Urological Instrumentation, Catheterization, Common Diagnostics
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- Acute retention
- Chronic retention
- Peri-operatively: SCIP (Core measure: Surgical Care Improvement Proj); to reduce surgical mortality and post op complications-reduce developing a uti undergoing surgery, remove by 48 hours unless they NEED to have it.
- -discontinue antibiotics after 24 hours!
- Accurate measurement of urine output (heart patients: CHF, ICU pts-shock, after transplant, acute renal failure)
- pressure ulcer stages III & IV (avoid moisurture or incontinence)
- End-of-life care
- =>Long-term care
- =>Principles of care
- Sterile drainage system: Implications?Keep it sterile, avoid kinks!Catheter and perineal care
- Positioning: Below bladder level, Avoid kinks
- Anchored (the velcro devices)
- Early removal
**Urethral cath: the most common route, involves inserton of a cath through the external meatus into the urethra and into bladder.
- **Ureteral cath: placed through ureters into the renal pelvs-iserted either by being headed up the rethra and bladder to the ureters under cystoscopic observation or by surgical insertion through the abdominal wall into the ureters. drains urine from renal pelvis, which has a capacity of 3-5 ml
- -do not clamp cath, or kink or compressed
- -irrigate with strict asceptic technique
- -check drainage q1-2 hours
Usually for long care like with neurogenic bladder, spinal cord inuries
- Nursing care: placed by urologist.
- Regular cath: replaced once a month
- Supra: every 3 months. Simplest and oldes method of diversion.
- Two methods of insertion 1. Through a small incision in abdominal wall and 2. By use of a trocar.; placed iunder general or local anesthesia.
- -Used in temp situations mostly
- -Prone to poor drainage b/c of mechanical obsruction of cath tip by the bladder wall-To ensure patency: preent kinking, maintaing gravity drainage, have the pt turn from side to side, and milk the tube
- Bladder spasms: oxybutin prescribed.
Goes straight into kidney, usually for short term-cancer pts: long period of time.
- NEVER irrigate, you will damage the parenchamal of the kidneys!IF THEY DO, no more than 5 ml (Cannot accomodate too much fluid)
- Closed system techniquesPatient education?
Before & During Surgery
Caring for it
- inserted on a temp basis to preserve renal function when a ureter is completely obstructed. THe tube in sinserted through a small flank incison diretctly into the pelvis of the kideny and attached to connectig tubing for closed drainage.
- -> Never kink, compress or clamp.
- -> Strict asceptic technique with no more than 5ml irrigation
Adults should not drink milk or eat solid food 8 hours before the procedure. Nonalcoholic liquids (water or broth) are acceptable for 2 to 3 hours before the procedure. Check with your doctor for specific instructions for adolescents and children.
- An x ray will be taken to confirm the position of this needle.
- Then, a guide wire will be placed through this needle and into the renal pelvis, and the needle will be removed. At this point, the nephrostomy tube will be placed over the guide wire and into the kidney. This part of the procedure may be uncomfortable, and the radiologist may give you more pain medication through your intravenous line.
When the nephrostomy tube is properly placed, the guide wire will be removed. Contrast dye will be injected again, and another x-ray will be taken to make sure the tube is in the right place.
Some nephrostomy tubes canbe secured firmly by forming a loop inside the kidney.
- CARING:For the first 2 weeks after nephrostomy tube placement, the sterile gauze dressing should be changed once a day. If you prefer to use sterile transparent dressing, it should be changed every 3 days.
- After the first 2 weeks, the dressing should be changed at least twice a week (for example, every Monday and Thursday). You must change your dressing if it is wet.
- => Showering: When to shower
- You may shower 48 hours after the tube has been inserted, but the tube site must stay dry. You may protect the dressing with plastic wrap taped to your skin so that the dressing is completely covered.
- The tube site should be kept dry for the next 14 days. After that time, when the site has healed, you may shower without the dressing and plastic wrap.The tube site should be cleaned with a mild liquid soap and water, and rinsed well. A single use washcloth should be used to clean the site. Bathing or swimming is not recommended as long as the tube is in place.
- => How do I flush the nephrostomy tube?When a nephrostomy tube is first inserted, you may have blood in your urine. If your doctor recommends that you flush your nephrostomy tube, follow the instructions you will be given.
- Flush the nephrostomy tube through the rubber stopper on the three-way stopcock attached to your nephrostomy drainage system. (A three-way stopcock is a plastic valve with three openings and a sidearm that controls the direction of fluid through the device.) Your doctor or nurse will connect the nephrostomy tube to the stopcock. The drainage bag will be attached to the stopcock.
- The third side (irrigation port) will have a rubber cap for flushing. All three-way stopcocks do not function the same way. Check the direction of fluid flow for the device you use. The flushing port should be in the OFF position when not in use. If your urine output stops, check the sidearm position and tube for kinks
- -aka "straight cath", alternative to long term indwelling cath
- -Used for neurogenic bladders,oliguric and anuric phases of actue ideyn injury
- -inserted every 3-5 hours
- -single use cath (closed-sterile) systems is useful for pts who have recurrent UTIs
**Urinary Diversion Types
the actual bladder is removed..
- CA of bladder
- neurogenic bladder
- trauma to bladder
=>With or without cystectomy
- Ileal conduit (INCONTINENT)
- Continent urinary diversions (Kock pouch)
- Orthotopic bladder reconstraction
divert urineto the large intestine, so no stoma is required. The client excretes urine withbowel movements, and bowel incontinence may result. Ileal reservoirs divert urineinto a surgically created pouch,or pocket, that functions as a bladder. The stoma is continent, and the client removes urine by regular self-catheterization.
- -pouch created by physican that they cath
- -Intraabdominal urinary reservor that can be catherized or that has an outlet controlled by the anal sphicter.
- Reservoirs constructed from the ileum, or colon
- -A continenc mechanism is formed between this large, low pressure reservoir nad the stoma by intususcepting a protion of bowel SO THAT the patient doens't leak involuntarily--forms a nipple
**Orthotopic Bladder Reconstruction
- -Construction of a new bladder in the bladder's nomral anatomic position with discharge through the urethra
- -More viable if cancer doesn't involve the bladder neck or urethraa
=> Creation of a neobladder
a. Creation of a neobladder is similar to the creationof an internal reservoir, with the differencebeing that instead of emptying throughan abdominal stoma, the bladder emptiesthrough a pelvic outlet into the urethra.
b. The client empties the neobladder by relaxingthe external sphincter and creating abdominal pressure or by intermittent selfcatheterization.
**Ileal Conduit (INCONTINENT)
You can have an illeal or colon conduit
Conduits: Collect urine in a portion of the intestine, which is then opened onto the skin surface as a stoma. After the creation of a conduit, the client MUST wear a pouch.
In this procedure a 5-8 inch segment of the illeum is converted into a conduit for urinary dirainage. The colon (colon conduit) can be used instead of the illeum.
The ureters are anastomosed into the end of the conduit and the other end of the bowel is brough out through the abdominal wall to form a stoma.
- -The bowel is anastamosed and continues to function normally.
- -There is no valve and no voluntary control over stoma, drops of urine flow from the stoma every few seconds and require a permanent external collecting device.
Divert urine directly to the skin surface through a ureteral-skin opening (stoma). After ureterostomy, the client must wear a pouch.
a. Ureterostomy may be performed as a palliative procedure if the ureters are obstructed by the tumor
.b. The ureters are attached to the surface of theabdomen, where the urine flows directly intoa drainage appliance without a conduit.
c. Potential problems include infection, skinirritation, and obstruction to urinary flowas a result of strictures at the opening.
Self-Irrigation and Catheterization of Stoma
- => Irrigation
- Instruct the client to wash hands and use clean technique.Instruct the client to use a catheter and syringe, instill 60 mL of normal saline or water into the reservoir, and aspirate gently or allow to drain.Instruct the client to irrigate until the drainage remains free of mucus but to be careful not to overirrigate.
- => Catheterization
- Instruct the client to wash hands and use clean technique.Initially, instruct the client to insert a catheter every 2 to 3 hours to drain the reservoir; during each week thereafter, increase the interval by 1 hour until catheterizationis done every 4 to 6 hours.Lubricate the catheter well with water-soluble lubricant, and instruct the client never to force the catheter into the reservoir.If resistance is met, instruct the client to pause, rotate the catheter, and apply gentle pressure to insert.Instruct the client to notify the physician if the client is unable to insert the catheter.When urine has stopped, instruct the client to take several deep breaths and move the catheter in and out 2 to 3 inches to ensure that the pouch is empty.Instruct the client to withdraw the catheter slowly and pinch the catheter when withdrawn so that it does not leak urine.Instruct the client to carry catheterization supplies with him or her.
1. Description: A urine test for evaluation of therenal system and renal disease
- 2. Interventions
- a. Wash perineal area and use a clean containerfor collection.
- b. Obtain 10 to 15 mL of the first morningvoiding if possible.
c. Refrigerated samples may alter the specificgravity.
d. If the client is menstruating, note this on thelaboratory requisition form.
Specific gravity determination
Increase vs Decrease Interpret
1. Description: A urine test that measures the abilityof the kidneys to concentrate urine
- 2. Interventions
- a. Specific gravity can be measured by a multipletestdipstick method (most common method),refractometer (an instrument used in the laboratorysetting), or urinometer (least accuratemethod).
- b. Factors that interfere with an accurate readinginclude radiopaque contrast agents, glucose,and proteins.
- c. Cold specimensmay produce a false high reading.
d. Normal value is 1.016 to 1.022 (may vary depending on the laboratory).
e. An increase in specific gravity (more concentratedurine) occurs with insufficient fluidintake, decreased renal perfusion, or increasedADH.
f. A decrease in specific gravity (less concentratedurine) occurs with increased fluidintake or diabetes insipidus; it may also indicaterenal disease or the kidneys inability toconcentrate urine.
Urine culture and sensitivity testing
A urine test that identifies the presenceof microorganisms (culture) and determinesthe specific antibiotics to treat the existingmicroorganism (sensitivity) appropriately
- 2. Interventions
- a. Clean the perineal area and urinary meatuswith a bacteriostatic solution.
- b. Collect the midstream sample in a sterilecontainer.
- c. Send the collected specimen to the laboratoryimmediately.
- d. Identify any sources of potential contaminantsduring the collection of the specimen,such as the hands, skin, clothing, hair, or vaginalor rectal secretions.e. Urine from the client who drank a very large amount of fluids may be too dilute to provide a positive culture.
Creatinine clearance test
- 1. Description
- a. The creatinine clearance test evaluates howwellthe kidneys remove creatinine from the blood.
- b. The test includes obtaining a blood sampleand timed urine specimens.
- c. Blood is drawn when the urine specimencollection is complete.
- d. The urine specimen for the creatinine clearanceis usually collected for 24 hours, butshorter periods such as 8 or 12 hours couldbe prescribed
- 2. Interventions
- a. Encourage fluids before and during the test.
- b. Instruct the client to avoid caffeinated beveragesduring testing.
- c. Check with the physician regarding theadministration of any prescribed medicationsduring testing.
- d. Instruct the client about the urine collection.
- e. At the start time, ask the client to void (orempty the tubing and drainage bag if the clienthas a Foley catheter) and discard the firstsample.
- f. Collect all urine for the prescribed time.
- g. Keep the urine specimen on ice or refrigeratedand check with the laboratory regardingadding a preservative to the specimen duringcollection.
- h. At the end of the prescribed time, ask the clientto empty the bladder (or empty the tubingand drainage bag if the client has aFoley catheter) and add that final urine tothe collection container.
- i. Send the labeled urine specimen to the laboratoryin a biohazard bag along with therequisition.
- j. Document specimen collection, time startedand completed, and pertinent assessments.
An x-ray procedure in which anintravenous injection of a radiopaque dye is used to visualize and identify abnormalities inthe renal system.
- 2. Preprocedure interventions
- a. Obtain an informed consent.
- b. Assess the client for allergies to iodine, seafood,and radiopaque dyes.
- c. Withhold food and fluids after midnight onthe night before the test.
- d. Administer laxatives if prescribed.
- e. Inform the client about possible throat irritation,flushing of the face, warmth, or a salty or metallic taste during the test.
- 3. Postprocedure interventions
- a. Monitor vital signs.
- b. Instruct the client to drink at least 1 L of fluidunless contraindicated.
- c. Assess the venipuncture site for bleeding.
- d. Monitor urinary output.
- e. Monitor for signs of a possible allergic reactionto the dye used during the test andinstruct the client to notify the physician if any signs of an allergic reaction occur.
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