NUR 111 Anne Marie Holler RN MSN(c)
Assignments Required Readings: Potter & Perry: pp. 1042-1085 Skills book: 809-840 Knowledge Base Anatomy Control Mechanisms Factors that inhibit micturation (voiding) Catheterization, irrigation
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
Anatomy Kidneys Ureters Bladder Urethra
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
Urinary Elimination Urethra- turbulent flow of urine through pelvic floor muscles Bladder capacity- 600-1000ml of urine Urge to urinate- 150-200ml Internal sphincter- no control (smooth muscle) External sphincter- can control (skeletal muscle)
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).
Sensory impulses http://www.youtube.com/watc h?v=qc9j4u6asj4 Afferent pathway- bladder to spinal cord Efferent pathwayspinal cord to bladder
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.
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.
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
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)
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:
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)
Urinary Retention Mechanical Retention of Urine: Congenital: urethral stricture, urinary tract malformation, spinal cord deformity Acquired: calculus/tumor, inflammatory/hyperplasia, trauma/pregnancy
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
Functional Retention Medications given for pain or during surgery Narcotics Anesthesia General and spinal Sedatives Anticholinergic Anti-histamines
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!!!
What do we do for residual urine? Residual- amount of urine left in the bladder 10-15 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) http://www.youtube.com/watch?v=1roblmnho VU Straight intermittent/catheterization
Assessment for Retention Abdominal assessment Palpating the bladder IPP (no A) Assess I&O Bladder scan- used to estimate volume of urine in bladder
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
Nursing Intervention (non-invasive) Promote normal voiding: Privacy Comfort Run water Positioning Warm water Crede Massage spine (S2,3,4 level) Bladder scan
Evaluation Did patient meet goal? Catheterize only if bladder is distended and patient is unable to void (per physician s order) Consider psychological implications
Catheterization Purpose: Place catheter into the urinary bladder to obtain urine (strict asepsis!!!!) Types of catheters: Straight Retention (double lumen foley) Triple lumen
Straight Catheter
Two lumen Retention (foley) Leg Bag
Triple Lumen Used for bladder irrigation
Urinary Catheters Supra Pubic Catheter Coude catheter
Foley Catheterization
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
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 14-18 fr Large meatal opening -20-30fr
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
Retention Catheter Balloon Size
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
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
Application of Lubricant Female- 4inches up the catheter Male- up to the Y connector *hold penis at a 90 degree angle Y connection
Anchor Tubing Use tape or foley catheter holder/band
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
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
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
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
Female catheterization http://www.youtube.com/watch?v=wepobk_misq&f eature=related
Male catheterization http://www.youtube.com/watch?v=isbaya_5cim
Intermittent or Self catheterization Single use catheter to drain the bladder Reasons: Neurogenic bladder Spinal cord injury
Self Catheterization Bladder capacity greater than 100ml Good vision Manual dexterity Cognitive ability Motivation Agility
Benefits Decrease in UTI s Independence Decrease in reflux Normal sexual relations Release from dribbling Return to work
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 syringe @ 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
Obtaining Sterile Urine Specimen
Obtaining a urine specimen and discontinuing a foley catheter http://www.youtube.com/watch?v=0-8ncpqw9ci
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
Closed Bladder Irrigation
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
Open Bladder Irrigation http://www.youtube.com/watch?v=- G1fNEIF8Kk&playnext=1&list=PL43CF5F54D3677F71&f eature=results_video
Final Tip Review objectives Study and practice the skill!!! Always maintain asepsis Use your critical thinking skills You can do it!!!
References Craigmdo. (2009, January 26). Sterile urine specimen & foley catheter removal [educational video]. Retrieved from http://www.youtube.com/watch?v=0-8ncpqw9ci Frenulum, M. (2013, February3). Micturition reflex [educational video]. Retrieved from http://www.youtube.com/watch?v=qc9j4u6asj4 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 http://www.youtube.com/watch?v=isbaya_5cim
References Tlinck1. (2010, March 2). Open bladder irrigation [educational video]. Retrieved from http://youtu.be/-g1fneif8kk Williamsdkw1956. (2010, May 12]. Female catheterization [educational video]. Retrieved from http://www.youtube.com/watch?v=wepobk_misq&feature=related