1 URINARY ELIMINATION CARE OF THE PATIENT WITH AN INDWELLING CATHETER

Some important facts: u CAUTI – catheter-associated urinary tract infections u Most frequent type of infection u Can be deadly –Infection from catheter  blood system  travel to vital organs  death

I MPORTANT INFORMATION ABOUT THE LOWER URINARY TRACT u The bladder is a sterile cavity u Pathogens that enter the bladder can travel to: –Ureters  –Bladder and Kidney infections u Sterile Technique – major focus with catheterization

Male vs Female Urinary System u Kidneys and ureters u Bladder u Urethra

The Urinary Bladder, Ureters, Urethra u Internal sphincter u External sphincter

CATHETERIZATION u Introducing a rubber or plastic catheter through urethra into the bladder u Sterile procedure –Urinary tract is sterile –E. coli (found in stool)  UTI –UTI  kidney infections

R EASONS FOR C ATHETERIZATION u Urinary retention u Sterile urine specimen u Empty bladder before, during, or after surgery u Monitor critically ill patients u Obstruction or paralysis

P OTENTIAL R ISKS u UTI u Trauma to urethra

T YPES OF C ATHETERIZATION

Intermittent u Straight cath –Insert…drain bladder…remove –5-10 minutes –Single lumen –Harder plastic

u Coudé catheter –Curved tip –For patients with enlarged prostate

Indwelling Catheter u Retention or foley catheter –Remains in the bladder –Inflatable balloon –Double lumen

u 3-way foley cath –3 lumens –When used? –_________________ T.U.R.P. (prostate surgery)

O THER F ACTS ABOUT C ATHETERS

Catheter Size u French Scale for size: –the larger the gauge number, the _______ the size u Women Fr u Men Fr larger

Types of catheters u Latex – beware of allergies! u Plastic – for intermittent u Silicon or Teflon – long-term use

Facts about the Balloon u Anchors catheter inside person u Different sizes for different reasons: –5 mL – allows optimal drainage –30 mL ( ↓ bleeding after prostate surgery)

u Balloon size on catheter u example: #18 French - 5 ml u Use sterile water (not normal saline)

C LOSED D RAINAGE S YSTEM  Ensures sterility  ↓ infection u Continuous emptying of bladder u Accurate monitoring of urine output

Potential sites of Infection of Closed Drainage System u Site of insertion u Drainage bag u Sealed connection

N URSING M ANAGEMENT OF P ATIENT WITH I NDWELLING C ATHETER

A SSESSMENT u Drainage system patent u Urine: –Color –Odor –Volume

u S/S of infection: –Cloudy urine, odorous –Hematuria –Fever –Chills –Anorexia –Malaise –Mental status changes in the elderly –Positive urine cultures

u Tenderness in suprapubic area u c/o discomfort u Observe urine for adequate amount –Critical value = < 30 ml u No kinks or lying on tubing u No leaks u Catheter anchored properly

u No loops of tubing below edge of bed

N URSING D IAGNOSIS u Risk for infection (urinary) R/T placement of an indwelling catheter

G OAL u Patient will remain free of UTI while catheter is in place a.e.b. freedom from: –Burning of urinary meatus –Fever –Chills –Cloudy urine –Strong odor –Positive urine culture

I NTERVENTIONS u Prevent Infection: –Sterile technique during insertion of cath –Good hand hygiene –Use closed drainage system –Do not disconnect tubing; however  v If drainage tube becomes disconnected: v Wipe end of tubing and catheter with alcohol swab

u Use sterile syringe to obtain specimen

u Bag Hangs on bed frame or wheelchair –Should not touch floor –Do not hang on bed rail!

u Prevent pooling of urine in tubing u Prevent reflux of urine into bladder –Do not raise drainage bag above level of bladder –If you need to raise the bag during transfer, what can you do? – ___________ –____________ Clamp tubing Empty tubing contents into drainage bag first

u Position tubing so urine flows into bag u Before ambulation, drain all urine from tubing into drainage bag u When ambulating patient – put below pt’s waist u Avoid kinking u Avoid extra movement of catheter

u Empty drainage bag at least every ___ hours u Encourage fluid intake (if not contraindicated); cranberry juice helps –Amount: 2000 to 2500 ml/day 8

u Remove catheter as soon as possible u Tape or secure catheter securely –Tape –Leg bag u Perform routine perineal hygiene

C ATHETER I NSERTION u Assess: –Time of last voiding –Amount –Palpate lower abdomen for distention –Check for abdominal discomfort/restlessness, pubic pain, feeling of fullness –Check for sx of urinary infxn u Check Dr’s orders

45 HAZARDS IN PROCEDURE u Introduce organisms - may lead to infxn u May enter vagina of female –What would you do? u May inflate balloon inside urethra u Can traumatize male urethra (esp if enlarged prostate)

46 ROUTINE CATHETER CARE u Soap and water u Do not push catheter in u Do daily and PRN u Can teach patients how to do own care u Always include observation of catheter site as part of your initial assessment

CATHETER REMOVAL u Information needed before removal: –Dr’s order –Size of balloon –Know if a specimen is needed

u Removing catheter: –Give peri care before removing –Have warm wet washcloth and towel available to wipe area after catheter has been removed –Place chux or towel: v female: under buttocks v male: on thighs

–Wear gloves; have plastic trash bag; syringe to withdraw solution from balloon –Make sure all solution is withdrawn –Pull out in one steady motion –Be sure to measure urine before throwing drainage system away –Check with policy in facility re: where to discard catheter and drainage system

After Catheter is removed u Reinflate balloon –to determine that balloon is intact and not leaving a portion in the bladder –can chart that balloon is intact

51 Nursing Measures for 24 hours after removal: u Check first voiding for time and amount –Need to void by 8 hours after removal –Check intake, discomfort, distention, temp –If not voided by 8 hours notify MD u Check frequency; amount, color (blood) - may be slight burning u Increase fluids unless contraindicated –8-10 glasses per day (1 glass/hour)

u Check for signs of burning or pain (bladder spasms) u Keep accurate I & O for first 24 hours after removal u Instruct patient in I & O measures

u Observe urine for: –Color - Pale to straw-colored, amber, –What do the following colors indicate: v Dark red – v Bright red – v Dark amber color – v Blue or green – v Polk-a-dotted or striped -

u Odor –The more concentrated the stronger –Ammonia smell u pH – (4.5 – 8) u Specific gravity –Concentration of urine –1.010 to u No glucose, ketones, blood u Should produce cc/hr

u Clarity of urine –Transparent at voiding –Becomes cloudy after standing for several minutes or longer –Cloudy or foamy – kidney disease –Thick and cloudy - bacteria

Documentation u #14-5 cc Foley catheter removed with balloon intact. 300 cc clear yellow urine discarded. Instructed to measure urine, call nurse with voiding first time. Encouraged one glass water per hour. Denies discomfort.

OTHER CATHETERS

58 CYSTOCATH (suprapubic) u Through abdominal wall - used with surgeries for: – bladder –urethra –Uterus –perineum

u Usually drains for hours; u then clamp for 3-4 hour periods during the day until pt can void on own u Measure pt’s residual after voiding to determine how well he/she is voiding;

u More comfortable u Meticulous skin care around catheter site; place 4x4 drain sponge. u Care for as if doing a wound dressing change.

CONDOM CATHETER u As means of catching urine –Noninvasive, thus less infection –Watch skin of penis for breakdown –Watch twisting of tubing –Use elastic type tape

Leg bag

Catheter Irrigations and Instillations u Irrigating or flushing a catheter u Purpose: –Maintain patency –Bladder infections –Both require sterile technique

Some Irrigating Solutions u Sodium chloride u Sterile water

Key Elements of Irrigating a Catheter or Bladder (Closed System)

u All Irrigations –Wear gloves –Use strict aseptic technique –Maintain the integrity of closed systems –Instill the correct amt & type of irrig solution or med –Instill fluid gently & slowly –Determine amt of urine in drainage bag beforehand –Assess the color & consistency of urine drainage