Catheterization and Continuous Bladder Irrigation – Flashcards
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What does catheterization have an increased risk of? and what are the contributing factors?
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UTI - increased age - female - number of days in place - improper technique (lack of aseptic technique) -improper use
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What are the two types of catheters and what are the indications for both?
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*straight (intermittent): single lumen catheter, inserted to empty bladder and then removed (one time use) - used when patient cannot urinate r/t urinary obstruction or neurological disorder (eg. spinal cord injury) * indwelling: double lumen catheter (one inflates ballon and the other empties bladder) catheter left in place, either short or long term, to drain urine - post op (spinal anesthesia, bladder sx), urinary retention, when accurate measurement of output is necessary for disease process, urinary obstructions
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What size catheter would you use for a male and female? children? and how much would you fill the balloon with?
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female: 14 to 16 fr male: 16 to 18 fr (10 ml balloon) children: 8 to 10 fr with 3 ml balloon
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What assessment would you complete prior to initiating a catheter?
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-doctors order -reason for catheter -assess for correct size and type -assess for bladder fullness: when last urinated? palpable above synthesis pubis, bladder scanner *indicates need for catheter -level of awareness, able to participate -mobility and physical limitations -allergies r/t tape, antiseptics, lubricant, latex -assess perineum (can be done during prewash) -assess medical history for conditions that would affect passage of catheter (enlarged prostate) -instruct pt on procedure and assess understanding
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How much urine do you expect to see every hour?
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30 ml/hr
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What would you document post catheter insertion?
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-type & size of catheter -amount of initial urine collected -appearance of urine (colour, odour, cloudy etc) -amount of fluid in balloon -how patient tolerated -any difficulties with procedure -INS & OUTS started
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How far do you expect to advance catheter in a male? female?
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male: 17 to 22.5 cm female: 5 to 7.5 cm
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What would you do if you received no urine back with a female catheterization?
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-leave catheter in as a landmark, attempt to insert another one as you might be in the vagina
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As you begin to inflate the balloon, the patient looks visibly uncomfortable and expresses pain, what should you do next?
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-deflated balloon, advance catheter further and attempt to inflate again
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Why is testing the balloon by injecting fluid prior to insertion no longer considered best practice?
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-might stretch the balloon and can lead to damage of urethra and increased trauma with insertion
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Why is it best practice to complete peri care prior to starting process and initial clean with NS prior to insertion?
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- decreases chance of UTI (decreases chance of bacterial or pathogen entering)
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How would you cleanse the area for male? female?
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male: hold penis with non dominant hand, clean in circular motion with cotton balls from urethra meatus down base of gland, repeat three times - if uncircumcised: pull foreskin back gently female: using non dominant hand, spread labia to expose urethral meatus (may require assistant to hold light source to identify), using NS soaked cotton balls to clean down middle of vagina and outsides (non-dominant hand must remain in position throughout the whole procedure, otherwise contaminates sterile field)
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What are the benefits of securing tubing to leg post insertion?
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-reduces chance of accidental dislodgment -minimizes risk for bleeding, trauma, and bladder spasms from pressure and traction
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What are teaching considerations for a person with an indwelling catheter?
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-explain procedure to patient -explain they can cooperate and participate during -pressure and or burning during procedure is normal, instruct them to inform you if a break is required -positioning of catheter while in bed: no dependent loops, catheter bag below leg, -encourage fluid intake to keep urine dilute and prevent catheter encrustation and obstruction
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What would you assess prior to catheter removal?
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-observe urinary output and urine characteristics -assess hx or presence of bowel incontinence (fecal material irritates perineum and acts as a source of bacteria) -pt. knowledge of catheter care -discharge or redness around urethral meatus (indicates possible infection), pain -assess need for catheter removal: how long has it been in place? is there an order? agency policy regarding best practice for length of time catheter can be in place for, appearance and amount of urine -amount of NS in balloon (check lumen on tube)
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What are unexpected outcomes prior to or post catheter removal and what would you do?
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*urethral or perineal irritation -observe for discharge -if not removing catheter, make sure it is anchored
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Post removal of catheter, your patients has complaints of foul smelling urine, small frequent voiding, bring while urinating. He has a temperature of 38.4. What does this indicate and what would you do?
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-possible UTI - take vital signs and assess urine -notify dr.
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8 hours after catheter removal, pt. states they are unable to void, what would you do?
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-assess bladder for distention -use bladder scanner to determine urine retention, vol greater than 150ml indicates need for further catheterization -notify physician
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When would you use a bladder scanner?
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-assess for post-void residuals (10 to 15 mins after void), bladder distention r/t to inability to urinate secondary to medical condition Normal PVR = less than 50 ml
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What are some indications for continuous bladder irrigation?
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-prevent formation and to remove blood clots in the patients bladder -instil medication -prevent venous hemorrhage following genitourinary sx, TUPR, bladder cancer
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What are the nurses and physicians responsibilities with CBI?
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physician: - inserts 3-way (3 lumen) foley -writes order: type of solution, colour of desired output, rate of irrigation Nurse: -initiates and manages CBI
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What assessments would you complete for CBI?
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-assess drainage system every 30min until flow is consistently pink to clear in colour *Q4h & PRN -Vs -pt. comfort r/t instillation of fluid -patency of system *Q8H & PRN -for fluid leaking around catheter -condition of urinary meatus -inflow & outflow obstruction -bladder distention
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What are some potential problems related to CBI?
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-over distention of bladder and eventual rupture -bleeding and hemorrhage -pain (insertion or d/t over distention) -infection -TUR syndrome
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What are nursing actions to prevent over distention?
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-monitor input and output -assess for distention q 1-h -assess vol collected (what goes in must come out) -adjust rate to maintain clear drainage -irrigate prn as needed (if obstr. noted) -do not let drainage bags fill completely, bladder will be unable to empty in this case
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What is a suprapubic catheter?
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-insertion of urinary catheter directly into bladder through the lower abdominal wall
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What assessments would you complete in relation to a suprapubic catheter?
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-assess urine in drainage bag for amount, clarity, colour, door and sediment -observe dressing for drainage and intactness (drainage indicates potential complication or infection) -assess insertion sites for signs of inflm (redness, swelling, and discharge) -assess for fever -assess pt. knowledge and understanding of the catheter
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What does site care of a newly inserted suprapubic catheter consist of?
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-wash hands, close curtain -clean gloves, remove existing dressing (assess) -(remove clean gloves, wash hands) apply sterile gloves -use non dom. hand to hold catheter in erect position without creating tension, use sterile NS soaked cotton tips to cleanse site in circular motion moving outward -use moistened gauze to cleanse tube moving away from insertion site -apply drainage sponge
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What does site care of an established suprapubic catheter consist of?
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-clean gloves -cleanse site with warm water and soap in circular motion cleansing outward, dry completely
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What would you do in the event a suprapubic catheter becomes dislodged?
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-cover site with sterile dressing -notify dr. immediately
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What nursing actions would you take in the event a patient with a suprapubic catheter develops symptoms of a UTI?
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-encourage fluids to at least 2l/day, unless contraindicated -monitor INS/OUTS -assess VS and temp -notify dr
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What nursing interventions would you take in the event the skin surrounding the insertion site of a suprapubic catheter becomes excoriated?
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-notify dr -consult wound care nurses for possible barrier cream or skin protectant around site -change dressing more frequently if used to keep site dry
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How can you manage the pain of a pt. with CBI?
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-prevent over distention & clotting, proper rate of irrigation -proper taping to side of leg (no tension) -admin. analgesic to avoid spasm of bladder (require order) -increase mobility if possible (however, do so with caution as this increases intrathoracic pressure and could add to discomfort)
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What are signs and symptoms of urosepsis related to CBI? how would you prevent it?
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-chills, hyperthermia, rigours, fever, increased HR, increased RR, decreased BP, altered LOC, oliguria -prevention: aseptic technique keep bag below to prevent back flow no dependent loops encourage PO fluids VS q4h keep bag off of floor
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Assessing and managing obstruction of catheter with CBI.
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-observe lower abd. to ensure catheter has not become blocked -assess for bladder distention (result of obstr.): round swelling above the pubis -examine drainage bag, dressings and incisional site for bleeding (post op) -note colour of urine (change from pink to amber indicates decreased bleeding) -VS -observe for restlessness, cold sweats, pallor, increased HR and drop in BP
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What is important to note about the vol. of fluid being drained?
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- vol. should match the amount that has been instilled in the patient (what goes in must come out)
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How does CBI work?
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-catheter inserted into bladder, irrigation fluid (usually NS) washes bladder and drains -rate is adjusted according to pt. symptoms as well as colour of drainage (want to maintain pink/clear drainage)
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What are some indications for catheterization?
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-post surgical (spinal block) -relieve urinary retention -comfort in palliative care -instillation of meds -determine residual vol (straight cath) -strict output monitoring -risk reduction pre-op -stage 3 and 4 pressure ulcers : reduce risk of further skin breakdown d/t incontinence
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What are some nursing interventions / assessments to prevent hemorrhage related to CBI?
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-maintain drainage to clear to light pink (adjust flow rate) -perform VS a min of q 4 hrs -assess for bladder distention -assess whole patient (symptoms and labs: hct, hgb) -watch closely if concerned -
