Transcript Urinary Elimination - Austin Community College

Urinary Elimination:
Catheterization
Austin Community College
Anatomy and Physiology Review
LOWER URINARY SYSTEM
An intact urinary system transports urine from the kidneys to the
ureters and then to the bladder for expulsion via the urethra. The
physiologic role of the bladder is to store urine at a low pressure and to
expel it at suitable intervals.
Urine capacity for bladders varies with the
individual, but typically, the bladder can hold
between 600-1000 ml of urine. 200-250 ml of
urine in the bladder causes moderate distention
and the urge to urinate. 400-600 ml causes
discomfort.
The muscle in your bladder wall is called the
detrusor muscle. The detrusor muscle relaxes to
allow your bladder to fill. When you empty your
bladder, it contracts to squeeze out urine.
a
The internal sphincter is a ring of muscle that
holds the neck of the bladder in place. Your body
opens and shuts it automatically without you
thinking about it.
The external sphincter acts like a tap and keeps
urine in the bladder. It is controlled by the pudental
nerve, which is controlled by the voluntary nervous
system. This means it’s under your control - you
decide when to let it open. The external sphincter
is also called the distal sphincter.
A&P Review
This slide is so that you can
appreciate the location of
the prostate. What would
hypertrophy of the prostate
likely cause?
Female urethra is much
shorter so they are at more
risk for UTI.
Micturition
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Sensory nerve fibers in the detrusor
muscle transmit messages to the brain
and the pons. The brain inhibits the
detrusor reflex until you consciously
decide to urinate. Then the brain
releases its inhibitory control over the
pons and your brain sends a series of
messages to enable your body to pass
urine:
to your detrusor muscle in the bladder
wall, telling it to contract and squeeze
the urine out into the urethra
to your sphincter, telling it to relax
and open
to your pelvic floor, telling it to relax
and allow the sphincter to open.
When your bladder is empty, your
sphincter closes, your pelvic floor
tightens and your detrusor muscles
relax, allowing your bladder to fill and
expand again.
Why do we use catheters?
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This is not just done to prevent the nurses and techs from having to
repeatedly change diapers or linens.
Some individuals hold too much urine in the bladder and some lose too
much out of the bladder. Sometimes we need to find out the amount
actually getting to the bladder from the kidneys, and sometimes we
need to find out how much remains in the bladder after urination. The
next few slides will demonstrate some common reasons to insert a urinary
catheter.
What is going on in this picture that
Why do we use catheters?
may cause the nurse to insert a
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urinary catheter?
Urinary retention
Causes of urinary retention:
regional (epidural) anesthesia
general anesthesia
Neuromuscular disease
(multiple sclerosis)- they may
not be able to relax the external
sphincter.
Mechanical obstruction
(enlarged prostate, tumor)
Local trauma
Uterine prolapse
Why do we use catheters?
Measuring output
Accurate assessment of urinary output is done in
patients with kidney problems or those on specific
medications. We used it as a reference for
women in preterm labor on a specific IV
medication used to prevent labor (Magnesium
Sulfate). One of the first signs of toxicity was a
decreased urine output.
Why do we use catheters?
Pre operative
Empties the bladder prior to surgery to decompress the bladder and gain access
to organs in that area and to prevent urinary retention post operatively.
Why do we use catheters?
Sterile specimen
Usually this is done as an intermittent catheterization, but you can
get a sterile specimen from an indwelling catheter using the port on
the tubing.
Why do we use catheters?
PVR (post void residual)
Measuring post void residual with an in
and out catheterization is common.
Some physicians order a bladder scan to
measure the amount of urine retained in
the bladder after urination.
Normal PVR is 50-75 ml. Anything
over 100 ml is usually repeated and may
need further testing. Abnormal findings
are PVR greater than 200ml on two
separate occasions.
There are two basic types of catheters.
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Straight (French) is a single lumen tube with one opening used for
intermittent catheterization.
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Retention (Foley) is a double lumen tube used for indwelling catheters.
One lumen is for inflation of the balloon at the tip. The second lumen to
drain the urine.
There are other types of catheters
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coude- has a curved tip to pass past an enlarged prostate
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Pezzar- mushroom tip used for suprapubic catheters
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Three lumen indwelling (for irrigation)
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They are sized according to the French scale. Each French unit equals
0.33mm. Larger the number on the lumen size the larger the catheter. For
adult women the size is typically 14-16 F. For men 14-18 F.
Types of catheters
Intermittent catheterization
Use this when you need to check for
residual urine or get a sterile specimen.
Can be self-cath.
How much urine can you take out of a
bladder at once?
Varying responses, for our purposes,
anything more than 700-1000 is the most
you can take out in one catheterization.
You remove the catheter and then recath
the patient an hour or so later.
Sterile specimen collection from
retention catheter
Evaluation for uti. May need to clamp
tube for 30 min or so to get urine in
tube.
Equipment needed:
Clean gloves
Sterile specimen cup or vacutainer
10 ml syringe with sterile 20 gauge
needle
Alcohol preps
Afterwards, make sure to label with
date, time, initials, and a pt ID label
Sterile technique
Sterile field is the tray that contains the
supplies and the bottom drape that comes
in the kit.
For check offs: you cannot cross the sterile
field with “dirty” objects or touch the field
with non sterile objects.
In real life: the part of the kit that absolutely
needs to stay sterile is the portion of the
catheter that is entering the urethra and
bladder. What if the outside of the tubing
near the bag gets contaminated? Would
that affect the patient? Remember, the
main thing is to keep the main thing the
main thing.
Clean vs. Sterile
The nurse is using the fenestrated drape. Looks like a good idea. Notice the
hand is resting on the drape, but since the glove is sterile, the field is not
contaminated.
Position in dorsal recumbent.
Which hand is still sterile?
Tell them, “This is cold” Show them the
betadine so they see the color. They may
wipe and think something is wrong if you
don’t.
Separate the labia with your nondominant
hand- is it sterile now??
Wipe with a downward motion just to the
side of the meatus. FOR CHECK OFFS:
You’re going to have to put the dirty cotton
ball somewhere without crossing the sterile
field… where is your trash can or bag?
Pick up second and wipe to the other side,
drop to side. Pick up third, wipe straight
down the middle. Look closely for the
meatus to wink at you… It may be lower
than you thought.
Don’t move your non dominant hand at this
point. The meatus is clean and if you shift
or let go, the labia will contaminate the
meatus and you’ll have to clean it again.
Alternate positioning
Inserting lubricant
Insertion of catheter
Insert this until there is visible urine return and then 1-2 more inches, or
up to the “Y”.
After insertion, fill the balloon.
Which hand is sterile now?
Then fill the balloon. This should not cause discomfort in any way- if it does, you
may still be in the urethra.
In this picture which hand is holding the catheter?
Secure attachment
Here is a picture of a type of
attachment device- there will be
alternatives in the hospitals to just tape.
Make sure everything is draining
DOWN. Remember the main thing is
to get the urine out of the bladder and
down into the bag.
Secure catheter
Documentation
3/26/08 0915 14 F Foley catheter inserted
without difficulty. 10 ml of sterile water
injected into balloon port. 300 ml clear
yellow urine returned. Pt tolerated procedure
with out incident. - T. Davis, RN
Bladder irrigation
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Injecting through port
Irrigating with 3 way catheter
Irrigating through 2 way catheter after
separating the catheter and tubing (open
system)
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Irrigation is flushing with a specified solution to treat a UTI or wash out the
bladder. It is always a sterile procedure. You need to be certain that what you put
into the bladder remains sterile and does not introduce new bacteria into the
bladder.
Bladder irrigation can be open or closed. It can also be intermittent or continuous.
Closed continuous irrigation may be used to prevent obstruction after prostate or
bladder surgery.
Intermittent irrigation may be used to relieve obstruction due to clots, mucus or
other causes.
I included a link to the Multiple Sclerosis Trust. It is there for you to see that
bladder irrigation can be used at home by patients that have bladder dysfunction.
The MD orders the type of irrigation (intermittent, continuous), the type and
amount of solution.
Bladder surgery patients or TURP (transurethral resection of the prostate) patients,
need irrigation for about 2 days to maintain its patency and prevent formation of
blood clots in the bladder or remove those that do form.
Continuous irrigation
Just wanted to show you this picture.
You have to spike the irrigating bag.
The blue plastic tip remains sterile and
the rest is clean. You do not need sterile
gloves. Flush the tubing.
When the bag is empty, do not let the
air into the tubing. Why not?
This picture is of a closed irrigation systemnot very portable, but sterile. Urine should
be pink, not burgundy or red.
You will titrate the rate of infusion
depending on the color of the urine returning
to the bag.
Documentation
3/27/08 1000 Foley catheter replaced with 3-way
Foley catheter. Continuous bladder irrigation
with normal saline at 100 ml/hour begun. Pt
tolerated procedure without incident.
Drainage from bladder slightly cloudy. –T
Davis, RN
Catheter Complications
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Nosocomial infection if left untreated may cause
pyelonephritiis.
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No urination after 8 hours
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Catheters, when used inappropriately or when left in place too
long, may be a hazard to the very patients it is designed to
protect.
An indwelling urinary catheter is a foreign body and can
cause discomfort. Many patients experience catheter cramp,
which results from irritation of the urethra and bladder and
usually subsides within the first 24 hours of catheter
insertion, though it can persist in some people.
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