NUR 111 Anne Marie Holler RN MSN(c)

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1 NUR 111 Anne Marie Holler RN MSN(c)

2 Assignments Required Readings: Potter & Perry: pp Skills book: Knowledge Base Anatomy Control Mechanisms Factors that inhibit micturation (voiding) Catheterization, irrigation

3 Question There are several factors that may disrupt the patient s micturition process including the following. Choose all that apply. a. Anesthetic drugs b. Urecholine c. Kidney stone d. Neuromuscular disease

4 Anatomy Kidneys Ureters Bladder Urethra

5 Urinary elimination depends upon function of: Kidneys- remove wastes from blood, nephron forms the urine Ureters- transports urine through peristaltic waves Bladder - detrusor muscle that rises above pubic bone when full, fills from bottom upwards

6 Urinary Elimination Urethra- turbulent flow of urine through pelvic floor muscles Bladder capacity ml of urine Urge to urinate ml Internal sphincter- no control (smooth muscle) External sphincter- can control (skeletal muscle)

7 Urinary Elimination Pathways send messages to brain to void Impulses from S2,3,4 allows voluntary control to void. Choosing to void allows external sphincter to relax, bladder muscle contracts, and empties (p. 1044).

8 Sensory impulses h?v=qc9j4u6asj4 Afferent pathway- bladder to spinal cord Efferent pathwayspinal cord to bladder

9 Factors affecting ability to void Anesthesia: General: acute urinary retention can follow all types of anesthetics or operations due to suppression of urinary reflex. Spinal: blocks the transmission of the afferent and efferent pathways, unable to sense the need to void, and inability of bladder muscles and urethral sphincters to respond.

10 Factors affecting ability to void Drugs: Anticholinergics: Atropine- used in surgery to decrease secretions (saliva), and increase heart rate. SE: decreased urgency to void and retention. Glycopyrolate (robinul)- reduces salivary secretions, GI anti-spasmodic, decreases GI motility, SE:urinary hesitancy and retention.

11 Factors affecting ability to void Surgery: Kidney- potential for blood in urine called Ureters- ureteroscopy with stone extraction, blood in urine, spasm Bladder- TURBT: bladder spasm, observe for bleeding Urethra- swelling from surgical manipulation, cysto

12 Factors affecting ability to void Pregnancy and Childbirth: Hormonal changes in pregnancy cause the bladder muscle to lose tone Muscles- pelvic floor tissue stretching during delivery resulting in nerve damage Trauma- Surgical instrumentation and difficult labor/delivery cause swelling, pain Nerve injury during delivery (afferent nerve branches (S2-4)

13 Urinary Retention Retention: (catheterize for retention) Urine fills the bladder but unable to empty properly Does not respond to the micturition reflex 3 Types of retention:

14 Urinary Retention Retention with overflow: bladder unable to respond to reflex, urine accumulates, bladder stretches, feelings of pressure, external urethral unable to hold back urine. Urethra temporarily opens to let a small overflow of urine out (25-60 ml)

15 Urinary Retention Mechanical Retention of Urine: Congenital: urethral stricture, urinary tract malformation, spinal cord deformity Acquired: calculus/tumor, inflammatory/hyperplasia, trauma/pregnancy

16 Urinary Retention Functional Retention Neurogenic bladder- impaired nerve pathways may interfere with normal micturition ie: MS, Parkinson's disease Post removal of an in-dwelling catheter Decreased peristalsis of ureters Anxiety

17 Functional Retention Medications given for pain or during surgery Narcotics Anesthesia General and spinal Sedatives Anticholinergic Anti-histamines

18 Meds to treat retention and frequency Cholinergic (urecholine) stimulates the bladder to contract, which improves urine flow (retention) Anti-cholinergic (ditropan) for pts with over active bladder. Antispasmodic that relaxes the muscles in the bladder to help decrease problems of urgency and frequent urination GOTTA GO!!!

19 What do we do for residual urine? Residual- amount of urine left in the bladder min post void Assess by: Bladder scanner: prior to use of a catheter to determine amt of urine retained in bladder AFTER voiding (10-15 min) VU Straight intermittent/catheterization

20 Assessment for Retention Abdominal assessment Palpating the bladder IPP (no A) Assess I&O Bladder scan- used to estimate volume of urine in bladder

21 Nursing Diagnosis Nursing diagnosis: Urinary retention RT spinal anesthesia and surgical intervention AMB patient s inability to void 8hrs after surgery Outcome: 1. The patient will void 240ml of amber urine within 8hrs of surgery 2. TPW have a urinary output of 30ml/hr AAT

22 Nursing Intervention (non-invasive) Promote normal voiding: Privacy Comfort Run water Positioning Warm water Crede Massage spine (S2,3,4 level) Bladder scan

23 Evaluation Did patient meet goal? Catheterize only if bladder is distended and patient is unable to void (per physician s order) Consider psychological implications

24 Catheterization Purpose: Place catheter into the urinary bladder to obtain urine (strict asepsis!!!!) Types of catheters: Straight Retention (double lumen foley) Triple lumen

25 Straight Catheter

26 Two lumen Retention (foley) Leg Bag

27 Triple Lumen Used for bladder irrigation

28 Urinary Catheters Supra Pubic Catheter Coude catheter

29 Foley Catheterization

30 Purpose To obtain a sterile urine specimen Measure the amount of residual urine Empty the bladder prior to surgery Prevent post op bladder distention Prevent urine from coming in contact with an incision or open wound To obtain accurate intake and output (I&O) Provide continuous or intermittent bladder irrigation Manage incontinence with skin breakdown

31 Catheter Size French system: the internal diameter of catheterthe larger the gauge # the larger the lumen size Infants and young children- 5-8fr (gastric feeding tube) Middle aged children- 12 fr Elderly, thin adults- 14 fr Adults fr Large meatal opening fr

32 Retention Catheter Balloon Size Child- 3ml Normal size adult- 5ml balloon with 10ml sterile water Long term use, post-op TURP, continuous bladder irrigation- 30ml *Not recommended to pre-test the balloon prior to insertion

33 Retention Catheter Balloon Size

34 Review Procedure on Video *An indwelling catheter must be ordered by a physician and is inserted only by a licensed nurse. Prepare patient Wash hands, gather equipment Female- need good lighting for visualization positioning, bearing down may ease catheter insertion

35 Catheterization Cleansing Labia- Hold labia with non dominant hand- Once hand is positioned, keep in place- DO NOT LET GO! If catheter is placed in the vagina: Leave it there Begin with new catheter NEVER use contaminated catheter

36 Application of Lubricant Female- 4inches up the catheter Male- up to the Y connector *hold penis at a 90 degree angle Y connection

37 Anchor Tubing Use tape or foley catheter holder/band

38 Risks of Catheterization See packet Unit VI- F9 for review Infection- Catheter associated urinary tract infections (CAUTI) account for 80% of hospital acquired infections Trauma Reflux

39 Nursing Diagnosis HRF Infection RT invasive procedure or devices (foley cath) AMB bacteria in the urine. Nursing Intervention (p. 1063): Provide perineal care q shift Empty drainage bag at least every 8 hrs Maintain a closed urinary system, free of kinks Hang drainage bag below level of bladder

40 Question Your patient returned from surgery with an indwelling catheter. What are appropriate ways to ensure patency and reduce risk for infection? Select all that apply. a. Avoid raising bag above bladder level b. Clamp the tubing q 4hrs c. Empty bag at least q 8hrs. d. Alcohol end of catheter if it becomes disconnected

41 Removal of Catheter Considerations: Wear clean gloves Check balloon size Completely deflate balloon (10ml syringe) Measure urine output (U/O) Observe for urinary retention post removal Assess for signs of UTI

42 Female catheterization eature=related

43 Male catheterization

44 Intermittent or Self catheterization Single use catheter to drain the bladder Reasons: Neurogenic bladder Spinal cord injury

45 Self Catheterization Bladder capacity greater than 100ml Good vision Manual dexterity Cognitive ability Motivation Agility

46 Benefits Decrease in UTI s Independence Decrease in reflux Normal sexual relations Release from dribbling Return to work

47 Obtaining a urine sample from foley 1. Clamp drainage bag tubing near the area where it attaches to Foley catheter for 30 min 2. Cleanse entry port with alcohol and insert 90 degree angle through self sealing port and withdraw urine. 3. Place into appropriate collection container 4. ***Must unclamp tubing 5. Send to lab for analysis per facility policy

48 Obtaining Sterile Urine Specimen

49 Obtaining a urine specimen and discontinuing a foley catheter

50 IRRIGATION CLOSED SYSTEM Triple lumen catheter Irrigation solution and tubing Run in amount of fluid per physician order Clamp during irrigation Unclamp to drain irrigant and urine Subtract irrigant from urine

51 Closed Bladder Irrigation

52 IRRIGATION OPEN SYSTEM Physician order Pour irrigant into container Put on gloves Cleanse port with alcohol Instill irrigant Allow irrigant to drain from catheter Subtract irrigant from urine total

53 Open Bladder Irrigation G1fNEIF8Kk&playnext=1&list=PL43CF5F54D3677F71&f eature=results_video

54 Final Tip Review objectives Study and practice the skill!!! Always maintain asepsis Use your critical thinking skills You can do it!!!

55 References Craigmdo. (2009, January 26). Sterile urine specimen & foley catheter removal [educational video]. Retrieved from Frenulum, M. (2013, February3). Micturition reflex [educational video]. Retrieved from Perry, A., Potter, P. A. & Ostendorf, W. R. (2014). Clinical nursing Skills & Techniques (8 th ed). St Louis, Missouri: Elsevier. Perry, A., Potter, P. A., Stockert, P. A., & Hall, A.M. (2013). Fundamentals of nursing (8 th ed). St. Louis, Missouri: Elsevier. Sterilefield. (2008, February 8). Male catheterization [educational video]. Retrieved from

56 References Tlinck1. (2010, March 2). Open bladder irrigation [educational video]. Retrieved from Williamsdkw1956. (2010, May 12]. Female catheterization [educational video]. Retrieved from

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