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Urinary Catheterization
PREPARED BY: Laurence Soriano Haena rose Tamayo Sandeep Kaur Pamela Galang
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REVIEW OF URINARY SYSTEM
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Urinary elimination depends on the function of the kidneys, ureters, bladder, and urethra
KIDNEYS remove wastes from the blood to form urine. URETERS transport urine from the kidneys to the bladder. The BLADDER holds urine until the urge to urinate develops. Urine leaves the body through the URETHRA.
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BLADDER - 600 mL of sterile urine.
Feel the urge (150 to 200 mL in an adult and 50 to 100 mL in a child). 2200–2700 mL in 24 hours. 30 mL per hour clear, straw-coloured, and slightly acidic. The urethra and bladder are the primary structures involved during insertion of a urinary catheter.
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Factors Influencing Urinary Elimination
Age Muscle tone Surgical Sociocultural Fluid intake Medications Psychological Disease conditions Diagnostics
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CATHETERIZATION Involves introducing a narrow tube through the urethra into the bladder to allow continuous flow of urine into a drainage receptacle. may be short term (2 weeks or less) or long term (more than 1 month)
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INDICATIONS OF CATHETERIZATION
TYPE OF CATHETERIZATION REASON INTERMITTENT STRAIGHT CATHETERIZATION Relief of discomfort from acute bladder distention To obtain a sterile urine specimen Assessment of post-void residual when a bladder scanner is unavailable. Long-term management of patients with chronic urinary retention from spinal cord injuries, neuromuscular degeneration, or incompetent bladders Sometimes used to instill a medication
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TYPE OF CATHETERIZATION
REASON SHORT-TERM INDWELLING Relief of urinary obstruction; for example, by enlarged prostate Perioperatively or postoperatively Prevention of urethral obstruction caused by blood clots; continuous or intermittent bladder irrigation Accurate monitoring of urinary output in critically ill patients
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TYPE OF CATHETERIZATION
REASON LONG-TERM INDWELLING Severe urinary retention Presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence Terminal illness when bed linen changes are painful for the patient
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TYPES OF CATHETERIZATION
INTERMITTENT A straight, single-use catheter 5 to 10 mins. Single-lumen catheters
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TYPES OF CATHETERIZATION
INDWELLING remains in place until a patient is able to void voluntarily and completely, or as long as accurate measurements are needed. Double- lumen Catheters, Triple- lumen Catheters
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TYPES OF CATHETERIZATION
COUDE Has a curved tip Is used for males with enlarged prostates that partly obstruct urethra Less traumatic Stiffer and easier to control
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GUIDELINES FOR APPROPRIATE CATHETER SELECTION
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Catheter Size based on age
Age(Yr) Catheter Size (French) 5-8 FR <5 8-10 FR 5-10 10 FR 10-14 10-16 FR >14
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GUIDELINES FOR APPROPRIATE CATHETER SELECTION
adults with an indwelling catheter: 14–16 Fr 5–6 Fr for infants; 8–10 Fr for children; and 12–16 FR for adults or young girls. Larger catheter diameters increase the risk for urethral trauma Larger catheters are usually used for urological surgery or in the presence of gross hematuria. Factors such as latex allergy, history of catheter encrustation, and susceptibility to infection. Latex catheters with special coatings reduce urethral irritation Silicone catheters have a larger internal diameter, helpful in frequent catheter changes due to encrustation
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Indwelling -balloon sizes from 3 mL, for a child, to 30 mL, for continuous bladder irrigation (CBI).
Recommended: adult is a 5-mL balloon Long-term use of larger balloons (30 mL) has been associated with -increased patient discomfort - irritation and trauma -increased risk of catheter expulsion -incomplete emptying of the bladder ONLY STERILE WATER -inflate the balloon LEAKAGE= change in lumen size or use of antispasmodic medication may be warranted. Catheters should be changed for leaking, blockage, and before obtaining a sterile specimen
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WAYS TO PREVENT INFECTION IN CATHETERIZED PATIENTS
Hand Good hand hygiene techniques. Never Never allow the spigot on the drainage system to touch a contaminated surface. Use Use only sterile technique to collect specimens from a catheter. Refrain If the drainage tube becomes disconnected, refrain from touching the ends of the catheter or tubing. Instead, wipe the ends of the tubing or catheter with an antimicrobial solution before reconnecting. WAYS TO PREVENT INFECTION IN CATHETERIZED PATIENTS
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Ensure that each patient has a separate receptacle for measuring urine.
Prevent pooling of urine in the tubing and reflux of urine into the bladder. Avoid raising the drainage bag above the level of the bladder. If it becomes necessary to raise the bag during transfer of the patient to a bed or stretcher, clamp the tubing or empty the tubing contents into the drainage bag first. Positioning the tubing above the drainage bag. Drain all urine from the tubing into the drainage bag
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Avoid prolonged kinking or clamping of the tubing, which prevents bladder emptying.
Empty the drainage bag at least every eight hours. Encourage fluid intake unless contraindicated. Tape or secure the catheter appropriately for the patient. Perform routine perineal hygiene
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DELEGATION AND COLLABORATION
Inserting a STRAIGHT OR INDWELLING urinary catheter CANNOT be delegated to unregulated care providers (UCPs). The nurse directs the UCP to do the following: Position the patient Focus lighting for the procedure Maintain privacy Aid in the patient's comfort during the procedure
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DELEGATION AND COLLABORATION
Monitor the patient's intake and output, emptying urine from the collection bag Assist with perineal care after catheter insertion Report abnormal colour, odour, and amount and report if the catheter is leaking or causes pain Report any patient complaints of discomfort or pressure Report any fever
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Catheter kit containing the following sterile items:
Sterile gloves Prefilled syringe with sterile water for balloon inflation Antiseptic cleansing solution Sterile drainage tubing with collection bag Waterproof drapes (one fenestrated–has an opening in centre of drape) Lubricant Forceps Cotton Balls
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Catheter kit containing the following sterile items:
Clean gloves, basin with warm water, soap, washcloth, and towel for perineal care Multipurpose tube holder or tape. Receptacle or basin ( Specimen container Sterile drainage tubing and bag (if not included in the kit) Bath blanket Waterproof absorbent pad
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Expected Outcomes: Patient’s bladder is not palpable.
Patient verbalizes absence of abdominal discomfort or bladder pressure or fullness. urine output of at least 30 mL/hr of urine less than 30 mL per hour could indicate the following: The catheter has slipped out of the bladder or is occluded. Severe dehydration has occurred. There is a decrease in renal perfusion. Patient verbalizes the purpose and expectations for the procedure.
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Evaluation After urinary catheterization, evaluate the following:
Palpate bladder for distention or use bladder scan. Ask patient to determine patient's level of comfort. Indwelling catheter: Observe character and amount of urine in drainage system Ensure that there is no urine leaking from catheter or tubing connections
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ASSESSMENT 1. Review patient's medical record, including health care provider's order and nurses' notes 2. Close bedside curtain or door. 3. Assess status of patients: a. Ask patient when he/she last voided b. Level of awareness or developmental stage c. Mobility and physical limitations of patients d. Patient gender and age e. Distended bladder f. Perform hand hygiene. Apply clean gloves. Inspect perineum. g. Note any pathologic condition that may impair passage of catheter. h. Allergies
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ASSESSMENT 4. Assess patients knowledge of the purpose for catheterization. 5. Explain procedure to patient 6. Arrange for extra nursing personnel to assist as necessary. 7. Perform hand hygiene 8. Raise the bed 9. Arrange equipment. 10. Raise the side rail on the opposite side of the bed, and put the side rail down on the working side. 11. Place a waterproof pad under the client.
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12. Position the client. A. Female client: (1) dorsal recumbent; relax her thighs so that the hips can be rotated externally. (2) side-lying (Sims’) position with the upper leg flexed at the hip if the client is unable to assume the dorsal recumbent position. B. Male client: Assist the client to a supine position with thighs slightly abducted. 13. Drape client. 14. Wearing disposable gloves, provide perineal care. 15. Hand hygiene
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16. Open the catheterization kit according to directions, keeping the bottom of the container sterile. 17. Place the plastic bag within reach in which used supplies can be disposed. 18. Put on sterile gloves. 19. Organize supplies on a sterile field. 20. Before inserting an in-dwelling catheter, test the balloon by injecting fluid from the prefilled syringe into the balloon port.
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21 Lubricate 2. 5–5 cm of the catheter for female clients and 12. 5–17
21 Lubricate 2.5–5 cm of the catheter for female clients and 12.5–17.5 cm for male clients. Apply the sterile drape: A. Female client: (1) Allow the top edge of the drape to form a cuff over both gloved hands. Place the drape on the bed between the client’s thighs. Slip the cuffed edge just under the client’s buttocks, taking care not to touch the contaminated surface with gloves. (2) Pick up the fenestrated sterile drape and allow it to unfold without touching any unsterile objects. Apply over the client’s perineum, exposing labia, taking care not to touch the contaminated surface with gloves.
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B. Male client: First method: -over the thighs and under the penis without completely opening fenestrated drape. Second method: -over the thighs just below the penis. Pick up the fenestrated sterile drape, allow it to unfold without touching any unsterile objects, and drape it over the penis, with the fenestrated slit resting over the penis.
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23. Cleanse the urethral meatus. A
23. Cleanse the urethral meatus. A. Female client: - Holding forceps in your sterile dominant hand, pick up a cotton ball saturated with antiseptic solution - Wiping from clitoris toward anus (front to back). Using a new cotton ball for each area B. Male client: - Use forceps to pick up a cotton ball saturated with antiseptic solution, and clean the penis. -circular motion from the urethral meatus down to the base of the glans. - repeat three more times, using a clean cotton ball each .
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24. Pick up the catheter with your gloved dominant hand, 7
24. Pick up the catheter with your gloved dominant hand, 7.5–10 cm from the catheter tip. Hold the end of the catheter loosely coiled in the palm of your dominant hand. 25. Insert the catheter. A. Female client: (1) Ask the client to bear down gently as if to void urine, and slowly insert through the urethral meatus. (2) Advance the catheter a total of 5–7.5 cm in an adult or until urine flows out the catheter’s end. When urine appears, advance the catheter another 2.5–5 cm. DO NOT USE FORCE AGAINST RESISTANCE. (3) Slowly inflate the balloon if the indwelling catheter is being used.
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B. Male client: (1) Lift the client’s penis to position perpendicular to the client’s body, and apply light traction. (2) Ask the client to bear down gently as if to void urine, and slowly insert the catheter through the urethral meatus. (3) Advance the catheter 17–22.5 cm (7–9 inches) in an adult or until urine flows out the catheter’s end. If resistance is felt, withdraw the catheter When urine appears, advance the catheter another 2.5–5 cm. DO NOT USE FORCE AGAINST RESISTANCE. (4) Place the end of the catheter in the urine tray. Inflate the balloon if an in-dwelling catheter is being used. (5) Reduce (or reposition) the foreskin.
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26. Collect the urine specimen as needed
26. Collect the urine specimen as needed. Fill the specimen cup or jar to the desired level (20–30 mL) by holding the end of the catheter over the cup with your dominant hand. 27. Allow the client’s bladder to empty fully (about 800–1000 mL) unless institution policy restricts the maximal volume. 28. After inflating the baloon, pull gently. 29. The drainage bag must be below the level of the bladder. Attach the bag to the bed frame; DO NOT PLACE THE BAG ON THE BED’S SIDE RAILS. 30. Anchor the catheter.
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A. Female client: (1) inner thigh or abdomen with a strip of non allergenic tape (or multipurpose tube holders with a Velcro strap). B. Male client: thigh or lower abdomen (with the penis directed toward the chest). 31. Assist the client to a comfortable position. Perineal care if needed. 32. Remove gloves and dispose of equipment, drapes, and urine in proper receptacles.
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33. Perform hand hygiene. 34. Palpate the client’s bladder. 35
33. Perform hand hygiene. 34. Palpate the client’s bladder. 35. Ask whether the client is comfortable Observe the character and amount of urine in the drainage system. 37. Ensure that no urine is leaking from the catheter or tubing connections. 38. Record and report catheterization 39. Initiate intake and output records.
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Video Catheterization
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SAFETY CONSIDERATIONS
Regularly assess patient's functional status. Evaluate a patient's normal pattern of micturition. Consider age. Patients that need assistance with elimination should have a call bell within easy reach and the offer for assistance made at regular intervals Explain the importance of Adequate oral intake especially if the patient has an indwelling urinary catheter.
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SAFETY CONSIDERATIONS
Evaluate urinary output. Know the average output range for a patient. Know the signs of dehydration and fluid overload. Assess a patient's most recent serum electrolyte measurements. Weigh the patient to determine fluid status. Ask the patient to empty their bladder. Maintain aseptic (sterile) technique when catheterizing a patient
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Unexpected Outcomes and Interventions
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APPLYING CONDOM CATHETER
Condom catheter or penile sheath, is a soft, pliable condomlike sheath Safe and non-invasive Soft silicone that reduces friction Held in place by adhesive coating of the internal lining of the sheath, a double-sided self-adhesive strip a brush-on adhesive applied to the penile shaft an external strap. suitable for incontinent patients who have complete and spontaneous bladder emptying. associated with less risk for UTI
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DELEGATION AND COLLABORATION
Applying a condom catheter CAN BE DELEGATED to a UCP. The nurse directs the UCP to do the following: Follow the manufacturer’s directions for applying the condom catheter and securing the device Monitor urine output and record I&O, if applicable. Immediately report any redness, swelling, or skin irritation or breakdown of the glans penis or penile shaft.
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•Patient's normal urinary pattern
ASSESSMENT •Patient's normal urinary pattern •Patient's ability to voluntarily urinate and degree of continence •Patient's mental status and functional ability to self-apply device •Condition of the skin on and surrounding the penis. Use the manufacturer's measuring guide to measure the diameter of penis in a flaccid state. The penile shaft should be at least 2 cm in length to ensure successful application. •The patient's level of understanding as to the purpose of the condom catheter. • ALLERGIES to: Latex or rubber products (or both) Antiseptic solutions (Betadine),
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PLANNING-EQUIPMENT Condom catheter kit:
Condom sheath of appropriate size Skin preparation to protect skin (per manufacturer’s directions) Securing device Basin with warm water and soap Towels and washcloth(s) Bath blanket Clean gloves Hair guard, or scissors and paper towel
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EXPECTED OUTCOMES EVALUATION
Patient’s skin is free from urine wetness. Glans and penile shaft are free of skin irritation or breakdown. Patient explains the purpose of the procedure and what to expect. EVALUATION Observe urinary drainage. Inspect penis with condom catheter in place within 15–30 minutes of application. Assess for swelling and discoloration of the penis, and ask patient if there is any discomfort. Inspect skin on penile shaft for signs of breakdown or irritation at least daily, when performing hygiene, and before reapplying condom.
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Unexpected Outcomes and Interventions
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SPECIMEN COLLECTION Urine samples can be clean or sterile
Strict aseptic technique A urine specimen can be collected only from a new sterile urine bag when an indwelling catheter is first inserted and connected to the bag. Always refer to facility policy and manufacturer's recommendations
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DELEGATION AND COLLABORATION
Sterile urine sample (indwelling catheter ) MAY BE DELEGATED to unregulated care providers (UCPs) familiar with aseptic technique. Sterile urine sample (straight catheter insertion) is INAPPROPRIATE TO DELEGATE to a UCP. The nurse informs the UCP about the following: Proper technique for obtaining the urine sample When to obtain the specimen How to appropriately handle and transport the specimen to the laboratory Reporting to the nurse if the urine is not clear DELEGATION AND COLLABORATION
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ASSESSMENT Assess the patient's or family members' understanding of the need to collect urine. Assess for signs and symptoms of urinary tract infection: Frequency Urgency Dysuria Changes in urine colour and odour Hematuria (blood in urine) Flank pain Fever Indwelling catheter- Luer-Lok port- no needle is used; urine is removed with a Luer-Lok syringe. If it is a self-sealing port, a needle can be used. For straight catheterization, assess for latex allergy.
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PLANNING—EQUIPMENT Obtaining a urine specimen from a urinary catheter:
Clean gloves (indwelling catheter); sterile gloves if urine is obtained during straight catheterization A 3-mL Luer-Lok syringe for needle-free port for culture (indwelling catheters only) A 20-mL Luer-Lok syringe for routine urinalysis (indwelling catheters only) Alcohol, chlorhexidine, or other disinfectant swab (indwelling catheters only) Specimen container Nonsterile for routine urinalysis Sterile culture container A completed identification label with appropriate patient identifiers A completed laboratory requisition including patient identification, date, time, name of test, and source of culture Small plastic biohazard bag for delivery of specimen to laboratory (or container specified by facility)
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PLANNING—EXPECTED OUTCOMES
A urine specimen is obtained from the catheter without contamination. Patient’s comfort The urinary catheter and drainage system remain intact. EVALUATION Evaluate your patient and the urine itself. The urine colour, characteristics, and amount Any discomfort Compare the results of the patient's laboratory report with normal laboratory values and report any abnormalities to the health care provider. Indwelling catheter Observe the urinary drainage system
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UNEXPECTED OUTCOMES & INTERVENTIONS
Related Interventions Urine specimen is contaminated during procedure Obtain a new specimen Urine does not collect in drainage tube Offer fluids if permitted to enhance urine production Urine culture reveals bacterial growth (determined by colony count of more than 10,000 organisms per millilitre) Report findings to health care provider Administer medications as ordered Monitor patient for fever and dysuria Lumen leading to balloon that holds catheter in bladder is punctured Notify health care provider Prepare for removal and insertion of new catheter Collect specimen
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Care and Removal of the Indwelling Catheter
Delegation and Collaboration CARE AND REMOVAL INDWELLING CATHETER- Can be delegated to unregulated care providers (UCPs) However, the nurse must first assess patient's status, verify the order, and validate that the UCP is allowed to do so as indicated by facility policy. The nurse directs the UCP to do the following: Check size of balloon and syringe needed to deflate balloon Report: Characteristics of the urine condition of patient's genital area bleeding after removal time and amount of first voiding after removal Signs of infection (CAUTI) Signs of UTI after removal
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ASSESSMENT Observe urinary output and characteristics.
Assess for history or presence of bowel incontinence. Observe for any discharge, redness, bleeding, or presence of tissue trauma around the urethral meatus. Assess patient’s knowledge of catheter care. Catheter removal: Review patient’s medical record, including health care provider’s order and nurses’ notes. Determine size of catheter inflation balloon by looking at balloon inflation valve.
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PLANNING—EQUIPMENT CATHETER CARE
• Clean gloves (needed for care and removal) Waterproof pad Bath blanket Soap, washcloth, basin, and water For removing a catheter, you need the following: 10-mL or larger syringe without needle. Graduated cylinder to measure urine Toilet, bedside commode, urine "hat," urinal, or bedpan Bladder scanner (if indicated) Washcloth and warm water
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Genital area is free of secretions, fecal matter, and irritation.
EXPECTED OUTCOMES CATHETER CARE: Genital area is free of secretions, fecal matter, and irritation. Patient will verbalize a feeling of comfort. CATHETER REMOVAL: Patient voids at least 150 mL with each voiding, no more than SIX TO EIGHT HOURS after removal. Patient’ S feeling of complete bladder emptying and absence of discomfort. Patient will identify signs and symptoms of UTI.
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Evaluate for signs and symptoms of a UTI.
EVALUATION Inspect the catheter and genital area for soiling, irritation, and skin breakdown. Observe time, and measure the amount of first voiding after catheter removal. The time of removal and the due-to-void time should be recorded and reported Evaluate for signs and symptoms of a UTI.
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UNEXPECTED OUTCOME & INTERVENTIONS
Water from inflation balloon does not return into syringe. Reposition patient; ensure that catheter is not pinched or kinked. Remove syringe. Attach new syringe and allow enough time for passive emptying. Attempt to empty balloon by gently pulling back on the syringe plunger. If a catheter balloon does not deflate, do not cut balloon inflation valve to drain the water. Notify the health care provider. Patient has one or a combination of fever, chills, burning, flank pain, back pain, hematuria, painful urination, urgency, frequency, lower abdominal pain, change in mental status, and/or lethargy Assess for bladder distention and tenderness. Monitor vital signs and urine output. Report findings to health care provider; signs and symptoms may indicate a urinary tract infection.
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UNEXPECTED OUTCOME & INTERVENTIONS
Patient is unable to void after catheter removal, has a sensation of not emptying, strains to void, or experiences small voiding amounts with increasing frequency. Assess for bladder distention. Ensure adequate intake and privacy, and facilitate urination by relaxation. Assist to normal position to void. Perform bladder ultrasound scan to assess for excessive urine volume in bladder. If patient is unable to void within six to eight hours of catheter removal or experiences abdominal pain, notify health care provider.
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REFERENCES Potter and Perry (2014) Suction Techniques Retrieved from Elsevier, Canada (2014) Canadian Fundamentals of Nursing Fifth Edition: Urinary Catheterization
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