Chapter 18 Urinary Elimination Copyright 2016 by Mosby

Chapter 18 Urinary Elimination Copyright © 2016 by Mosby, an imprint of Elsevier Inc.

Urinary Elimination It is the role of the nurse to support bladder emptying by assisting the patient as needed in toileting, which may include use of a commode, urinal, and/or bedpan. During acute illness a patient may require urinary catheterization Ø Ø for close monitoring of urine output to facilitate bladder emptying when bladder function is compromised. The nurse also implements measures to minimize risk for infection when bladder function is impaired or urinary drainage tubes are required. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 2

Patient-Centered Care When a patient is no longer able to access a toilet independently or the bladder empties inadequately, nursing intervention is required. Nursing care may include insertion of a catheter into the bladder or assisting patients using a urinal or bedpan. It is essential that the nurse acknowledge the patient’s feelings and respect patient privacy and dignity as much as possible. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 3

Safety The use of indwelling urinary catheters is associated with a number of complications: Ø Ø Ø Ø Catheter-associated urinary tract infection (CAUTI) Discomfort Bladder pain and spasms Genitourinary trauma Formation of bladder calculi Blood in the urine (hematuria) Squamous cell carcinoma of the bladder Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 4

Safety (Cont. ) The risk for life-threatening infection increases whenever the urinary tract is compromised such as during catheterization. Nursing care must include measures to minimize catheter-related complications and infection: Ø Ø Ø using aseptic technique when inserting urinary catheters maintaining a closed urinary drainage system providing catheter care that uses principles of asepsis anchoring catheters removing urinary catheters as soon as medically indicated Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 5

Evidence-Based Practice Use aseptic catheter insertion using sterile equipment. Secure indwelling catheters to prevent pulling on the catheter. Maintain a closed urinary drainage system Maintain an unobstructed flow of urine through the catheter, drainage tubing, and drainage bag. Keep the urinary drainage bag below the level of the bladder. When emptying the urinary drainage bag, use a separate measuring receptacle for each patient. Do not let the drainage spigot touch the receptacle. Perform routine perineal hygiene daily and after soiling. Quality improvement/surveillance programs should be in place that alert providers that a catheter is in place and include regular educational programming about catheter care. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 6

Procedural Guide 18 -1: Assisting with the Use of a Urinal A urinal is a container used to hold urine when access to a toilet is restricted. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 7

Procedural Guide 18 -1: Assisting with the Use of a Urinal (Cont. ) Delegation and Collaboration The skill of assisting a patient with a urinal can be delegated to nursing assistive personnel. Ø The nurse instructs the NAP to: • Assist the patient with special needs/adaptations related Ø to positioning or holding the urinal. • Provide personal hygiene as necessary after urination. • Report immediately any changes in urine color, clarity, and odor; development of incontinence (involuntary loss of urine); patient reports of dysuria, which could indicate an infection; and any changes in the frequency and amount of urine output. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 8

Skill 18 -1: Applying a Condom. Type External Catheter The external catheter, also called a condom catheter or penile sheath, is a soft, pliable condomlike sheath that fits over the penis, providing a safe and noninvasive way to contain urine for men who have complete and spontaneous bladder emptying. Latex catheters are still available and used by some patients. It is important to verify that a patient does not have a latex allergy before applying this type of catheter. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 9

Skill 18 -1: Applying a Condom. Type External Catheter (Cont. ) Condom-type external catheters are held in place by an adhesive coating on the internal lining of the sheath, a double-sided self-adhesive strip, brush-on adhesive applied to the penile shaft, or an external strap or tape. They may be attached to a small-volume (leg) drainage bag or a large-volume (bedside) urinary drainage bag, both of which need to be kept lower than the level of the bladder. Ø There a variety of styles and sizes, so it is important to refer to the manufacturer’s guidelines for fitting and correct application. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 10

Skill 18 -1: Applying a Condom. Type External Catheter (Cont. ) Assessment Identify patient using two identifiers (e. g. , name and birthday or name and account number, according to facility policy). Ø Review health care provider’s order for the size and type of condom-type external catheter. Ø Assess urinary elimination patterns, ability to empty the bladder effectively, and degree of incontinence. Ø Assess mental status of patient and patient’s knowledge of the purpose of an external catheter. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 11

Skill 18 -1: Applying a Condom. Type External Catheter (Cont. ) Assessment (Cont. ) Assess condition of penis. Use manufacturer’s measuring guide to measure the diameter of the penis in a flaccid state. The penile shaft should be at least 2 cm (0. 8 inches) in length. Ø Assess for latex allergy. Ø Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 12

Skill 18 -1: Applying a Condom. Type External Catheter (Cont. ) Planning/Expected Outcomes Delegation/Collaboration The skill of applying a condom catheter can be delegated to nursing assistive personnel depending on facility policy. Ø The nurse instructs the NAP to: • Follow manufacturer’s guidelines for applying and Ø securing the condom catheter. • Measure and record urine output and I&O if applicable. • Report pain immediately Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 13

Skill 18 -1: Applying a Condom. Type External Catheter (Cont. ) Evaluation Unexpected Outcomes Ø Ø Urination is reduced in amount or frequency. Skin on penis is reddened, ulcerated, or denuded. Condom catheter does not stay on. Penile swelling or discoloration occurs. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 14

Recording and Reporting • Record condom application; condition of penis, skin, and scrotum; urinary output and voiding pattern; and patient response to external catheter application. • Report penile erythema, rashes, and/or skin breakdown. • Document your evaluation of patient learning. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 15

Special Considerations Pediatric Ø Condom catheters are uncommon in children. When used in adolescents, take precautions to minimize embarrassment. Geriatric Evaluate patients with neuropathy carefully before application of a condom catheter and assess penile skin at more frequent intervals, at least twice daily. Ø Condom catheters are not recommended in patients with prostatic obstruction. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 16

Special Considerations (Cont. ) Home Care Teach patient and family caregivers appropriate assessments such as signs and symptoms of a urinary tract infection, signs of skin irritation, or poor-fitting catheter sheath. Ø Loose-fitting clothing may be needed to accommodate the catheter and drainage system. Ø Ensure that patient and caregiver understand correct steps in applying the condom catheter and how to empty the drainage bag. Manufacturers often supply educational materials for the patient. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 17

Procedural Guideline 18 -2: Bladder Scan A bladder scanner is a noninvasive device that measures the volume of urine in the bladder by creating an ultrasound image of the bladder from which calculations are made to report urine volumes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 18

Procedural Guideline 18 -2: Bladder Scan (Cont. ) Delegation and Collaboration In some settings the use of the bladder scanner can be delegated to nursing assistive personnel. Ø The nurse, in collaboration with the health care provider, determines the timing and frequency of bladder scan measurement, assesses the patient’s ability to toilet prior to measurement of PVR, assesses the abdomen for distention if urinary retention is suspected, and interprets the measurements obtained. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 19

Procedural Guideline 18 -2: Bladder Scan (Cont. ) Delegation and Collaboration (Cont. ) Ø The nurse instructs the NAP to: • Follow the manufacturer’s recommendations for the use of the device. • Measure PVR volumes within 5 -15 minutes after assisting patient to void. • Report and record bladder scan volumes. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 20

Quick Quiz! When performing a bladder scan on a woman who has had a hysterectomy, the nurse will set the gender designation on the scanner as “male. ” A. True B. False Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 21

Skill 18 -2: Insertion of a Straight or Indwelling Catheter Urinary catheterization is the placement of a tube into the bladder to remove urine. This is an invasive procedure that requires a medical order and sterile technique. Conditions that require use of urinary catheters include the need to monitor urine output, relief of urinary obstruction, postoperative care, or a bladder that inadequately empties as a result of a neurological condition. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 22

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Urinary incontinence, an involuntary leakage of urine, may require indwelling catheterization if the leaking urine interferes with wound healing. Excessive accumulation of urine in the bladder increases the risk for UTI and can cause backward flow of urine up the ureters to the kidneys, causing kidney infection and/or damage. Intermittent catheterization is used to measure PVR when a bladder scanner is not available or as a way to manage chronic urinary retention. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 23

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) The steps for inserting an indwelling and a single-use straight catheter are the same. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 24

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) A health care provider chooses a catheter on the basis of factors such as latex allergy, history of catheter incrustation, and susceptibility for infection. Cather materials Ø Ø latex or silicone special coatings to reduce irritation silver coated rubber or polyvinyl chloride (straight) Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 25

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the catheter. Most adults with an indwelling catheter should have a size 14 -16 Fr to minimize trauma and risk for infection. Larger-catheter diameters increase the risk for trauma to the bladder neck and urethra. Older women, or older men with an enlarged prostate, may need a smaller size (12 -14 Fr). 5 -6 Fr for infants and an 8 -10 Fr for children. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 26

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Indwelling catheters come in a variety of balloon sizes. The size of the catheter and balloon is usually printed on the catheter port Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 27

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Catheter changes For patients requiring long-term catheterization (e. g. , as a result of urinary retention or critical illness), catheter changes should be individualized, not routine. Ø Catheters should be changed for leaking or blockage and before obtaining a sterile specimen for urine culture. Ø Long-term catheterization should be avoided due to its association with urinary tract infections. Ø Every effort should be make to remove catheters as soon as the patient can void. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 28

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Urinary drainage bag placement An indwelling catheter is attached to a urinary drainage bag to collect the continuous flow of urine. Ø Always hang the bag below the level of the bladder on the bed frame or a chair so urine will drain down, out of the bladder. Ø The bag should never touch the floor. Ø When ambulating, a patient should carry the bag below the level of the bladder. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 29

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Assessment Identify patient using two identifiers (e. g. , name and birthday or name and account number, according to facility policy). Ø Review health care provider’s order. Note previous catheterization, including catheter size, response of patient, and time of last catheterization. Ø Assess patient’s knowledge and prior experience with catheterization. Ø Review the medical record for any pathological condition that may impair passage of catheter. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 30

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Assessment Ø Ø Ø Ask patient and check medical record for allergies. Assess patient’s weight, level of consciousness, developmental level, ability to cooperate, and mobility. Assess patient’s gender and age. Ask patient the time of last voiding and/or check I&O flow sheet. Assess the bladder for fullness by palpating it over the symphysis pubis or by using the bladder scanner. Apply clean gloves. Inspect perineal region, observing for perineal landmarks, erythema, drainage, or discharge and odor. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 31

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Planning/Expected Outcome Delegation/Collaboration The skill of inserting an indwelling or straight urinary catheter cannot be delegated to nursing assistive personnel. Ø The nurse instructs the NAP to: • Assist the nurse with patient positioning, focus lighting for Ø the procedure, maintain patient privacy, empty urine from the collection bag, and assisting with perineal care. • Report any changes in the color, amount, and odor of the urine and if the indwelling catheter leaks or causes pain. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 32

Skill 18 -2: Insertion of a Straight or Indwelling Catheter (Cont. ) Evaluation Unexpected Outcomes Patient complains of discomfort during inflation of balloon. Ø Catheter goes into vagina. Ø Sterility is broken during catheterization by nurse or patient. Ø Patient complains of bladder discomfort, and the catheter is patent as evidenced by adequate urine flow. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 33

Recording and Reporting • Report and record the reason for catheterization, type and size of catheter inserted, amount of fluid used to inflate balloon, specimen collection (if applicable), characteristics and amount of urine, patient’s response to procedure, and any education. • Record on I&O flow sheet record. • Report persistent catheter-related pain and discomfort. • Document your evaluation of patient learning. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 34

Special Considerations Pediatric When caring for an infant or young child, explain procedures to parents. Describe procedure to child at level the child is able to understand. Ø Catheterization in infants and children may be more comfortable with the use of an adequate amount of lubricant containing 2% lidocaine (Xylocaine). Ø Teaching young children to blow into a straw or pinwheel can aid in relaxing pelvic muscles. Ø In uncircumcised infant boys it is not possible to fully retract the foreskin. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 35

Special Considerations (Cont. ) Geriatric The urethral meatus of an older woman may be difficult to identify because of urogenital atrophy. Ø Symptoms of a UTI in the older adult may be difficult to recognize and may only be indicated by a change in mental status or fever. Ø Older adults have an increased risk for UTI related to increased prevalence of chronic disease such as diabetes and prostatic hypertrophy and a higher prevalence of incontinence. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 36

Special Considerations (Cont. ) Home Care Patients who are at home may use a leg bag during the day and switch to a larger-volume bag at night. If a patient changes from a large-volume bag to a leg bag, instruct in the importance of handwashing and cleansing of the connection ports with alcohol before changing bags. Ø Teach patients and family caregivers signs of UTI, how to properly position the drainage bag, empty the urinary drainage bag, and observe urine color, clarity, odor, and amount. Ø Arrange for home delivery of catheter supplies, always ensuring that there is at least one extra catheter, insertion kit, and drainage bag in the home. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 37

Skill 18 -3: Removal of an Indwelling Catheter Removal of indwelling catheters is an important intervention to reduce risk of CAUTI. When removing the catheter, it is important to ensure that the catheter balloon is fully deflated to minimize trauma to the urethra. All patients should have their voiding monitored after catheter removal for at least 24 to 48 hours by using a voiding record or bladder diary. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 38

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts can indicate inadequate bladder emptying that requires intervention. Symptoms of infection can develop 2 or more days after catheter removal. Patients need to be informed of the risk for infection, prevention measures, and signs and symptoms that need to be reported to the primary care provider. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 39

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Assessment Identify patient using two identifiers (i. e. , name and birthday or name and account number, according to facility policy). Ø Review health care prescriber’s order. Note length of time catheter has been in place. Ø Assess patient’s knowledge and prior experience with catheter removal. Ø Assess urine color, clarity, odor, and amount. Note any urethral discharge or the presence of incrustation. Ø Determine size of catheter inflation balloon. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 40

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Planning/Expected Outcomes Patient voids at least 150 m. L with each voiding no more than 6 to 8 hours after catheter removal. Ø Patient verbalizes feeling of comfort after catheter is removed. Ø Patient identifies signs and symptoms of UTI. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 41

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Delegation and Collaboration Assessment of the patient’s condition cannot be delegated to nursing assistive personnel. Ø However, the skill of removing a urinary catheter may be delegated as indicated by facility policy. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 42

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Ø The nurse instructs the NAP to: • Report characteristics of urine (color, odor, and amount) before and after catheter removal and to record urine volume on the I&O record. • Report the condition of the patient’s genital area (e. g. , color, rashes, open areas, odor, soiling from fecal incontinence, and trauma to tissues around urinary meatus). • If allowed to remove a catheter: check size of balloon and size of syringe needed to deflate balloon, report if balloon does not deflate and if there is bleeding after removal. Report time and amount of first voiding after catheter is removed. • Report how the patient tolerated the procedure, the exact time the catheter was removed, and the time and amount of subsequent voiding. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 43

Skill 18 -3: Removal of an Indwelling Catheter (Cont. ) Evaluation Unexpected Outcomes Water from inflation balloon does not return into syringe. Patient exhibits one or more of the following after catheter removal: fever, chills, painful urination, cloudy and/or foulsmelling urine, abdominal pain, flank pain, frequent smallvolume voiding, hematuria, change in mental status, lethargy. Ø Patient is unable to void after catheter removal, has a sensation of not emptying the bladder, strains to void, or experiences small voiding amounts with increasing frequency. Ø Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 44

Recording and Reporting • Record and report time catheter was removed; teaching related to increasing fluid intake and signs and symptoms of UTI; and time, amount, and characteristics of first voiding. • Record intake and voiding times and amounts on voiding record or bladder diary as indicated. • Report hematuria, dysuria, inability or difficulty voiding, and any new incontinence after a catheter is removed. • Document your evaluation of patient learning. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 45

Special Considerations Pediatric Ø Geriatric Ø Do not force catheter out of bladder if resistance is met. When excessive tubing has been inserted in the bladder, there have been occurrences of knotting of the tubing. Older adults may exhibit atypical signs and symptoms of UTI such as a change in mental status attributed to delirium. A change in mental status may include confusion, agitation, and/or lethargy. Home Care Ø Include family caregivers in the plan of care. Some may need extra support when learning how to take care of someone who now needs regular help with toileting. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 46

Procedural Guideline 18 -3: Care of an Indwelling Catheter Indwelling urinary catheters are one of the most common sources for hospital-acquired infection. Delegation and Collaboration Routine catheter care can be delegated to nursing assistive personnel and is often incorporated into perineal care. Ø The nurse instructs the NAP to: Ø • Report characteristics of the urine (color, clarity, odor, and amount). • Report the condition of the patient’s genital area (e. g. , color, rashes, open areas, odor, soiling from fecal incontinence, trauma to tissues around urinary meatus). • Record urine output. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 47

Skill 18 -4: Suprapubic Catheter Care A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 48

Skill 18 -4: Suprapubic Catheter Care (Cont. ) Assessment Identify the patient using two identifiers (i. e. , name and birthday or name and account number, according to facility policy). Ø Review health care provider’s order for sterile versus clean technique needed for care. Ø Assess urine in drainage bag for amount, clarity, color, odor, and sediment. Ø Assess catheter insertion site for inflammation, pain, erythema, edema, drainage, and for the growth of overgranulation tissue. Ask patient if there is any pain at site; if so, have patient rate on scale of 0 -10. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 49

Skill 18 -4: Suprapubic Catheter Care (Cont. ) Assessment Assess for elevated temperature and chills. Assess site where catheter is secured on abdomen for signs of irritation. Ø Check for allergies. Ø Assess patient’s and/or family caregiver’s knowledge of purpose of catheter and its care. Ø Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 50

Skill 18 -4: Suprapubic Catheter Care (Cont. ) Planning/Expected Outcomes Delegation and Collaboration The skill of caring for a newly established suprapubic catheter cannot be delegated to nursing assistive personnel; however, care of an established suprapubic catheter can be delegated. Ø The nurse instructs the NAP to: Ø • Report if the patient has discomfort from the tube. • Empty the drainage bag, document urinary output on the I&O record, and report any change in the amount and character of the urine. • Report any signs of redness, drainage, or foul odor around catheter insertion site. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 51

Skill 18 -4: Suprapubic Catheter Care (Cont. ) Evaluation Unexpected Outcomes Patient complains of lower abdominal pain and/or distention; urine flow slows or stops. Catheter suspected to be obstructed (blood clots or sediment form; tip of catheter in bladder is positioned against bladder wall). Ø Patient develops symptoms of a UTI or catheter site infection. Ø Urine leaks around catheter. Ø Catheter becomes dislodged. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 52

Recording and Reporting • Record and report character of urine and type of dressing change, including assessments of insertion site and patient’s comfort level with the catheter and dressing change. • Record urine output on I&O flow sheet. In a situation in which there is both a suprapubic and a urethral catheter, record outputs from each catheter separately. • Document your evaluation of patient learning. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 53

Special Considerations Home Care Patients and family caregivers should learn how to cleanse and apply a dressing (if applicable) using a clean technique. Ø Caution patients and/or caregivers to avoid the use of powders, creams, or ointments around the catheter unless specifically instructed to do so. Ø Teach patients and/or caregivers how to properly position the drainage bag; empty the urinary drainage bag; recognize signs of catheter obstruction, urinary tract infection, and wound infection; and observe urine color, clarity, odor, and amount. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 54

Quick Quiz! A patient with a suprapubic catheter complains of lower abdominal pain. He is lying in bed, on his left side and the nurse notices that the flow of urine has stopped. What should the nurse’s first action be? A. B. C. D. Change the catheter Reposition the patient Irrigate the catheter None of the above Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 55

Skill 18 -5: Performing Catheter Irrigation Urinary catheter irrigations to maintain catheter patency are performed on an intermittent or continuous basis. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 56

Skill 18 -5: Performing Catheter Irrigation (Cont. ) Assessment Identify the patient using two identifiers (i. e. , name and birthday or name and account number, according to facility policy). Ø Review health care provider’s order for: • The order for method (continuous or intermittent) and Ø type (sterile saline or medicated solution) and amount of irrigant. • Type of catheter in place. Ø Palpate bladder for distention and tenderness. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 57

Skill 18 -5: Performing Catheter Irrigation (Cont. ) Assessment Assess patient for abdominal pain or spasms, sensation of bladder fullness, or catheter bypassing (leaking). Ø Observe urine for color; amount; clarity; and presence of mucus, clots, or sediment. Ø Monitor I&O. Ø Assess patient’s knowledge regarding purpose of performing catheter irrigation. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 58

Skill 18 -5: Performing Catheter Irrigation (Cont. ) Planning/Expected Outcomes Delegation and Collaboration The skill of catheter irrigation cannot be delegated to nursing assistive personnel. Ø The nurse instructs the NAP to: • Report if the patient complains of pain or discomfort or Ø leakage of fluid around the catheter. • Watch and record I&O; report immediately any decrease in urine output. • Report any change in the color of the urine, especially the presence of blood clots. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 59

Skill 18 -5: Performing Catheter Irrigation (Cont. ) Evaluation Unexpected Outcomes Irrigation solution does not return (intermittent irrigation) or is not flowing at prescribed rate. Ø Drainage output is less than amount of irrigation solution infused. Ø Bright-red bleeding with irrigation drip wide open. Ø Patient experiences pain with irrigation. Ø Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 60

Recording and Reporting Record irrigation method, amount of and type of irrigation solution, amount returned as drainage, characteristics of output, and urine output. • Report catheter occlusion, sudden bleeding, infection, or increased pain. • Record I&O. • Document your evaluation of patient learning. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 61

Special Considerations Home Care Ø Patients and/or family caregivers can learn to perform catheter irrigations with adequate support, demonstration/return demonstration, and written instructions. Copyright © 2016 by Mosby, an imprint of Elsevier Inc. 62