ELIMINATION NEED

INTRODUCTION
Elimination is the expulsion of waste products from the
body through the skin, lungs, kidneys and rectum.
 Urinary elimination is the natural process in which the
body excretes waste products and material those
exceeded bodily needs.
Bowel elimination is a natural process in which body
excrete waste product of digestion
URINARY ELIMINATION
DEFINITION
Urinary elimination is def in ed as expulsion of
waste products from the body through the
urinary system
Elimination from the urinary tract helps to
remove the waste products from body. It is
essential to the body's physical well being.
 PHYSIOLOGY OF URINATION
 Volume of urine increase in bladder
 Stretching of bladder wall
 Sending sensory impulse to micturation center in the sacral spinal cord.
 Parasympathetic impulse from the centers stimulate the detrusor muscle to
contract rhythmically.
 Internal sphincter also relaxes so urine may enter in urethra.
 As the bladder contracts nerve impulses travel up the spinal cord to the mid
brain and cerebral cortex.
 A person is thus conscious of the need to urinate
 If the person chosen not to voids the external urinary sphincter remains
contracted and micturation reflex inhibited.
 However if a person ready to void micturation ref le x stimulated the detrusor
muscle contract and urination occurs.
 PHYSIOLOGY OF URINE ELIMINATION
 Kidney removes waste from the blood to form urine.
 Ureter transport urine from the kidneys to the bladder and the
bladder holds the urine until the urge.
 Usually infant or children with 6-8 kg excrete 400-500 ml /day and
child cannot withhold urination
 the adult normally void 1500-1600ml/day, ageing also impairs
urination.
 All organs of the urinary system must be intact and functional for
successful removal of urinary waste .
 The normally hold as much as 600 ml of urine.
 The desired to urinate can be sensed when the bladder contains
only a small amount of urine[150-200 ml in adult and 50-200 ml in
child]
 Volume of urine increase in
bladder

Stretching of bladder wall

Sending sensory impulse to micturation

center in the sacral spinal cord
Parasympathetic impulse from the centers
stimulate the detrusor muscle to contract
rhythmically
Internal sphincter also relaxes so urine
may enter in urethra
As the bladder contracts nerve impulses
travel up the spinal cord to the mid brain
and cerebral cortex
A person is thus conscious of the need
to urinate
 COMPOSITION OF URINE
Urine consists of 96% of water and 4% of solids.The
solids include organic and inorganic substances
► ORGANIC:-Urea, uric acid,creatinine, ureates, chlorides,
phosphates, sulphates, and Oxalates
► INORGANIC:-Sodium,potassium,calcium,magnesium,
glucose etc
GENERAL CHARACTERISTICS OF NORMAL URINE

PH--- 4.5-8 [AVERAGE 6.0]slightly acidic

SPECIFIC GRAVITY------1.003-1.030
OSMOTIC CONCENTRATION---- 855-1335 mOsm/L
WATER CONTENT-----93-97%
VOLUME-----700-2000 ML/DAY
COLOR-------CLEAR YELLOW
ODOR----------VARIES WITH COMPOSITION
BACTERIAL COMTENT--------------NONE[STERILE]
 CHARACTERISTICS OF URINE
SL Characte Normal Abnormal NURSING ACTION
NO ristics
1 24 hr 1200-1500 ml Below1200ml,a large -Check total I/O if it is less than 30
urine in amount over intake ml/hr.
adult -It indicates decreased blood flow to
kidney
2 Color, Straw, amber Dark amber, cloudy, -Check for concentrated urine is
clarity transparent dark orange brown , darker in color dilute urine will be clear.
Mucus plug, viscid and -hematuria indicates red blood cells in
thick urine evidence as rusty brown ,pink
-wbc and pus indicates bright red or
rusty urine
3 odor Faint aromatic offensive -Check for and infected it has fetid
odor, with high glucose it has sweet
odor

4 Sterility No Microorganism
microorganisms present
 FACTORS INFLUENCING URINARY ELIMINATION
 DEVELOPMENTAL FACTORS:
 Infants usually amount of voiding is 15 to 60 ml a day afterbirth
increasing to 250-500 ml a day. An infant may urinate as often as 20
times a day it is colourless and odour less .infants are born without
urinary control. Preschoolers pre-schoolers is able to take responsibility
for independent toileting.
 ENURESIS :-
 involuntary passage of urine Nocturnal enuresis or bed wetting is the
involuntary passing of urine during sleep
 School age children their elimination system reaches maturity
 Older adults the excretory function of kidneys diminishes with age. due
to decreased kidney's filtering ability, decreased muscle tone and
contractility of detrusor muscle decreased reabsorptive and secretory
capabilities.
 CONT…
PSYCHOLOGICAL FACTORS:
 Anxiety and emotional stress may cause a sense of urgency and
increased frequency of urination. Anxiety can prevent a person from
being able to urinate completyPrivacy, normal positions, suf fic ient
time can stimulate the micturition reflex.
 FLUID INTAKE:
 If f luid intake is greatly increased, frequency of voiding increases. if f luid intake
is decreased, frequency of voiding decreases. Ingestion of certain fluids directly
affects urine production and excretion .eg.coffee, tea, cola drinks.
 FOOD INTAKE:
 Increase urine production and elimination if foods high in f luid content.eg.fruits,
vegetables.
 Foods and f luids high in sodium retains water, decrease urine production and
elimination.eg:potato chips, pickles Change the color of the urine:eg beetroots
cause urine to appear red.
 Cont..
 BODY POSITION
Eg:some men f ind it dif ficulty to empty their bladder fully
into urinal while lying flat in bed
 MEDICATIONS
Eg:cholinergics,diuretics cause urinary elimination
Anticholinergics, opioid analgesics cause urinary
retention
Some medicine cause change in color of urine.eg:Red-
methyldopa To brown or black-levodopa, ferrous sulphate,
ferrous gluconate
 Cont..
 MUSCLE TONE AND ACTIVITY:-
 Regular exercise increases muscle tone and metabolic rate. Good
muscle tone is necessary to maintain stretch and contractility of
muscle tone.
 PATHOLOGICAL CONDITIONS:-
 Some diseases and pathologies can affect the formation and excretion
urine.EgDiabetic mellitus, multiple sclerosis. Parkinson's disease-
possible loss of bladder tone.
 Benign prostatic hyperplasia-may cause urinary retention and
incontinence. Cognitive impairments such as Alzheimer's disease-lose
the ability to sense a full bladder or unable to recall the procedure for
voiding.
 Diabetes insipidus:increases urine production Neurogenic bladder the
client does not perceive bladder fullness and is unable to control the
urinary sphincter.
 CONT..
DIAGNOSTIC PROCEDURES:-
 Eg:Urethra may swell following cystoscopySurgical procedures on any
part of urinary tract may result in post-operative bleeding
 A restriction in fluid intake commonly lowers urine output.
 Surgery of lower abdomen and pelvic structures sometimes impairs
urination because of local trauma to surrounding tissue.
 SOCIOCULTURAL FACTORS:-
 Certain life-style behaviours can affect urinary elimination by delaying
voiding due to ignoring the urge to void because of Insuf fic ient time,
unavailability of toilet facilities, lack of privacy, inability to assume a
normal position Delay in voiding can stretch and weaken the detrusor
muscle lead to incomplete emptying of the bladder, residual urine left
in the bladder and bladder infection:
 COMMON ALTERATION IN URINARY ELIMINATION:-
1. POLYUREA:-Polyurea is the diuresis refers to productions of
abnormally large amount of urine by the kidneys,about 2500
ml or more /day
2. OLIGURIA:-It refers to voiding scanty amount of urine such as
100ml-500ml/day.
3. ANURIA:-It refers to voiding less than 100 ml/day. The term
complete kidn ey s h u tdown ren al failu re an d u rin ary
suppression have the same meaning
4. FREQUENCY:-Void at frequent interval due to cystitis stress
pressure on bladder are some of the cause listed.
5. NOCTURIA:-It is an increased frequency at night. That is not
the result of an increase in f lu id intake. It is expressed in
term of the number of times the person gets out of bed to
void.
Cont…
5.DYSURIA:-It means voiding that is either painful or dif ficult. It can
be caused by stricture of urethera,urinary infection and injury to
the bladder of urethra.
6.ENURESIS:-it is def in ed as repeated involuntary urination in
children byond 4-5 year of age,when voluntary bladder control is
normally acquired. Enuresis can be nocturnal[night time]and
diurnal [day time]or both.
7.HERITANCY:-It is def ined as delay or dif ficulty in initiating voiding.
it may be due to urethral structure, prostatic enlargement post
catheterization and urethritis.
8.URINARY INCONTINENCE:-it is the ability to control passage of
urine to continence may be caused by stress ,neurological
impairedment and injury to urethral sphincter.
9.URINARY RETENTION:-it is the accumulation of urine in the
bladder associated with inability of the bladder to empty itself .
 RENAL CONDITION CAUSING ALTERED URINE ELIMINATION
 RENAL CONDITION:-
PRERENAL CONDITION:-
 use of nephrotoxic drug
 De c re ase i ntrav asc ul ar [gentamycin]
v o l um e , d e hyd rati o n,  glomerulo nephritis,
hemorrhage,burns,shock  neoplasm's and infections.
 Systemic disease[diabetes]
 Altered peripheral vascular
 Hereditary disease [polycystic
resistance,sepsis, kidney]
anaphylactic shock and  POST RENAL CAUSES:-
reactions  urinary tract obstruction,calculi,
prostatic hypertrophy,
 congestive heart failure,
 neurogenic bladder, and pelvic
myocardial infraction and tumor, retro peritoneal fibrosis
hypertensive heart disease,
valvular disease, pericardial
 URINARY INCONTINENCE
 UI is the involuntary passage of
urine.
 It refers to the inability to control
passage of urine.
 It is a symptom, not a disease.
 It may be temporary or
permanent.
 Leakage may be continuous or
intermittent.
 TYPES OF INCONTINENCE AND CLINICAL MANIFESTATIONS

1. STRESS INCONTINENCE: Involuntary loss of urine through an intact

urethra as a result of sudden increase in intra abdominal pressure. It is
seen mainly in women who have had vaginal deliveries.
2. URGE INCONTINENCE: Involuntary loss of urine associated with a
strong urge to void that cannot be suppressed.
3. REFLEX INCONTINENCE:Anvoluntary loss of urine due to hyper
reflexia in the absence of normal sensation
4. OVERFLOW INCONTINENCE (functional incontinence)It is the
involuntary loss of urine associated with over distention of the bladder.
CAUSES OF INCONTINENCE
 It usually occurs when the
pressure due to a completely  STDs,
filled bladder exceeds a certain
threshold  paralysis,
THE CAUSES ARE :-
 Overactive bladder  leakage when coughing,
 Mental health problem sneezing due to increased
 Prostate problem abdominal pressure,
 Excess urine production
 Blockage in the urinary system  fecal impaction,
 UTI,  old age,
 Surgery,
 trauma causing sphincter  cognitive impairment,
damage,  unconscious
 MEASURES TO REDUCE THE PROBLEM OF
INCONTINENCE
 Establish a REGULAR VOIDING schedule for the patient.
 PERINEA EXERCISES: these increases the tone of muscles concerned with the
micturation, in particular the perineal and abdominal muscles.Periodic
tightening of the perineal muscles, intentionally stopping and then starting the
urine stream etc can help in gaining voiding control.
 Arrange toilet or bedpan within the easy reach of the patient .
 Medical and surgical correction of the causative factors.
 BLADDER TRAINING PROGRAM Includes: education of the client and support
people.
 Bladder training, which requires that the client postpone voiding. Resist or
inhibit the sensation of urgency and void according to a timetable rather than
according to urge to void. The goal are to gradually lengthen the interval
between urination., to stabilize the bladder and to diminish urgency.
 HABIT TRAINING
MEASURES TO REDUCE INCONTINENCE
 Lifestyle change
 Pelvic floor exercise [kegel’s exercise]
 Bladder training
 Medications
 Percutaneous tibial nerve stimulation
 Botox treatment
URINARY RETENTION
 The state in which one experiences incomplete emptying of the
bladder. When the emptying of bladder is impaired, urine
accumulates and the bladder becomes over distended. Over
distention of the bladder causes poor contractility of detrusor
muscle further impairing urination.
CAUSES OF URINARY RETENTION
 Obstruction of urine f lo w (prostate gland enlargement,
pregnanc y, urethral edem a, bladder stone, surgery or
diagnostic examinations) .
 Alteration in motor or sensory innervations to the detrusor
muscle and internal sphincter.eg.spinal cord injury peripheral
nerve trauma, degeneration of peripheral nerves.
 Inability to relax external sphincter (emotional stress or anxiety
muscle tension).
 PREVENTION AND TREATMENT OF RETENTION
OF URINE
 METHODS USED IN INDUCING NATURAL URINATION ARE:
Assist the patient to his or her normal position for voiding.
Provide privacy.
Offer a bedpan or urinal that is warm a bedpan that is cold to
touch may cause contraction of the perineal muscles
Foster the muscles relaxation by providing necessary physical
support to the patient and by relieving pain.
Provide any assistance when the patient feels the need to void .
Micturition is a conditioned response. running water within the
hearing of the patient or flushing the toilet stimulate the
micturition reflex.
 Cont..
 Provide enough time for micturation.
 Reassurance and emotional support are helpful to ref lex
the patient
 A hot enema, if permitted may relieve the retention of the
urine.
 Give fluids freely unless contra-indicated.
W h e n a l l t h e s e n u r s i n g i n t e r v e n t i o n s f a i l e d ,
catheterisation of the bladder is done with the doctor's
permission.
 Certain drugs which cause contraction of the bladder may
be ordered by the doctor.
 COLLECTING URINE SPECIMEN
 DEFINITION:-
Urine analysis in which the components of urine are identified ,is a
part of every client assessment at the beginning and during the
illness.
 PURPOSE:-
1. To make diagnosis and to help in treatment.
2. To note progress or reacess of disease.
3. To observe the effect of special treatment and drugs.
4. To assess the general health of patient.
5. To investigate the nature of disease.
 PRINCIPLES OF COLLECTING URINE SPECIMEN
 Contaminated and improperly collected specimens will produce false
result which will adversely affect the diagnosis and treatment of
patient.
 Specimen allowed to stand at room temperature for a long time will
give false result due to decomposition of specimen, multiplication of
undesirable and destruction of pathogenic bacteria.
 Blood chemistry is not uniform through out the day. It varies with the
food intake.
 The accuracy and reliability of f indings depends upon the correct
method collection. Transportation of the specimen to the laboratory
and recording of reports.
 Inaccurate results may lead the physician in wrong diagnosis and
treatments of patients.
GENERAL INSTRUCTION
 Provide adequate explanation regarding collection of specimen.
 Ask the patient to wash the external genitalia area with soap and
water then rinse with water alone before collecting urine
specimens.
 Equipment used for the collection of specimen should be clean
and dry.
 No antiseptic should be present in the specimen bottle.
 As far as possible morning specimen should be collected.
 Specimen should be always be fresh for the laboratory
examination.
 Bacteria multiply in the room temperature so,The specimen not
tested immediately should be kept in refrigerator.
 Container should have a wide mouth prevent spilling of the
specimen.
PROCEDURE
 Instruct patient to wash perineum.
 Instruct to avoid directly into clean ,dry container or into
bedpan and then transfer.
 Instruct not to be contaminated outside the container.
 Instruct to collect ¾ of container.
 Wear gloves while handling urine.
 NURSING ALERT
 Label specimen containers or bottles before the client voids.

 Note on the specimen label if the female client is menstruating at that time.

 Maintain body substances precautions when collecting all type of urine

specimen.

 To avoid contamination and necessity of collecting another specimen, soap

and water cleansing of the genitalia immediately preceding the collection of
specimen is supported.

 Wake a client in the morning to obtain a routine specimen.

 Be sure to document the procedure in the designated place and mark it off on
the kardex.
 TYPES OF COLLECTING URINE SPECIMEN:-

1.SPECIMEN TYPE:- 2.COLLECTION OF URINE

a) Random specimen SPECIMEN:-
b) First morning specimen or a. Urine collection from test tube
8hr specimen b. Urine collection from U-bag for
c) Fasting specimen infant.
d) 2hr postprandial c. Urine collection from catheter
specimen
d. 24 hr urine collection
e) 24 hr specimen
f) Catheterized specimen e. Collection of mid stream urine.
g) Mid-stream “clean catc
h "specimen”
h) Supra pubic aspiration
 SPECIMEN TRANSPORT GUIDELINE
 All urine collection and/or transport containers should be
clean and free of particles or interfering substances.
 The collection and/or transport container should have a
secure lid and be leak-resistant.
 Leak-resistant containers reduce specimen loss and
healthcare worker exposure to the specimen while also
protecting the specimen from contaminants.
 It is a good practice to use containers that are made of break
-resistant plastic, which is safer than glass.
 CONT…
Specimen containers should not be reused.
Take collection container that holds at least 50 mL, has a
wide base and an opening of at least 4 cm. The wide base
prevents spillage and a 4 cm opening is an adequate target
for urine collection.
The 24-hour containers should hold up to 3 L.
The containers should have secure closures to prevent
s pec i men l os s an d to pr otec t th e s pec i men fr om
contaminants.
Transport tubes should be compatible with automated
systems and instruments used by the lab.
 URINE SPECIMEN HANDLING
 Guidelines Labels include the patient's name and identification on it.
 Make sure that the information on the container label and the requisition
match.
 If the collection container is used for transport, the label should be
placed on the container and not on the lid, since the lid can be mistakenly
placed on a different container.
 Ensure that the labels used on the containers are adherent under
refrigerated conditions.
 Ensure that there is sufficient volume to fill the tubes and/or perform the
tests.
 Under filling or overfilling containers with preservatives may affect
specimen-to-additive ratios.
 Collection date and time should be included on the specimen label. This
will confirm that the collection was done correctly.
 For timed specimens, verify start and stop time of collection.
URINE TESTING
 Urine analysis methods comprise testing reaction, specific gravity, albumen
sugar bile,acetone,pus blood and yeasts microscopically.

PURPOSE OF URINE TESTING

 To detect the reaction, in cystitis the reaction is alkaline.
 To detect sugar, it is present in diabetes mellitus.
 To detect protein, it present in kidney damage ,pre -eclamecia and is
called proteinuria.
 To detect acetone ,it is present due to incomplete metabolism of fat.
 To detect bile ,it is seen in case of obstructive jaundice or hemolytic
jaundice.
 To detect pus cell it is present due to urinary tract infection.
 CHARACTERISTIC OF NORMAL URINE
 Volume;-1000 to 2000 ml in 24 hr
 Appearance :-clear
 Odor :-aromatic odor
 Color :-Amber or pale straw in color
 Reactions:-normal urine is slightly acidic.
 Specific gravity:-1.010 -1.025
 Constituent of the normal urine:-water 96%,urea 2% and uric acid,
urate,creatinine,chloride,phosphatase,sulphates,oxalate-2%
CHARACTERISTICS OF ABNORMAL URINE
Volume:- COLOR :-
 Green or brownish –yellow:-
 Polyurea
bile salt and bile pigment
 Oligourea  Reddish brown:-urobilinogen
 Anuria  Bright red:-a large amount of
fresh blood
 Suppression;-failure of
 Smoky brown:-blood
the kidney to secrete pigment
urine  Milky white:-chyluria due to
filariasis
 Cont..

APPEARANCE:-
REACTION:-
 MUCUS:-Appears as a  ALKALIN:-cystitis
flocculent cloud.  DIABETES MELLITUS:-increased
 PUS:-settles at the bottom as specific gravity
a heavy cloud.  RENAL DISEASE: High Specific
 STONES:- as fine sand Gravity
 Uric acid :-as grains of pepper  KIDNEY DAMAGE:-Albumin
ODOR:-
 SWEETISH OR FRUITY ODOR:
-seen in diabetes
URINE CULTURE VIAL URINE RE/ME VIAL
 FACILITATING URINARY ELIMINATION
 ASSESSMENT:-a complete assessment of a client urinary functions includes
a. Nursing history
b. Physical assessment
c. Measuring urinary output
A.NURSING HISTORY
 Determine the clients normal voiding pattern and frequency,
appearance of urine and any recent changes ,any past or current
problem with urination, the presence of an ostomy and factors
influencing the elimination pattern.
B.PHYSICAL ASSESMENT:-
 It include precussion of the kidneys to detect areas of tenderness
 palpation and precaution of bladder are also done.
 Inspect the urethral meatus of both male and female client for swelling
inflammation and discharge.
 Assess the skin of perineum for excoriation due to incontinence,dribling
of urine.
 Cont…
 Assess the colour and consistency and urinary output to f ind out
any abnormalities,
ex.:-infective hepatitis,hematuria,renal failure
C.MEASURING URINARY OUTPUT:-
 Normally the kidneys produce urine at a rate of approximately
60ml/hr or about 1500ml/day.
FACTORS AFFECTING URINARY OUTPUT:-
 Fluid intake ,body f lu id losses through other routes such as
perspiration and breathing or diarrhea and the cardiovascular
and renal status of the individual.
 Urine output >30 ml/hr may indicate kidney malfunction and
must be reported.
 CONT…
 DIAGNOSTIC TEST:-
 Blood level of two metabolically pro duce substances, urea and creatinine
are routinely used evaluate renal function.
 Urine the end product of protein metabolism is measured as blood urea
nitrogen[BUN]
 SPECIAL CONSIDERATION:-
 The application of a condom or external catheter connected to a
urinary drainage system is commonly prescribed for incontinent,
unconsciousness, MALE PATIENT due to poisioning,CVA ,head injury,
neurological surgeries etc.
 In FEMALE patients catheterization is done to drain the urine before
surgery and after surgery e.g;-cs delivery
 Indwelling catheterization is used in bed ridden patient
 PROVIDING URINAL AND BED PAN


 A bedpan or a urinal can be described as devices, which are used by
patients who are unable to get out of bed to urinate or have a bowel
movement.
 The reason for using a bedpan can be any, such as an injury of disease,
which makes people unable to walk
 Urinal is used by patients to urinate while the bed pan is used for the bowel
movement.
 However, a female patient may bedpan for both the purposes.
ARTICLES REQUIRED
1. A bedpan/Urinal
2. A basin containing lukewarm water
3. Towels Wash clothes
4. Powder
5. Mackintosh and towel
 PROCEDURE
1. At first, the bedpan is kept under the warm water. It is then dried. The nurse
must make sure that the bedpan is not hot before providing it to the patient.
2. Put some powder on the bed pan.
3. Wear gloves.
4. Spread Mackintosh and towel under the patient.
5. If there is no contraindication, the head end is raised.
6. Provide a screen or pull curtains for privacy. Don't leave the client if he's
weak or requires monitoring.
7. The nurse then lifts the lower back of the patient and supports it while he/she
places the bed pan with his/her other hand under the patient's buttocks.
8. While providing urinal, make sure in females the mouth of urinal (female
urinal has wider mouth is snugly fitting to perineum to prevent spillage.
9. In males, urine flow is directed into urinal.
10. Provide ample time to the patient and don't hurry.
11. When the patient is done, follow the same procedure of supporting and lifting
the lower back and then pull the bedpan kept underneath the buttocks.
12. Cover it using a lid or towel. Lower the head end.
 CONDOM DRAINAGE
 Condom drainage is a method of managing the
incontinence in male patients in which a condom
is used to attach to a plastic drainage tube and is
rolled over the penis. The tube, from the other end
is connected to a drainage bag.
 It can be used over night or it can be continuous
process.
PURPOSE:-
U r i n e c o l l e c t i o n a n d c o n t r o l l i n g
incontinence.
 Allow the client to perform physical activity
while the client still has urinary
incontinence.
 Prevent the skin from moisture due to
leaking urine, thus preventing bedsores.
 To prevent UTIs resulting due to invasive
procedures such as indwelling catheter
 PROCEDURE
 Before beginning the procedure, the nurse must introduce herself, and explain the procedure to
the patient.
 Perform the hand washing procedure.
 The client must be given either supine or sitting position to perform the procedure.
 Privacy must be provided using the curtains or screens, and only the penis should be exposed
and the client must be covered using the drape or top sheet.
 Wear gloves.
 Clean the penis and inspect for any other deformities or injuries.
 Apply the condom by rolling it over the penis and secure it to the penis. The condom shouldn't be
too tight or too loose.
 After securing the condom with a strip of elastic tape, the drainage system is attached to it.
 The client is then taught about the mechanism of the procedure.
 The nurse then observes for outflow of urine for the next 30 minutes and then at a regular
interval of 4 hours.
 Document the procedure and any other findings.
URINARY CATHETERIZATION
 Urinary catheterization is a procedure that uses a f le xible tube called a
catheter to drain urine from the bladder or inject liquids into it. It can be
used for both diagnostic and therapeutic purposes.

PURPOSE:-
 To get a sterile urine specimen for diagnostic purposes.
 To empty the bladder when a condition of retention is thought to exist
 To measure the amount of residual urine when bladder is incompletely
emptied.
 To empty the bladder prior to surgery involving rectum, vagina, and pelvic
organs
 To prevent urine passing over a wound.
 To provide for intermittent or continuous bladder drainage and irrigation
 To manage incontinence.
PARTS OF CATHETER
 CONT…
TYPES OF CATHETERIZATION:-
There are three main types of urinary catheterization,
1. Intermittent
2. Retention/indwelling catheterization-also called as Foley's catheterization
and condom drainage.
3. Suprapubic catheterization.
 1.INTERMITENT CATHETERIZATION
 Intermittent Catheterization is a procedure
performed medically in a situation when a patient
is in need of catheterization, but for a shorter
period of time.
 The intermittent catherization is required for
urinary bladder emptying.
 It can be done easily by the patient himself at
home or by the nurse at hospital settings.
The major indication for intermittent
catheterization is neurogenic bladder.
 The time duration can range from 2-3 hours to 4-6
hours.
 Ask t he client t o t ry and urinat e w it hout
catherization. However, all the supplies and
equipment must be ready in order to catheterize
the client, if unable to void.
INTERMITTENT CATHETERIZATION
CONSIDERATION
 Check for any signs of infection.
 The signs can include burning sensation while urinating, pain, or
physical changes in the urine.
 Make sure that the client is taking adequate fluids orally
 As the catheterization is done, the urine is collected and assessed if
there is presence of any blood in urine.
 The urine is assessed for any other physical changes.
 INDWELLING CATHETERIZATION
 An indwelling catheter is a tube that's
inserted into the bladder to drain urine and
left in place for a period of time. It's often
used t o t reat urinary incont inence or
retention, or after surgery.

 The catheter that inserted inside sterile in

nature.

PURPOSE
 For bladder emptying.
 For collecting sterile urine sample
 To relieve bladder distensions.
 T o r e l i e v e u r i n a r y i n c o n t i n e n c e

 ARTICLES REQURED
 Tray containing articles:
1. Sterile dressing set (two bowls, artery forceps, thumb forceps,
sponge holder, cotton and gauze piece, kidney tray)
2. Sterile sheet (hole sheet)
3. Antiseptic solution, saline
4. Syringe for balloon inflation
5. Foley's catheter and Urobag
 PROCEDURE OF INTRODUCING AN INDWELLING
CATHETER
 The nurse has to introduce herself before beginning the procedure.
 Verify the patient.
 Explain the procedure to the patient and family.
 Explain why the procedure is necessary, and its indications.
 Wash the hands properly.
 Provide screen for privacy.
 Position the patient.
 Appropriately cover the patient and allow only the perineum to be exposed.
 Open the catheterization tray and wear sterile gloves to perform the
procedure.
 Spread sterile hole sheet on the perineal area.
 FEMALE
CATHETERIZATIONPROCEDURE
 Place The Patient In The Supine Position With The Knees
f le xed and separated and feet f lat on the bed, about 60 cm
apart.
 If this position is uncomfortable, instruct the patient either to
f lex only one knee and keep the other leg f lat on the bed, or to
spread her legs as far apart as possible.
 A lateral position may also be used for elderly or disabled
patients.

 With the thumb, middle and index fingers of the non-dominant

hand, separate the labia majora and labia minora. Pull slightly
upward to locate the urinary meatus. Maintain this position to
avoid contamination during the procedure.
 With your dominant hand, cleanse the urinary meatus, using
FEMALE CATHETERIZATION
 Place the drainage basin containing the catheter between the patient’s
thighs.
 Pick up the catheter with your dominant hand.
 Insert the lubricated tip of the catheter into the urinary meatus.
 Advance the catheter about 5-5.75 cm, until urine begins to flow then
advance the catheter a further 1-2 cm.
 If the catheter slips into the vagina, leave it there to assist as a landmark.
With another lubricated sterile catheter, insert into the urinary meatus until
you get urine back. Remove the catheter left in the vagina at this time.
 Attach the syringe with the sterile water and inflate the balloon. It is
recommended to inflate the 5cc balloon with 7-10cc of sterile water, and
to inflate the 30cc balloon with 30-35cc of sterile water.
 Improperly inflated balloons can cause drainage and leakage difficulties.
 Gently pull back on the catheter until the balloon engages the bladder neck.
 MALE CATHERIZATION
 Place the patient in the supine position with legs
extended and flat on the bed.
 Prepare the catheterization tray and catheter and
drape the patient appropriately using the sterile
drapes provided. Place a sterile drape under the
patient’s buttocks and the fenestrated (drape with
hole) drape over the penis.
 Apply water-soluble lubricant to the catheter tip.
 With your non-dominant hand, grasp the penis just
below the glans and hold upright.
 If the patient is uncircumcised, retract the foreskin.
Replace the foreskin at the end of the procedure.
 With your dominant hand, cleanse the glans using
chlorhexidine soaked cotton balls. Use each cotton
ball for a single circular motion.
 MALE CATHETERIZATION


 Place the drainage basin containing the catheter on or next to the thighs.
 With you non-dominant hand, gently straighten and stretch the penis. Lift it to an
angle of 60-90 degrees. At this time you may use the urojet to anesthetize the
urinary canal, which will minimize the discomfort.
 With your dominant hand, insert the lubricated tip of the catheter into the urinary
meatus.
 Continue to advance the catheter completely to the bifurcation i.e. until only the
inf la tion and drainage ports are exposed and urine f lows (this is to ensure proper
placement of the catheter in the bladder and prevent urethral injuries and
hematuria that result when the Foleys catheter balloon is inflated in the urethra).
 If resistance is met during advancement of the catheter: Pause for 10-20 seconds.
Instruct the patient to breathe deeply and evenly. Apply gentle pressure as the
patient exhales
 If you still meet resistance, stop the procedure and repeat above steps.
 Attach the syringe with the sterile water and inf late the balloon. It is recommended
to inf la te the 5cc balloon with 7-10cc of sterile water, and to inf la te the 30cc
balloon with 35cc of sterile water. Improperly inf lated balloons can cause drainage
and leakage difficulties.
 Cont,,,
 Gently pull back on the catheter until the balloon engages the bladder
neck.
 Attach the urinary drainage bag and position it below the bladder
level. Secure the catheter to the thigh. Avoid applying tension to the
catheter.
 Remove drapes and cover patient. Ensure drainage bag is attached to
bed frame. Remove your gloves and wash hands.
 Never inf late a balloon before establishing that the catheter is in the
bladder and not just in the urethra.
 If the patient reports discomfort, withdraw the f luid from the balloon
and advance the catheter a little further, then re-inflate the balloon.
 AFTER CARE OF THE PATIENT AND ARTICLES
 Wash hands and dry the perineum
 Remove the drape sheet and replace the bed linen
 Position the patient in correct alignment
 Measure urine and observe the characteristics of urine and record it
 Wash the articles and replace in utility room
 Send the urine specimen for laboratory investigation
 Maintain an intake-output chart
 For indwelling catheter ensure complete closed urinary drainage system.
empty the collection bag.atleast 8 hours.
 keep tubings free of kinks
 Remove Foley's catheter by first completely deflating the ballon.
 Perineal exercise help restore sphincter control after a catheter is removed.
 REMOVAL OF CATHETER
FOLEYS CATHETER
 Wear clean gloves.
 Empty the Urobag and then with the help of syringe and needle deflate the
balloon by withdrawing the fluid from it and hold the two gauze piece in non-
dominant near to the perineum, in such a way that catheter is in the center.
 Now withdraw the catheter with dominant hand.
 Throw the catheter and uro bag as per BMW policy of the hospital
CONDOM DRAINAGEREMOVAL
 Wear gloves, empty the urobag and note down the output
 Roll down the condom drainage and dispose of the condom drainage
apparatus.
Cont..
SUPRAPUBIC CATHETER Removal
 Wear clean gloves
 Remove the dressing and discard
 Wash hands and wear sterile gloves clean the site of insertion of
suprapubic catheter and def la te the balloon near the tip of the
catheter and remove the catheter while patient is exhaling
 Pull the purse string at the incision site and close the opening.
 Apply paraffin gauze and sterile dressing on it to seal the air entry.
 Discard the apparatus as per BMW policy.
 COMPLICATIONS
 Urinary tract infection
 Allergic reaction to the material used in the catheter such as latex
 Hematuria
 Tissue trauma during the insertion of the catheter.
 BLADDER IRRIGATION
 It is the washing out of the bladder, by directing a stream of solution into
the bladder, through the urinary meatus by means of the catheter.
PURPOSE
 To ensure patency of the urinary drainage system.
 To cleanse the bladder from stagnant urine, bacteria, excess mucus, us and
blood clot.
 To relieve congestion and pain inflammatory condition.
 To promote healing
 To medicate the lining of bladder
 To arrest bleeding
 To prepare the bladder for surgery as a pre-operative measure
 TYPES OF IRRIGATION
1.OPEN METHOD
 It is done with an asepto syringe in which is introduced into the urinary
bladder and drained out simultaneously
2.CLOSED METHOD
 This provides for frequent intermittent or continuous irrigation without
disruption of the sterile catheter system.
SOLUTION USED:
 Distilled water, normal saline, sodium nitrate (1:8000), boric acid 2%,
potassium permanganate (1:10000), acrif lavin | in1000, silver nitrate1 in
5000, acetic acid in 400.
 METHOD OF ADMINISTRATION OF IRRIGATION
SOLUTION

 Funnel and tubing method [open method]

 Irrigation can, rubber tubing and Y connection.
 Asepto syringe[ open method]
ARTICLES FOR IRRIGATION

 Disposable gloves
 Disposable, water resistant, sterile towel/mackintosh
 Three-way retention catheter
 Sterile drainage tubing & bag in place
 Sterile antiseptic swab
 Sterile irrigating solution warmed or at room temperature
 Normal saline
 Distilled water
 Solution as prescribe by physician
 Infusion tubing
 IV pole
 Kidney basin
 PROCEDURE
 Check physician's order & nursing care plan for type, amount & strength
of irrigation fluid & reason for irrigation.
PREPARE THE PATIENT
 Explain the procedure & purpose to the patient.
 Provide for privacy & drape the patient. Empty, measure & record the
amount & appearance of urine present in the urine bag.
PREPARE THE EQUIPMENT
 Wash hand
 Connect the irrigation infusion tubing to the irrigating solution & flush
the tubing with solution.
 Connect the irrigation tubing to the input port of the 3-way catheter.
 Connect the drainage bag & tubing to the urinary drainage port if not
already in place
 GENERAL INSTRUCTION
 Should not be done without written order.
 As far as possible, bladder irrigation are to be avoided.
 The fluid should be instilled gently and allowed to drain back by gravity.
 If the fluid flows easily into the bladder but fails to return, there is a clot
over the eye of the catheter.
 In such situation no more fluid is introduced into the bladder but try to
dislodge the clot by milking the tubing.
 Practice strict aseptic technique.
 All the articles that are used for the irrigation must be sterile.
 CONT..
 Maintain an accurate records of the amount of f luid used for irrigation
and the total amount of urinary drainage.
 Subtract the total amount of f luid used, from the total amount of urinary
drainage to find out the amount of urine secreted by the kidneys.
 For salt restricted patient use dextrose 5% solution instead of normal
saline.
 Irrigation are carried out until the return flow is clear.
 The color of the drainage should be checked and recorded. If bleeding
takes place stop the procedure and inform to the doctor.
 Record the procedure on the nurse's record with date and time.
 Recorded procedure should include- purposes, amount and kind of the
solution used, amount and characteristics of the drainage from the
bladder, result of irrigation, any complication etc.
PRILIMINARY ASSESSMENT
 Connect the irrigation infusion tubing to the irrigating solution and
flush the tubing with solution.
 Connect the irrigation tubing to the input port of the 3 way catheter.
 Connect the drainage bag and tubing to the urinary drainage port if
not already in place.
 Cont…
IRRIGATE THE BLADDER
1.CONTINUOUS IRRIGATION
2.INTERMITTENT IRRIGATION
3.MANUAL IRRIGATION [It is used when the catheter is blocked by clot or
debris]

1.CONTINUOUS IRRIGATION
 Open the f low clamp on the urinary drainage tubing (if present)Open the
regulating clamp on the irrigating tubing & adjust the flow rate as prescribed
by the physician or to 40-60 drops/minute if not specified.
 Assess the drainage for amount, colour & clarity.
2.INTERMITTENT IRRIGATION
 Determine whether the solution is to remain in the bladder for a
specified time.
 If solution is to remain in the bladder during a bladder irrigation or
instillation close the flow clamp on the urinary drainage tubing.
Intermittent catheterization cont..
 Open the flow clamp on the irrigation tubing, allowing the specified
amount of solution (75-100 ml) to infuse & then clamp the tubing
After retaining the solution for specific period of time, open the
drainage tubing flow clamp & allow the bladder to empty.
 If the solution being instilled is to irrigate the catheter, open the flow
clamp on the urinary drainage tubing.
 Assess the patient condition, urinary output, color, odour & clarity of
drainage.
 Discard all used disposable articles, clean & replace reusable
articles.
 Wash hands
 Record procedure in nurse's record.
AFTER CARE
 Tape the catheter securely to the thigh
 Assess the patient's condition and tolerance of the procedure
 Discard all used disposable articles, clean and replace reusable
articles
 Wash hands
 Record procedure in nurse's record.
 PERINEAL CARE
 Perinea care is the care of perineum which involves cleaning of the
external genitalia and the surrounding area.
PURPOSE:
 To remove normal perineal secretions and odour.
 To promote client comfort.
INDICATIONS:
 Client, who are unable to do self care to maintain perineal hygiene,
genitourinary tract infection, incontinence, indwelling catheter,
postpartum clients, any surgery, ulcer or injury on the perineal area.
 PROCEDURE
 Explain the procedure
 Provide privacy
 Remove all articles that may interfere with the procedure.
 Offer bedpan
 Wash hands
 Pour water antiseptic solution over the perineum.
 Clean the perineum using the wet swabs
 Hold the swabs with forceps and clean from above down to anal orifice.
 Use one swab for one swabbing
 Clean the perineum from the midline outward in the following order
 The vulva, labia minora both sides, labia majora both sides, thighs
 Clean the anus thoroughly
 Remove bedpan by supporting hips.turn the patient to one side and dry buttocks with
dry gauze pieces
 NURSING MANAGEMENT OF PATIENT WITH
FASCILITATING URINARY ELIMINATION
ASSESSMENT:
1.NURSING HISTORY:
 client's normal voiding pattern, frequency, appearance of urine, any recent
changes, any past or current problems with urination, presence of ostomy,
factors influencing the elimination pattern.
2.PHYSICAL ASSESSMENT:
 Palpation of kidneys to detect areas of tenderness, palpation and percussion
of the blad d er, urethral meatus inspec ted for swelling, d isc harge,
inflammation.
 Skin of perineum should be inspected for irritation
 Assessing urine
 Easure urinary output.
 Measuring residual urine.
 NURSING DIAGNOSIS
 Impaired urinary elimination related to (anatomic obstruction, sensory
motor impairment, urinary tract infection
 Functional urinary incontinence related to (alteration in cognitive
functioning, neuromuscular impairments, psychological impairments)
 Urinary retention related to(blockage in urinary tract, strong sphincter, high
urethral pressure. Risk for infection related to (catherisation)
GOAL
1. Maintain or restore a normal voiding pattern
2. Regain normal urine output
3. Prevent associated risks
4. Perform toileting activites independently with or without assistive devices
IMPLEMENTATION
 Maintaining normal urinary elimination: Promoting f luid intake. increasing f luid
intake increases urine production, which in turn stimulates the micturation
reflex.A normal daily intake averaging 1500 ml of measurable fluids is adequate
for most adult clients.
 Maintaining normal voiding habits. (bladder training).
 Preventing urinary tract infection;(drinking plenty of water, frequent voiding,
avoiding use of irritating soaps, powder. Sprays, avoiding tight f it ting pants,
wearing cotton underclothes
 Managing urinary incontinence: bladder training, pelvic muscle exercises(kegel
exercise), maintaining skin integrity applying external urinary draining devices
 Managing urinary retention:(catheterisation, Nursing intervention for clients
with indwelling catheters:Encourging large amount of f lu id intake, Dietary
measures: acidifying the urine of clients with retention catheter reduce the risk
of UTI and calculus formation.(foods such as eggs, meat, tomatos, plums etc)
 Perineal care:Changing the catheter and tubing
 SUPRA PUBIC CATHETER CARE

 A Suprapubic catheter is inserted surgically

t hrough t he abdominal w all abov e t he
symphysis pubis into the urinary bladder.
 Care of clients with a suprapubic catheter
includes regular assessment of the client's
urine, f luid intake, maintenance of a patent
drainage syst em, skin care around t he
inser tion site, periodic clamping of the
catheter preparatory to removing it if it is not
a permanent appliance.
 INDICATION FOR SUPRAPUBIC CATHETERIZATION
 Urinary retention when urethral catheterization not feasible.
 When the urethra is damaged or injured.
 If the pelvic f loor muscles are weakened, causing a urethral catheter to
fall out.
 After surgeries that involve the bladder, uterus prostate, or nearby organs.
 Contraindications for Suprapubic Catheterization.
CONTRAINDICATIONS
 No distended bladder and bladder malignancy.
 Active skin infection, coagulopathy, osteomyelitis of the pubis.
COMPLICATIONS OF SUPRAPUBIC CATHETERIZATION
 Bowel injury.
 Bleeding and vascular injury.
 Obstruction of the tube and failure to enter the bladder during
CARE OF URINARY DIVERSION

 A urinary diversion is the surgical

rerouting of urine from the kidneys
to a site other than the bladder.
 It is a surgical procedure in which
the urine is diverted from kidneys
and is directed to body part other
than the bladder
 In case of cystectomy urinary
diversion can performed. Also
other malignant condition requires
this procedure.
 TYPES OF DIVERSION
2 CATEGORIES OF DIVERSIONS;
1.INCONTINENT[ Use Continuous Drain Urine From The Through A Stoma]
2.CONTINENT [A Way To Pass Urine After You Have Surgery To Remove Your Bladder]
INCONTINENT:-
a. URETEROSTOMY:-one or both of the ureters may be brought directly to the side of
abdomen to form small stomas. As the stoma is created a direct port of entry is
provided for the microorganism to enter into the body.
b. NEPHROSTOMY :-diverts urine from the kidney to a stoma
c. VESICOSTOMY it is formed when the bladder is left intact but voiding through the
urethra is not possible the ureters remain connected to the bladder and the bladder wall
is surgically attached to an opening in the skin below the naval forming an incontinent
stoma.
d. ILEAL CONDUIT OR ILEAL LOOP a segment of the ileum is removed and the intestinal
ends are reattached. One end of the portion removed is closed with sutures to create a
pouch and the other end is brought out through the abdominal wall to create stoma. The
ureters are implanted into the ileal pouch
 CONT..

CONTINET URINARY DIVERSION

 Unlike the incontinent diversion, the continent diversion helps the patient
to control the urine f lo w. This can be done either by the intermittent
catheterization of inner reservoir, i.e., Kock pouch or by straining during
voiding (neobladder)
 A reservoir for urine is formed inside the body using the part of ileum. If a
patient has undergone this procedure, there may be certain problems due
to body image and sexuality. However, these activities are resumed
shortly after the procedure.
KONCK POUCH
 In the 'Kock' pouch, small nipple valves are created as the tissue is doubled backward in
the reservoir, the junction where the pouch and skin connect and the ureter and pouch
connect.
 The valves fill up with the urine, which prevents the leakage and reflux of urine.
 The pouch can be emptied by inserting a catheter by the patient himself at a regular
interval. In between the catheterization, the stoma is covered using a small dressing for
the protection purpose. This dressing also prevents the spoilage of cloths.
NEOBLADDER
 In neobladder, the original bladder is replaced with a piece of ileum since
the bladder could be diseased or damaged beyond repair. This piece of
ileum, acting as the bladder is then sutured to the urethra and thus, the
patient can void easily with complete control over the voiding process
ROLE OF NURSE IN URINARY ELIMINATION
 The role and responsibility of nurse ,when managing the urinary
elimination in his and her clients include the following.
 Taking nursing history pertaining to client with partial emphasis on
urinary elimination.
 Conducting And Assessing Physical Assessment Of Kidneys,bladder,
urethral Orifice ,Skin Integrity And Hydration And Urine.
 In addition carrying out the following assessment meassures like
measuring urine output ,collecting urine specimens, determining the
presence of abnormal constituents' ,assisting with diagnostic
procedure.