These muscles are particularly needed when abdominal pressure changes from sneezing, coughing, or lifting a heavy object. The muscular elements of the urethra rely on supportive structures to provide an optimal configuration allowing them to contract and relax efficiently. Loss of support interferes with efficient urethral sphincter function.

FACTORS AFFECTING ELIMINATION

Age

A client’s age or developmental level will affect control over urinary and bowel patterns. Infants initially lack a pattern to their elimination. Control over bladder and bowel movements can begin as early as 18 months of age but is typically not mastered until age 4. Nighttime control usually takes longer to achieve, and boys typically take longer to develop control over elimination than girls.

Control of elimination is generally constant through out the adult years, with the exception of illness and pregnancy stages, when temporary loss of control, urgency, and retention may develop. With increasing age comes loss of muscle tone and therefore bladder control; this is usually accompanied by the urge to void more frequently.

Diet

Adequate fluid and fiber intake are critical factors to a client’s urinary and bowel health. Inadequate fluid intake is a primary cause of constipation, as is ingestion of constipating foods such as certain dairy products. Diarrhea and flatulence (discharge of gas from the rectum) are a direct result of foods ingested, and clients need to be educated as to which foods and fluids promote healthy elimination and which foods may inhibit it.

Exercise

Exercise enhances muscle tone, which leads to better bladder and sphincter control. Peristalsis is also aided by activity, thus promoting healthy bowel elimination patterns.

Medications

Medications can have an impact on a client’s elimination health and patterns and should be assessed during the health history interview. Cardiac clients, for instance, are commonly prescribed diuretics, which increase urine production. Antidepressants and antihypertensives may lead to urinary retention. Some over-the-counter (OTC) cold remedies, especially antihistamines, may also result in urinary retention. Other OTC medications are designed specifically to promote bowel elimination or to soften stools; the nurse needs to inquire about all medications being taken in order to provide proper care for a client experiencing alterations in elimination patterns.

COMMON ALTERATIONS IN URINARY ELIMINATION

Urinary incontinence and urinary retention are the most common causes of altered urinary elimination patterns. Urinary incontinence is the uncontrolled loss of urine that constitutes a social or hygienic problem.

Urinary retention is the inability to completely evacuate urine from the bladder during micturition. There are two primary types of urinary incontinence, acute and chronic. In addition, chronic urinary incontinence can be subdivided into several distinctive types. Because each has its own etiology and management, it is important to determine the type of incontinence before subjecting the client to the expense, potential risks, and rigors of a treatment program.

Acute Urinary Incontinence

Acute urinary incontinence is a transient and reversible loss of urine. It may occur during an acute illness or after an injury. Common causes of acute urinary incontinence include urinary tract infection, atrophic vaginitis, polyuria related to diabetes, acute confusion, immobility, and sedation. Medications that increase or decrease bladder or urethral sphincter tone also may contribute to acute incontinence.

Chronic Urinary Incontinence

Acute incontinence is distinguished from established or chronic incontinence. There are four predominant types of chronic urine loss: stress urinary incontinence, instability incontinence, functional incontinence, and extraurethral incontinence.

Stress Urinary Incontinence

Stress urinary incontinence (SUI) is the uncontrolled loss of urine caused by physical exertion in the absence of a detrusor muscle contraction. SUI is associated with urethral hypermobility or with intrinsic sphincter deficiency.

Urethral hypermobility is the abnormal movement of the bladder base and urethra during physical exertion.

The relationship between urethral hypermobility and SUI is not entirely understood, although several mechanisms have been proposed. Descent of the urethra into the lower portion of the pelvis may cause a loss of abdominal pressure transmission when compared with forces that affect the bladder. In addition, muscular contraction is compromised in the hypermobile urethra.

Loss of the normal anatomical relationships between the urethral sphincter and related structures also may contribute to SUI by reducing the efficiency of the muscular elements of the sphincter. The contribution of estrogen deficiency, which compromises the elements of urethral coaptation in the woman, remains unclear. Table 39-1 identifies common factors that contribute to SUI. Intrinsic sphincter deficiency is a disorder of the muscular components of the urethral sphincter. Sphincter closure is compromised, and urinary leakage is often severe. Severe urine loss caused by intrinsic sphincter deficiency is defined as Total Incontinence by the North American Nursing Diagnosis Association (NANDA) system. Unlike urethral hypermobility, which is a women’s health concern, intrinsic sphincter deficiency occurs in both genders and is related primarily to iatrogenic or neuropathic causes. Table 39-1 identifies common causes of intrinsic sphincter deficiency. It is important to note that intrinsic sphincter deficiency and urethral hypermobility frequently coexist in women.

Instability Incontinence

Instability incontinence is the loss of urine caused by a premature or hyperactive contraction of the detrusor. In the person with normal sensations of the lower urinary tract, these unstable detrusor contractions initially cause a precipitous desire to urinate, followed by urinary leakage unless the opportunity to toilet is immediately available. In those without sensations of bladder filling and impending urination, the contraction is followed by urinary incontinence that is often described as unpredictable. The NANDA classification schema divides this type of incontinence into two forms: Urge Incontinence and Reflex Incontinence. This distinction is clinically relevant because reflex incontinence is commonly associated with detrusor sphincter dyssynergia, an uncontrolled contraction of striated muscle of the sphincter mechanism during micturition. Dyssynergia, or a loss of coordination between the bladder and sphincter mechanism, causes a functional obstruction of the bladder outlet and urinary retention. Table 39-2 outlines common causes of instability incontinence of urine.

Functional Incontinence

Functional incontinence is the loss of urine caused by altered mobility, dexterity, access to the toilet, or changes in mentation. Altered mobility and dexterity produce incontinence when the individual is unable to reach the toilet within a reasonable time after the onset of the urge to urinate. These conditions are worsened in an unfamiliar environment, such as a hospital, where side rails are raised on beds and sedatives are used to enhance sleep. Difficulty in reaching the toilet due to environmental factors, such as stairs, poor lighting, toilet height, narrow doors that are impassable to wheelchairs or walkers, or other conditions also produce functional incontinence when they render the person unable to enter the bathroom with reasonable ease.

Acute confusion or dementia causes urinary incontinence when the signals to toilet become unclear. Functional incontinence exists as a separate entity from stress or instability urinary leakage. Nonetheless, it is important to remember that functional limitations also exacerbate these forms of urine loss.

Functional incontinence related to dementia may be managed by a prompted voiding technique. Prompted voiding is a technique of providing the opportunity to toilet on the basis of an individualized urge response toileting program (PURT) or using a routine schedule. A PURT program is based on knowledge of the individual’s typical voiding pattern. The client’s voiding pattern is assessed by the use of a specially designed device to monitor urinary elimination patterns or by routine assessment of containment devices for wetness. The client is then placed on a prompted voiding schedule requiring the nurse or other caregiver to approach the client, offer the opportunity to urinate, and assist with toileting. Voiding is praised, as is dryness during the period before voiding.

PURT is limited to clients with adequate cognitive awareness to respond to the prompted voiding and to those with caregivers willing to comply with the demands of this ongoing program. Prompted voiding programs also may be instituted using a more arbitrary schedule for toileting, usually every 2 to 3 hours.

Extraurethral Incontinence

Extraurethral incontinence is the uncontrolled loss of urine that exists when the sphincter mechanism has been bypassed. According to the NANDA classification system, extraurethral leakage is termed Total Incontinence, although that term is also applied to severe SUI. The three causes of extraurethral incontinence are ectopia (a congenital defect in which leaks occur from a source outside the urethra), a fistula (acquired passage allowing urinary leakage), or a surgical bypass of the urinary bladder (such as the ileal conduit). The severity of extraurethral incontinence varies from a dribbling leakage superimposed on an otherwise normal voiding pattern to a continuous urine loss that replaces any recognizable voiding pattern.

Urinary Retention

Urinary retention is caused by two conditions: bladder outlet obstruction and deficient detrusor muscle contraction strength. Bladder outlet obstruction causes incomplete bladder evacuation by blocking the outflow of urine through the sphincter mechanism or the urethra. Deficient detrusor muscle contraction strength occurs when contractions are insufficient to maintain urethral opening long enough for complete emptying of the bladder’s contents. Because the management of each condition is different, it is important to differentiate between these disorders during evaluation. Table 39-3 describes common causes of urinary retention.

ASSESSMENT

The nursing assessment of elimination is based on a client interview, evaluation of an objective log or record of urinary or fecal elimination patterns, focused physical examination, and review of diagnostic laboratory data. When altered patterns of elimination indicate a significant health problem, additional diagnostic information is used to formulate a plan of care.

Health History

Because issues of elimination may produce feelings of anxiety, guilt, or shame among clients, the interview must be instigated by the nurse and conducted in a setting that provides adequate privacy. Clients are asked to describe their usual elimination habits. Table 39-4 presents the typical questions asked when assessing urinary and fecal elimination patterns.

When screening questions concerning altered patterns of elimination reveal significant findings, the interview should be expanded to include specific questions about the nature of the elimination disorder.

These questions explore the type of incontinence, complicating factors, and bladder (Table 39-5) and bowel management strategies currently used by the client.

Physical Examination

The physical examination for elimination patterns focuses on functional issues associated with urinary or fecal incontinence and assesses the perineal and perianal areas. Functional evaluation begins with the interview and continues throughout the physical examination. Mental status can be evaluated by listening to the client’s responses to questions and by observing interactions with others. When mental assessment reveals changes from normal or expected function, a more specific tool, such as the Mini-Mental Status Examination may be administered (see Chapter 36 for a complete discussion of the Mini-Mental Status Examination).

Mobility and dexterity are evaluated by observation or by asking the client to perform simple tasks. Mobility may be evaluated by observing the client undress or move onto a table, chair, or bed. Dexterity is assessed by observing the client remove clothing; particular attention is paid to the manipulation of zippers, buttons, shoestrings, and snaps.

The perineum is initially inspected for skin integrity. Among clients with severe urinary leakage, the characteristic odor of urine may be present, and the skin may show signs of a monilial rash (maculopapular, red rash with satellite lesions) or an ammonia contact dermatitis (papular rash with saturated, macerated skin). Among patients with severe fecal incontinence, the skin is frequently denuded, red, and painful to touch, particularly if it has been exposed to liquid stool. The integrity of the skin typically remains intact with mild to moderate fecal or urinary incontinence, although a monilial rash may be present. This monilial rash may involve the inner aspect of the thighs, and it frequently extends throughout the skin surface covered by a containment device.

The vaginal vault of the woman is inspected for signs of atrophic vaginitis and for bladder and urethral support. The atrophic vagina has a dry, thin, friable mucosa with a loss of rugae (regular folds of tissue observed in the normal vagina). It is tender to touch, pale, and cracks or bleeds easily. The vaginal introitus and vault may be quite small, and the client may be intolerant of even gentle efforts to distend the vagina for examination. Atrophic vaginal changes are important to assess because they are associated with SUI, irritative voiding symptoms, and urge incontinence.

Pelvic support is assessed in the woman because it is associated with pelvic muscle weakness. Loss of pelvic muscle tone is associated with pelvic descent, increasing the risk of urethral hypermobility or intrinsic sphincter deficiency. Both can lead to SUI or defects of the anal sphincter or rectocele, causing chronic constipation and incomplete evacuation of stool with defecation.

Paravaginal support is assessed using a gloved hand or speculum. The posterior vaginal wall is supported using either a Sims’ speculum or a gloved finger gently inserted into the vagina. The woman is asked to cough or strain down, and movement of the posterior vaginal wall is evaluated. Bulging of the anterior wall indicates a cystocele or loss of support of the bladder base. This maneuver is repeated, and the posterior vaginal wall is evaluated for the presence of a rectocele. Uterine prolapse is noted when the uterus or cervix migrates toward the vaginal introitus in response to physical exertion. The sensations of the perineal area are assessed, using a small needle to evaluate sharp versus dull stimuli and using two probes to determine one- versus twopoint discrimination. The bulbocavernosus reflex (BCR) is evaluated by gently tapping on the clitoris while observing the anal sphincter. A positive reflex will produce an anal “wink” or contraction of the perianal muscle. A weaker response is assessed by placing a gloved finger at the anus or by pelvic muscle electromyogram using patch or needle electrodes. Loss of sensations or absence of the BCR indicates neurologic damage associated with urinary incontinence or retention.

The prostate is examined for size, consistency, and induration when urinary retention is suspected. Benign prostatic hyperplasia, a common cause of urinary retention in older men, produces a uniform enlargement of the prostate. In contrast, prostate cancer causes asymmetric enlargement or discrete, hard nodules.

When altered patterns of urinary or fecal elimination are suspected from the health history, a log or diary should be completed. The simple bladder log is kept over a long period of time to determine patterns of urinary elimination and patterns of incontinence. A more detailed log allows the nurse to evaluate fluid intake, client responses to prompted toileting, functional bladder capacity, and the estimated volume of an incontinent episode.

Diagnostic and Laboratory Data

When significant urinary or fecal elimination problems are observed, further testing is needed to evaluate the underlying cause of the condition and to determine treatment options. When urinary incontinence exists, a dipstick urinalysis is obtained and evaluated for nitrites, leukocytes, hemoglobin, glucose, and specific gravity. When nitrites or leukocytes are present, a microscopic analysis is completed to determine the presence of white blood cells in the urine (pyuria) and bacteria in the urine (bacteriuria). Urine culture and sensitivity testing are completed and the client is treated for a urinary tract infection. If glucose is noted in the urine, the patient may undergo further evaluation for diabetes mellitus, or methods of glucose control may be reviewed and adjusted in the client with known diabetes. If the specific gravity (weight of urine compared with weight of distilled water) of the urine is abnormally low (below 1.010), the volume of fluid consumed by the client over a 24-hour period is evaluated further. Hematuria (blood in the urine) may be noted.

More detailed diagnostic testing of lower urinary tract function may be obtained in cases of complex urinary retention or incontinence. Urodynamics is a set of tests that measure bladder and surrounding abdominal pressures. Pressure data are combined with electromyography of the pelvic muscles and urinary flow rate to determine lower urinary tract function during bladder filling and micturition.

NURSING DIAGNOSIS

The following nursing diagnoses are frequently encountered in clients experiencing changes in urinary and bowel habits.

Impaired Urinary Elimination

Impaired Urinary Elimination is the state in which the individual experiences a disturbance in urine elimination. Defining characteristics include dysuria (painful urination), frequency, hesitancy, incontinence, nocturia, retention, and urgency. Altered urinary elimination patterns can result from multiple causes, including anatomic obstruction, sensory motor impairment, and urinary tract infection.

Stress Urinary Incontinence

Stress urinary incontinence is the state in which an individual experiences a loss of urine less than 50 ml occurring with increased abdominal pressure. Major characteristics include reported or observed dribbling with increased abdominal pressure. Minor characteristics may include urinary urgency and urinary frequency (more often than every 2 hours). The client may also be experiencing related factors such as degenerative changes in pelvic muscles and structural supports associated with increased age, high intra-abdominal pressure (e.g., obesity, gravid uterus), incompetent bladder outlet, overdistension between voidings, or weak pelvic muscles and structural supports.

Reflex Urinary Incontinence

The state in which an individual experiences an involuntary loss of urine, occurring at somewhat predictable intervals when a specific bladder volume is reached, is known as Reflex Urinary Incontinence. Major characteristics include no awareness of bladder filling, no urge to void or feelings of bladder fullness, and uninhibited bladder contraction or spasm at regular intervals.

Related factors include a neurologic impairment (e.g., spinal cord lesion that interferes with conduction of cerebral messages above the level of the reflex arc).

Urge Urinary Incontinence

Urge Urinary Incontinence is the state in which an individual experiences involuntary passage of urine occurring soon after a strong sense of urgency to void. Major characteristics include urinary urgency, frequency (voiding more often than every 2 hours), and bladder contracture or spasm. Minor characteristics include nocturia (more than two times per night), voiding small amounts (less than 100 ml) or large amounts (more than 550ml), and inability to reach the toilet in time. Urge incontinence may be related to decreased bladder capacity (e.g., history of pelvic inflammatory disease, abdominal surgeries, indwelling urinary catheter), irritation of bladder stretch receptors causing spasm (e.g., bladder infection), alcohol, caffeine, increased fluids, increased urine concentration, or overdistension of the bladder.

Functional Urinary Incontinence

The state in which an individual experiences an involuntary, unpredictable passage of urine is called Functional Urinary Incontinence. Major characteristics include urge to void or bladder contractions sufficiently strong to result in loss of urine before reaching an appropriate receptacle. Altered environment, sensory, cognitive, or mobility deficits may contribute to functional incontinence.

Total Urinary Incontinence

Total Urinary Incontinence is the state in which an individual experiences a continuous and unpredictable loss of urine. Major characteristics include constant flow of urine occurring at unpredictable times without distension, uninhibited bladder contractions or spasms, unsuccessful incontinence refractory treatments, and nocturia. Related factors include neuropathy that prevents transmission of the reflex that indicates bladder fullness, neurologic dysfunction causing triggering of micturition at unpredictable times, independent contraction of the detrusor reflex owing to surgery, trauma, or disease that affects spinal cord nerves, or anatomy (fistula).

Urinary Retention

The state in which the individual experiences incomplete emptying of the bladder is known as Urinary Retention. Major characteristics for urinary retention include bladder distension and small, frequent voiding or absence of urine output. Minor characteristics include sensation of bladder fullness, dribbling, residual urine, dysuria, and overflow incontinence. High urethral pressure caused by weak detrusor, inhibition of reflex arc, strong sphincter, and blockage are related factors for urinary retetion.

Removing an Indwelling Catheter

Catheterizing a Noncontinent Urinary Diversion

PROCEDURE CHECKLIST

Inserting a Straight Urinary Catheter (Male)

1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.

2. Selects a catheter kit that contains lubricant in a prefilled syringe.

3. Provides good lighting; takes a procedure lamp to the bedside if necessary.

4. Works on the right side of the bed if right-handed; the left side, if left-handed.

5. Places patient supine, legs straight and slightly apart.

6. If patient is confused or unable to follow directions, obtains help.

7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis.

8. Dons clean procedure gloves and washes the penis and perineal area with soap and water; dries gently.

9. If using 2% Xylocaine gel for the procedure, uses a syringe to insert it into the urethra.

10. Removes and discards gloves.

11. Washes hands.

12. Organizes the work area:

a. Bedside or over-bed table within nurse’s reach.

b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.

c. Positions a plastic bag or other trash receptacle so that nurse does not have to reach across the sterile field (e.g., near the patient’s feet); or places a trash can on the floor beside the bed.

13. Applies sterile drape(s) and underpad.

Variation: Waterproof underpad packed as top item in the kit.

a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.

b. Allows drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient’s thighs.

c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.)

d. Picks up fenestrated drape; allows it to unfold without touching other objects; places hole over the penis.

Variation: Sterile gloves packed as top item in the kit. Uses the following steps instead of Steps 12 a-d:

e. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.

f. Grasps the edges of the sterile underpad and places it shiny side down across the top of the patient’s thighs.

g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile.

h. Places fenestrated drape so that hole is over the penis.

14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.

a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)

b. Lays forceps near cotton balls (omit step if kit includes swabs).

c. Opens specimen container if a specimen is to be collected.

d. Removes any unneeded supplies (e.g., specimen container) from the field.

e. Expresses a small amount of sterile lubricant into the kit tray; lubricates the first 1 to 2 inches of the catheter by rolling it in the lubricant. Does not lubricate catheter if Xylocaine gel has already been inserted into the urethra (Step 9).

15. With nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If penis is uncircumcised, retracts foreskin with nondominant hand to expose the meatus.

16. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure.

17. Continuing to hold the penis with the nondominant hand, holds forceps in dominant hand and picks up a cotton ball.

18. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis.

19. Repeats with at least one more cotton ball.

20. Discards cotton balls as they are used; does not move them across the open, sterile kit and field.

21. Maintaining sterile technique, places the plastic urine receptacle close enough to the urinary meatus for the end of the catheter to rest inside the container as the urine drains (e.g., places container between patient’s thighs)

22. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction.

23. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, lubricates 5 to 7 inches (12.5 to 17.7 cm) of the catheter. This is not the technique of choice, however.)

24. With the dominant hand, holds the catheter 3 inches (7.5 cm) from the proximal end, with remainder coiled in the palm of the hand; or otherwise ensures that the distal end of the catheter is in the plastic container.

25. Asks the patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.

26. Continues gentle insertion of catheter until urine flows. This is about 7 to 9 inches (17 to 22.5 cm) in a man. Then inserts the catheter another 1 to 2 inches (2.5 to 5 cm).

27. If resistance is felt, withdraws the catheter; does not force the catheter.

28. Continues to hold the penis and catheter securely in hand while the urine drains from the bladder.

29. If a urine specimen is to be collected, uses dominant hand to place the specimen container into the flow of urine; caps container using sterile technique.

30. When the flow of urine has ceased and the bladder has been emptied, pinches the catheter and slowly withdraws it from the meatus.

31. Discards catheter.

32. Removes the urine-filled receptacle and sets aside to be emptied when the procedure is finished.

33. Cleanses and dries patient’s penis and perineal area as needed; replaces foreskin over end of penis.

34. Removes gloves; washes hands.

35. Returns patient to a position of comfort.

36. Discards supplies in appropriate receptacle.

PROCEDURE CHECKLIST

Inserting an Indwelling Urinary Catheter (Female)

1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.

2. Provides good lighting; takes a procedure lamp to the bedside if necessary.

3. Works on the right side of the bed if right-handed; the left side, if left-handed.

4. Assists to dorsal recumbent position (knees flexed, feet flat on the bed). Instructs patient to relax her thighs and let them rotate externally (if patient is able to cooperate).
Alternatively, uses Sims’ position (side-lying with upper leg flexed at hip.

5. If patient is confused, unable to follow directions, or unable to hold her legs in correct position, obtains help.

6. Drapes patient. If dorsal recumbent position is used, folds blanket in a diamond shape, wraps corners around legs, anchors under feet, and folds upper corner down over perineum. If in Sims’ position, drapes so that rectal area is covered.

7. Dons clean procedure gloves and washes the perineal area with soap and water; dries perineal area.

8. While washing perineum, locates the urinary meatus.

9. Removes and discards gloves.

10. Washes hands.

11. Organizes the work area:

a. Bedside or over-bed table within nurse’s reach.

b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.

d. Positions the procedure light or has assistant hold a flashlight.

e. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.

12. Applies sterile drape(s) and underpad.

Variation: Waterproof underpad packed as top item in the kit.

f. Removes the underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.

g. Touching only the corners and shiny side, places the drape flat on the bed, shiny side down, and tucks the top edge under the patient’s buttocks.

h. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.

i. Dons sterile gloves (from kit). (Touching only the glove package, removes it from sterile kit before donning gloves).

j. Picks up fenestrated drape; allows it to unfold without touching other objects; places over perineum with the hole over the labia.

Variation: Sterile gloves packed as top item in the kit.

Uses the following steps instead of Steps 12 a-j:

k. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.

l. Grasps the edges of the sterile underpad and folds the entire edge down 2.5 to 5 cm (1 to 2 inches) and toward self, forming a cuff to protect the sterile gloved hands.

m. Asks patient to raise her hips slightly if she is able.

n. Slides the drape under patient’s buttocks without contaminating the gloves.

o. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Creates “cuff” to protect gloves, as in step 12-l.

p. Places fenestrated drape so that hole is over labia.

13. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.

a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)

b. Lays forceps near cotton balls (omits step if using swabs).

c. Opens specimen container if a specimen is to be collected.

d. Removes any unneeded supplies (e.g., specimen container) from the field.

e. Removes plastic covering from catheter.

f. Opens package and expresses sterile lubricant into the kit tray; lubricates the first 1 to 2 inches (2.5 to 5 cm) of the catheter by rolling it in the lubricant.

g. Removes plastic cover from catheter. Attaches the saline-filled syringe to the side port of the catheter and inflates the balloon.

h. Deflates balloon and returns catheter to the kit, leaving the syringe connected to the port.

14. Touching only the sterile box or inside of the wrapping, places the sterile catheter kit (tray and box) down onto the sterile field between the patient’s legs.

15. If the drainage bag is preconnected to the catheter itself, leaves the bag on or near the sterile field until after the catheter is inserted.

16. Cleanses the urinary meatus.
a. Places nondominant hand above the labia and with the thumb and forefinger spreads the patient’s labia, pulls up (or anteriorly) at the same time, to expose the urinary meatus.
b. Holds this position throughout the procedure—firm pressure is necessary.
c. If the labia slip back over the urinary meatus, considers it contaminated and repeats cleansing procedure.

d. With dominant hand, picks up a wet cotton ball (or swab), using forceps, and cleanses perineal area, taking care not to contaminate the sterile glove.

e. Uses one stroke for each area.

f. Wipes from front to back..

g. Uses a new cotton ball for each area.

h. Cleanses in this order: outside far labium majus, outside near labium majus, inside far labium, inside near labium, and directly down the center over the urinary meatus.
If there are only 3 cotton balls in the kit, labia majora should be washed with soap and water initially; and in this step, cleanses only the inside far labium majus, inside near labium, and down center directly over the meatus.

17. Discards used cotton balls or swabs as they are used; does not move them across the open, sterile kit and field.

18. With the dominant hand, holds the catheter approximately 3 inches (7.5 cm) from the proximal end; coils remainder of catheter in palm of hand or otherwise protects it from contamination.

19. Asks the woman to bear down as though she is trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.

20. Continues gentle insertion of catheter until urine flows. This is about 2 to 3 inches (5 to 7.5 cm) in a woman. Then inserts the catheter another 1 to 2 inches (2.5 to 5 cm).

21. If resistance is felt, twists the catheter slightly or applies gentle pressure; does not force the catheter.

22. If the catheter touches the labia or nonsterile linens, or is inadvertently inserted in the vagina, considers it contaminated and inserts a new, sterile catheter.

23. If catheter is inadvertently inserted into the vagina, leaves the contaminated catheter in the vagina while inserting the new one into the meatus.

24. Continues to hold the catheter securely with the dominant hand; after urine flows, stabilizes the catheter’s position in the urethra and uses the nondominant hand to pick up the saline-filled syringe and inflate the catheter balloon.

25. If the patient complains of severe pain upon inflation of the balloon, the catheter is probably in the urethra. Allows the water to drain out of the balloon and repositions the catheter by advancing it 1 inch (2.5 cm).

26. Connects the drainage bag to the end of the catheter if it is not already preconnected. Hangs the drainage bag on the side of the bed, below the level of the bladder.

27. Using a tape or a catheter strap, secures the catheter to the thigh.

28. Cleanses patients perineal area as needed, and dries.

29. Removes gloves; washes hands.

30. Returns patient to a position of comfort.

31. Discards supplies in appropriate receptacle.

PROCEDURE CHECKLIST

Inserting an Indwelling Urinary Catheter (Male)

1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.

2. Selects a catheter kit that contains lubricant in a prefilled syringe.

3. Provides good lighting; takes a procedure lamp to the bedside if necessary.

4. Works on the right side of the bed if right-handed; the left side, if left-handed.

5. Places patient supine, legs straight and slightly apart.

6. If patient is confused or unable to follow directions, obtains help.

7. Drapes patient. Covers upper body with blanket; folds linens down to expose the penis.

8. Dons clean procedure gloves and washes the penis and perineal area with soap and water; dries gently.

9. If using 2% Xylocaine gel for the procedure, uses a syringe and inserts it into the urethra.

10. Removes and discards gloves.

11. Washes hands.

12. Organizes the work area:

a. Bedside or over-bed table within nurse’s reach.

b. Opens sterile catheter kit and places on bedside table, without contaminating the inside of the wrap.

13. Applies sterile drape(s) and underpad.

Variation: Waterproof underpad packed as top item in the kit.

a. Removes the waterproof underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.

b. Allows drape to fall open as it is removed from the kit. Touching only the corners and shiny side, places the drape shiny side down across top of patient’s thighs.

c. Dons sterile gloves (from kit). (Touching only the glove package, removes it from the sterile kit before donning the gloves.)

d. Picks up fenestrated drape; allows it to unfold without touching other objects; places hole over the penis.

Variation: Sterile gloves packed as top item in the kit.

Uses the following steps instead of Steps 12 a–d:

e. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.

f. Grasps the edges of the sterile underpad and places it shiny side down across the top of the patient’s thighs.

g. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Keeps gloves sterile.

h. Places fenestrated drape so that hole is over the penis.

14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.

a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)

b. Lays forceps near cotton balls (omit step if using swabs).

c. Opens specimen container if a specimen is to be collected.

d. Removes any unneeded supplies (e.g., specimen container) from the field.

f. Attaches the saline-filled syringe to the side port of the catheter and checks balloon by inflating; deflates balloon and returns it and the catheter to the kit. Leaves syringe attached to catheter.

15. Touching only the kit or inside of the wrapping, places the sterile catheter kit down onto the sterile field between or on top of the patient’s thighs.

16. If the drainage bag is preconnected to the catheter, leaves the bag on the sterile field until after the catheter is inserted.

17. With nondominant hand, reaches through the opening in the fenestrated drape and grasps the penis, taking care not to contaminate the surrounding drape. If penis is uncircumcised, retracts foreskin to expose the meatus.

18. If the foreskin accidentally falls back over the meatus, or if the nurse drops the penis during cleansing, repeats the procedure.

19. Continuing to hold the penis with the nondominant hand, holds forceps in dominant hand and picks up a cotton ball.

20. Beginning at the meatus, cleanses the glans in a circular motion in ever-widening circles and partially down the shaft of the penis.

21. Repeats with at least one more cotton ball.

22. Discards cotton balls or swabs as they are used; does not move them across the open, sterile kit and field.

23. Using the nondominant hand, holds the penis gently but firmly at a 90° angle to the body, exerting gentle traction.

24. Gently inserts the tip of the prefilled syringe into the urethra and instill the lubricant. (If the kit contains only a single packet of lubricant and if no other kits are available, then lubricates 5 to 7 inches (12.5 to 17.7 cm) of the catheter. This is not the technique of choice, however.)

25. With the dominant hand, holds the catheter 3 inches (7.5 cm) from the proximal end, with remainder of the catheter coiled in palm of hand.

26. Asks the patient to bear down as though trying to void; slowly inserts the end of the catheter into the meatus. Has the patient take slow deep breaths until the initial discomfort has passed.

27. Continues gentle insertion of catheter until urine flows. This is about 7 to 9 inches (17 to 22.5 cm) in a man. Then inserts the catheter another 1 to 2 inches (2.5 to 5 cm).

28. If resistance is felt, withdraws the catheter; does not force the catheter.

29. After urine flows, stabilizes the catheter’s position in the urethra with nondominant hand; uses dominant hand to pick up saline-filled syringe and inflate catheter balloon.

30. If patient complains of severe pain upon inflation of the balloon, the balloon is probably in the urethra. Allows the water to drain out of the balloon, and advances the catheter 1 inch (2.5) farther into the bladder.

31. If it is not preconnected, connects the drainage bag to the end of the catheter.

32. Hangs the drainage bag on the side of the bed below the level of the bladder.

33. Using tape or a catheter strap, secures the catheter to the thigh or the abdomen.

34. Cleanses patient’s penis and perineal area as needed, and dries. Ensures that foreskin is no longer retracted.

35. Removes gloves; washes hands.

36. Returns patient to a position of comfort.

37. Discards supplies in appropriate receptacle.

PROCEDURE CHECKLIST

Inserting a Straight Urinary Catheter (Female)

1. Takes an extra pair of sterile gloves and an extra sterile catheter into the room.

2. Provides good lighting; takes a procedure lamp to the bedside if necessary.

3. Works on the right side of the bed if right-handed; the left side, if left-handed.

5. If patient is confused, unable to follow directions, or unable to hold her legs in correct position, obtains help.

7. Dons clean procedure gloves and washes the perineal area with soap and water; dries perineal area.

8. While washing perineum, locates the urinary meatus (for women).

9. Removes and discards gloves.

10. Washes hands.

11. Organizes the work area:

a. Bedside or over-bed table within nurse’s reach.

b. Opens sterile catheter kit and places on bedside table without contaminating the inside of the wrap.

d. Positions the procedure light or has assistant hold a flashlight.

12. Lifts corner of privacy drape (e.g., bath blanket) to expose the perineum.

13. Applies sterile drape(s) and underpad.

Variation: Waterproof underpad packed as top item in the kit.

e. Removes the underpad from the kit before donning sterile gloves. Does not touch other kit items with bare hands. Allows drape to fall open as it is removed from the kit.

f. Touching only the corners and shiny side, places the drape flat on the bed, shiny side down, and tucks the top edge under the patient’s buttocks.

g. Lifts corner of privacy drape (e.g., bath blanket) to expose perineum.

h. Dons sterile gloves (from kit). (Touching only the glove package, removes it from sterile kit before donning gloves).

i. Picks up fenestrated drape; allows it to unfold without touching other objects; places over perineum with the hole over the labia.

Variation: Sterile gloves packed as top item in the kit.

Uses the following steps instead of Steps 12 a–i:

j. Removes gloves from package, being careful not to touch anything else in the package with bare hand. Dons gloves.

k. Grasps the edges of the sterile underpad and folds the entire edge down 2.5 to 5 cm (1 to 2 inches) and toward self, forming a cuff to protect the sterile gloved hands.

l. Asks patient to raise her hips slightly if she is able.

m. Slides the drape under patient’s buttocks without contaminating the gloves.

n. Places fenestrated drape: Picks it up, allowing it to unfold without touching any other objects. Creates “cuff” to protect gloves, as in step 12(k).

o. Places fenestrated drape so that hole is over labia.

14. Organizes kit supplies on the sterile field and prepares the supplies in the kit, maintaining sterility.

a. Opens the antiseptic packet; pours solution over the cotton balls. (Some kits contain sterile antiseptic swabs; if so, opens the “stick” end of the packet.)

b. Lays forceps near cotton balls.

c. Opens specimen container if a specimen is to be collected.

d. Removes any unneeded supplies (e.g., specimen container) from the field.

e. Opens the packet of sterile lubricant and squeezes it into the kit tray.

f. Lubricates the first 1 to 2 inches of the catheter by rolling it in the lubricant.

15. Touching only the kit or the inside of the wrapping, places the sterile catheter kit down onto the sterile field between the patient’s legs.

16. Cleanses the urinary meatus.

a. Places nondominant hand above the labia and with the thumb and forefinger spreads the patient’s labia, pulls up (or anteriorly) at the same time, to expose the urinary meatus.
b. Holds this position throughout the procedure—firm pressure is necessary.
c. If the labia slip back over the urinary meatus, considers it contaminated and repeats cleansing procedure.

d. Using forceps, with dominant hand, picks up a wet cotton ball and cleanses perineal area, taking care not to contaminate the sterile glove.

e. Uses one stroke for each area.

f. Wipes from front to back.

g. Uses a new cotton ball for each area.

h. Cleanses in this order: outside far labium majus, outside near labium majus, inside far labium, inside near labium, and directly down the center over the urinary meatus.

(Some kits have only 3 cotton balls, so the order would be inside far labium, inside near labium, and directly down the center; the outside labia majora would have already been cleansed with soap and water.)

17. Discards used cotton balls as they are used; does not move them across the open, sterile kit and field.

18. Maintaining sterile technique, places the urine receptacle close enough to the urinary meatus for the end of the catheter to rest inside the container as the urine drains (4 inches or 10 cm from the meatus).

20. Continues gentle insertion of catheter until urine flows. This is about 2 to 3 inches (5 to 7.5 cm) in a woman. Then inserts the catheter another 1 to 2 inches (2.5 to 5 cm).

21. If resistance is felt, twists the catheter slightly or applies gentle pressure; does not force the catheter.

22. If the catheter touches the labia or nonsterile linens, or is inadvertently inserted in the vagina, considers it contaminated and inserts a new, sterile catheter.

23. If catheter is inadvertently inserted into the vagina, leaves the contaminated catheter in the vagina while inserting the new one into the meatus.

24. Continues to hold the catheter securely with the nondominant hand while urine drains from the bladder.

25. If a urine specimen is to be collected, uses dominant hand to place the specimen container into the flow of urine; caps container using sterile technique.

26. When the flow of urine has ceased and the bladder has been emptied, pinches the catheter and slowly withdraws it from the meatus.

27. Discards catheter, observing universal precautions.

28. Removes the urine-filled receptacle and sets aside to be emptied when the procedure is finished.

29. Cleanses patient’s perineal area as needed, and dries.

30. Removes gloves; washes hands.

31. Returns patient to a position of comfort.

32. Discards supplies in appropriate receptacle.

PROCEDURE CHECKLISTS

Applying an External (Condom) Catheter

PROCEDURE CHECKLIST

Continuous Bladder Irrigation