Transcript Urinary Catheterization Anatomy and Physiology Bladder - Anatomy Neuroanatomy of Voiding Neuroanatomy of Voiding • Frontal lobe – Micturition center – Sends inhibitory signals • Pons (Pontine Micturition Center) –

Urinary Catheterization
Anatomy and
Physiology
Bladder - Anatomy
Neuroanatomy of Voiding
Neuroanatomy of Voiding
• Frontal lobe
– Micturition center
– Sends inhibitory signals
• Pons (Pontine Micturition Center)
– Major relay/excitatory center
– Coordinates urinary sphincters and the
bladder
– Affected by emotions
• Spinal cord
– Intermediary between upper and lower
control
Peripheral Nervous System
• Somatic (S2-S4)
– Pudendal nerves
• Excitatory to external
sphincter
• Parasympathetic (S2S4)
– Pelvic nerves
• Excitatory to bladder,
relaxes sphincter
• Sympathetic (T10-L2)
– Hypogastric nerves to
pelvic ganglia
– Inhibitory to bladder
body, excitatory to
bladder base/urethra
Normal Voiding
• SNS primarily controls bladder and the IUS
– Bladder increases capacity but not pressure
– Internal urinary sphincter to remain tightly closed
– Parasympathetic stimulation inhibited
• PNS
– Immediately prior to PNS stimulation, SNS is suppressed
– Stimulates detrusor to contract
– Pudendal nerve is inhibited  external sphincter opens
 facilitation of voluntary urination
Innervations of the Lower
Urinary Tract
Function
Balance between suprasacral
modulating pathways, sacral cord
and the pelvic floor
Emptying phase: “Voiding Reflex”
Series of coordinated events
involving outlet relaxation,
detrusor contraction
Storage phase: “Guarding
reflexes” constant afferent input
to maintain continence
Bladder Dysfunction
Functional Classification
• Failure to store
– Because of bladder
– Because of outlet
• Failure to empty
– Because of bladder
– Because of outlet
• Combination
Pathophysiology of Voiding
• Brain lesion above pons destroys
master control center
– Ex – stroke, brain tumor,
hydrocephalus, CP….
– Result – urge incontinence, night
incontinence, coordinated sphincter
• Spinal cord lesion,
myelomeningocele, MS
– Detrusor hyperreflexia
– Spastic bladder
– Areflexic bladder
Pathophysiology of Voiding
• Lumbosacral spinal lesion
– Ex – spinal tumor, sacral SCI, herniated
disc, lumbar laminectomy, radical
hysterectomy, pelvic trauma
– Result – areflexic bladder
• Peripheral nerve injury
– Ex – AIDS, diabetes, polio, Result –
urinary retention
Medication Options
Bladder Management
Options
Management Options
Type of Management
Advantage
Disadvantage
Indwelling catheter
Convenience
Less caregiver
assistance
Infection
± Urethral damage
± Bladder cancer
Intermittent catheter
± Reduced infection
Need anticholinergic
± Urethral damage
Assistance
Cost
Labor
Management Options
Type of
Management
Advantage
Disadvantage
Reflex voiding
Non-invasive
± High pressure
± Continence
± High residuals
± Need for
sphincterotomy
Electrical stimulation Improved bowel fxn
+ rhizotomy
Reduced labor/cost
Cosmetically
appealing
Significant surgery
Side effectsrhizotomy
↓ Reflex erection
↓ Reflex ejaculation
Management Options
Type of
Management
Advantage
Disadvantage
Surgical diversion
May produce
Significant surgery
continence
Committed to
Continent pouch
collection
easier for female to device/cath
cath
Risk of cancer
Electrical Stimulation
Bladder Augmentation
• Procedure that increases bladder capacity using
intestinal segments
– Ileum, colon, or stomach are used
• Goals
– Decreasing intravesicle pressure
– Restore urinary continence
– Preserve upper urinary tracts by alleviating reflux and
hydronephrosis
• Can combine with a continent abdominal stoma
• Consider in patients with
– Intractable involuntary bladder contractions causing
incontinence
– Patients who are able and motivated to perform CIC
– Reflex voiders wishing to convert to CIC
– Females with paraplegia
Urinary Diversion
• Diverts the urine flow from the bladder
• Secondary form of bladder management when primary
methods have failed
• Ureters transected just above the bladder and connected to
a segment of intestine (terminal ileum) which is in turn
brought to the skin of the lower abdominal wall
• External appliance used as collection device
• Considered if:
–
–
–
–
Lower urinary complications secondary to indwelling catheters
Urethrocutaneous fistulas, perineal decubitus ulcers
Urethral destruction in females
Hydronephrosis secondary to a thickened bladder wall and for
hydronephrosis secondary to vesicoureteral reflux or failed
reimplant.
– Bladder malignancy requiring cystectomy
Recommendations
Recommendations
• Recommendation 1: Intermittent
catheterization is the preferable method
for bladder emptying for men and women
who have adequate hand function or a
willing caregiver to perform the
catheterization and have bladders that do
not empty adequately.
• Recommendation 2: Intermittent
catheterization should be ideally
performed every 4 to 6 hours to keep
bladder volumes below 400ccs.
Recommendations from the
PVA Guidelines
• Recommendation 5: Consider sterile
catheterization for those individuals with
recurrent symptomatic infections
occurring with clean intermittent
catheterization. Rationale: Lower
infection rates can be achieved with sterile
techniques and with pre-lubricated self
contained catheter sets
Recommendations from the
PVA Guidelines
• Recommendation 5: Risk of
symptomatic infection is at least
comparable and may be less in
individuals with indwelling catheters
than those managing their bladders
with clean intermittent
catheterization.
Recommendations from the
PVA Guidelines
• Recommendation 6: Patient should be
advised of long-term complications of
indwelling catheterization, including:
– Bladder stones
– Kidney stones
– Urethral erosions
– Bladder cancer
– Epididymitis
– Recurrent symptomatic urinary tract
infections
Genitourinary
Assessment of Function
Assessment of Function
• U/a and c & s
• BUN & Cr
– if compromised renal function is suspected
• Postvoid residual urine
– If high, the bladder may be contractile or the
bladder outlet may be obstructed
Renal/Bladder US
Mainstay
of screening in many institutions
• Advantages
– Simple
– Eval kidney,
parenchymal loss,
abnl echogenicity
– Eval for
hydronephrosis,
stones
• Disadvantages
– Low sensitivity for
small stones
– Ureters not
evaluated well
Nuclear Renal Scan
• Advantages
– Functional info
– No nephrotoxic
reactions
– Low radiation
• Disadvantage
– Less anatomic info
– Cannot detect
stones
KUB
• Historically, routinely used to detect
renal and bladder stones
• Disadvantages
– Poorly sensitive to stones
– “KUB not justified in routine f/u of
urinary tract in SCI”
• Tins et al. Spinal Cord 2005
Secondary Conditions
• Increased risk of
– Bladder infection
– Kidney infection
– Hydronephrosis
– Urethral trauma/laxity
Urinary Stones and SCI
• Higher incidence, especially in first 6
mos
– 3-6% upper tract
– 11-15% bladder
• Etiology
– Stasis
– Calcium metabolism
– Infection
• Diagnosis
– CT is gold standard
No Indwelling Catheter For
You!
Red Rubbers, $.50
Sterile single use
catheters $1.00
No-touch kits with collection bags $4.00
No-touch catheters $2.00
“Bitch catheter”
Ultimately, we do what is
right for each of our
patients,
just like we would treat
our own family
UTI
• Indications to treat - No catheter &
three of the following present…
• Fever (increase in temp >2 degrees F (1.1
degrees C) or rectal temperature >99.5
degrees F (37.5 degrees C) or single
measurement of temperature >100 degrees
F (37.8 degrees C) );14
• New or increased burning pain on urination,
frequency or urgency;
• New flank or suprapubic pain or tenderness;
• Change in character of urine (e.g., new
bloody urine, foul smell, or amount of
sediment) or as reported by the laboratory
(new pyuria or microscopic hematuria);
and/or
• Worsening of mental or functional status
UTI
• Indications to treat – w/ catheter & two
of the following
• Fever or chills;
• New flank pain or suprapubic pain or
tenderness;
• Change in character of urine (e.g., new bloody
urine, foul smell, or amount of sediment) or as
reported by the laboratory (new pyuria or
microscopic hematuria); and/or
• Worsening of mental or functional status.
• Local findings such as obstruction, leakage, or
mucosal trauma (hematuria) may also be
present.
UTI Follow up
• Recurrent UTIs
• Predisposing Factors
– structural abnormalities - a referral
to a urologist
– poor perineal hygiene
• PRIMARY - reconsider the
relative risks and benefits of
continuing the use of an
indwelling catheter.
Neurogenic Bladder
What is a neurogenic
bladder?
• A medical term for overflow
incontinence, secondary to a
neurologic problem
• However, this is NOT a type of
urinary incontinence
Urinary Catherization
• Equipment:
• Straight catheters
• Box of supplies: foley, 3 way foley,
cath kits with sterile gloves,
drainage bags with urin Bag,
Drape and towel
• Tape
• Skin so soft lubricant
• Overbed table
• Good lighting
Complication of catheterization
1. Infection- (primary cause)
2. Uretheral tares
3. Ruptured bladder
4. Bladder spasm
5. Possible allergic reaction to tape
or latex
Urinary Catherization
A. Purposes of catherization:
1. Relief of discomfort due to bladder
distention
2. Assess amount of residual urine
3. Obtain a urine specimen
4. Empty bladder prior to procedure
5. Manage incontinence
6. Provide for bladder irrigation
7. Prevent urine coming in contact with
wound
8.facilitate accurate measurement of output
in critically ill clients
9. Self catherization for management of
• Types of Equipment:
- Catheters
1. Sizes – range from 8 to 18 French
indicates
diameter.
2. Types
a. Straight- single use for intermittent
catherization ; has 1 opening
b. Foley- inflatable balloon (5cc-30cc),
known as indwelling or retention
catheters,
has 2 openings
c. Continuous catheter-3 openings or
lumens (1 to drain urine, 1 for
filling balloon,
and 1 for irrigation), used
for periodic or
continuous bladder
irrigation
d. Coude’- curved tip, used on male
clients
with enlarged prostates or for
obstruction
e. Suprapubic-inserted through abdominal wall
over
suprapubic bone and into bladder .
f. Condom catheter- used for incontinence,
also
known as a sheath or Texas
catheter (pg1098)
Drainage Bags:
1. Regular
2. Urometer
3. Leg bag
Psychological Implications
1. Maintain privacy
2. Anxiety- need for explainition
•
Cultural Considerations
1. Gender.
2. Explain the procedure to client
3. Meticulous hygiene observed (Muslims use
left hand for unclean procedures)
4. Strict Sterile procedure need to be observed
A. In and Out Catherization (no ballon)
1. After client voids, I&O cath to determine
amount of
residual urine after a foley catheter has been
removed
2.
Use straight catheter
3. If over 200 cc obtained then physician may
order
retention catheter (foley catheter)
B. Indwelling catherization (Foley) has
ballon
1. Need for extra lighting
2.
Follow procedure as outlined during
practice
3.
Discuss taping for male and femalepressure on
penilescrotal angle can lead to necrosis
4.
Collection of specimen from port on
7. Catheter care- once every 8 hours as outlined
by policy (peri-care with soap, water, rinse- for
uncircumsized males remember to pull back
foreskin for cleaning and return to previous
position)
8. Encourage fluid intake 2000cc-3000cc per day
( if not on fluid restriction) in order to maintain
catheter patency
9. Removal of indwelling catheter- clean gloves,
towel, chux, and syringe to accommodate
removal of saline in balloon ( never cut)instruct client to bear down. Note amount of
voiding & time after removal of catheter.
10. Equipment changes- foleys should be
changed every 10 to 30 days in order to
prevent bladder neck necrosis- change bags as
needed.
• Documentation
1.
2.
3.
Size of catheter and balloon
Amount ,color, odor and consistency of urine
How client tolerated procedure
•
Complications
1.
Infection
a. Most common
b. Sources- identify sites on catheter system
2. Uretheral Trauma
1.
Not frequent
2. After catheter removal edema may
interfere with
urine flow.
3. Obstructed catheter
1. Medications- some may cause precipitation
of uric
acid crystals
2. Clots- post prostatecomy. May run CBI at a
rate so
as to reduce clots
• Bladder Irrigation
1.
2.
3.
Open- disconnect catheter from drainage bag
and instill irrigating solution or medication
(pg 1096)
Closed intermittent- need to clamp drainage
tubing below port and instill irrigant through
port
Closed Continuous (CBI)- use 3 way foley
catheter, hang irrigating solution on IV pole (
usually NSS for post prostatecomy clients)
and adjust flow rate; if catheter clogs during
CBI, no drainage will flow but irrigation will
continue to run in; How to calculate true
urine output- subtract amount of irrigation
which has infused from the amount of
drainage from the catheter= urine output. (pg
• Self catherization
Indication:
1.
Spinal cord injury- neurogenic bladder
Procedure:
1.
2.
3.
4.
5.
6.
Knowledge of clean versus sterile
Knowledge of anatomy and physiology
Children can be taught as young as 6 years
Performed every 6-8 hours
Controlled fluid intake regimen
May reuse catheter if washed and bagged
properly
• Things to Remember
1. Know signs of dehydration and fluid overload
2. Usual output is 30cc/hour;if acutely ill need to
measure more frequently
3. Measure output every 8 hours or more if
needed
4. Encourage fluid intake of 2000ml/day if not
restricted
5. Check most recent serum electrolyte
6. Foley of males to tape on abdomen; females to
legs
7. When taping provide slack to more around in
bed
8. Foley drainage bag below level of bladder and
OFF
FLOOR
9. Make sure cleanse uncircumcised males before
insertion of catheter
11. Do not drain more than 500 to 1000 cc at one
12. Do Catheter care daily on all clients who have
foley
catheters
13. Make sure catheter tubing does not kink
15. When aspirating the balloon, if the balloon says
5cc
there maybe 10cc in the balloon
16. Check old adults for atypical signs and
symptoms of UTI
17. If client is unable to void 6-8 hrs after catheter
removal notify MD
18.
If client voiding around catheter may to
have a larger catheter
19 NEVER cut the tubing on the balloon to
remove a
foley catheter
20 NEVER force the catheter in a child if met
resistance
wait 20 seconds until sphincter
relaxes and then try again
21. If patient has a foley for a long period of
time, may
have to retrain bladder, this is sometimes
done with
orthopedic trauma patients
22. Patients who have long term use of foley’s are
prone
to kidney stones because of small
amounts of fluid
intake