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Urinary Elimination – Catheterization and Bladder Irrigation Notes

Module 5: Urinary Elimination – Catheterization and Bladder Irrigation

Anatomy and Physiology of Urinary Tract

  • Kidneys: Remove waste from the blood to form urine.
  • Ureters: Transport urine from the kidneys to the bladder.
  • Bladder: Reservoir for urine until the urge to urinate develops.
  • Urethra: Urine travels from the bladder and exits through the urethral meatus.

Terminology Review

  • Urination: Act of passing urine voluntarily through the urethra.
  • Oliguria: Diminished capacity to form and pass urine.
  • Anuria: Cessation of urine production.
  • Polyuria: Excretion of an abnormally large volume of urine.
  • Dysuria: Painful or difficult urination
  • Hematuria: Abnormal presence of blood in the urine
  • Nocturia: Urination at night
  • Cystitis: Inflammation of the urinary bladder characterized by pain, urgency, and frequency of urination

Urinary Catheterization

  • Urinary catheterization involves inserting a tube into the bladder to drain urine.
  • Challenges in gaining consent may arise due to patient anxiety or lack of understanding.

Types of Catheters

Straight Catheter

  • Also known as an intermittent urinary catheter or “in and out”.
  • Single lumen.
  • Immediate removal.
  • Lower rate of infection.
  • Indications: Used for immediate drainage, such as obtaining a sterile urine specimen or relieving urinary retention.

Indwelling Catheter

  • Also known as a continuous urinary or Foley catheter.
  • Double or triple lumen.
  • Held in place with a balloon.
  • Indications: Continuous bladder drainage, monitoring urine output in critically ill patients, managing urinary incontinence when other options have failed.

Coudé Catheter

  • Can be intermittent or indwelling.
  • Generally used to bypass an enlarged prostate.
  • Less traumatic and painful because it is stiffer and easier to control.
  • Indications: Bypassing urethral obstructions or strictures, particularly in males with enlarged prostates.

Suprapubic Catheter

  • A catheter placed percutaneously through the anterior abdominal wall into the urinary bladder.
  • Insertion site above the symphysis pubis (pubic bone).
  • Indications:
    • Severe urine retention
    • Bladder outlet obstruction
    • Incontinence

Urinary Diversions

  • Provides an alternate route for urine flow when a disorder impedes normal drainage.
  • Examples:
    • Ileal conduit
    • Neobladder
    • Indiana pouch
    • Ureterostomy
    • Nephrostomy
  • Temporary or permanent.
  • Incontinent urinary diversions require ostomy appliance.

Catheter Sizing

  • Lumen size – French (Fr) system
    • Child – 8 Fr to 10 Fr
    • Adult female – 10 Fr to 12 Fr
    • Adult male – 12 Fr to 16 Fr
    • Urological procedure – 20 Fr to 24 Fr
  • Balloon size
    • 3 mL (peds) to 30 mL (urological surgeries)
    • 5 mL to 10 mL most common for adults
    • Check packaging for manufacturer’s recommendation of volume to instill

Drainage Systems

  • Urometer: For precise measurement of urine output.
  • Leg Bag: For ambulatory patients.
  • Standard Drainage Bag: Typically a 2000 mL bag for general use.

Nursing Assessments

  • Assessments before inserting a urinary catheter include:
    • Patient's medical history
    • Allergies
    • Level of consciousness
    • Mobility
    • Anatomical landmarks.
  • Patient positioning:
    • Male: Supine with legs slightly abducted.
    • Female: Dorsal recumbent or Sims’ position.
  • Continuous monitoring for:
    • Urine output
    • Color
    • Clarity
    • Odor
    • Signs of infection.
Patient Positioning
  • Apply slight upward traction of penis
  • Position penis perpendicular to body for catheter insertion.

Urinary Tract Infections

  • Urinary tract infections are the leading cause of health care associated infection.
  • Symptoms of UTIs:
    • Dysuria
    • Frequency
    • Urgency
    • Fever
    • Cloudy urine
  • Factors Contributing to CAUTI:
    • Prolonged catheterization
    • Breaks in sterile technique
    • Inadequate hand hygiene
  • Prevention of CAUTI:
    • Strict adherence to sterile technique during insertion
    • Proper catheter care
    • Timely removal of catheter
    • Using the smallest effective catheter size.

Removing an Indwelling Catheter

  • Indwelling urinary catheter removal should occur as soon as the catheter is no longer clinically indicated – verify physician order.
  • Ensure balloon is fully deflated using appropriately sized syringe.
  • Remove catheter while patient exhales.
  • Discard in biohazard or appropriate receptacle as indicated by facility.
  • Assessments following removal:
    • Time of first void
    • Amount
    • Any discomfort
    • Signs of urinary retention.

Bladder Ultrasonography (Bladder Scanning)

  • A noninvasive method of assessing bladder volume to monitor for urine retention and postvoid residual volume (PVR).
  • Steps for use:
    • Position the patient, indicate sex on scanner
    • Apply ultrasonic transmission gel
    • Position the scanner probe and scan
    • Interpret and document results
  • Potential risks of relying exclusively on bladder scanner results:
    • False readings
    • Overestimation or underestimation of urine volume
    • Delay in necessary interventions.

Patient Teachings

  • Teachings about catheterization:
    • Purpose of catheterization
    • Proper hygiene
    • Signs of infection
    • Catheter care
    • Reporting any issues.

Documentation – Catheter Insertion

  • Date and time of urinary catheter insertion
  • Indication for use (assessments gathered)
  • Size and type of catheter
  • Characteristics of the urine obtained
  • Amount of sterile water used to inflate the balloon (indwelling catheter)
  • Type of securement device (indwelling catheter)
  • Complications
  • Name of the practitioner notified
  • Date and time of notification
  • Prescribed interventions
  • Response to those interventions
  • Collection of a urine specimen (if applicable)
  • Date and time of specimen delivery to the laboratory
  • Teaching provided to the patient and family (if applicable)
  • Understanding of that teaching
  • Follow-up teaching needed

Bladder/ Catheter Irrigation

  • Purpose is to:
    • Prevent or dislodge blockage & maintain catheter patency
    • Instill medication directly into the bladder
  • Types of irrigation include:
    • Continuous bladder irrigation (CBI)
    • Closed intermittent (aka manual) catheter irrigation
    • Open intermittent (aka manual) catheter irrigation
  • Signs and symptoms of potential catheter obstruction:
    • Decreased urine output
    • Bladder distention
    • Bladder discomfort.

Continuous Bladder Irrigation (CBI)

  • Indications for CBI:
    • Helps prevent urinary tract obstruction after prostate or bladder surgery by flushing out small blood clots
    • May also be used for intravesical medication infusion

Continuous Bladder Irrigation Equipment

  • Triple lumen catheter
  • Ordered sterile irrigation solution – room temp.
    *Irrigation tubing with irrigation clamp & IV pole.
  • Monitoring:
    *Intake and output.
    *Drainage.
    *Pain/ bladder distention.
    *Bladder spasms

Complications of Continuous Bladder Irrigation – Case Study

  • If drainage output is significantly lower than the infused irrigation fluid, patient reports increased abdominal pain and bladder fullness, and the urine color in the bag has changed to bright red, suspect a clot or obstruction.

Intermittent (Manual) Catheter Irrigation

  • Closed:
    • Irrigation is done through an aspiration port on urinary drainage bag (same port used for specimen collection)
  • Open:
    • The catheter is disconnected from the urinary drainage bag before the syringe is connected to the catheter for flushing

Intermittent (Manual) Catheter Irrigation - Indication

  • Indicated if:
    • a catheter is occluded, and it is deemed harmful to remove the catheter
    • If possible, it is recommended to change the catheter rather than irrigate.
    • Instillation of ordered bladder medications

Patient Teaching – Irrigation

  • Educate patients about the purpose of irrigation, the procedure, and potential complications.

Documentation – Continuous Bladder Irrigation

  • Date, time, and amount of fluid you administered on the intake and output record
  • Time and amount of fluid each time you empty the drainage bag
  • Appearance of the outflow drainage
  • Complaints expressed by the patient
  • Tolerance of the procedure
  • Complications
  • Name of the practitioner notified
  • Date and time of notification
  • Prescribed interventions
  • Response to those interventions
  • Teaching provided to the patient and family (if applicable)
  • Understanding of that teaching
  • Follow-up teaching needed

Documentation – Intermittent Bladder Irrigation

  • Date and time of irrigation
  • Type and volume of irrigating solution
  • Amount, color, and consistency of return urine
  • Patient's tolerance of the procedure
  • Any resistance during instillation of the solution
  • Intake and output
  • Whether the return volume was less than the amount of solution instilled
  • Teaching provided to the patient and parents or guardians
  • Understanding of that teaching
  • Follow-up teaching needed