19.4 Nursing Management of Elimination

Assessing Bladder Function

The creation and elimination of urine alone do not guarantee normal or adequate fluid and electrolyte balance. The patient may be able to void light-yellow urine but still have a FVE or deficit and an electrolyte imbalance. The nurse must consider a full fluid and electrolyte assessment to determine if the patient is meeting the demands for homeostasis. However, one aspect of fluid and solute waste elimination is bladder function.

If the patient’s fluid and regulatory systems, discussed throughout this section, result in the formation of urine, then adequate bladder function is necessary to eliminate urine. If a patient is consuming or receiving adequate intake but is not eliminating urine, the nurse should perform a bladder assessment to determine if urine is present in the bladder.

The patient should be comfortably lying supine, and privacy ensured. Beginning with light palpation, the nurse will assess the lower abdomen. The bladder is below the umbilicus in the lower abdomen and is not palpable when empty. Using deeper palpation, the nurse should attempt to feel the base of the bladder. If the bladder is palpable, the nurse should continue to palpate, outlining the bladder. A bladder that is mildly full will be slightly firm and nontender, below the umbilicus. A bladder that is full may be firm and may extend above the umbilicus.

A more objective method to assess for the presence of urine in the bladder is to use a bladder scanner. To perform a bladder scan, place the scanner head about 1 inch above the symphysis pubis, pointing slightly down toward the expected bladder location. The screen will display an ultrasound image of the bladder. The bladder should be centered on the screen—often within a crosshair image. Once the nurse has the correct position, the scanner will scan the bladder and indicate a volume of urine within the bladder. Often, nurses will perform multiple scans to guarantee an accurate reading.

A straight catheter is used for intermittent catheterization of urine. The catheter is inserted to allow for the flow of urine and then is immediately removed, so a balloon is not required at the insertion tip. Intermittent catheterization is used for the temporary relief of urinary retention. It may be performed once, such as after surgery when a patient is experiencing urinary retention due to the effects of anesthesia, or several times a day to manage chronic urinary retention. Some patients may also independently perform self-catheterization at home to manage chronic urinary retention caused by various medical conditions. In some situations, a straight catheter is also used to obtain a sterile urine specimen for culture when a patient is unable to void into a sterile specimen cup. According to the CDC, intermittent catheterization is preferred to indwelling urethral catheters whenever feasible because of decreased risk of developing a urinary tract infection (UTI).

At times, the patient may be making urine and able to eliminate some urine, but not fully empty their bladder. If this is suspected, the provider may request a post-void residual (PVR) assessment. The nurse should ask the patient to fully empty their bladder, and then, using either a bladder scanner or straight catheterization, assess how much urine is left in the bladder. This amount is reported to the provider and/or documented. A PVR of less than 50 mL is expected if the bladder is adequately emptying. In older adult patients, that volume may increase to 100 mL and still be considered adequate emptying. A PVR of greater than 200 mL is considered abnormal, and a value of 400 mL or greater is considered a high amount of urinary retention (Ballstaedt & Woodbury, 2023). The provider should be notified of anything outside the normal range.

Incontinence

Urinary output can be difficult for the nurse to measure, and urinary elimination can be difficult for the patient to manage during urinary incontinence (UI). Urinary incontinence is a loss of urine from the bladder that is unplanned or uncontrolled. Urinary incontinence can range from an occasional small leak of urine to full bladder emptying.

There are several types of UI. To assist in determining what type the patient experiences, the nurse should ask the patient about urinary frequency, urinary urgency, and urinary leaking. Urinary frequency can indicate a type of UI called overflow incontinence. In overflow incontinence, the bladder does not fully empty during trips to the toilet, and incontinence occurs because the bladder is too full or overflowing. In this case, pharmacological treatment is directed toward medications that increase bladder contraction, which are cholinergic drugs, such as bethanechol (e.g., Urecholine). Urinary urgency may result in urge incontinence. Urge incontinence, often termed overactive bladder, results in the feeling of the need to urinate and urine leaking even when the bladder is not full. Typically, drugs that are anticholinergic, such as oxybutynin (Ditropan) are used to treat urge incontinence. Another type of urinary incontinence, stress incontinence, is the result of a weak urethral sphincter, weak pelvic floor muscles, or both, that allow urine to escape during times of increased intra-abdominal pressure, such as may occur with laughing, coughing, jumping, and so forth. Stress incontinence treatments often focus on increasing pelvic floor muscle strength. Kegel exercises are one example. Often, UI is a combination of two or more types and is called mixed incontinence.

Lastly, functional urinary incontinence may be the most difficult type of UI to manage. In functional UI, the bladder and support structures are functioning properly but other illness or disability prevents the patient from being able to access the toilet. Examples include patients experiencing dementia for whom acknowledging and communicating the need to urinate are challenging, or patients who require assistance to the toilet as a result of residual physical deficits from a cerebral vascular accident, falls, or other debilitations.

Most UI is treatable. Unfortunately, there is a misconception that UI is a normal part of aging and often is not addressed. Fifty percent of residents in long-term care facilities experience UI (McDaniel et al., 2020). Urinary incontinence is associated with a decreased quality of life and decreased interpersonal interaction due to embarrassment, frustration, depression, and loss of self-esteem. Additionally, UI is associated with a higher risk for skin integrity alterations, falls, and UTIs. It is estimated that medical cost associated with UI exceeds $5 billion (McDaniel et al., 2020).

Indwelling Urinary Catheter Management

An indwelling urinary catheter (IUC) is a urinary catheter that stays in the bladder for a time. The term “Foley catheter” is used interchangeably, although “Foley” is the brand name of a type of IUC invented by a man named Frederic Foley in 1929 (UroToday, n.d.). An IUC has two proximal lumens and an inflatable balloon on the distal end. The balloon volume can vary, but is generally 10 mL to 30 mL. The IUC is inserted through the urethra into the bladder. The balloon is inflated inside the bladder by injecting sterile water into one of the proximal lumens. The other proximal lumen terminates with a hole on the end of the catheter and drains urine into a collecting bag (Figure 19.13). In IUCs that have three proximal lumens, the third is for bladder irrigation. These are called “three-way IUCs.”

Figure 19.13 An IUC drains urine from the bladder into a collection bag. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

A catheter-associated urinary tract infection (CAUTI) is a common, life-threatening complication caused by IUCs. The development of a CAUTI is associated with patients’ increased length of stay in the hospital, resulting in additional hospital costs and a higher risk of death. It is estimated that up to 69 percent of CAUTI cases are preventable, meaning that up to 380,000 infections and 9,000 patient deaths per year related to CAUTI can be prevented with appropriate nursing measures (CDC, 2015).

Nurses can save lives, prevent harm, and lower healthcare costs by following key interventions (American Nurse’s Association, n.d.):

• Ensure the patient meets CDC-approved indications before inserting an IUC. If the patient does not meet the approved indications, contact the provider and advocate for an alternative method to facilitate elimination.
• According to the CDC, appropriate indications for inserting an IUC include the following:
  • end-of-life care
  • healing of open sacral and perineal wounds in patients with UI
  • hourly monitoring of urinary output in critically ill patients
  • perioperative use for selected surgeries
  • prolonged immobilization
  • urinary retention or bladder outlet obstruction
• Inappropriate reasons for inserting an IUC include the following:
  • prolonged postoperative care without appropriate indications
  • substitution of nursing care for a patient or resident with incontinence
  • to obtaining a urine culture when a patient can voluntarily void
• After an IUC is inserted, assess the patient daily to determine if the patient still meets the CDC criteria for an indwelling catheter and document the findings. If the patient no longer meets the approved criteria, follow agency policy for removal.
• When an IUC is in place, prevent CAUTI by following the maintenance steps outlined by the CDC.
• Continually monitor for signs of a CAUTI and report concerns to the healthcare provider.
• Signs and symptoms of a CAUTI to urgently report to the healthcare provider include fever greater than 100.4°F (38°C); change in mental status, such as confusion or lethargy; chills; malodorous urine; and suprapubic or flank pain. Flank pain can be assessed by assisting the patient to a sitting or side-lying position and percussing the costovertebral areas.

Dialysis

For some patients, the body is unable to adequately filter water, electrolytes, and waste products. In this case, the patient will require an external method to adequately clean the blood. These patients must undergo dialysis, a procedure to remove waste products and excess fluids from the blood when the kidneys are unable to do so. There are two types of dialysis: peritoneal dialysis (PD) and hemodialysis (HD). Both types of dialysis rely on water osmosis and solute diffusion between the blood and another compartment.

Assessment of the Access Site

The peritoneal catheter is placed percutaneously by a surgeon using a laparoscopic technique. The catheter is a flexible silicone tube with several holes inside and a closable external port. A cuff is present on the outside of the patient’s abdomen to prevent the catheter from migrating too far into the abdomen and to allow the catheter to be secured to the abdomen. In some cases, a cuff is also present under the skin surface. The nurse will assess and instruct the patient to monitor the insertion site for signs and symptoms of infection. Skin flora is the most likely cause of catheter insertion site infection, so the site should be cleansed with soap and water or another approved antiseptic and covered with a sterile dressing when not being used. Additionally, the site should be monitored for leakage around the catheter during use. Too much leakage can decrease the effectiveness of dialysis. The patient should report any concern to their nephrologist.

Monitoring for Complications

The nurse will instruct the patient to closely monitor how much dialysate is instilled and how much effluent (dialysate plus all waste) is returned. The patient’s nephrologist will provide an acceptable quantity of effluent, but the amount of effluent is always greater than the amount of dialysate. If all dialysate is not returned, the patient may need to reposition. In some cases, the peritoneal catheter may be clogged or dislodged. In such situations, the patient should seek urgent medical care. In addition to the amount of effluent, the nurse will educate the patient to note the color and clarity of the effluent.

Assessment of the Access Site

Hemodialysis access can take two different forms. A large-bore central venous catheter, often referred to as a Vascath, is a short-term HD access catheter. There is a significant risk of infection with Vascaths due to their size, location, and the frequency with which they are accessed. In most cases, nurses specially trained in HD care for HD catheters. However, the nurse caring for the patient will still assess the catheter insertion site for signs and symptoms of infection and monitor the patient for fever and/or white blood cell count elevation, Additionally, the nurse should assess the catheter dressing and ensure it is clean, dry, and intact. If there is drainage present or the dressing is not occlusive, the nurse should change the dressing using sterile procedure for central-line dressing changes.

A variation of the Vascath is the tunneled catheter. The tunneled catheter, commonly called a permacath, is also a large-bore central catheter, but the insertion site differs. The tunneled catheter is inserted several inches away from where it enters the vein. The catheter is inserted and then “tunneled” underneath the skin of the abdomen and/or chest wall before it enters the vein. In this way, skin flora and other organisms are not directly in line with the venous system and there is a lower risk of infection (Figure 19.16).

Figure 19.16 A tunneled HD catheter decreases the risk for infection. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

A more permanent HD access is a surgical procedure that connects an artery and a vein, usually in the patient’s upper arm. If the connection is made by opening and sewing together an artery and a vein, the result is called an arteriovenous (AV) fistula. If the connection is made using a graft, either from a blood vessel from the patient or a synthetic graft, the result is called an AV graft. In either case, a surgical procedure is performed, and the nurse will assess the patient for postsurgical complications and for incision healing. Additionally, due to the high blood flow through the fistula or graft, the nurse will assess for a thrill by gently palpating the fistula or graft site. A positive thrill feels like a vibration. The nurse will auscultate using a stethoscope and listen for a bruit over the fistula or graft site. A bruit sounds like a strong arterial whooshing. The patient should also be taught to also feel for a thrill. The presence of a thrill indicates blood is flowing through the fistula or graft. If the thrill and bruit are not present, the nurse and/or the patient should contact the nephrologist and the HD unit or clinic.

The nurse should teach the patient to avoid wearing any tight clothing or shirt sleeves near the HD access site. Patients should avoid carrying purses or grocery bags hanging from the affected arm. Patients should also be aware that no blood pressure cuffs or tourniquets should be used on that arm. In the hospital setting, the nurse should follow hospital protocol to notify other staff and ensure no blood pressure, IVFs, or blood draws occur on the affected side.

Monitoring for Complications

Several HD complications are related to the access site. Infection, sepsis, and air embolism are possible with HD catheters. Fistulas and grafts can occlude and leave the patient without HD access. Other complications are related to the rapid change in a patient’s fluid volume status and electrolyte levels. Hemodialysis is usually performed about three times each week. Prior to HD, patients may experience FVE, hypervolemia, hypertension, and altered electrolyte and acid-base balances. Immediately after HD, patients can experience hypovolemia and hypotension, and although electrolyte and acid-base balance is restored, the rapid change can cause nausea, vomiting, headache, and muscle cramping. Most patients report feeling fatigued after dialysis. The nurse will assess for manifestations of these alterations and focus on providing the patient rest.