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. 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. Anatomy and Physiology Review
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. 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
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.
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. Micturition
Why do we use catheters? 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.
Why do we use catheters? What is going on in this picture that may cause the nurse to insert a 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. Straight (French) is a single lumen tube with one opening used for intermittent catheterization. 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 coude- has a curved tip to pass past an enlarged prostate Pezzar- mushroom tip used for suprapubic catheters Three lumen indwelling (for irrigation) 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.
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.
Which hand is still sterile? Position in dorsal recumbent. 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.
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.
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 Injecting through port Irrigating with 3 way catheter Irrigating through 2 way catheter after separating the catheter and tubing (open system)
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 system- not 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 Nosocomial infection if left untreated may cause pyelonephritiis. No urination after 8 hours 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.