PURPOSE: CONSIDERATIONS: Note

Urinary – Bladder Training: Non-Neurogenic BladderStrength of Evidence Level: 3PURPOSE:To keep the patient dry and free from odor; to preventurinary tract infections and preserve renal function; tohelp the patient maintain social acceptance.CONSIDERATIONS:1. The following are important to patient teaching andplanning a bladder training program:a. Patient’s emotional attitude and motivation tobe dry.b. Patient’s ability to cooperate.c. Patient’s understanding of his/herresponsibilities in the training program.2. During the training period, it is suggested that fluidsbe spaced throughout the day and limited in theevening. Serve small amounts (100-150 mL)frequently. Vary the flavor, color, temperature,container and beverage.3. Fluid intake should total 1500-2500 mL a dayunless the patient is on a fluid restriction. If thepatient has been drinking less than 250 mL a day,do not expect him/her to start drinking this amountimmediately.4. Regularity is the key to success.5. The nurse should evaluate the feasibility ofinstructing the patient in self-catheterization inconjunction with bladder training.6. Obtain physician order for frequency of evaluationfor residual.EQUIPMENT:Bladder scanner (optional)Intermittent catheter kit (optional)Toilet hatsPROCEDURE:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Instruct patient to void every 1 to 2 hours, theinterval may be lengthened as control is gained.4. Give patient a measured amount of fluid to drink(100-150 mL).5. Instruct the patient to wait 30 minutes and then askpatient to attempt to void.a. Position patient with thighs flexed, feet andback supported.b. Instruct patient to press or massage overbladder area or increase intra-abdominalpressure by leaning forward, which helps toinitiate evacuation of bladder.c. Have the patient move around on the toilet tochange position and attempt to void a secondtime.6. Have the patient keep a voiding calendar - acontinuous record of time and amount of fluidingested and time and amount of each voiding.SECTION: 11.057.8.9.Encourage the patient to hold urine until specifiedvoiding time if possible.Assess for signs of urinary retention, test (bladderscan or catheterize) for residual urine, as directed.Encourage patient to continue self-care andexercise programs. Encourage patient to wear ownclothing to promote normal activities.Patient with Indwelling Catheter:1. Remove catheter.2. Proceed with bladder training.Bladder Training:1. Teach Kegel Exercises.2. Have patient keep a voiding diary for 3 days,during the day only. Record: Time voided, amountvoided, whether patient was dry at voiding, if wet atvoiding, and precipitating factors (running water,sneeze, etc.).3. Review diary with patient to discern shortest periodpatient is able to remain dry. Initiate bladdertraining program.a. Patient voids upon arising.b. Patient voids again at shortest interval able tostay dry per voiding diary (e.g. 15 minutes, 30minutes).4. Patient voids at shortest intervals (daytime only)until able to stay dry for 3 days.5. Patient increases voiding interval by 15 minutesand continues to increase by 15 minutes in order tostay dry for that interval for 3 days. DO NOT rushthis voiding increase, continue for 3 days.6. Teach patient relaxation exercises to promotecontinence.Relaxation Exercises:1. When you get the urge to urinate, DO NOT standimmediately.2. Take two deep breaths while quickly squeezingyour rectum.3. When the urge passes, stand up and SLOWLYwalk to the bathroom.4. As you walk, subtract 7 from 100 (100 - 7 93 -7 86 -7 79, etc.). This will occupy your mind andhelp prevent your bladder from emptying.AFTERCARE:1. Document in patient’s record:a. Procedure and observations.b. Instructions given to patient/caregiver.c. Response to procedure.

Urinary – BLANKStrength of Evidence Level: BlankSECTION: 11.06

Urinary – Clean Catch Urine Specimen CollectionStrength of Evidence Level: 3PURPOSE:To obtain voided, uncontaminated specimen forlaboratory analysis.CONSIDERATIONS:1. It is preferable to obtain early morning specimendue to concentration of sediment.2. Keep specimen refrigerated to prevent chemicalchanges if unable to transport specimen to the labimmediately.4. Transport specimen to the lab as soon as possible.Generally, microscopic examination should be donewithin 1 hour after collection to prevent bacterialgrowth.5. A “clean catch” urine specimen (one that containsno outside bacteria) is necessary for an accurateurine culture. Make sure that you or patient does nottouch the inside of the specimen cup.EQUIPMENT:Cleansing solutionGauze spongesSterile specimen containerGlovesImpervious trash bagPROCEDURE:Male patient:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Position patient to use toilet or urinal. Clean penisand area around meatus with cleansing solutioncleaning from urethra out to surrounding meatus.4. Allow initial urinary flow to escape into toilet orurinal.5. Collect midstream urine specimen in the sterilecontainer.6. Avoid collecting the last few drops of urine that maycontain prostatic secretions.7. Place the lid on the specimen container and writepatient's name, date, identification number and timeof collection on label.[Note: Some have to transfer the urine into a specialtube. Follow the manufactures directions.]8. Discard soiled supplies in appropriate containers.Female patient:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Position patient to use toilet or bedpan.4. Separate labia to expose the meatus and cleanseeach side of labia using a downward stroke withcleansing solution. Use 3 front to back cleansingpads/swabs.5. Instruct patient to void forcibly while continuing tokeep labia separated.SECTION: 11.076.7.8.Allow the initial urine to flow into the toilet or bedpanthen catch the midstream specimen in a sterilecontainer. DO NOT let specimen cup touch skin.Place the lid on the specimen container and writepatient's name, identification number, date and timeof collection on label.[Note: Some have to transfer the urine into aspecial tube. Follow the manufacturer’s directions.]Discard soiled supplies in appropriate containers.AFTER CARE:1. Instruct caregiver to take specimen to thedesignated laboratory immediately or deliver directlyto the lab yourself.2. Instruct laboratory personnel regarding specimen.3. Document in patient's record:a. Procedure and observations.b. Laboratory where specimen is taken.c. Instructions given to patient/caregiver.

Urinary – Cutaneous Ureterostomy, Transureterostomy CareStrength of Evidence Level: 3PURPOSE:To protect the skin, contain the urine and odor.CONSIDERATIONS:1. When the bladder has to be removed or urine flowdiverted from the bladder, a urinary diversion iscreated. There are many techniques used to createthese, such as cutaneous ureterostomy,transureterostomy, ileal conduit, etc. For thepurpose of this procedure, we refer to these asurostomies. Generally, the care and placement ofan ostomy appliance is the same.2. There are a variety of products that are used forurostomies. There are 1-piece, 2-piece ornonadherent appliances. Manufacturer’s directionsshould be followed when applying these devices.3. The other factor in choosing an appliance is theappearance of stoma and its location. There are flatappliance wafers and convex appliance wafers.Convex is usually used with flat stomas or stomaslocated in creases.4. Karaya is generally never to be used with urostomy.It does not hold up well to liquid drainage. Use ofextended wear wafers are generally used forurostomies such as Durahesive, Flextend, ExtendedWear depending on manufacturer.5. Generally, a bedside drainage system is used fornocturnal use.7.EQUIPMENT:12.Correct size of wafer and corresponding pouch for 2piece system or correct wafer size for 1-piece system.Paste or barrier rings/ strips (optional)Washcloth/gauzePaper/Cloth tape (optional)Skin prep (optional)Tampon or rolled up paper towel (optional)GlovesImpervious trash bagPROCEDURE:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Prepare equipment at bedside. Whenever possible,have all equipment ready and prepared to apply.4. Measure stoma at largest area.[Note: New stomas will need to be measuredfrequently for about 8 to 12 weeks, as they willdecrease in size.]5. After the size has stabilized, then a precut sizewafer may be used. Create a pattern to cut thewafer. Generally, the wafer is cut approximately to1/8 (one-eighth) inch larger than stoma. Removepaper backing from the wafer and set aside.6. Drain and remove existing appliance from thepatient. Save the valve cover/adaptor, if one is8.9.10.11.13.14.SECTION: 11.08used. If the physician has placed stents or othertubes into the stoma be careful not to pull on ordislodge these tubes.Use a clean washcloth or gauze to cleanse skinaround stoma with warm water and mild soap. Ifsoap is used, remember soap can build up on skininterfering with adhesion.[Note: Be cautious using “baby wipes” or soaps withmoisturizer in them, as they will interfere with waferadhesion to skin.]Rinse and pat dry. A tampon or rolled piece of papertowel may be used as wick to absorb urine whileapplying water, hold it over top of stoma.Skin protectant/barrier wipes is not usuallyrecommended by many manufacturers, as it mayinterfere with adhesion.Apply stoma adhesive paste or barrier rings/strips atthis time, if they will be used. It can be applied in asmall bead around the stoma or to the back of thewafer around cut opening for stoma. Allow to set upabout 1 minute.[Note: These products are to act as a barrier toprotect skin and/or a “caulking” to decreaseleakage. It does not help the wafer to stick to skin. Ifit is spread around on skin or wafer it will interferewith adhesion to the skin.]Apply wafer, making sure the skin is dry and nourine has dripped onto the skin. Gently smooth allareas of the wafer.Apply urostomy pouch (if using a 2-piece system)making sure pouch is secure by gently pulling onpouch after application. Position of pouch isdependent on facilitation of drainage.Confirm that the valve at bottom of urostomy pouchis turned in the off position, unless it is beingconnect to a drainage bag system. Apply cover capif needed.Discard soiled supplies in appropriate containers.AFTER CARE:1. Document in patient's record:a. Amount, color and consistency of urine.b. Condition of skin.c. Condition of stoma.d. Patient's response to procedure.e. Instructions given to patient/caregiver.

Urinary – Decontamination of Vinyl Urinary Drainage BagStrength of Evidence Level: 3PURPOSE:To provide a safe, effective and inexpensive procedurefor decontaminating urinary drainage bags.CONSIDERATIONS:1. Generally, a patient with an indwelling cathetershould have two bags of each type - leg andbedside drainage. These provide for a rotation ofbags during cleaning periods and an extra bag incase of damage.2. Leg and bedside bags should be decontaminateddaily after use.3. Usually bags that are decontaminated daily may bereused for 4 weeks. As a rule, when the catheter ischanged so should the drainage bags.4. Cleaning products that can be used todecontaminate are sold at medical supplies storesbut usually a 1:10 concentration (150 mL of cold tapwater and 15 mL of bleach) of household bleach(sodium hypochlorite 5.25% only) or a 1:3concentration of white vinegar only (1 quart of whitevinegar and 3 quarts of cold tap water; store in aclean gallon container).[Note: Bleach (sodium hypochlorite) solution shouldbe mixed daily because it will lose its strengthquickly and not be effective.]5. Bleach solution is preferred because it decrystalizessediment and inhibits bacterial growth. Safehandling of bleach must be taught. It bleach cannotbe used safely then vinegar solution is thealternative solution.6. Instruct patient/caregiver regarding the properhandling of bleach, including measures to preventinhalation or contact with the skin, eyes andclothing. Avoid bleach contact with stainless steel,chrome and other bathroom fixtures because it willcause rust or corrosion.EQUIPMENT:Household bleach 1:10 solution or white vinegar 1:3solutionCold tap waterGraduated irrigating bottle, 60 mL syringe, turkey basteror funnelGlovesPROCEDURE:1. Adhere to Standard Precautions.2. Obtain the prepared decontamination solution(bleach or white vinegar), approximately 200 mL.3. Empty all urine from bag into the toilet.4. Fill the bag with cold tap water. If it is a leg bag, fill itthrough the connector and extension tubing. If it is abedside bag, fill it through the top tubing with 200mL cold tap water.5. Vigorously agitate water in the bag for 10 seconds.SECTION: 11.096.Empty the water through the bag's drainage spigotinto the toilet.7. Repeat Steps 4-5 and 6. Rinsing must be donetwice.8. Instill the decontamination solution into the drainagebag using the irrigation bottle, funnel, turkey basteror 60 mL syringe. For bleach solution: Agitate thesolution in the bag for 30 seconds, ensuring that thesolution touches all inner surfaces of the bag. Forwhite vinegar solution, fill bag about 1/2 full ofsolution, close the tubing cap and drain and allow todwell for 30 minutes.9. If using bleach solution, drain the solution into thetoilet, avoiding contact with metal fixtures. DO NOTrinse bag.10. If using white vinegar solution, drain the solution,then rinse entire system with tap water, and drainagain.11. Hang bag with all caps and spouts open overshower/towel rail to air dry. Protect surface underwhere drying to prevent damage from any drippingdecontamination solution, especially bleach.12. Discard soiled supplies in appropriate containers.AFTER CARE:1. Document in patient's record:a. Procedure and observations.b. Instructions given to patient/caregiver.c. Patient’s/caregiver’s response.

Urinary – Female Urinary Pouch: Application and RemovalStrength of Evidence Level: 3PURPOSE:To collect urine by a one-piece external disposablesystem.CONSIDERATIONS:1. The pouch, designed to be worn externally, is madefrom odor-barrier film and features a foam-backedsynthetic skin.2. If needed, the pre-cut opening in the barrier may beenlarged to accommodate the anatomy of thepatient.3. The pouch outlet connects to tubing and may beattached to a bedside receptacle for continuous ornighttime collection.4. The pouch is primarily used for incontinent patientsin which an indwelling catheter is contraindicated.5. The pouch may be used to collect a clean urinespecimen.6. The pouch should be changed every 3-5 days.7. Use of this product may not be advisable for womenwith active genital herpes or chronic urinaryretention.8. Discontinue use of this product if any of thefollowing symptoms appear: swelling, severeredness, itching, pain, fever or abnormal vaginaldischarge.SECTION: 11.106.7.8.9.10.11.12.13.14.15.EQUIPMENT:1 female urinary pouch, e.g., Hollister One 0.5 oz. tube paste, e.g., Hollister Premium Paste Microporous adhesive1 packet skin-gel wipesBedside drainage system (optional)Waterproof, absorbent underpadSkin cleanser, e.g., soap, Pericare Impervious trash bagScissorsBasinWarm waterTowelGlovesRulerPROCEDURE:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Place patient in supine position with knees flexedand separated with a waterproof, absorbent padunder buttocks.4. Cleanse the external genitalia with soap and water;dry.5. Separate the labia (minora and majora) and pushback firmly to expose the urethral meatus,16.17.periurethral floor and vaginal introitus. (Refer tomanufacturer's instructions.)Approximate the size of the vulva opening, and thenrelease the labia.Using scissors enlarge the pouch opening so that itcorresponds with the measurement obtained. DONOT cut beyond the line indicated in the backingpaper.Wipe the genital area with the skin-gel wipe and airdry.Close the convenience drain cap on the pouch.Remove the protective paper from the skin barrier;apply a thin coat of paste around the opening of thepouch.Leaving the labia in a normal position, apply thepouch to the barrier to the perineum at the distalend. Gently press the barrier material against theskin until it is contacting the skin at all points.Press the barrier material against the skin for 1 fullminute, then allow the patient to assume a normal,comfortable position.Apply the strips of microporous adhesive on the rimof the pouch for added security.Draining the pouch: Remove the cap on theconvenience drain and empty the urine into anappropriate receptacle; replace the cap.For continuous or nighttime collection: Remove thecap on the convenience drain at the bottom of thepouch and attach the tubing from the bedsidereceptacle.Removing the pouch:a. Empty the pouch before removing it.b. If the pouch is connected to a bedside drainagebag, disconnect tubing and replace theconvenience drain cap.c. Remove the strips of tape.d. Ease the skin barrier away from the skin in thedirection of hair growth. A water-based jelly maybe used.e. DO NOT discard into the toilet.Discard soiled supplies in appropriate containers.AFTER CARE:1. Document in patient's record:a. Procedure and observations.b. Condition of perineal area.c. Patient's response to procedure.d. Instructions given to patient/caregiver.

Urinary – Ileal Conduit: (Urostomy) Application of Disposable ApplianceStrength of Evidence Level: 3PURPOSE:To protect the skin and contain the drainage and odor.CONSIDERATIONS:1. Depending on the type of pouch available, allappliances should be worn with a skin barrier, e.g.,Stomahesive Holihesive skin prep (checkmanufacturer’s recommended skin barrier).2. Karaya is never to be used with a urinary diversion,as it is water-soluble.EQUIPMENT:Correct size of Stomahesive wafer and correspondingurostomy pouchStomahesive pastePaper tapeBedside drainage systemGlovesImpervious trash bagPROCEDURE:1. Adhere to Standard Precautions.2. Explain procedure to patient.3. Prepare equipment at bedside.4. Pattern Stomahesive wafer to 1/8 inch larger thanstoma. Remove paper backing and set aside.[Note: If durahesive is used, it should be cut to fitsnugly against stoma.]5. Drain and remove existing appliance from thepatient, saving the valve adaptor, if one is used. Becareful not to pull on tubes.6. Cleanse stoma and peristomal skin with warmwater. Rinse and pat dry.7. Apply Stomahesive paste to base of stoma,moistening gloved finger when applying paste.8. Apply wafer, ensuring that the skin is dry and nourine has dripped onto the skin.9. Apply urostomy pouch. Position of pouch isdependent on ambulatory status. If the patient isremaining in bed the majority of the day, positionappliance to side of bed, allowing for easier flow ofurine. If ambulatory, position the appliance in aperpendicular position.10. Apply paper tape to all edges of pouch overlapping1/4 inch onto skin surface (picture-frame).11. Cap bottom of bag or connect to continuousdrainage system.12. Discard soiled supplies in appropriate containers.AFTER CARE:1. Document in patient's record:a. Amount, color and consistency of drainage.b. Condition of skin.c. Condition of stoma.d. Patient's response to procedure.e. Instructions given to patient/caregiver.SECTION: 11.11

Urinary – Insertion of Indwelling Catheter: FemaleStrength of Evidence Level: 3PURPOSE:To provide continuous urinary drainage through anindwelling catheter.CONSIDERATIONS:1. The Centers for Disease Control and Prevention(CDC) and the Agency for Healthcare Research andQuality (AHRQ) have identified four situations forthe long-term use of indwelling catheters, asappropriate:a. Urinary retention that cannot otherwise bemanaged.b. Management of terminally ill or severely illpatients.c. Management of patients with stage 3 or 4pressure ulcers on trunk until the ulcers arehealed.d. Management of urinary incontinence in homebound patient who is incapable or self-toiletingand whose caregiver is unable to manage theincontinence effectively any other way.2. Indwelling catheters must be ordered by a physicianand should indicate:a. If there is a frequency of change and size.b. If a specialty catheter, e.g., silicone or silvercoated, then a specific order should beobtained.c. If catheter is to be irrigated, with what solutionand frequency of irrigation.3. Small diameter catheters are preferred because thegoal is to minimize the distortion of urethra. Size ofcatheter for an adult is typically 14 to 18 French,unless patient has blood clots or sediment thatfrequently occludes the lumen.4. Evidence does not support routine monthly catheterchanges. Rather, nurses should monitor patientsclosely for signs of blockage or encrustations andshould change based on specific patient needs.Generally, the accepted frequency has beenmonthly but with frequency shorter or longerdepending on patient situation, verified with aphysician order.5. Patency can be maintained and prolonged byabsence of infection. High intake of fluids, correctplacement, handling and securing of catheter with astrap or securement device will help reduce risk ofinfection.6. Generally, at least one spare catheter should be leftin the home at all times.7. Per Joint Commission recommendations, all tubesand catheters should be labeled to prevent thepossibility of tubing misconnections.EQUIPMENT:Catheter insertion traySterile glovesPrepping ballsSECTION: 11.12Antimicrobial solutionWaterproof, absorbent underpadFenestrated drapeSterile lubricating jellyPre-filled 10 mL syringe of sterile waterPlastic forcepsGraduated basinSterile c

rate of infusion and how long continuous irrigation will be needed. 3. Note expiration date of irrigant solution. 4. Irrigation tubing should be changed every 48 hours. 5. Be sure that irrigation tubing fits correctly into irrigation solution container. EQUIPMENT: Irrigation solution Irrigatio