This aspect of the chapter considers the care of people with urological disorders. Some of the common disorders of the renal system are discussed. The nursing care of those who have a renal disorder is outlined.
Retention of urine
Retention of urine is the inability to pass urine despite the desire to urinate. If untreated, in the long term, urinary retention can cause bladder enlargement and severe cases can affect the ureters and the kidneys, for example hydroureter and hyrdonephrosis (Lemone and Burke, 2008). There are many reasons why individuals cannot void urine.
Causes of retention of urine
r
Enlarged prostate gland causing stricture of the urethrar
Urethral stricture due to trauma, urinary tract infection and bladder calculir
Certain drugs, i.e. antihistamines, antidepressants or antipsychoticsr
Some surgery adjacent to the urethra, i.e. abdomino perineal resectionr
Neurogenic bladder due to disruption of the nerves to the bladder, multiple sclerosis and faecal impactionSigns and symptoms
Patients may complain of nocturia, i.e. getting up two or more times during the night to pass urine. They may have difficulty in passing urine (dysuria) and may find that they cannot empty their bladder fully (Kumar and Clark, 2005). The patient may complain of ‘dribbling’ leading to urine-stained clothing. Incomplete emptying of the bladder can lead to over distention causing loss of muscle tone to the bladder. Haematuria may be present in the urine due to stricture of the urethra (Fickenscher, 1999).
Nursing care
The nurse must undertake a full assessment of the patient and establish when he or she last passed urine. The nurse should obtain a full nursing history in order to establish the cause of retention prior to treating the patient. If urinary retention was not due to mechanical obstructions such as an enlarged prostate or stricture of the urethra, the nurse may attempt to try to make the patient relaxed. If necessary the nurse may need to assist the patient to the toilet so that he or she can have privacy when attempting to void urine. For some patients the sound of running water from a tap may encourage them to pass urine.
Some patients may find it difficult to pass urine postoperatively. This may be due to pain from the surgical incision or they may find it difficult to pass urine when they are lying down in bed. The nurse should determine if the patient is in any pain and if so provide the prescribed analgesia in order to attempt to relax the patient.
If the above measures fail then the patient may need to be catheterised in order to artificially empty his or her bladder. The nurse should observe strict aseptic technique when catheterising a patient and must adhere to local policy and procedures related to the catheterisation of a patient. When the catheter is in situ, the patient should be encouraged to drink at least 2.5 L of fluid per day providing that the patient is not suffer- ing from other physiological problems such as congestive cardiac failure (Wilson, 2001).
An accurate record of all fluid intake and urine output must be maintained and recorded on a fluid balance chart; all those involved in caring for the patient should be made aware of the importance of maintaining an accurate fluid balance chart (Walsh, 2002).
Discharge planning
The patient may be discharged once the cause of the problem responsible for the reten- tion of urine is resolved and the patient is able to void urine without the assistance of a urinary catheter. The patient should be encouraged to maintain his or her fluid intake of at least 2.5 L per day. This would promote constant urinary production, which may help to prevent urinary tract infection (Wilson, 2001). The patient should be encouraged to visit the toilet regularly to void and not to ignore the urge to micturate. This could prevent urinary tract infection and the development of an atonic bladder, which could in turn lead to retention of urine.
Bladder irrigation
Bladder irrigation is performed using a three-way urinary catheter. This procedure is undertaken in patients who have undergone, for example, transurethral resection of the prostate gland (TURP). The prostate gland becomes enlarged because of a malignancy or for benign reasons. Patients with an enlarged prostate gland may experience difficulty in voiding urine and can develop retention of urine. These patients may need to undergo TURP to alleviate the problem of urinary retention. Post-TURP patients usually return to the ward with bladder irrigation in situ, bladder irrigation is used postoperatively primarily to remove debris from the bladder (Walsh, 2002).
Nursing care
The nurse should check to ensure that the irrigating fluid is running as prescribed. The drip rate of the irrigating fluid can be adjusted by the roller clamp on the giving set tubing. The rate should be adjusted according to the colour of urine in the catheter bag (Smith et al., 2004). The nurse should increase the rate of fluid if urinary output is dark red and contains blood clots and to decrease the flow rate if the output is pink and clear of clots. The irrigation system must be a closed continuous system and the nurse must ensure that there is no leaking occurring at the connections. The patient is assessed every hour by the nurse to ensure that he or she is not in any discomfort as a result of retention of urine or pain related to surgery.
The drainage systems should be checked half hourly for the first 36–48 hours for patency (Walsh, 2002). The colour, consistency or sediment in drainage should be noted.
The urine will be bloodstained for at least for the first 24 hours and gradually become less bloodstained. The nurse must empty the catheter bag as often as is necessary (Dougherty and Lister, 2008) and maintain a strict fluid balance chart. It is important to observe that the volume drained is the same as the volume used for irrigation plus any
urine that may be produced. If the volume drained is less than the volume instilled, the nurse incharge must be informed immediately. The rationale for the reduced drainage may be due to obstruction of the drainage tube by a blood clot, which could lead to retention of urine and discomfort for the patient.
Once the patient is fully conscious and is able to tolerate fluids, unless contraindicated the nurse should encourage him or her to drink and gradually increase fluid intake to at least 2–2.5 L of fluid per day. Once the patient is tolerating fluids, bladder irrigation should be discontinued if the urine output is free of blood clots and the urine is draining freely into the urinary drainage bag. Catheter care, as described below, should be provided daily to prevent the possibility of an infection.
Discharge planning
r
Encourage the patient to continue taking 2.5 L of fluid daily to ensure that the urine output is clearr
Ask the patient to observe the colour of the urine. If bleeding is observed, he or she should consult his doctor immediatelyr
Avoid becoming constipated as straining during defaecation could put pressure on the urethral passage and cause bleeding (Walsh, 2002)r
Some would suggest that patients should avoid sex (including masturbation) for about 3 weeksCatheter hygiene
Urinary catheters are used to remove urine from the bladder or to instil fluid or drugs into the bladder. Urinary catheters come in various sizes and there are different types of catheter made from different types of materials. When catheterising a patient, nurses should ensure that they use the correct size catheter, i.e. 12–4 Fr (Ch) (Marjoram, 1999).
A catheter between 10 and 12 Fr (Ch) is recommended for women and between 12 and 14 Fr (Ch) for men. An incorrect catheter size may result in damage to the urethra during insertion and can cause urethral scarring and stricture.
Reasons for catheterisation
r
Acute or chronic urinary retentionr
Preoperatively and postoperatively in abdominal, rectal and pelvic surgeriesr
For administration of drug treatments, for example cytotoxic drugsr
To irrigate the bladder to remove blood clots or sedimentTeflon-coated catheters reduce urethral irritation and may be used for patients who need short- to medium-term catheterisation. This type of catheter may remain in situ for up to 1 month. Silicone catheters have a longer life span compared to Teflon-coated catheters, which may remain in situ for approximately up to 3 months. The hydro- gel catheters absorb water and cause less friction when catheterising a patient. These catheters may last in situ for up to 4 months (Marjoram, 1999) (Table 7.2).
Nursing care
Patients with a urinary catheter in situ should be encouraged to drink at least 2.5 L of fluid per day, provided they do not have other physiological problems such as cardiac
Table 7.2 Some types of catheters.
Types Description
Teflon The rubber is Teflon coated
Short- to medium-term use Silicone-coated latex Soft and causes less irritation
Catheter may be left in situ for up to 3 months
Hydrogel-coated latex Absorbs water and are easy to insert Last up to 12 weeks in situ
failure. Approximately 2–2.5 L of fluid normally results in an increase in urine production, which in turn will help to prevent urinary tract infection. It is important that the nurse maintains an accurate fluid balance chart for monitoring input and output.
If necessary, daily meatal hygiene should be undertaken to ensure that the patient does not develop urinary tract infection. Routine personal hygiene is all that is needed to maintain meatal hygiene (Pratt et al., 2001). For uncircumcised males, gently retract the foreskin over the head of the penis away from the catheter. Using soap and clean water, cleanse around the meatus. Gently apply tortion to the catheter and clean away from the tip of the penis where the catheter enters the penis, wiping 7–10 cm down the tubing towards the catheter bag (Smith et al., 2004).
When cleaning the meatus of the penis, the nurse must ensure not to introduce any infection into the bladder. Ensure that the catheter bag is not lying on the floor and that it is attached to a catheter bag stand. Furthermore, make certain that there are no kinks in the catheter drainage system that might prevent the urine from flowing unimpeded into the bag (Smith et al., 2004). All care and outcomes must be documented accordingly to ensure that the care provided is based on an individual assessment of the patient’s needs.
Conclusions
The overall aim of this chapter was to provide the reader with insight into some of the problems associated with elimination and the care of a patient with certain disorders connected with the alimentary and eliminatory tracts. The content of this chapter in- cluded disorders of the gastrointestinal tract and the urinary system. It is not possible to include all the disorders related to these areas; some of the more common problems have been discussed in this chapter.
Attending to the patient’s elimination needs is an important part of holistic care. Nurses are often involved in assisting or giving advice to patients who have elimination problems.
These problems could affect the patient both psychologically and physically. The inability to defaecate and urinate may be caused by various disorders, for example carcinoma.
These disorders may impinge on the patients’ ability to perform their activities of living.
Some patients may need assistance with defaecation in the form of suppositories or enemata, whilst others may need a colostomy as a result of cancer of the colon.
Patients who are catheterised for urinary problems such as retention of urine or male patients who have had prostatectomy and have a catheter in situ will need catheter care
in order to prevent urinary tract infection (Dougherty and Lister, 2008). The nurse must provide evidenced-based care resulting from individualised and holistic assessment.
Glossary
Accessory organs Organs that contribute to digestion but are not part of the digestive tract Cardiac region Surrounds the cardiac orifice through which food enters the stomach Chyme Semisolid substance containing partially digested food and gastric juices
found in the stomach
Electrolyte Chemical substances such as salts, acids and bases found in the blood and other body fluids
Emulsify The dispersion of large fat molecules into smaller molecules in the presence of bile
Endocrine A ductless gland that secretes hormones into the blood stream Enzymes A substance that speeds chemical reaction
Exocrine A gland that secretes hormones into ducts that carries the secretions to other sites
Homeostasis A state of equilibrium of the internal and the external environment of the body
Mastication Chewing process
Peristalsis Wave-like movements of the intestinal tract that helps to move foodstuff down the intestine
Pyloric region Funnel-shaped portion of the stomach where the pyloric sphincter is situated, which controls emptying of the stomach
Sensory receptors Specialised neurons that detect changes or respond to a stimulus Ulcer An erosion or loss of continuity of a mucous membrane, which may lead to
the formation of pus
Vestibule Enlarged area at the beginning of a canal
Post-chapter quiz
1. List the digestive juices of the stomach 2. List the functions of the colon
3. Describe chemical and mechanical digestion
4. Is the gallbladder essential for the digestive process? Explain your answer 5. Which position will you ask the patient to lie in prior and during the administering
of enema or suppositories? Explain your answer 6. Identify the reasons for the formation of a colostomy 7. What is the primary function of the urinary system?
8. Discuss the possible complications of bladder irrigation
9. What actions should the nurse take in attempting to reduce urinary tract infec- tion in those patients with an indwelling urinary catheter?
10. List the roles and functions of the multidisciplinary team with specific reference to caring for people with elimination problems
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