316 Unit 15 urological nursing interventions – Flashcards

*Restore and maintain patency when catheter is obstructed with sediment from stagnant urine or blood clots *Maintain patency of catheter in post-operative period following bladder/prostate surgeries *Instill medications (antiseptics, antibiotics) into bladder

* Open Intermittent Irrigation * Closed Intermittent Irrigation * Closed Continuous or Continuous Bladder Irrigation (CBI)

*Can be done on double or triple lumen catheter *Performed by disconnecting catheter from drainage system and instilling sterile solution (room temperature) *Requires aseptic technique, 60 ml catheter tip syringe *Start with 30 mL, repeat up to 3 times to a maximum of 120 mL, then call doctor if unable to irrigate or absence of irrigate in output *Irrigation may not be tolerated by patient, can try aspirating, requires cystoscopy otherwise to remove clots *Done with caution as excess pressure can cause disruption of suture lines in bladder

*Same process as Open Intermittent except for... * need 60 ml luer lock tip syringe (in order to attach needle) * need sterile 19-22 gauge 2.5cm needle * catheter clamp * catheter and catheter bag tubing remain attached for this process * use port on catheter bag tubing as access for needle/syringe containing irrigation solution

*Most common procedure for BPH...benign prostatic hyperplasia *Enlarged prostate decreases ability to urinate *Prostate is reached via urethra thru tiny incision in bladder neck *Large #22-26g three-way Foley catheter is inserted & connected to CBI *CBI required due to vascular nature of prostate & bladder...prevents clotting and obstruction of urethra, clots in bladder

1. Alpha1 adrenergic blocker- Tamsulosin (Flomax) * *2. Androgen Hormone Inhibitor- Finasteride (Proscar)

*Also called closed continuous irrigation *Requires aseptic technique *Need doctor's order to initiate, patient may arrive from OR with CBI running *Irrigation occurs with 3000mL bags of sterile NS infusing thru irrigation lumen while drainage exits via drainage lumen *Infusion is run fast enough to clear clots *Infusion rate should equal drainage rate

Meticulous aseptic technique is essential * Ensure Irrigation bags do not run dry * If urine is red and contains clots consider speeding up the irrigation----REPORT THIS * If urine clear (you can see through the drainage) consider slowing down the irrigation----- REPORT THIS * LPN...know agency policy re: scope of practice KGH... *Catheter drainage bags are left open and drain into a bucket *Change NS bag q24h *Change irrigation set q72h maximum

Usually bedrest x 24 hrs *Monitor VS q4h, more frequently if unstable *Moderate bleeding (small clots ; pink to deep pink is normal) *Bright red with numerous clots may indicate hemorrhage - report to RN *CBI bags (usually two hanging), hang one bag higher then the other *Infusion rate is usually 40-60 gtts/min *Infusion rate must = outflow *Outflow less than infusion rate: *report to RN *stop infusion immediately *assess tubing patency and/or bladder distension *Assess for shock if returns are bright red *Hypotension, tachycardia *Pallor, diaphoresis, restlessness

*Assess for shock if returns are bright red *Hypotension, tachycardia *Pallor, diaphoresis, restlessness *Assess tubing patency...kinks can cause bladder distension, pain (bladder spasms) *Encourage fluids *If glycine (an amino acid) is used in solution, assess for hyponatremia...this solution is usually used in OR and discontinued in PACU *Muscle twitching, convulsions, confusion *LPN - monitors system, adds bags, empties drain bags, adjusts flow rates (system set up in OR) *Pt may need to lie flat if spinal anaesthetic used or HOB up to 30 degrees *Large drainage bag used and is drained into a large bucket that is rinsed after each use *Bucket emptied as per facility policy *When CBI d/c'd - 3 way catheter stays in place and irrigating lumen is plugged

*Kinks or occlusions in the system can cause bladder distention, pain (bladder spasms) *Milking tubing- What does this mean? * *Treatment- notify physician- may order intermittent irrigations until clots clear

Bladder irrigation is a procedure in which sterile fluid is used to prevent clot retention by continuously irrigating the bladder via a three-way catheter. Bladder irrigation is required due to the vascular nature of the prostate, and to a lesser extent the bladder and its potential to bleed in the post-operative period.

Sodium chloride 0.9% is the recommended solution. Water is not used as it may be absorbed via osmosis from the bladder, this may cause dilution of electrolytes in the circulatory system. Irrigation is usually discontinued when the urine has been only lightly blood stained for 24- 48hours

To remove blood clots from the patient's bladder. To prevent formation of blood clots in the patient's bladder. To ensure patency of urinary drainage system. To prevent injury to the bladder by toxic agents excreted in the urine. Occasionally used in the treatment of hypothermia Continuous bladder irrigation is initiated by the RN/LPN, upon a written physician's order.

The urinary catheter remains patent and urine is able to drain freely The patient's comfort is maintained Clot formation within the bladder or Indwelling catheter is prevented or minimized The patient's risk of Urinary Tract Infection is minimized, through use of aseptic technique when connecting bladder irrigation to indwelling catheter

A physician's order is required for Foley catheter insertion and continuous bladder irrigation (CBI) May use Urojet (sterile Xylocaine jelly. Use for both males and females, if no allergy) Note any special instructions e.g." Run slowly until clear." Use strict aseptic technique when handling any of the equipment to prevent introduction of microorganisms into the urinary tract. Insertion and maintenance of (three way) Foley catheter patency usually involves a closed drainage system. At KGH the surgeons allow drainage from the collection bag to go into a pail Saline solution for infusion should be stored and infused at room temperature to avoid bladder spasms. With the frail elderly and/or patients with a history of pelvic floor or bladder radiation; these patients are at high risk for bladder perforation.

Catheter blockage manifests as: * *Supra-pubic bladder distention *Severe discomfort in abdomen *Bypassing of fluid around catheter *Reduced/no urine output *Vasovagal symptoms...sweating, tachycardia, hypotension, rectal urgency

*Traction applied to provide tamponade to vessels of bladder neck area *Requires surgeon's order to apply *Tension is only put on the inflation limb of catheter and firmly secured with tape to patient's thigh *Usually 2-4 hours, confirm with doctor

*Electrolytes *Clotting Factors *CBC *PSA- Prostate Specific Antigen

*Type of irrigation used *Drainage *Sanguineous, rose, tea coloured, clear (can see through) *Clots *Size and frequency *Patient's response

Verify Physician's order to commence CBI Prime the irrigation delivery set to purge the air from the tubing. Height of solution bags not to exceed 70 cm. (2 ft). The urologists at KGH are happy with 30 cm (1 ft) from the bottom of the bag Open the roller clamps on both delivery lines. The bags may be staggered in height. This allows for better visualization of volume delivered and ensures the solution bags do not go empty at the same time If the output is to be monitored, open the clamp on only one bag at a time Do not completely fill the drip chamber because it will not be possible to monitor the rate of instillation Begin irrigation and continue as necessary depending on the degree of haematuria (ensure adequate supply of irrigant nearby) Visually check to see that the infusion rate equals the drainage rate. If not it may indicate a blockage of the catheter Run the infusion fast enough to clear the clots. If the orders state to run the irrigation until returns are clear, this means until no clots or sediment is present. The urine color may still be rosé. If the physician's order indicates strict input and output, after each bag is complete, empty urine drainage bag and record urine output on the fluid balance chart, prior to commencement of the next irrigation bag. The urologists at KGH feel it is ok to have an open system i.e. the drainage bag drainage tube can be left open to drain into a pail. Regular catheter care is required in order to minimize the risk of catheter related urinary tract infection (As per KGH Best Practice Guideline for Catheterization Urinary Catheter care provided should be documented in the progress notes and nursing care plan. Include patient comfort, urine color/degree of hematuria and urine output. Also record presence of clots, if any, and why manual bladder washout was necessary. Solution bags should be changed every 24 hours The irrigation set must be changed at 72 hours maximum

Clot retention (catheter blockage) manifests itself with suprapubic bladder distention, severe discomfort in the lower abdomen and passing of fluid around the catheter (bypassing). Other symptoms include reduced or no urine output, and vaso-vagal symptoms e. g. sweating, tachycardia, hypotension, rectal urgency. If the catheter becomes blocked during continuous bladder irrigation, the irrigation should be turned off immediately to prevent further discomfort to the patient Surgeons at KGH say the catheter can be manipulated if necessary to help clear the blockage Manual bladder irrigation is necessary when the catheter cannot be unblocked If the catheter cannot be unblocked using manual bladder irrigation, notify the Urology surgeon immediately. Re-catheterization should not be attempted by nursing staff following urological surgery (unless the nurse is experienced in Urology nursing and has been authorized to do so by the Urology surgeon) If catheter is to be removed and replaced 1) phone the Dr. and 2) usually go a size larger than the one being removed. Can go to 24-26. If clot evacuation is unsuccessful with this approach, the patient may undergo cystoscopy in the operating room with clot evacuation and fulguration of bleeding sites.

Manual bladder irrigation is used for clearing clot retention. Catheter blockage is a very common complication in postoperative irrigations. Up to 50% of long term catheters are changed prematurely due to catheter blockages Manual bladder irrigation involves flushing a urinary catheter by hand with a 60cc. catheter tipped syringe and normal saline. If the patient has had open bladder surgery, manual irrigation should only be done on the recommendation of the surgeon as increased pressure on the suture lines can result in suture line disruption and extravasation of urine, Instill the normal saline and allow it to drain via gravity. If there are no returns then actively aspirate using a 60cc.catheter tipped syringe

If application of traction to the catheter is ordered, it will usually be done by the physician at the time of surgery. If it has to be done on the floor it requires a physician's order. The inflation limb is the one traction is applied to and it should be left in place no longer than 2-4 hours. The traction is intended to provide a tamponade to the vessels of the bladder neck area. The inflation limb is pulled firmly and then taped to the patient's thigh.

Manual irrigation must proceed with caution on patients who have had the bladder surgically opened, as any excess pressure can cause disruption of the bladder suture line and extravasation of urine. If in the first 24hrs post TUPR the catheter cannot be unblocked, the Urology surgeon should be notified. The nurse must not attempt re-catheterization unless authorized by Urology surgeon as there is a danger of prostatic capsular perforation or subtrigonal catheter placement on re-instrumentation

Stop the irrigation. (Recalculate I ; O) Ensure that tubing is not kinked or looped below bladder level Palpate bladder for distention. (Use bladder scanner if available, to facilitate genitourinary assessment as per your unit's routine). If obstruction is suspected, gentle manual irrigation may be required as per physician's orders. Cleanse the catheter opening well with chlorhexidine. Use nothing smaller than a 60cc syringe and sterile saline. Use slow, even pressure to avoid damaging the bladder wall. Do not force if resistance met. Allow irrigation to flow back freely Notify physician if previous measures unsuccessful.

Increase rate of irrigation infusion Irrigation of catheter as outlined in #1 to aid in clot removal may be indicated. If large amount blood or clots persists, notify physician, monitor blood work e.g. Hgb and Vital Signs e.g. pulse, blood pressure.

Palpate or scan bladder to determine presence of distention Check drainage tubing for kinks Observe drainage for adequate amount, presence of clots that might be blocking drainage tube. Evaluate I ; O Avoid cold irrigation solution as it may cause bladder spasm

Full or distended bladder Assess if patient is orientated to time, place person Notify physician of patient's change in LOC Have relevant information ready to share with physician; e.g. amount of opioids received, amount of CBI received, true urine output, time of onset of alteration in orientation, Sodium level; in Transurethral syndrome (TUR) an overload of fluid through the prostatic sinuses can lead to dilutional hyponatremia, confusion and hypertension

Patient's comfort/pain level (how procedure is being tolerated) Colour and type of drainage, presence of clots/fragments Intake and output; use following calculation; CBI infused - Foley output = true urine output Interventions required (manual irrigation, use of bladder scanner) Health teaching done with patient and family Patient concerns/adverse reactions (e.g. continued bladder spasms, decreased total urine output), the nursing actions taken and patient outcomes

or distended bladder can cause the patient to experience autonomic dysreflexia. This is caused by an afferent stimuli trigger and causes an increase in blood pressure via a sympathetically mediated vasoconstriction in muscle, skin and splanchnic (gut) vascular beds. Patients experience remarkably high blood pressure (often with systolic pressures over 200 mm. Hg), intense headaches, profuse sweating, facial erythema, goose bumps, nasal stuffiness, and a "feeling of doom". An elevation of 40 mm. Hg. over baseline systolic should be suspicious for dysreflexia.

Assess for bladder spasms Refer to #1 - assessing for obstruction Consider administering antispasmodic e.g. Buscopan, O; B suppositories

Dressing pack x1 Catheter tip 60ml syringe x1 Chlorhexidine swabs 70% alcohol Blue pad Unsterile jug 500ml bottle Normal Saline PPE i.e. sterile gloves, goggles and apron