Observe patient's voiding pattern. Document urine color and characteristics, intake and output, and patient's daily weight. Report any changes. Urine characteristics help to identify potential problems.- Assess for dehydration (poor skin turgor; flushed, dry skin; confusion; dry mucous membranes; fever; and rapid, thready pulse). Dehydration leads to decreased circulatory blood volume and decreased urine output.
- Palpate the abdomen above the symphysis pubis every 2 hours to detect bladder distention and the degree of fullness.
Administer appropriate care for the urologic condition and monitor progress (e.g., strain urine). Report favorable and adverse responses to the treatment regimen. Appropriate care helps patient recover from the underlying disorder. Reporting responses to treatment allows modification of the treatment, as needed.
Explain reasons for therapy and intended effects to patient and family members to increase patient's understanding and build trust in caregivers. If urinary diversion is needed, prepare the patient for a change in body appearance (instruct patient and family members how to care for the ostomy site postoperatively). Preparation and appropriate information helps patient and family members cope with changes.- If patient requires surgery, give appropriate preoperative and postoperative instructions and care. Accurate information allows patient to understand the procedure and builds trust in caregivers.
- Assist with bladder elimination procedure as indicated.
- For bladder training, place patient on the commode or toilet every 2 hours while awake and once during the night. Maintain regular fluid intake while patient is awake. Provide privacy. Teach patient how to perform Kegel exercises to strengthen sphincter control. These measures aid adaptation to routine physiologic function. Women with good muscle tone can improve levator muscle action significantly if they perform Kegel exercises regularly.
- For intermittent catheterization, catheterize patient using clean or sterile technique every 2 hours. Record amount voided spontaneously and amount obtained with catheterization (e.g., 7 a.m., spontaneous void of 200 mL; catheter void of 150 mL). Record bladder balance daily. These measures promote normal voiding, prevent infection, and help maintain integrity of ureterovesical function. Catheterization schedule is based on flow sheet data and can provide a baseline chart.
- Monitor bladder balance for amount of residual urine/amount of voided urine.
- For external catheterization (in a male patient), monitor patency. Apply a condom catheter according to the established policy. Applying a foam strip in a spiral fashion increases the adhesive surface and reduces the risk of impairing circulation. Avoid constriction. Observe the skin condition of the penis, and clean with soap and water at least twice daily. These measures prevent infection and ensure therapeutic effectiveness.
- For an indwelling urinary catheter, monitor patency. Keep the tubing free from kinks, and keep the drainage bag below the level of the bladder to avoid urine reflux. Clean the urinary meatus according to the established policy, and maintain a closed drainage system to prevent skin irritation and bacteriuria. Secure the catheter to patient's leg (female) or abdomen (male); avoid tension on the sphincter. Anchoring the catheter avoids straining the trigone muscle of the bladder and prevents friction leading to inflammation.
- For a suprapubic catheter, monitor patency. Change the dressing, and clean the catheter site according to policy. Keep the tubing free from kinks; keep the drainage bag below bladder level. Maintain a closed drainage system. Suprapubic drainage allows increased patient mobility and reduces the risk of bladder infection.
- Provide supportive measures, as indicated:
- Encourage fluids, as ordered, to moisten mucous membranes and maintain fluid balance.
- Refer patient to a dietitian for instructions on diet. Dietary changes may decrease urinary infections.
- Assist with general hygiene and comfort measures, as needed. Cleanliness prevents bacterial growth and promotes comfort.
- Maintain the patency of catheters, drainage bags, and other urinary elimination equipment to avoid reflux and risk of infection and ensure the effectiveness of therapy.
- Provide meatal care according to facility policy to promote cleanliness and comfort and reduce the risk of infection.
- Provide privacy during the toileting procedure to avoid inhibiting elimination.
- Respond to patient's call bell quickly, assign patient to the bed next to the bathroom, and have patient wear easily removed clothing (such as a gown rather than pajamas). These measures reduce delay and impediments to the voiding routine.
- Alert patient and family members to the signs and symptoms of a full bladder: restlessness, abdominal discomfort, sweating, and chills. Adequate education increases patient's and family members' ability to maintain health level and to prevent patient from harming himself.
- Instruct patient and family members on catheterization techniques to be used at home; provide time for return demonstrations until they can perform the procedure well. Knowledge of procedures and rationales reduces anxiety and promotes comfort. Demonstrations may progress through several sessions until patient can perform independently.
- Encourage patient to ventilate feelings and concerns related to his or her urologic problem. Active listening conveys respect for patient; ventilation helps pinpoint patient's fears.
Refer patient and family members to a psychiatric liaison nurse, sex counselor, or support group, when appropriate. These resources help patient gain knowledge of self and the situation, reduce anxiety, and promote personal growth. Community resources usually provide support and care not available in other health agencies.- Explain the urologic condition to patient and family members, including instructions on preventive measures, if appropriate. Prepare for discharge according to individual needs. Accurate health knowledge increases patient's ability to maintain health. Involving family members assures patient of continued care.
Suggested NIC Interventions
Anxiety Reduction; Fluid Management; Urinary Elimination Management; Urinary Retention Care; Weight Management; Urinary Bladder Training; Urinary Catheterization |