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Management of Patients with Urinary

Disorders

The patient is encouraged to drink liberal amounts of fluids (water is the best choice) to
increase urine production and flow, which flushes the bacteria from the urinary tract.
Frequent voiding (every 2 to 3 hours) is encouraged to empty the bladder completely
because this can significantly lower urine bacterial counts, reduce urinary stasis, and
prevent reinfection. The patient should be encouraged to shower rather than bathe.
Stress incontinence is the involuntary loss of urine through an intact urethra as a result of
sudden increase in intra-abdominal pressure. Reflex incontinence is loss of urine due to
hyperreflexia or involuntary urethral relaxation in the absence of normal sensations
usually associated with voiding. Overflow incontinence is an involuntary urine loss
associated with over-distension of the bladder. Functional incontinence refers to those
instances in which the function of the lower urinary tract is intact, but other factors
(outside the urinary system) make it difficult or impossible for the patient to reach the
toilet in time for voiding.
The patient may use a clean (nonsterile) technique at home, where the risk of crosscontamination is reduced. The average daytime clean intermittent catheterization
schedule is every 4 to 6 hours and just before bedtime. The female patient assumes a
Fowlers position and uses a mirror to help locate the urinary meatus. The nurse teaches
her to catheterize herself by inserting a catheter 7.5 cm (3 inches) into the urethra, in a
downward and backward direction.
The patient will most likely require extensive teaching about the care and maintenance of
a new urinary diversion. A diversion does not create a serious risk of fluid volume deficit.
Mobility is unlikely to be impaired after the immediate postsurgical recovery. The sacral
plexus is not threatened by the creation of a urinary diversion.
Protein is restricted to 60 g/d, while sodium is restricted to 3 to 4 g/d. Low-calcium diets
are generally not recommended except for true absorptive hypercalciuria. The patient
should avoid intake of oxalate-containing foods and there is no need to increase
potassium intake.
The patient should report the presence of foul-smelling or cloudy urine since this is
suggestive of a UTI. Unless contraindicated, the patient should be instructed to drink
large quantities of fluid each day to flush the kidneys. Sand like debris is normal due to
residual stone products. Hematuria is common after lithotripsy.
Because urine samples (especially in women) are commonly contaminated by the
bacteria normally present in the urethral area, a bacterial count exceeding 105
colonies/mL of clean-catch, midstream urine is the measure that distinguishes true
bacteriuria from contamination. A diagnosis does not require three consecutive positive
results and urine does not contain a normal flora in the absence of a UTI. Most UTIs have
a bacterial etiology.
Pelvic floor muscle exercises (sometimes called Kegel exercises) represent the
cornerstone of behavioral intervention for addressing symptoms of stress, urge, and
mixed incontinence. None of the other listed interventions has a behavioral approach.
When the patient cannot void, catheterization is used to prevent overdistention of the
bladder. In the case of prostatic obstruction, attempts at catheterization by the urologist

Management of Patients with Urinary


Disorders

may not be successful, requiring insertion of a suprapubic catheter. A prostatectomy may


be necessary, but would not be undertaken for the sole purpose of relieving a urethral
obstruction. Delaying by applying compresses or administering medications could result
in harm.
In adults older than 60 years of age, 50 to 100 mL of residual urine may remain after each
voiding because of the decreased contractility of the detrusor muscle. Consequently,
further interventions are not likely warranted.
Unless contraindicated by renal failure or hydronephrosis, patients with renal stones
should drink at least eight 8-ounce glasses of water daily or have IV fluids prescribed to
keep the urine dilute. A urine output exceeding 2 L a day is advisable.
A urine output below 30 mL/hr may indicate dehydration or an obstruction in the ileal
conduit, with possible backflow or leakage from the ureteroileal anastomosis.
To reduce the risk of bacterial proliferation, the nurse should empty the collection bag at
least every 8 hours through the drainage spout, and more frequently if there is a large
volume of urine. Vigorous cleaning of the meatus while the catheter is in place is
discouraged, because the cleaning action can move the catheter, increasing the risk of
infection. The spout (or drainage port) of any urinary drainage bag can become
contaminated when opened to drain the bag. Irrigation of the catheter opens the closed

system, increasing the likelihood of infection.


The antibacterial activity of the prostatic secretions that protect men from bacterial
colonization of the urethra and bladder decreases with aging. The prevalence of infection
in men older than 50 years of age approaches that of women in the same age group. Men
are not more likely to be asymptomatic and are not known to be reluctant to report UTIs.
The correct appliance size is determined by measuring the widest part of the stoma with a
ruler. The permanent appliance should be no more than 1.6 mm (1/8 inch) larger than the
diameter of the stoma and the same shape as the stoma to prevent contact of the skin with
drainage.
Nursing measures to encourage normal voiding patterns include providing privacy,
ensuring an environment and body position conducive to voiding, and assisting the
patient with the use of the bathroom or bedside commode, rather than a bedpan, to
provide a more natural setting for voiding. Most people find supine positioning not
conducive to voiding.
Nursing management is based on the premise that incontinence is not inevitable with
illness or aging and that it is often reversible and treatable. Diuretics cannot always be
safely discontinued. Fluid restriction and catheterization are not considered to be safe,
first-line interventions for the treatment of incontinence.
Dullness on percussion of the suprapubic region is suggestive of urinary retention.
Patients retaining urine are typically restless, not drowsy. A patient experiencing retention
usually voids frequent, small amounts of urine and the use of beta-blockers is unrelated to
urinary retention.

Management of Patients with Urinary


Disorders

Following ESWL, the nurse should strain the patients urine for gravel or sand. There is
no need to administer an IV bolus after the procedure and there is not a heightened risk of
fluid overload. Catheter insertion is not normally indicated following ESWL.
A healthy stoma is pink or red. A change from this normal color to a dark purplish color
suggests that the vascular supply may be compromised. A loose ostomy appliance and
infections do not cause a dark purplish stoma.
If voiding dysfunction goes undetected and untreated, the upper urinary system may
become compromised. Chronic incomplete bladder emptying from poor detrusor pressure
results in recurrent bladder infection. Incomplete bladder emptying due to bladder outlet
obstruction, causing high-pressure detrusor contractions, can result in hydronephrosis
from the high detrusor pressure that radiates up the ureters to the renal pelvis. This
problem does not normally cause nephritic syndrome or pyelonephritis. Nephrotoxicity
results from chemical causes.
Dietary and medication histories and family history of renal stones are obtained to
identify factors predisposing the patient to stone formation. When caring for a patient
with renal stones it would not normally be a priority to assess the vaccination history or
surgical history, since these factors are not usually related to the etiology of kidney
stones.
When indwelling catheters are used, the risk of UTI increases dramatically. Limiting their
use significantly reduces an older adults risk of developing a UTI. Regular toileting
promotes continence, but has only an indirect effect on the risk of UTIs. Prophylactic
antibiotics are not normally administered. Mobility does not have a direct effect on UTI
risk.
The most common subjective presenting symptom of UTI in older adults is generalized
fatigue. The most common objective finding is a change in cognitive functioning. Food
cravings, increased thirst, and upper abdominal pain necessitate further assessment and

intervention, but none is directly suggestive of a UTI.


Yeast vaginitis occurs in as many as 25% of patients treated with antimicrobial agents
that affect vaginal flora. Yeast vaginitis can cause more symptoms and be more difficult
and costly to treat than the original UTI. Antibiotics do not affect menstrual periods and
serial urine cultures are not normally necessary. Resistance is normally a result of failing
to complete a prescribed course of antibiotics.
Unless contraindicated, 3 to 4 L of fluids per day is encouraged to dilute the urine,
decrease burning on urination, and prevent dehydration. No need to supplement this fluid
intake with additional calories or sodium.
Many medications affect urinary continence in addition to causing other unwanted or
unexpected effects. Stress and dietary changes could potentially affect the patients
continence, but medications are more frequently causative of incontinence. UTIs can
cause incontinence, but these infections do not result from contact with infected
individuals.

Management of Patients with Urinary


Disorders

Research shows that written or verbal instruction alone is usually inadequate to teach an
individual how to identify and strengthen the pelvic floor for sufficient bladder and bowel
control. Biofeedback-assisted pelvic muscle exercise (PME) uses either
electromyography or manometry to help the individual identify the pelvic muscles as he
or she attempts to learn which muscle group is involved when performing PME. This
objective assessment is likely superior to weekly contact with the patient. Surgery is not
necessarily indicated if behavioral techniques are unsuccessful.
To enhance emptying of a flaccid bladder, the patient may be taught to double void.
After each voiding, the patient is instructed to remain on the toilet, relax for 1 to 2
minutes, and then attempt to void again in an effort to further empty the bladder.
Relaxation does not affect the neurologic etiology of a flaccid bladder. Sodium restriction
and massage are similarly ineffective.
Catheters create a high risk for UTIs. Because of this acute physiologic threat, the
patients risk for infection is usually prioritized over functional and psychosocial
diagnoses.
Immediately after the indwelling catheter is removed, the patient is placed on a timed
voiding schedule, usually every 2 to 3 hours. At the given time interval, the patient is
instructed to void. The bladder is then scanned using a portable ultrasonic bladder
scanner; if the bladder has not emptied completely, straight catheterization may be
performed. An indwelling catheter would not be reinserted to resolve the problem and
diuretics would not be beneficial. Ongoing incontinence is not an expected finding after
catheter removal.
Patients who are confused and agitated risk trauma through the removal of an indwelling
catheter which has the balloon still inflated. Recent VTE, amputation, and fluid
restriction do not directly create a risk for injury or trauma associated with indwelling
catheter use.
Stones lodged in the ureter (ureteral obstruction) cause acute, excruciating, colicky,
wavelike pain, radiating down the thigh and to the genitalia. Often, the patient has a
desire to void, but little urine is passed, and it usually contains blood because of the
abrasive action of the stone. This group of symptoms is called ureteral colic. Diarrhea is
not associated with this presentation and a fever is usually absent due to the noninfectious
nature of the health problem.
The patient with kidney stones is often in excruciating pain, and this is a high priority for
nursing interventions. In the short term, this would supersede the patients need for IV
fluids or for catheterization. Kidney stones cannot be aspirated.
Increased fluid intake is encouraged to prevent the recurrence of kidney stones. Protein
intake from all sources should be limited. Most patients do not require a low-calcium
diet, but increased calcium intake would be contraindicated for all patients. Eating small,
frequent meals does not influence the risk for recurrence.
Following ESWL, the development of a fever is abnormal and is suggestive of a UTI;
prompt medical assessment and treatment are warranted. It would be inappropriate to
delay further treatment.

Management of Patients with Urinary


Disorders

People who smoke develop bladder cancer twice as often as those who do not smoke.
High alcohol intake and low vitamin intake are not noted to contribute to bladder cancer.
The patient is allowed to eat and drink before the instillation procedure. Once the bladder
is full, the patient must retain the intravesical solution for 2 hours before voiding. The
solution is instilled through the meatus; it is not consumed orally. There is no need to
avoid acidic foods and beverages during treatment.
Because severe alkaline encrustation can accumulate rapidly around the stoma, the urine
pH is kept below 6.5 by administration of ascorbic acid by mouth. An increased pH may
suggest a need to increase ascorbic acid dosing. This is not treated by administering
bicarbonate or citric acid, nor by increasing fluid intake.
Because mucous membrane is used in forming the conduit, the patient may excrete a
large amount of mucus mixed with urine. This causes anxiety in many patients. To help
relieve this anxiety, the nurse reassures the patient that this is a normal occurrence after
an ileal conduit procedure. Urine testing for culture or pH is not required.
The patient is instructed to avoid moisturizing soaps and body washes when cleaning the
area because they interfere with the adhesion of the pouch. To maintain skin integrity, a
skin barrier or leaking pouch is never patched with tape to prevent accumulation of urine
under the skin barrier or faceplate. Fluids should be encouraged, not limited, and the
collection bag should not be allowed to become more than one-third full.
Allowing the patient to express concerns and anxious feelings can help with body image,
especially in adjusting to the changes in toileting habits. The nurse may have to initiate
dialogue about the management of the diversion, especially if the patient is hesitant.
Provision of educational materials is rarely sufficient to address a sudden change and
profound change in body image. Emphasizing the role of the diversion in cancer
treatment does not directly address the patients body image.

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