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Terms in this set [181]
What do the kidneys do?
-Filter metabolic wastes, toxins, excess ions and water & excrete these as urine
-regulate blood volume, blood pressure, electrolyte levels, and acid-base balance
What is a Nephron?
-Basic
structural and functional unit of the kidney
-consists of bowman's capsule enclosing a glomerulus, a series of filtrating tubules and a collecting duct
How is Urine formed?
-filtration, reabsorption and secretion
Glomerular Filtration
process of urine formation
First step= filtration, occurs in the glomeruli. Blood pressure forces plasma, disolved substances, and small proteins out of the porous glomeruli into Bowman's Capsule to form a liquid caleld filtrate.
Normally small particles filtered from blood. If damage/inflammation, large molecules [blood cells, proteins] can pass. Affects ability to dilute and concentrate urine.
Glomerular Filtration Rate [GFR]
the amount of filtrate formed by the kidneys per minute.
How much urine is formed per hour?
50-60ml per hour
How much urine can your bladder hold?
1000-2000ml a day [LOOK UP IN NOTES JUST TO DOUBLE CHECK]
1500ml per day [the book says]
How long is the men's urethra versus the women's urethra?
men:
20cm
women: 3-4cm
What muscle expels the urine out of the bladder?
the detrusor muscle and the internal urethral sphincter relaxes = conscious urge to void
How much can a normal bladder store?
500ml, but it may distend when needed to a capacity twice that amount
Voiding can be voluntary due to what sphincter
the external urethral sphincter
How often do most people void?
5-6 times a day
What can increase urinations indicate?
-increased intake, diabetes mellitus, or a UTI
To void normally you need:
-normal functioning of the bladder and urethra
-brain, spinal cord and nerves supplying the bladder and urethra to be intact
As the concentration of urine solutes increases...
specific gravity increases
What is the specific gravity of distilled water?
1.00 because there are no dissolved solutes
Normal specific gravity for urine is
1.010-1.025
What can a low specific gravity mean?
A low specific gravity [ex. 1.001] can mean the kidney is ineffective in concentrating the urine
What can a high specific gravity mean?
The patient is dehydrated, ex. 1.029, or anything greater than 1.025
If a person is consuming lots of water and the SG becomes a 1.000 the color of urine will
become diluted and lighter in color to almost clear
If a person has diarrhea or vomitting, the urine will
darken as specific gravity rises
How much does a newborn void a day?
-15-60ml per kg of body weight of urine per day
-Newborns cannot concentrate urine very well
What is the specific gravity of a newborn's urine?
1.008
How many times may a newborn void during the first 24 hours?
25 times
Infants:
-may wet 8-10 diapers per day
-do not have voluntary control of voiding because the neuromuscular functioning is immature
Toddlers:
-toilet training beginning around 18-36 months
-must be able to control the external sphincter
-Enuresis: occasional wetting
Nocturnal enuresis
nighttime bed
wetting
-occurs in 5%-10% of 5 year old children
-males have higher rates then females
Older Adults:
-size and function of kidneys begin to decrease around age 50
-age 80: only 2/3 of the nephron are functioning
-decline in filtration rate
-normally does not create an imbalance unless an illness occurs
More problems with older adults
-bladder's elasticity declines
-need to urinate more frequently
-women: leakage: due to weakened walls
Why do people putt off voiding?
personal, sociocultural and environmental factors
Personal, Sociocultural and environmental factors
-anxiety: anxious or tense and cannot relax the abdominal
muscle
-lack of time: when they feel rushed
-lack of privacy: feel embarrassed or scared in a new environment
-loss of dignity: patients who need assistance
-cultural influences: need same gender in the bathroom with them
What substances increase urine production?
caffeine, coffee, tea, cola and chocolate [act like a diuretic]
How does alcohol increase urine production?
impairs the release of ADH resulting in increased production
What substances decrease urine production?
-salts, heavy exercise, or when fluid intake is inadequate [ these hold in/conserve water & fluids]
What medications help patients void? or make them want to void?
Diuretics: treat hypertension, edema and fluid retention by increasing the elimination of urine
What are the nephrotoxic drugs?
-Antibiotics: Gentamycin, amphotercin B
-high dose, long term use of aspirin or ibuprofen
Drugs used to treat bladder conditions:
-anticholinergics
-antidepressants
-antipasmodics
-muscarinic receptor
antagonists
-estrogen
- Botulin toxin = FDA approved for use in
overactive bladder r/t nerve damage
such as with spinal cord injury or MS.
what disorders can affect urinary elimination?
-infection or inflammation of the bladder, kidneys, or ureters [KUB]
-renal calculi or tumors
-hypertrophy [excessive growth] of prostate gland: in older men [begins to become cancerous or benign which
interferes with urine flow from bladder to urethra]
What disorders INDIRECTLY affect the urinary system?
-Cardiovascular and metabolic disorders: decreases blood flow through the glomeruli and this impair filtration and urine production
-Nervous Systems: affect the control of the urinary system -ex. neurogenic bladder occurs as result of impaired neurological function!
-Systemic Infection: causes kidneys
to reabsorb and retain water
-Immobility and impaired communication: may interfere with ability to get to bathroom
-Cognitive changes: may lead to incontinence, alter perception of urge to void
Urinary Tract Infections [UTIs]
Normally urine is free of bacteria, viruses, and fungi. A UTI occurs when microorganisms, usually E.Coli that live harmlessly in the colon, enter the urethra and begin to multiply
overwhelming the normal flora.
Urethritis or Cystitis
Urethritis
an infection limited to the urethra
Cystitis
infection that occurs when bacteria travels up the urethra and into the bladder
pyelonephritis
infection [UTI] that has spread/progressed upward to the ureters or kidneys
Risk Factors for UTI
-sexually active women
-spermicidal contraceptive gel
-pregnant women
-older women: loss of estrogen associated with menopause leads to drying of the mucosa
-men with enlarged prostate
-kidney stones
-indwelling catheter
-diabetes mellitus
-immunocompromised
-history of UTI's
Signs and Symptoms of UTI's
-back pain
-bladder spasms
-pain during urination
-frequency of urination
-urgency of urination
-foul-smelling urine
What are the classic signs of UTI's
-WBC,s pyuria, dysuria, urgency and frequency
What to educate your patient on about the UTI?
-drink at
least 8-10 glasses of water daily
-urinate on first urge
-wipe front to back
-wear cotton underwear
-urinate after intercourse
-Avoid bubble baths
Etiologies of urinary elimination
-obstruction
-swelling/inflammation
-neurological problems
-medications
-anxiety
What medications can cause temporary problems with urinary elimination?
-anesthesia, antihistamine, anticholinergics, tricyclic antidepressants
What is urinary incontinence?
lack of voluntary control over urination
What is incontinence associated with?
-skin impairment
-obesity
-UTI's
-depression
-social isolation
-increased caregiver
burden
Risk factor for incontinence
-older age
-neurological disease
-obesity
-sedentary lifestyle
-depression
-diabetes
What are the two major types of incontinence?
-transient
-established urinary incontinence
Transient:
acute or reversible, UTI's, stress and medications
Established urinary incontinence:
chronic or persistant
Types of urinary incontinence
1. urge
2. stress
3. mixed
4. overflow
5. functional
6. reflex
7. enuresis
8. Nocturnal enuresis
Urge incontinence
the involuntary loss of large amounts of urine accompanied by a strong urge to void. often referred to as overactive bladder
Stress
-Involuntary loss of small amounts of urine with activities that increase intraabdominal pressure such as sneezing, laughing, coughing and exercise.
-Causes might be pregnancy, childbirth, obesity, chronic constipation, and straining of stool
mixed
combination of urge and stress incontinence
Overflow
loss of urine in combination with a distended bladder
Causes include fecal impaction, neurological disorders, and an enlarge prostate
Functional
Untimely loss of urine when no urinary, or neurological cause is involved; no fix to it
Usually caused by physical disability, immobility, pain, external obstacles, or problems in thinking or communicating that prevent a person from reaching the toilet.
Reflex
Loss of urine when the person does not realize the bladder is full and has no urge to void
Commonly caused by CNS disorders and multisystem problems
Assessing the Urine
measuring urine output and conducting variety of bedside tests
What to do when measuring intake and output?
know what container to use and how much it will hold
Whats considered an intake fluid?
oral fluids, semi-liquid foods, ice chips, IV fluids, tube feedings, and irrigations
Whats considered a fluid output?
urine output, GI fluid loss such as emesis, liquid feces, drainage from suction devices or wounds
How to measure liquid feces?
in a hat
What other factors contribute to urinary output?
ability of heart to circulate blood, adequate kidney functioning and the ability of the patient to void
Freshly voided specimen
pour the urine into a specimen container labeled with the patient's name, the date and the time of collection
Clean-Catch Specimen
-wipe appropriately, front to back, catch urine mid-stream because initial flow of urine may contain microorganisms from the urethral meatus
Sterile specimen
-Aids in determining the presence of a urinary tract infection
-inserting a catheter into the bladder
-do not take urine from collection bag because that urine may be several hours old
24-hour urine collection
-may be prescribed to evaluate some
renal disorders by showing kidney function at different times of the day and night
-use large container and preserve all the urine voided in that 24hours
Routine Urinalysis
-most commonly prescribed laboratory
-used to diagnose renal, hepatic and other disease
-freshly voided sample
-DIPSTICK testing and or microscopic analysis
Acute renal failure [ARF]:
an acute rise in the serum creatinine level of 25% or more
Anuria
absence of urine
dysuria
painful or difficult urination
end stage renal disease [ESRD]
chronic rise in serum creatinine levels associated with loss of kidney function that must be treated w/ dialysis or transplantation. AKA Chronic Renal Failure [CRF]
Enuresis
involuntary loss of urine
frequency
the need to urinate at short intervals
hematuria
blood in the urine
micturition
to start the stream of urine
nephropathy
broad term meaning disease of the kidney
nephrotoxic
substance that damages kidney tissue
Some antibiotics [gentamicin, tobramycin, and amikacin] and NSAIDs, lead, and contrast media have the potential to be toxic to kidneys
nocturnal enuresis
involuntary loss of urine while asleep
oliguria
urine output of less than 400ml in 24 hours
pessary
incontinence device that is inserted into the vagina to reduce organ prolapse or pressure on the bladder
polyuria
excessive urination.
May be caused by excessive hydration, DM, DI, or kidney disease.
proteinuria
-presence of protein in the urine
-sign of infection or kidney disease
pyuria
Pus in the urine.
May
be caused by lesiosn or infection in the urinary tract.
urgency
sudden almost uncontrollable need to urinate
Dipstick Testing
-determine pH and specific gravity and the presence of protein, glucose, ketones and occult blood in the urine
-designed to detect a specific substance
What should you always do when handling urine?
wear gloves
Blood Studies
BUN and creatinine levels are commonly measured to assess renal function and hydration
Assessment of the urinary system
-voiding patterns, habits, past history of urinary problems
-physical examination of urinary
system
primary goal of urinary system
Patient will comfortably void approximately 1500 ml of light yellow urine in 24 hours
Promoting normal urination
-providing privacy, positioning, scheduling elimination, providing and monitoring fluid and nutrition and assisting with hygiene
Managing Urinary Retention
salt intake, medications, environment they feel comfortable going in
Urinary functioning as the problem:
-incontinence
-pattern alteration
-urinary retention
Urinary functioning as the etiology:
anxiety, caregiver role strain, risk for infection
Reasons to Catheter
1. obtain sterile specimen
2. drain for surgical purposes
3. patient cannot void themselves
What should you ask patients before inserting a catheter?
making sure they're not allergic to latex or iodine
What medications turn your urine a deep/orange/red?
Phenazopyridine hydrochloride [Pyridium]
-bladder anelgesic
Straight Catheter
single lumen tube that is inserted for immediate drainage of the bladder
-used for sterile specimen, or to relieve temporary bladder distention
Indwelling Catheter
aka foley or retention catheter
-continous bladder drainage,
double lumen tube, one is used for drainage and the other is to inflate the balloon,
-triple lumen, one tube is drainage/irrigation
Men usually need a....
larger lumen than women
Suprapubic catheter
-continous urine drainage, when the urethra must be bypassed
Caring for patient with indwelling catheter:
-prevention of UTI: keep bag below patient
-maintain free flow of urine
-maintain skin and mucosal integrity
What are the two types of bladder irrigation?
1. Intermittent: medication instillation
2. Continous: maintain potency when blood clots or debris is anticipated
what is the main reason for bladder irrigation?
Maintaining patency of the urinary catheter
A client that requires continuous irrigation requires what type of catheter
triple lumen
Removing the Catheter:
1. must clean around meatus and perineum
2. have patient notify you when their next void is
3. compare
intake and output for next 8-12 hours
4. palpate bladder for distention
5. Remove them at night so in morning the patient will have to void
Behavioral Interventions for Urinary incontinence
-lifestyle modification: limiting certain foods, if obese, losing weight
-Bladder Training: enable patient to hold more volume of liquid
-Scheduled Voiding: going at certain times every day, creating
habits
-Pelvic floor muscle rehabilitation: Kegal's exercises, strengthen perineal muscles
-vaginal weight training: small weighted cone is placed adjunct to vagina, patient will ambulate and retain weight for 15 mins
-Biofeedback: electrodes to skin
Pessary:
removable device inserted into the vagina, to relieve pressure of the pelvic organs on the urethra and is an effective treatment for stress incontinence
external occlusive device
removed before voiding
Internal utrethral meatus plug
disposable single-used plug, activities for stress incontinence,
Valved catheter
allows urine to be drained on schedule
bed alarm
wake the patient if incontinence occurs
external collection device
condom caths
Which catheter is the last resort?
The indwelling catheter
Cutaneous Uretostomy
rerouting of the ureters to the surface of the abdomen
Illeal Conduit/Ureal stomy
removal of portion of ileum taken to abdominal wall with stoma
Continent Urinary Reservior
surgical pouch is created
Neobladder
mimics function of the urinary bladder, portion of intestines is made into reservoir connected to urethra
Urinary elimination
AKA: voiding, micturition.
- Occurs when contraction of the detrusor muscle pushes stored urine through the relaxed internal urethral sphincter into the urethra. This triggers the conscious urge to void.
- voiding may be voluntarily delayed by inhibiting the release of a second external urethral sphincter. When the person is ready to urinate, the brain signals the external sphincter to relax and urine flows through the urethra.
- further contraction of the detrusor muscle normally forces out any urine remaining in the bladder. After the detrusor muscle relaxes, the bladder begins to fill with urine again.
Urinary elimination continued
Process:
- filling of the bladder to 200-450 mL of urine.
-
activation of stretch receptors in bladder wall.
- signaling the voiding reflex center
- contraction of detrusor muscle.
- conscious relaxation of external urethral sphincter.
15 to 60 mL per kg
Produce 8 to 10 wet diapers per day
No voluntary control
infants
Older adults
Decline in GFR is the most important
functional deficit caused by aging.
- Kidney function decreases
- Urgency and frequency common
- Loss of bladder elasticity and muscle tone leading to nocturia and incomplete emptying and reduced volume of bladder
- nocturnal frequency and urine retention increasing risk for infection.
Anxiety, lack of time, lack of privacy, and loss of dignity can affect the ability to urinate.
Personal Factors Affecting Urinary Elimination
toileting assistance to be provided by a person of the same gender, or they will wait until a visit from a family member before acknowledging their need for help with voiding.
Sociocultural Factors Affecting Urinary Elimination
which substances act as diuretics and increase urine production?
that contain caffeine, such as coffee, tea, cola, and chocolate
Consuming large amounts of alcohol impairs the release of
antidiuretic hormone [ADH], resulting in increased production of urine.
which substance causes water retention and decreases urine production.
salt
high doses or long-term use of aspirin and ibuprofen can be
nephrotoxic [damaging to the kidneys].
renal calculi
kidney stones
in older men, what could cause impair urinary elimination
hypertrophy of the prostate gland
GFR
Glomerular filtration rate:
amount of filtrate formed by the kidneys per minute.
- decreases with age due to decreased blood flow.
Normal urination patterns
Kidneys produce urine at a rate of about 50 to 60 mL per hour or 1500 mL per day.
- output may fluctuate by 1000 mL to 2000 mL depending on various factors.
- most people void about five or six times
per day, even eight times is normal.
Pyriduim
Turns urine bright orange
Anticholinergics
prevent bladder spasms, increasing its capacity, and delaying the urge to avoid for people with urge incontinence.
- given orally or transdermally
Specific gravity
Measure of dissolved solutes in a solution.
- as concentration of solutes increases, specific gravity increases.
- Low specific gravity may indicate the kidney is ineffective in concentrating urine.
- high specific gravity means the person is dehydrated.
- as more water is ingested urine becomes dilute and lighter in color and approaches a specific gravity of 1.000.
Antidepressants
Can reduce stress incontinence by causing bladder muscles to relax. Some drugs work by stimulating the nerves controlling the urethral sphincter.
Antispasmodics
Relax the bladder and prevent urge incontinence. Overactive bladder.
Muscarinic receptor antagonists
Block nerve receptors in the smooth muscle of the bladder.
- Control
bladder contraction and reduces urinary frequency for those suffering from overactive bladder and urge incontinence.
Estrogen
for postmenopausal women when incontinence is secondary to atrophic vaginitis.
Botulinum toxin
Injections to control spasms of overactive bladder by relaxing the muscles. Approval for use an overactive bladder related to nerve damage such as with spinal cord injury or MS.
Pathological conditions:
Disorders of the urinary system that affect urinary elimination include:
infection or inflammation of the
-bladder
-ureter's
-kidneys
renal calculi or tumors, hypertrophy of the prostate glan
-which obstruct the normal flow of urine
Pathological conditions: cardiovascular and metabolic disorders
Decrease blood flow to the glomeruli and thus decreases filtration and urine production.
Nervous system
Affect control of urinary system organs impairing urinary elimination.
- neurogenic bladder occurs as a result of impaired neurological function
Immobility and impaired communication
Interferes with the ability to get to the bathroom in time or to communicate need for assistance.
- results in urination in inappropriate settings or at inappropriate times.
Cognitive changes
Alter the perception of the urge to void or severe psychiatric conditions involving altered perception or ability to manage activities of daily living may lead to incontinence.
UTI
[UTIs] occur when microorganisms, usually Escherichia coli [E. coli], which normally lives harmlessly in the colon
infection limited to the urethra is called
urethritis.
when bacteria travel up the urethra into the bladder causing a bladder infection
cystitis
Pyelonephritis
inflammation of the kidney and renal pelvis
Urinary retention
Inability to empty the bladder completely
caused by:
obstruction, inflammation and swelling, neurological problems, medications, anxiety.
medications associated with urinary
retention:
antihistamine, anti-cholinergics, tricyclic antidepressants.
Urinary incontinence
Lack of voluntary control over urination.
- affect about 2/3 of older adults to some degree.
- associated with the skin impairment, obesity, UTIs, self rated poor health, reduced mobility, depression, and increased caregiver burden.
- can lead to social isolation
Types of incontinence: Transient
Acute or reversible and characterized by sudden onset usually reversible signs and symptoms such as UTIs and medications, especially diuretics.
Types of incontinence: Urge
Involuntary loss of larger amounts of urine accompanied by a strong urge to void.
- Often called overactive bladder.
Types of incontinence: stress
Involuntary loss of small amounts of urine with activities increasing abdominal pressure.
- pregnancy, childbirth, obesity, chronic constipation, straining
- laughing, exercise, sneezing, coughing, lifting.
Types of incontinence: mixed
Combination of of urge and stress incontinence
Types of incontinence: overflow
Loss of urine in combination with a distended bladder.
- fecal impaction, neurological disorders, enlarged prostate.
Types of incontinence: functional
Lots of urine when no urinary or neurological cause is involved.
- inability of a usually continent person to reach the toilet in time to avoid
unintentional loss of urine.
- occurs from physical disability, immobility, pain, external obstacles, or problems in thinking or communicating.
Types of incontinence: reflex
Loss of urine when the person does not realize the bladder is full and has no urge to void.
- CNS disorders and multisystem problems.
- involuntary loss of urine at somewhat predictable intervals when a specific bladder
volume is reached
- tissue damage from radiation, cystitis, bladder inflammation, or radical pelvic surgery.
Nursing assessment: measuring I&O
Kidneys produce 50-60 mL/hour or 1500 mL/day.
- Record all fluid intake: Oral fluids, semi liquid fluids, ice chips, IV fluids, tube feedings, and irrigations instilled and not withdrawn immediately.
- Accord all fluid output: urine, G.I. fluid loss
from emesis, liquid feces, and drainage from suction devices or wounds.
- totals for each shift as well as for 24 hour period. In ICU may be hourly.
- use specimen hat container in toilet seat for mobile patients.
- specimen bag from Foley catheter.
Promoting normal urination
1. Provide for privacy.
2. Assist with positioning: whenever possible, assist the patient to the bathroom to use the toilet
and allow them to assume their preferred position.
- if patient is in bed place a female in the semi Fowler's position to urinate unless contraindicated.
3. Facilitate toileting routines.
Nursing diagnoses
Functional urinary incontinence
Impaired urinary elimination
Reflex urinary incontinence
Risk for urge urinary incontinence
Stress urinary incontinence
Urge urinary
incontinence
Urinary retention
Overflow urinary incontinence
Readiness for enhanced urinary elimination
Risk for infection, urinary tract
Risk for ineffective renal perfusion
As etiology
Anxiety related to urinary urgency and a recent episode of incontinence.
Disturbed body image secondary to new urostomy.
Social isolation related to frequent periods of incontinence.
Urinary catheterization: straight catheter
Single lumen tube inserted for immediate drainage of the bladder.
- to obtain sterile urine specimen, measure post void residual volume, or relieve temporary bladder distention.
- after the bladder is empty or the sample obtained, catheter removed and patient resumes voiding independently.
aka: red robin catheter
Urinary catheterization: indwelling catheter: Foley
Continuous bladder drainage.
- balloon holds catheter in place and is size according to the volume of fluid used to inflate.
- most patients you will use a 5 mL balloon for children a 3 mL balloon, and for achieving hemostasis after a prostatectomy, A 30 mL balloon.
- A triple lumen indwelling catheter or is used when the patient requires intermittent or continuous bladder irrigation.
Urinary catheterization: suprapubic catheter
Used for continuous urine drainage when the urethra must be bypassed.
- A suprapubic catheter is inserted through an incision above the symphysis pubis. Often sutured in place but may occasionally be a double lumen catheter held in place by a balloon.
Nursing care [for urinary catheter]
Prevent urinary
tract infection
Prevent backflow of urine
Encourage fluids
Ensure perineal hygiene
Managing urinary incontinence: pharmacological interventions
Estrogen may be prescribed for postmenopausal women when incontinence is secondary to atrophic vaginitis.
- for urge incontinence, medication may be used to relax the detrusor muscle and increase bladder capacity.
- for stress incontinence, drugs may be
given to improve urethral sphincter muscle functioning.
Managing urinary incontinence: surgical interventions
When incontinence is caused by cystocele, rectocele, or enlarged prostate, surgical techniques may be appropriate
fluid restriction is recommended for managing urinary incontinence if daily fluid intake is greater than
300 ml per day
Freshly voided specimen
To collect a freshly voided sample, collect the urine in the same manner as when you are measuring intake and output. Pour the urine into a specimen container labeled with the patient's name, the date, and the time of collection. Many facilities require packaging the container in a moisture-proof specimen-handling bag. Follow agency policy on additional packaging. Transport the specimen to the lab as soon as possible [according to agency policies]. If there is a delay in getting the specimen to the lab, most agencies recommend refrigeration.
Clean catch
The client must cleanse the genitalia before voiding and collect the sample in midstream because the initial flow of urine may contain organisms from the urethral meatus, distal urethra, and perineum. A midstream sample is free of these contaminants.
Sterile specimen
You can obtain a sterile urine specimen by inserting a catheter into the bladder or by withdrawing a sample from an indwelling catheter. Do not take the specimen from the collection bag because that urine may be several hours old.
24-hr urine
You must use a large container and preserve all urine voided in the 24-hr time period. Occasionally you will be asked to store each voiding in a separate container. To begin collecting, have the patient void and record the time. Discard this first voiding, but save all urine for the next 24 hr. Be sure to inform the patient and all staff about the collection. Post signs in prominent locations, such as the client's bathroom or entry door, to remind staff of the ongoing test and alert them to not discard urine.
Urinalysis
Urinalysis techniques include "dipstick" testing and/or microscopic analysis
refractometer
Instrument used to measure the specific gravity of urine
CDC [2009] Criteria for Indwelling Urinary Catheter [IUC] Insertion:
- Acute urinary retention [sudden and painful inability to urinate [SUNA, 2008]] or
bladder outlet obstruction
- To improve comfort for end-of-life care if needed - Critically ill and need for accurate measurements of I&O [e.g., hourly monitoring]
- Selected surgical procedures [GU surgery/colorectal surgery]
- To assist in healing open sacral or perineal wound in the incontinent patient - Need for intraoperative monitoring of urinary output during surgery or large volumes of fluid or diuretics anticipated
- Prolonged immobilization [potentially unstable
thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures]
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