FUNDAMENTALS+OF+NURSING+PRACTICE+1+LECTURE+PRESSURE+AREA+CARE.pdf
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Sep 13, 2024
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About This Presentation
Slide Content
PERSONAL
HYGIENE
HYGIENE
CARE OF
PRESSURE
AREAS
PRESSURE
AREAS
Pressure area
care
▶Pressure area care refers to moving the patient into another
position to relieve pressure on a part of the body and prevent
the development of a pressure ulcer or ‘bed sore’.
▶One of the best ways of preventing a pressure ulcer is to reduce or
relieve pressure on areas that are vulnerable to pressure ulcers
(e.g, bony parts of the body). This is done by moving around and
changing position as much as possible.
care
▶Pressure area care refers to moving the patient into another
position to relieve pressure on a part of the body and prevent
the development of a pressure ulcer or ‘bed sore’.
▶One of the best ways of preventing a pressure ulcer is to reduce or
relieve pressure on areas that are vulnerable to pressure ulcers
(e.g, bony parts of the body). This is done by moving around and
changing position as much as possible.
Common pressure area
sites
▶ Common sites include the
sacrum, back, buttocks,
heels, back of the head, and
elbows.
▶Occiput
▶Acromion process
▶Scapula
▶Olecranon
▶Sacrum
▶Ischial tuberosity
▶Thoracic vertebrae
▶Lumbar vertebrae
▶Iliac crest
▶Coccyx
▶Trochanter
▶Lateral tibia condyle
▶Metatarsals (toes)
▶Calcaneus (heel)
▶Medial malleolus (inner
ankle)
▶Lateral malleolus (outer
ankle)
▶Medial tibia condyle
sites
▶ Common sites include the
sacrum, back, buttocks,
heels, back of the head, and
elbows.
▶Occiput
▶Acromion process
▶Scapula
▶Olecranon
▶Sacrum
▶Ischial tuberosity
▶Thoracic vertebrae
▶Lumbar vertebrae
▶Iliac crest
▶Coccyx
▶Trochanter
▶Lateral tibia condyle
▶Metatarsals (toes)
▶Calcaneus (heel)
▶Medial malleolus (inner
ankle)
▶Lateral malleolus (outer
ankle)
▶Medial tibia condyle
Common pressure area
sites
sites
Indications
▶Paralysed patients
▶Obese patients
▶Emaciated patients
▶Incontinent patients
▶Unconscious patients
▶Very ill patients who are unable to turn
themselves
▶Paralysed patients
▶Obese patients
▶Emaciated patients
▶Incontinent patients
▶Unconscious patients
▶Very ill patients who are unable to turn
themselves
Procedur
e
▶Wash each area, massage well with the palm of your hand using
soap.
▶Rinse each area, dry it and apply powder, cream or vaseline
depending on the
patient’s need.
▶If needed, patient may be seated on an air ring or soft pillow to
relieve
pressure
e
▶Wash each area, massage well with the palm of your hand using
soap.
▶Rinse each area, dry it and apply powder, cream or vaseline
depending on the
patient’s need.
▶If needed, patient may be seated on an air ring or soft pillow to
relieve
pressure
PRESSURE ULCERS
▶A pressure ulcer is any lesion caused by unrelieved pressure that
results in
damage to underlying tissue
▶Also known as decubitus ulcers, pressure sores or bed sores.
▶A pressure ulcer is any lesion caused by unrelieved pressure that
results in
damage to underlying tissue
▶Also known as decubitus ulcers, pressure sores or bed sores.
Pressure ulcer (Decubitus
ulcer)
ulcer)
Etiology of pressure ulcers
▶Occur due to localized ischaemia.
▶When blood cannot reach the tissues, the cells are deprived of
oxygen and nutrients. The waste products of metabolism
accumulate in the cells and the tissue consequently dies.
▶Prolonged, unrelieved pressure also damages the small blood
vessels.
▶Occur due to localized ischaemia.
▶When blood cannot reach the tissues, the cells are deprived of
oxygen and nutrients. The waste products of metabolism
accumulate in the cells and the tissue consequently dies.
▶Prolonged, unrelieved pressure also damages the small blood
vessels.
Risk factors
1.Immobility – reduction in the amount and control of movement a person has e.g due to
paralysis, weakness, pain
2.Inadequate nutrition causes weight loss, muscle atrophy and loss of subcutaneous tissue
3.Fecal and urinary incontinence – Moisture from incontinence promotes skin maceration
(tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded
and susceptible to injury.
4.Decreased mental status – e.g. unconscious or heavily sedated
5.Diminished Sensation-Paralysis , stroke, or other neurologic disease may cause loss of
sensation reducing the ability to respond to trauma, to injurious heat and cold, and to the
tingling ("pins and needles") that signals loss of circulation.
6.Excessive Body Heat - elevated body temperature increases the metabolic rate thus
increasing the cells’ need for oxygen
7.Advanced Age
8.Certain chronic conditions such as diabetes and cardiovascular disease are risk factors for
skin breakdown and delayed healing.
9.Other factors – poor lifting techniques, incorrect positioning, repeated injections on the same
site, hard support surfaces, incorrect application of pressure – relieving devices
1.Immobility – reduction in the amount and control of movement a person has e.g due to
paralysis, weakness, pain
2.Inadequate nutrition causes weight loss, muscle atrophy and loss of subcutaneous tissue
3.Fecal and urinary incontinence – Moisture from incontinence promotes skin maceration
(tissue softened by prolonged wetting or soaking) and makes the epidermis more easily eroded
and susceptible to injury.
4.Decreased mental status – e.g. unconscious or heavily sedated
5.Diminished Sensation-Paralysis , stroke, or other neurologic disease may cause loss of
sensation reducing the ability to respond to trauma, to injurious heat and cold, and to the
tingling ("pins and needles") that signals loss of circulation.
6.Excessive Body Heat - elevated body temperature increases the metabolic rate thus
increasing the cells’ need for oxygen
7.Advanced Age
8.Certain chronic conditions such as diabetes and cardiovascular disease are risk factors for
skin breakdown and delayed healing.
9.Other factors – poor lifting techniques, incorrect positioning, repeated injections on the same
site, hard support surfaces, incorrect application of pressure – relieving devices
Development of pressure
ulcer
ulcer
Stages of development of
pressure ulcers
▶Stage 1: just erythema of the skin.
▶Stage 2: erythema with the loss of partial thickness of the skin
including
epidermis and part of the superficial dermis.
▶Stage 3: full thickness ulcer that might involve the subcutaneous
fat.
▶Stage 4: full thickness ulcer with the involvement of the muscle
or bone.
pressure ulcers
▶Stage 1: just erythema of the skin.
▶Stage 2: erythema with the loss of partial thickness of the skin
including
epidermis and part of the superficial dermis.
▶Stage 3: full thickness ulcer that might involve the subcutaneous
fat.
▶Stage 4: full thickness ulcer with the involvement of the muscle
or bone.
Prevention
▶Massage pressure areas to promote blood circulation
▶Two hourly turning of bed - ridden patients
▶Use of pressure-relieving aids. Pressure-relieving aids such as
specialized mattresses or beds may be indicated in high-risk patients
with very restricted mobility.
▶ Furniture such as chairs should be carefully chosen to ensure
that the patient is able to rise from them easily
▶Massage pressure areas to promote blood circulation
▶Two hourly turning of bed - ridden patients
▶Use of pressure-relieving aids. Pressure-relieving aids such as
specialized mattresses or beds may be indicated in high-risk patients
with very restricted mobility.
▶ Furniture such as chairs should be carefully chosen to ensure
that the patient is able to rise from them easily
pressure relieving mattress
Heel protector
Lunderg Bedsore Pillow Positioning
Wedge
Wedge
Donut Cushion For Pressure
Relief
Relief
▶As you prevent the bed sores, take precaution for complications like Deep Vein
Thrombosis
▶Prevent deep vein thrombosis
Encourage patient to do foot, leg and breathing exercises every hour to
maintain circulation. Frequent leg exercises are important to prevent the stasis of
blood in the lower limbs, and deep breathing assists venous return to the heart.
▶Discourage crossing of legs. Let the legs stay flexed for long periods or sit or
lie with pressure under the calves, for example, by placing a pillow beneath the
calves. These activities promote venous stasis and so predispose thrombus
formation by exerting direct
pressure on the leg veins.
Thrombosis
▶Prevent deep vein thrombosis
Encourage patient to do foot, leg and breathing exercises every hour to
maintain circulation. Frequent leg exercises are important to prevent the stasis of
blood in the lower limbs, and deep breathing assists venous return to the heart.
▶Discourage crossing of legs. Let the legs stay flexed for long periods or sit or
lie with pressure under the calves, for example, by placing a pillow beneath the
calves. These activities promote venous stasis and so predispose thrombus
formation by exerting direct
pressure on the leg veins.
Application of Compression stockings
Patient fitted with thrombo-embolic deterrent – TED – stockings. Use
of graduated compression stockings is effective in preventing deep
vein thrombosis in hospital patients.
Contraindicated in some patients with peripheral vascular disease or
diabetic neuropathy
The correct size of stockings must be ascertained by taking accurate
measurements with a tape measure.
Patient fitted with thrombo-embolic deterrent – TED – stockings. Use
of graduated compression stockings is effective in preventing deep
vein thrombosis in hospital patients.
Contraindicated in some patients with peripheral vascular disease or
diabetic neuropathy
The correct size of stockings must be ascertained by taking accurate
measurements with a tape measure.
Risk Assessment Tools
Although clients may be at risk for developing a number of different alterations
in skin integrity, the most common and most preventable are pressure ulcers.
Several risk assessment tools are available that provide the nurse with
systematic means of identifying clients at high risk for pressure ulcer
development.
Tools include data collection in the areas of immobility, incontinence, nutrition,
and level of consciousness.
In 1987, Bergstrom, Braden, Laguzza, and Holman published the Braden
Scale for Predicting Pressure Sore Risk.
Their scale consists of six subscales: sensory perception, moisture, activity,
mobility, nutrition, and friction and shear. A total of 23 points is possible.
An adult who scores below 18 points is considered at risk.
Although clients may be at risk for developing a number of different alterations
in skin integrity, the most common and most preventable are pressure ulcers.
Several risk assessment tools are available that provide the nurse with
systematic means of identifying clients at high risk for pressure ulcer
development.
Tools include data collection in the areas of immobility, incontinence, nutrition,
and level of consciousness.
In 1987, Bergstrom, Braden, Laguzza, and Holman published the Braden
Scale for Predicting Pressure Sore Risk.
Their scale consists of six subscales: sensory perception, moisture, activity,
mobility, nutrition, and friction and shear. A total of 23 points is possible.
An adult who scores below 18 points is considered at risk.
Norton's Pressure Area Risk Assessment Form Scale
Includes the categories of general physical condition, mental state, activity,
mobility, and incontinence. A category of medications was added in 1987,
resulting in a possible score of 24. Scores of 15 or 16 should be viewed as
indicators, not predictors, of risk.
The Braden and Norton tools should be used when the client first enters the
health care agency and whenever the client's condition changes.
In some long-term care facilities, a risk assessment scale such as the Braden
or Norton scale is done on admission and then on a regular basis, usually
weekly.
This increases awareness of specific risk factors and serves as assessment
data from which to plan goals and interventions to either maintain or improve
skin integrity.
Includes the categories of general physical condition, mental state, activity,
mobility, and incontinence. A category of medications was added in 1987,
resulting in a possible score of 24. Scores of 15 or 16 should be viewed as
indicators, not predictors, of risk.
The Braden and Norton tools should be used when the client first enters the
health care agency and whenever the client's condition changes.
In some long-term care facilities, a risk assessment scale such as the Braden
or Norton scale is done on admission and then on a regular basis, usually
weekly.
This increases awareness of specific risk factors and serves as assessment
data from which to plan goals and interventions to either maintain or improve
skin integrity.
MOUTH CARE
Also mouth toilet; the practice of keeping the oral cavity healthy through
cleaning of gums, teeth, tongue, lips and dentures
Also mouth toilet; the practice of keeping the oral cavity healthy through
cleaning of gums, teeth, tongue, lips and dentures
Mouth care
Purpose
▶ To remove food particles from around and between the
teeth
▶ To remove dental plaque to prevent dental caries
▶ To increase appetite
▶ To enhance the client’s feelings of well-being
▶ To prevent sores and infections of the oral tissue
▶ To prevent bad odor or halitosis
Purpose
▶ To remove food particles from around and between the
teeth
▶ To remove dental plaque to prevent dental caries
▶ To increase appetite
▶ To enhance the client’s feelings of well-being
▶ To prevent sores and infections of the oral tissue
▶ To prevent bad odor or halitosis
Benefits of oral hygiene
▶Promote self-esteem and comfort
▶Improve appetite and enjoyment of food and drink, as poor oral hygiene can
affect taste
▶Improve social acceptability and social interaction by preventing halitosis.
▶Promote self-esteem and comfort
▶Improve appetite and enjoyment of food and drink, as poor oral hygiene can
affect taste
▶Improve social acceptability and social interaction by preventing halitosis.
▶ Assessment to obtain initial information regarding the patient’s
oral health is necessary to provide baseline information and to
assist the evaluation of mouth care interventions.
Procedure for oral assessment
▶ Gain consent.
▶ Wash hands.
▶ Wear gloves and apron.
▶Maintain privacy as required.
▶Assess using an appropriate assessment tool. You may need
a tongue depressor and a torch.
oral health is necessary to provide baseline information and to
assist the evaluation of mouth care interventions.
Procedure for oral assessment
▶ Gain consent.
▶ Wash hands.
▶ Wear gloves and apron.
▶Maintain privacy as required.
▶Assess using an appropriate assessment tool. You may need
a tongue depressor and a torch.
The following are indicators of a healthy mouth:
Pink moist tongue, oral mucosa and gums
Teeth/dentures clean and free of debris
Well-fitting dentures
Adequate salivation
Smooth and moist lips
No difficulties with eating and drinking.
Pink moist tongue, oral mucosa and gums
Teeth/dentures clean and free of debris
Well-fitting dentures
Adequate salivation
Smooth and moist lips
No difficulties with eating and drinking.
Undertake mouth care on a regular basis according to the patient’s
needs.
Patients with dry mouths may appreciate opportunities to rinse their
mouths with diluted mouthwash or fresh water several times a day
between meals
Purpose
▶To provide a baseline, initial information about the condition of the
patient’s oral cavity.
▶ To monitor progress of oral care/treatments.
▶ To identify any new problems
needs.
Patients with dry mouths may appreciate opportunities to rinse their
mouths with diluted mouthwash or fresh water several times a day
between meals
Purpose
▶To provide a baseline, initial information about the condition of the
patient’s oral cavity.
▶ To monitor progress of oral care/treatments.
▶ To identify any new problems
Mouth care
Equipment Required
▶Torch
▶Toothbrush and paste
▶Tongue depressor
▶Cotton tipped applicator, padded applicator
▶Vaseline (if necessary)
▶Kidney dish
▶Suction equipment (if appropriate)
▶Clean procedure gloves
▶Tissues or wipes
Equipment Required
▶Torch
▶Toothbrush and paste
▶Tongue depressor
▶Cotton tipped applicator, padded applicator
▶Vaseline (if necessary)
▶Kidney dish
▶Suction equipment (if appropriate)
▶Clean procedure gloves
▶Tissues or wipes
Mouth care
Procedure for mouth care
▶Gain consent
▶Assemble equipment – soft toothbrush, toothpaste, clothing
protection, receiver, glass of water for rinsing mouth and
tissues/gauzes
▶Ask the patient to get into an upright position if possible or
assist them to do this.
(If the patient needs to lie flat special care must be taken to
avoid choking. The procedure should be undertaken with the
patient’s head turned to the side, and suction equipment should
be to hand)
Procedure for mouth care
▶Gain consent
▶Assemble equipment – soft toothbrush, toothpaste, clothing
protection, receiver, glass of water for rinsing mouth and
tissues/gauzes
▶Ask the patient to get into an upright position if possible or
assist them to do this.
(If the patient needs to lie flat special care must be taken to
avoid choking. The procedure should be undertaken with the
patient’s head turned to the side, and suction equipment should
be to hand)
Mouth care
▶Wet the toothbrush head and apply a small amount of toothpaste
only. Use a gentle, rotational movement to clean the inner, outer and
biting surfaces of the teeth. You may also gently brush the surface of
the tongue and the gums;
▶If the patient cannot tolerate the use of a toothbrush (e.g. due to
mouth tenderness) foam sticks and mouthwash can be used instead
▶Allow the patient to take mouthfuls of water, rinse the mouth and
spit into the receiver.
▶Use tissues/gauzes to dry around the mouth
▶Apply moisturizer to the patient’s lips if required.
▶Wet the toothbrush head and apply a small amount of toothpaste
only. Use a gentle, rotational movement to clean the inner, outer and
biting surfaces of the teeth. You may also gently brush the surface of
the tongue and the gums;
▶If the patient cannot tolerate the use of a toothbrush (e.g. due to
mouth tenderness) foam sticks and mouthwash can be used instead
▶Allow the patient to take mouthfuls of water, rinse the mouth and
spit into the receiver.
▶Use tissues/gauzes to dry around the mouth
▶Apply moisturizer to the patient’s lips if required.
Mouth care for unconscious patient
Position
Side lying with the head of the bed lowered, the saliva automatically
runs out by gravity rather than being aspirated by the lungs or if
patient's head can not be lowered, turn it to one side:the fluid will
readily run out of the mouth, where it can be suctioned.
Use oral suction equipment and Yankuer sucker to aspirate all fluid
whilst rinsing the teeth to prevent it from trickling down the patient’s
throat and causing them to cough or gag.
Rinse the patient's mouth by drawing about 10 ml of water or mouth
wash in to the syringe and injecting it gently in to each side of the
mouth.
Position
Side lying with the head of the bed lowered, the saliva automatically
runs out by gravity rather than being aspirated by the lungs or if
patient's head can not be lowered, turn it to one side:the fluid will
readily run out of the mouth, where it can be suctioned.
Use oral suction equipment and Yankuer sucker to aspirate all fluid
whilst rinsing the teeth to prevent it from trickling down the patient’s
throat and causing them to cough or gag.
Rinse the patient's mouth by drawing about 10 ml of water or mouth
wash in to the syringe and injecting it gently in to each side of the
mouth.
Mouth care for unconscious patient
If injected with force, some of it may flow down the clients throat and
be aspirated into the lung
All the rinse solution should return; if not suction the fluid to prevent
aspiration
Vaseline or soft paraffin can be applied to the lips with a gauze swab
to keep lips moist and soft.
All solutions should be discarded and the equipment cleaned and
replaced.
Ensure patient is comfortable.
Wash her hands
If injected with force, some of it may flow down the clients throat and
be aspirated into the lung
All the rinse solution should return; if not suction the fluid to prevent
aspiration
Vaseline or soft paraffin can be applied to the lips with a gauze swab
to keep lips moist and soft.
All solutions should be discarded and the equipment cleaned and
replaced.
Ensure patient is comfortable.
Wash her hands
Denture care
▶ Gain consent
▶Assemble equipment – gloves and apron, a denture brush or
toothbrush, and denture cleaner or toothpaste denture
products are preferable if available as they preserve the
condition of the dentures compared with toothpaste (Major,
2005);
▶ Assess the oral cavity as above;
▶ Remove dentures and partial dentures from the oral cavity
▶ Clean at a sink
▶ Pat dry and rinse with cold water before repositioning in
patient’s mouth
▶ Gain consent
▶Assemble equipment – gloves and apron, a denture brush or
toothbrush, and denture cleaner or toothpaste denture
products are preferable if available as they preserve the
condition of the dentures compared with toothpaste (Major,
2005);
▶ Assess the oral cavity as above;
▶ Remove dentures and partial dentures from the oral cavity
▶ Clean at a sink
▶ Pat dry and rinse with cold water before repositioning in
patient’s mouth
Dentures should be thoroughly cleaned with denture cleansing
products and brush and replaced if appropriate or stored in a
designated container/denture pot.
Dentures may be soaked occasionally – use specific soaking solution
and follow manufacturer’s instructions. Always use a dedicated
denture container, carefully labelled with the patient’s details.
products and brush and replaced if appropriate or stored in a
designated container/denture pot.
Dentures may be soaked occasionally – use specific soaking solution
and follow manufacturer’s instructions. Always use a dedicated
denture container, carefully labelled with the patient’s details.
EYE
CARE
CARE
Eye care
Definition
▶Eye care is the practice of assessing, cleaning or irrigating
the eye
and/or the instillation of prescribed ocular preparations
Indications
▶To relieve pain and discomfort
▶To prevent or treat infection
▶To prevent or treat injury to the eye
▶To detect disease at an early stage
Definition
▶Eye care is the practice of assessing, cleaning or irrigating
the eye
and/or the instillation of prescribed ocular preparations
Indications
▶To relieve pain and discomfort
▶To prevent or treat infection
▶To prevent or treat injury to the eye
▶To detect disease at an early stage
Eye
care
▶To detect drug induced toxicity at an early stage
▶To prevent damage to the cornea in sedated or unconscious
patients
▶To maintain contact lenses and care for false eye prostheses
▶Eye care may also include patient education and health and
safety advice
care
▶To detect drug induced toxicity at an early stage
▶To prevent damage to the cornea in sedated or unconscious
patients
▶To maintain contact lenses and care for false eye prostheses
▶Eye care may also include patient education and health and
safety advice
EYE SWABBING
Process of cleaning eyes with a sterile swab
Indications
▶Eye examination
▶Drug instillation
▶Before and after surgery
▶Eye infections
▶Diagnostic purposes
Process of cleaning eyes with a sterile swab
Indications
▶Eye examination
▶Drug instillation
▶Before and after surgery
▶Eye infections
▶Diagnostic purposes
EYE
SWABBING
Equipment
Top shelf
▶Sterile dressing pack
▶Sterile cotton swab
▶Sterile 0.9% sodium chloride for irrigation or sterile
water for irrigation
Bottom shelf
▶Warm bowl of water
▶Medication e.g eye drops
▶Receiver for dirty swabs
▶Strapping
SWABBING
Equipment
Top shelf
▶Sterile dressing pack
▶Sterile cotton swab
▶Sterile 0.9% sodium chloride for irrigation or sterile
water for irrigation
Bottom shelf
▶Warm bowl of water
▶Medication e.g eye drops
▶Receiver for dirty swabs
▶Strapping
EYE
SWABBING
Procedure
▶Explain to the patient
▶Wheel trolley to the bedside
▶Wash hands and wear gloves
▶Ask assistant to pour solution
▶Dip each swab in the solution and swab the
unaffected eye from the inner canthus to the
outer canthus
▶Repeat procedure for the other eye
SWABBING
Procedure
▶Explain to the patient
▶Wheel trolley to the bedside
▶Wash hands and wear gloves
▶Ask assistant to pour solution
▶Dip each swab in the solution and swab the
unaffected eye from the inner canthus to the
outer canthus
▶Repeat procedure for the other eye
Instillation of Eye Drops
Equipment
1.Appropriate eye drops (any preparation must be checked
against the
prescription)
2.Cotton swab
3.If infection present, gloves may be used.
Equipment
1.Appropriate eye drops (any preparation must be checked
against the
prescription)
2.Cotton swab
3.If infection present, gloves may be used.
ASSISTING PATIENTS WITH ELIMINATION
Elimination
•Elimination patterns are essential to maintain health.
•The urinary and gastrointestinal systems together provide for
the elimination of body wastes.
•The urinary system filters and excretes urine from the body,
thereby maintaining fluid, electrolyte, and acid-base balance.
•Normal bowel function provides for the regular elimination of
solid wastes.
•During periods of stress and illness, clients experience
alterations in elimination patterns.
•Elimination patterns are essential to maintain health.
•The urinary and gastrointestinal systems together provide for
the elimination of body wastes.
•The urinary system filters and excretes urine from the body,
thereby maintaining fluid, electrolyte, and acid-base balance.
•Normal bowel function provides for the regular elimination of
solid wastes.
•During periods of stress and illness, clients experience
alterations in elimination patterns.
•Nurses assess for changes, identify problems, and intervene
to assist clients with maintaining proper elimination patterns.
•Elimination is normally a private function done without
assistance.
•However, during periods of immobility and illness, assistance
is needed.
•The main focus of the nurse is to provide maximum
comfort and privacy to lessen the client’s
embarrassment.
to assist clients with maintaining proper elimination patterns.
•Elimination is normally a private function done without
assistance.
•However, during periods of immobility and illness, assistance
is needed.
•The main focus of the nurse is to provide maximum
comfort and privacy to lessen the client’s
embarrassment.
Factors affecting elimination
•Age - A client’s age or developmental level will affect control
over urinary and bowel patterns. Infants initially lack a pattern
to their elimination. Control over bladder and bowel
movements can begin as early as 18 months of age but is
typically not mastered until age 4.
•Diet - Adequate fluid and fiber intake are critical factors to a
client’s urinary and bowel health. Inadequate fluid intake is a
primary cause of constipation. Diarrhea and flatulence
(discharge of gas from the rectum) are a direct result of foods
ingested, and clients need to be educated as to which foods
and fluids promote healthy elimination and which foods may
inhibit it.
•Age - A client’s age or developmental level will affect control
over urinary and bowel patterns. Infants initially lack a pattern
to their elimination. Control over bladder and bowel
movements can begin as early as 18 months of age but is
typically not mastered until age 4.
•Diet - Adequate fluid and fiber intake are critical factors to a
client’s urinary and bowel health. Inadequate fluid intake is a
primary cause of constipation. Diarrhea and flatulence
(discharge of gas from the rectum) are a direct result of foods
ingested, and clients need to be educated as to which foods
and fluids promote healthy elimination and which foods may
inhibit it.
Factors affecting elimination
•Exercise - enhances muscle tone, which leads to better bladder and
sphincter control. Peristalsis is also aided by activity, thus promoting
healthy bowel elimination patterns.
•Medications - can have an impact on a client’s elimination health
and patterns and should be assessed during the health history
interview.
•Cardiac clients, for instance, are commonly prescribed diuretics,
which increase urine production. Antidepressants and
antihypertensives may lead to urinary retention. Some over-the-
counter (OTC) cold remedies, especially antihistamines, may also
result in urinary retention.
•Exercise - enhances muscle tone, which leads to better bladder and
sphincter control. Peristalsis is also aided by activity, thus promoting
healthy bowel elimination patterns.
•Medications - can have an impact on a client’s elimination health
and patterns and should be assessed during the health history
interview.
•Cardiac clients, for instance, are commonly prescribed diuretics,
which increase urine production. Antidepressants and
antihypertensives may lead to urinary retention. Some over-the-
counter (OTC) cold remedies, especially antihistamines, may also
result in urinary retention.
Assessment of elimination
patterns
•Many people, consider incontinence to be a hygienic rather
than a health concern.
•Parents may view incontinence in children to be a form of
misbehavior.
•Some adults consider incontinence to be a form of childlike or
infantile behavior, or they may believe that urinary or fecal
leakage is an inevitable consequence of aging.
•The physical examination for elimination patterns focuses on
functional issues associated with urinary or fecal incontinence
and assesses the perineal and perianal areas.
patterns
•Many people, consider incontinence to be a hygienic rather
than a health concern.
•Parents may view incontinence in children to be a form of
misbehavior.
•Some adults consider incontinence to be a form of childlike or
infantile behavior, or they may believe that urinary or fecal
leakage is an inevitable consequence of aging.
•The physical examination for elimination patterns focuses on
functional issues associated with urinary or fecal incontinence
and assesses the perineal and perianal areas.
Indications for Elimination Nursing Care
1.Patient with spinal injury.
2.Postoperative patients.
3.Patients with fracture and traction.
4.Chronic bedridden patients.
5.Patients those who are strict bed rest
1.Patient with spinal injury.
2.Postoperative patients.
3.Patients with fracture and traction.
4.Chronic bedridden patients.
5.Patients those who are strict bed rest
URINARY ELIMINATION
Urinary elimination
•Continence in the adult requires anatomic integrity of the urinary system,
nervous control of the detrusor muscle, and a competent sphincter
mechanism.
•Urinary incontinence occurs when abnormalities of one or more of these
factors causes an uncontrolled loss of urine that produces social,
physiological, or hygienic difficulties for the client.
•Common urinary elimination alterations
1.Urinary retention
2.Urinary incontinence(stress, total, acute)
•Continence in the adult requires anatomic integrity of the urinary system,
nervous control of the detrusor muscle, and a competent sphincter
mechanism.
•Urinary incontinence occurs when abnormalities of one or more of these
factors causes an uncontrolled loss of urine that produces social,
physiological, or hygienic difficulties for the client.
•Common urinary elimination alterations
1.Urinary retention
2.Urinary incontinence(stress, total, acute)
Urinary Retention
•The state in which the individual experiences incomplete
emptying of the bladder.
•Major characteristics for urinary retention include bladder
distension and small, frequent voiding or absence of urine
output.
•Minor characteristics include sensation of bladder fullness,
dribbling, residual urine, dysuria, and overflow incontinence.
•High urethral pressure caused by weak detrusor, inhibition of
reflex arc, strong sphincter, and blockage are related factors
for urinary retention.
•The state in which the individual experiences incomplete
emptying of the bladder.
•Major characteristics for urinary retention include bladder
distension and small, frequent voiding or absence of urine
output.
•Minor characteristics include sensation of bladder fullness,
dribbling, residual urine, dysuria, and overflow incontinence.
•High urethral pressure caused by weak detrusor, inhibition of
reflex arc, strong sphincter, and blockage are related factors
for urinary retention.
Total Urinary Incontinence
•Total Urinary Incontinence is the state in which an individual
experiences a continuous and unpredictable loss of urine.
•Major characteristics include constant flow of urine occurring
at unpredictable times without distension, uninhibited bladder
contractions or spasms, unsuccessful incontinence refractory
treatments, and nocturia.
•Related factors include neuropathy that prevents transmission
of the reflex that indicates bladder fullness, neurologic
dysfunction causing triggering of micturition at unpredictable
times, independent contraction of the detrusor reflex owing to
surgery, trauma, or disease that affects spinal cord nerves, or
anatomy (fistula).
•Total Urinary Incontinence is the state in which an individual
experiences a continuous and unpredictable loss of urine.
•Major characteristics include constant flow of urine occurring
at unpredictable times without distension, uninhibited bladder
contractions or spasms, unsuccessful incontinence refractory
treatments, and nocturia.
•Related factors include neuropathy that prevents transmission
of the reflex that indicates bladder fullness, neurologic
dysfunction causing triggering of micturition at unpredictable
times, independent contraction of the detrusor reflex owing to
surgery, trauma, or disease that affects spinal cord nerves, or
anatomy (fistula).
•Giving Urinals
•They should be covered when being taken to and from the patient
•If the patient is able to assist himself, hand him/herself, hand the
urinal to him but if helpless help them to ensure the urinal is properly
positioned
•Assess urine before emptying, measure and record if necessary
•Clean and decontaminate the urinals.
•They should be covered when being taken to and from the patient
•If the patient is able to assist himself, hand him/herself, hand the
urinal to him but if helpless help them to ensure the urinal is properly
positioned
•Assess urine before emptying, measure and record if necessary
•Clean and decontaminate the urinals.
Types of Urinals.
Urinary Catheterization
Urinary catheterization
•Urinary catheterization is an aseptic procedure but is also the
most common cause of hospital-acquired infections, which can
occur during insertion or removal of the catheter.
•Repeated catheterization causes trauma and results in
infection.
•Patients should be catheterized only if clinically indicated
•It is important to use the correct urinary catheter for the
condition. Foley catheters require no more than 5-10 ml water.
•The balloon can cause obstruction and stasis of the urine if it is
too large, thus increasing the risk of infection.
•A catheter is chosen that minimizes urethral irritation and
maximizes drainage from the bladder.
•Urinary catheterization is an aseptic procedure but is also the
most common cause of hospital-acquired infections, which can
occur during insertion or removal of the catheter.
•Repeated catheterization causes trauma and results in
infection.
•Patients should be catheterized only if clinically indicated
•It is important to use the correct urinary catheter for the
condition. Foley catheters require no more than 5-10 ml water.
•The balloon can cause obstruction and stasis of the urine if it is
too large, thus increasing the risk of infection.
•A catheter is chosen that minimizes urethral irritation and
maximizes drainage from the bladder.
Definition of Key Terms
•A catheter A catheter is a tube made of vicryl or latex and is
inserted into the urinary bladder to drain urine
•Catheterization is the process of inserting a catheter into a
body cavity to allow body fluids to pass out of the body
•Urinary catheterization reduces the risk of infection and kidney
damage by making sure that bladder is emptied, either
continuously or at regular intervals.
•Catheterization can be used when a person cannot empty their
bladder without assistance, either permanently or on a
temporary basis (such as after certain kinds of surgery).
•A catheter A catheter is a tube made of vicryl or latex and is
inserted into the urinary bladder to drain urine
•Catheterization is the process of inserting a catheter into a
body cavity to allow body fluids to pass out of the body
•Urinary catheterization reduces the risk of infection and kidney
damage by making sure that bladder is emptied, either
continuously or at regular intervals.
•Catheterization can be used when a person cannot empty their
bladder without assistance, either permanently or on a
temporary basis (such as after certain kinds of surgery).
Indications for
Catheterization.
1.When a patient is suffering from urinary incontinence.
2.A patient has a problem of urine retention.
3.Blocked urine flow owing to kidney or bladder stones, blood
clots in the urine and severe enlargement of the prostate
gland.
4.Prostate gland surgery.
5.Surgery in the genital area like hysterectomy.
Catheterization.
1.When a patient is suffering from urinary incontinence.
2.A patient has a problem of urine retention.
3.Blocked urine flow owing to kidney or bladder stones, blood
clots in the urine and severe enlargement of the prostate
gland.
4.Prostate gland surgery.
5.Surgery in the genital area like hysterectomy.
6. To drain the bladder during childbirth, if epidural anesthetic is administered.
7. To drain the bladder prior to any surgery, like – womb, ovaries or bowels.
8. To directly administer medicine into the bladder during chemotherapy for bladder cancer.
9. Spinal cord injury.
10. For investigations
11. To accurately measure the urine output
12. Dementia.
13. Spina bifida.
7. To drain the bladder prior to any surgery, like – womb, ovaries or bowels.
8. To directly administer medicine into the bladder during chemotherapy for bladder cancer.
9. Spinal cord injury.
10. For investigations
11. To accurately measure the urine output
12. Dementia.
13. Spina bifida.
Contraindications of urethral
catheterization
Nurses should not perform catheterization without first seeking medical
advice on the following:-
• Patients who have a history of urethral stricture
• Patients who have undergone trans-urethral resection of the prostate
gland in the previous 48 hours
• Patients with a phimosis (tight foreskin)
• Patients who have a past history of difficulty in catheterisation
• Undiagnosed haematuria
• Urinary tract infection with clinical symptoms
catheterization
Nurses should not perform catheterization without first seeking medical
advice on the following:-
• Patients who have a history of urethral stricture
• Patients who have undergone trans-urethral resection of the prostate
gland in the previous 48 hours
• Patients with a phimosis (tight foreskin)
• Patients who have a past history of difficulty in catheterisation
• Undiagnosed haematuria
• Urinary tract infection with clinical symptoms
Types of catheters
1. According to Site
a) Urinary Catheter
Inserted through the urethral meatus into the bladder
b) Supra – pubic Catheter
Inserted through an incision made at the supra – pubic area into
the bladder
It is used when there is obstruction of urethra or after urethral
operation
c) Uridom/Uricondom
It is used in male patients to cover the penis.
It is an external male catheter used in patients with urinary
incontinence
1. According to Site
a) Urinary Catheter
Inserted through the urethral meatus into the bladder
b) Supra – pubic Catheter
Inserted through an incision made at the supra – pubic area into
the bladder
It is used when there is obstruction of urethra or after urethral
operation
c) Uridom/Uricondom
It is used in male patients to cover the penis.
It is an external male catheter used in patients with urinary
incontinence
2. According to Duration
a) Straight or In and Out Catheter/ intermittent
Inserted to drain urine and removed immediately and discard
b) In–dwelling/Retention
•The catheter remains in place for sometime and is anchored
by an inflated balloon inside the bladder
•The most commonly used of Foley's catheter which contains
two cavities, one for urinary out flow and the other for
inflating the balloon
Others may have three or more cavities e.g. those used for
bladder irrigation
•Foley catheter is typically inserted through the urethra. In
some cases, it is inserted through a hole in the abdomen, and
referred to as a suprapubic catheter.
a) Straight or In and Out Catheter/ intermittent
Inserted to drain urine and removed immediately and discard
b) In–dwelling/Retention
•The catheter remains in place for sometime and is anchored
by an inflated balloon inside the bladder
•The most commonly used of Foley's catheter which contains
two cavities, one for urinary out flow and the other for
inflating the balloon
Others may have three or more cavities e.g. those used for
bladder irrigation
•Foley catheter is typically inserted through the urethra. In
some cases, it is inserted through a hole in the abdomen, and
referred to as a suprapubic catheter.
Types of Catheters
Two – way catheter
Three – way catheter
Pre-connected drainage system
•Intermittent catheter, also called short term
catheter, or in and out catheter – it is used
temporarily to empty the bladder once, then
removed.
•Intermittent catheterization needs to be done
several times a day, at a designated interval or
when there is a need to pass urine.
•Traditional intermittent catheters can be washed
and reused.
• Disposable intermittent catheters are designed for
one time use and discarded.
catheter, or in and out catheter – it is used
temporarily to empty the bladder once, then
removed.
•Intermittent catheterization needs to be done
several times a day, at a designated interval or
when there is a need to pass urine.
•Traditional intermittent catheters can be washed
and reused.
• Disposable intermittent catheters are designed for
one time use and discarded.
Coudé Catheter
•The use of a coudé catheter is indicated when intermittent
catheterization is needed.
•The coudé catheter works much like the other catheters; however, a
distinguishing feature is that the tip of the catheter is more pointed and
curved.
•The coudé catheter does not have a balloon; therefore it cannot be used
for a procedure requiring an indwelling catheter.
•The use of a coudé catheter is indicated when intermittent
catheterization is needed.
•The coudé catheter works much like the other catheters; however, a
distinguishing feature is that the tip of the catheter is more pointed and
curved.
•The coudé catheter does not have a balloon; therefore it cannot be used
for a procedure requiring an indwelling catheter.
•2.External catheters
•Or condom catheters, are used by men to treat urinary incontinence.
•This type of catheter consists of a flexible sheath that slides over the
penis just like a condom with a tube connected to a bag.
•Many men find this style to be a great alternative to the more invasive
catheters that require insertion through the urethra.
•External catheters are only used for urinary incontinence, not urinary
retention, and they’re only available for men.
•Condom catheters can manage spontaneous leakage, but if the person
cannot urinate on their own, external catheters would not work.
•Or condom catheters, are used by men to treat urinary incontinence.
•This type of catheter consists of a flexible sheath that slides over the
penis just like a condom with a tube connected to a bag.
•Many men find this style to be a great alternative to the more invasive
catheters that require insertion through the urethra.
•External catheters are only used for urinary incontinence, not urinary
retention, and they’re only available for men.
•Condom catheters can manage spontaneous leakage, but if the person
cannot urinate on their own, external catheters would not work.
Catheterization
procedures
procedures
Catheterization Procedure
Requirements
A clean trolley arranged as follows:
Top Shelf
A sterile pack containing:
•Pair of gloves
•4 Draping towel
•Gallipot
•Kidney dish
•Needle
•Straight artery forceps
•Bowl containing cotton wool and gauze swabs
Requirements
A clean trolley arranged as follows:
Top Shelf
A sterile pack containing:
•Pair of gloves
•4 Draping towel
•Gallipot
•Kidney dish
•Needle
•Straight artery forceps
•Bowl containing cotton wool and gauze swabs
Bottom Shelf
•A bottle of antiseptic e.g. Hibitane
•Sterile specimen bottle if required
•2 Sterile Foley catheters size 14 and 16
•Sterile spigot if required
•Receiver for used swabs
•Protective mackintosh and draw sheet
•Strapping
•Sterile water for injection in a bottle
•20 cc sterile syringes
•Measuring jug, urine bag, lubricant
•Decontaminant in receiver for used instruments
•A bottle of antiseptic e.g. Hibitane
•Sterile specimen bottle if required
•2 Sterile Foley catheters size 14 and 16
•Sterile spigot if required
•Receiver for used swabs
•Protective mackintosh and draw sheet
•Strapping
•Sterile water for injection in a bottle
•20 cc sterile syringes
•Measuring jug, urine bag, lubricant
•Decontaminant in receiver for used instruments
1. Female Catheterization
Procedure
•Clean and disinfect the trolley and arrange items
•Explain the procedure to the patient
•Screen the bed and close nearby windows
•Ensure adequate work space
•Place the trolley beside the bed appropriately
•Ask assistant to position the patient appropriately and to fix
mackintosh under the buttocks
•Put on gloves
Procedure
•Clean and disinfect the trolley and arrange items
•Explain the procedure to the patient
•Screen the bed and close nearby windows
•Ensure adequate work space
•Place the trolley beside the bed appropriately
•Ask assistant to position the patient appropriately and to fix
mackintosh under the buttocks
•Put on gloves
•Ask the assistant to:
•Pour antiseptic solution into the sterile bowl
•Open the Foley’s catheter and drop on the sterile field
•Open one spigot and drop it on the sterile field
•Open and drop the 20 cc syringe and needle on the sterile field
•Ask the assistant to hold the bottle of sterile water, swab the
top of it with antiseptic, and using the sterile syringe and
needle, draw up to 20 cc of water and place the syringe in the
sterile field
•Pour antiseptic solution into the sterile bowl
•Open the Foley’s catheter and drop on the sterile field
•Open one spigot and drop it on the sterile field
•Open and drop the 20 cc syringe and needle on the sterile field
•Ask the assistant to hold the bottle of sterile water, swab the
top of it with antiseptic, and using the sterile syringe and
needle, draw up to 20 cc of water and place the syringe in the
sterile field
•Drape the patient using the four towels
•Swab the vulva as follows:
•Using the right hand to pick the moistened swab and dropping
it in the left hand, swab the furthest labia majora starting from
up downwards stroke and discard the swab.
•Repeat the same to the nearest majora, then the furthest
labia minora, ending with the nearest labia minora
•Using the left index fingers and thumb separate the labia to
expose the vestibule and use the right hand, to swab it using
the up downward stroke
•Swab the vulva as follows:
•Using the right hand to pick the moistened swab and dropping
it in the left hand, swab the furthest labia majora starting from
up downwards stroke and discard the swab.
•Repeat the same to the nearest majora, then the furthest
labia minora, ending with the nearest labia minora
•Using the left index fingers and thumb separate the labia to
expose the vestibule and use the right hand, to swab it using
the up downward stroke
•Ask the assistant to pour lubricant into the gallipot
•Place the sterile kidney dish below the vulva
•Using your right hand pick the catheter and insert the tip into
the lubricant
•Gently insert the lubricated tip into urethra for 4 – 5 cm and
let the urine flow into the kidney dish
•Secure the catheter with a strapping to prevent it from
slipping out
•If the catheter is to be retained, balloon the catheter with the
sterile water in the syringe, following the instructions on the
catheter
•Place the sterile kidney dish below the vulva
•Using your right hand pick the catheter and insert the tip into
the lubricant
•Gently insert the lubricated tip into urethra for 4 – 5 cm and
let the urine flow into the kidney dish
•Secure the catheter with a strapping to prevent it from
slipping out
•If the catheter is to be retained, balloon the catheter with the
sterile water in the syringe, following the instructions on the
catheter
•Collect specimen if required
•Connect the drainage bag or insert sterile spigot
•Leave the patient comfortable
•Clear as follows:
•Take trolley to sluice room
•Observe urine, color, deposits and amount
•Document in cardex or input /output chart
•Specimen labeled and sent to the laboratory
•Connect the drainage bag or insert sterile spigot
•Leave the patient comfortable
•Clear as follows:
•Take trolley to sluice room
•Observe urine, color, deposits and amount
•Document in cardex or input /output chart
•Specimen labeled and sent to the laboratory
Balloon size
• Use the smallest balloon size possible. This keeps residual urine
minimal, reduces the likelihood of bladder spasm, and minimizes
damage to the bladder neck from the weight of the balloon
• Balloon sizes: 5 – 30 mls. The most commonly indicated balloon
size is 10ml. Always inflate the balloon to the manufacturers
recommended volume indicated on the inflation valve of the
catheter as well as written on the packaging.
• The 30ml balloon is designed specifically as a haemostat post
urological procedure, and should not be used for routine
catheterisation
• Inflate with sterile water. Air is not suitable as it will cause the
balloon to float. Tap water is not sterile, and saline may block the
inflation channel with crystals, making subsequent deflation difficult
• Use the smallest balloon size possible. This keeps residual urine
minimal, reduces the likelihood of bladder spasm, and minimizes
damage to the bladder neck from the weight of the balloon
• Balloon sizes: 5 – 30 mls. The most commonly indicated balloon
size is 10ml. Always inflate the balloon to the manufacturers
recommended volume indicated on the inflation valve of the
catheter as well as written on the packaging.
• The 30ml balloon is designed specifically as a haemostat post
urological procedure, and should not be used for routine
catheterisation
• Inflate with sterile water. Air is not suitable as it will cause the
balloon to float. Tap water is not sterile, and saline may block the
inflation channel with crystals, making subsequent deflation difficult
Performing catheterization:
Female client
Action Rationale
2. Assist the client to a supine position with
legs spread and feet together or to a side-lying
position with upper leg flexed.
3. Drape client’s abdomen and thighs.
4. Ensure adequate lighting of the perineum.
6. Separate the perineum and, using forceps,
cleanse the periurethral mucosa with a
povidone-iodine or other antimicrobial
cleanser
7. Generously coat the distal portion of the
catheter with water-soluble, sterile lubricant.
8. Gently insert the catheter into meatus until
urine is noted. Continue inserting for 1 to 3
additional inches.
2. Facilitates visualization of area and promotes
client comfort.
3. Promotes client comfort and warmth.
4. Facilitates proper execution of technique.
6. Removes dirt and minimizes the risk of
urinary tract infection by removing surface
pathogens.
7. Avoids urethral trauma and discomfort
during catheter insertion.
8. Ensures adequate catheter insertion before
retention balloon is inflated.
Female client
Action Rationale
2. Assist the client to a supine position with
legs spread and feet together or to a side-lying
position with upper leg flexed.
3. Drape client’s abdomen and thighs.
4. Ensure adequate lighting of the perineum.
6. Separate the perineum and, using forceps,
cleanse the periurethral mucosa with a
povidone-iodine or other antimicrobial
cleanser
7. Generously coat the distal portion of the
catheter with water-soluble, sterile lubricant.
8. Gently insert the catheter into meatus until
urine is noted. Continue inserting for 1 to 3
additional inches.
2. Facilitates visualization of area and promotes
client comfort.
3. Promotes client comfort and warmth.
4. Facilitates proper execution of technique.
6. Removes dirt and minimizes the risk of
urinary tract infection by removing surface
pathogens.
7. Avoids urethral trauma and discomfort
during catheter insertion.
8. Ensures adequate catheter insertion before
retention balloon is inflated.
Performing catheterization: Female
client
Action Rationale
9. Inflate the retention balloon using
manufacturer’s recommendations or according
to physician orders.
10. Instruct the client to immediately report
discomfort or pressure during balloon inflation;
if pain occurs, discontinue the procedure,
deflate
the balloon, and insert the catheter further into
the bladder.
11. Gently pull the catheter until the retention
balloon is snuggled against the bladder neck
(resistance will be met).
12. Secure the catheter to the abdomen or
thigh.
13. Place the drainage bag below the level of
the bladder.
9. Ensures retention of the balloon; up to twice
the recommended volume of fluid may be
inserted safely into the retention balloon if
needed.
10. Pain or pressure indicates inflation of the
balloon in the urethra; further insertion will
prevent misplacement and further pain or
bleeding.
11. Maximizes continuous bladder drainage.
12. Prevents excessive traction from the balloon
rubbing against the bladder neck, inadvertent
catheter removal, or urethral erosion.
13. Maximizes continuous drainage of urine
from the bladder (drainage is prevented when
the drainage bag is placed above the abdomen).
client
Action Rationale
9. Inflate the retention balloon using
manufacturer’s recommendations or according
to physician orders.
10. Instruct the client to immediately report
discomfort or pressure during balloon inflation;
if pain occurs, discontinue the procedure,
deflate
the balloon, and insert the catheter further into
the bladder.
11. Gently pull the catheter until the retention
balloon is snuggled against the bladder neck
(resistance will be met).
12. Secure the catheter to the abdomen or
thigh.
13. Place the drainage bag below the level of
the bladder.
9. Ensures retention of the balloon; up to twice
the recommended volume of fluid may be
inserted safely into the retention balloon if
needed.
10. Pain or pressure indicates inflation of the
balloon in the urethra; further insertion will
prevent misplacement and further pain or
bleeding.
11. Maximizes continuous bladder drainage.
12. Prevents excessive traction from the balloon
rubbing against the bladder neck, inadvertent
catheter removal, or urethral erosion.
13. Maximizes continuous drainage of urine
from the bladder (drainage is prevented when
the drainage bag is placed above the abdomen).
2. Male Catheterization
•Same as female up to preparation of vulva. Instead:
•Clean the prepuce or area around the glans penis
•Using your left hand if necessary to place a sterile swab over
the prepuce. If necessary retract it so that the meatus is
exposed. Clean the area with antiseptic lotion wiping with a
backward motion from the meatus
•Using your right hand pick the catheter and insert the tip into
the lubricant
•To straighten the urethra, by lifting the penis with your left
hand at an angle of 60 degrees
•Same as female up to preparation of vulva. Instead:
•Clean the prepuce or area around the glans penis
•Using your left hand if necessary to place a sterile swab over
the prepuce. If necessary retract it so that the meatus is
exposed. Clean the area with antiseptic lotion wiping with a
backward motion from the meatus
•Using your right hand pick the catheter and insert the tip into
the lubricant
•To straighten the urethra, by lifting the penis with your left
hand at an angle of 60 degrees
•With the right hand insert the lubricated catheter gently for about
16 cm and let the urine flow into the kidney dish.
•Do not force the catheter into the urethra
•Complete the procedure as for female after insertion of the
catheter
16 cm and let the urine flow into the kidney dish.
•Do not force the catheter into the urethra
•Complete the procedure as for female after insertion of the
catheter
Performing catheterization:
Male client
Action Rationale
1. Provide for privacy and explain procedure
to client.
2. Set the bed to a comfortable height to
work, and raise the side rail on the side
opposite you.
3. Assist the client to a supine position with
legs slightly spread.
4. Drape the client’s abdomen and thighs,
and place the penis over the thighs.
5. Ensure adequate lighting of the penis.
6. Wash hands, don disposable gloves, and
wash perineal area.
7. Remove gloves and wash hands.
1. Promotes cooperation and client dignity.
2. Promotes proper body mechanics and assures
client safety.
3. Relaxes muscles to facilitate insertion of the
catheter.
4. Promotes client comfort and warmth.
5. Facilitates proper execution of technique.
6. Reduces transfer of microorganisms.
7. Reduces transfer of microorganisms.
Male client
Action Rationale
1. Provide for privacy and explain procedure
to client.
2. Set the bed to a comfortable height to
work, and raise the side rail on the side
opposite you.
3. Assist the client to a supine position with
legs slightly spread.
4. Drape the client’s abdomen and thighs,
and place the penis over the thighs.
5. Ensure adequate lighting of the penis.
6. Wash hands, don disposable gloves, and
wash perineal area.
7. Remove gloves and wash hands.
1. Promotes cooperation and client dignity.
2. Promotes proper body mechanics and assures
client safety.
3. Relaxes muscles to facilitate insertion of the
catheter.
4. Promotes client comfort and warmth.
5. Facilitates proper execution of technique.
6. Reduces transfer of microorganisms.
7. Reduces transfer of microorganisms.
Performing catheterization: Male client
Action Rationale
8. Prepare a sterile field, apply sterile gloves, and
connect the catheter and drainage system (if
necessary).
9. Gently retract the foreskin (if present) and, using
forceps, cleanse the glans penis with a povidone-
iodine solution or other antimicrobial cleanser.
10. Inject 10 ml water-soluble lubricant (use a 2%
xylocaine lubricant whenever feasible) into the
urethra before catheter insertion; generously coat
the distal portion of the catheter with water-
soluble, sterile lubricant.
11. Hold the penis perpendicular to the body and
pull up gently.
12. Steadily insert the catheter about 8 inches,
until urine is noted. Continue inserting until the
hub of the catheter (bifurcation between drainage
port and retention balloon arm) is met.
8. The catheter and drainage system may be
preconnected; otherwise it is connected before
catheterization to avoid exposing the client to
ascending infection from an open-ended catheter.
9. Removes dirt and minimizes the risk of urinary
tract infection by removing surface pathogens.
10. Avoids urethral trauma and discomfort during
catheter insertion and facilitates insertion.
11. Facilitates catheter insertion by straightening
urethra.
12. Ensures adequate catheter insertion before
retention balloon is inflated.
Action Rationale
8. Prepare a sterile field, apply sterile gloves, and
connect the catheter and drainage system (if
necessary).
9. Gently retract the foreskin (if present) and, using
forceps, cleanse the glans penis with a povidone-
iodine solution or other antimicrobial cleanser.
10. Inject 10 ml water-soluble lubricant (use a 2%
xylocaine lubricant whenever feasible) into the
urethra before catheter insertion; generously coat
the distal portion of the catheter with water-
soluble, sterile lubricant.
11. Hold the penis perpendicular to the body and
pull up gently.
12. Steadily insert the catheter about 8 inches,
until urine is noted. Continue inserting until the
hub of the catheter (bifurcation between drainage
port and retention balloon arm) is met.
8. The catheter and drainage system may be
preconnected; otherwise it is connected before
catheterization to avoid exposing the client to
ascending infection from an open-ended catheter.
9. Removes dirt and minimizes the risk of urinary
tract infection by removing surface pathogens.
10. Avoids urethral trauma and discomfort during
catheter insertion and facilitates insertion.
11. Facilitates catheter insertion by straightening
urethra.
12. Ensures adequate catheter insertion before
retention balloon is inflated.
Performing catheterization: Male
client
Action Rationale
13. Inflate the retention balloon using manufacturer’s
recommendations or according to physician orders.
14. Instruct the client to immediately report discomfort or
pressure during balloon inflation; if pain occurs, discontinue
the procedure, deflate the balloon, and insert the catheter
farther into the bladder.
15. Gently pull the catheter until the retention balloon is
snuggled against the bladder neck (resistance will be met)
16. Secure the catheter to the abdomen or thigh.
17. Place the drainage bag below the level of the bladder.
18. Remove gloves, dispose of equipment, and wash hands.
19. Help client adjust position.
20. Assess and document the amount, color, odor, and quality
of urine.
13. Ensures retention of the balloon;
up to twice the recommended volume
of fluid may be inserted safely into the
retention balloon if needed.
14. Pain or pressure indicates inflation
of the balloon in the urethra; further
insertion will prevent misplacement
and further pain or bleeding.
15. Maximizes continuous bladder
drainage.
client
Action Rationale
13. Inflate the retention balloon using manufacturer’s
recommendations or according to physician orders.
14. Instruct the client to immediately report discomfort or
pressure during balloon inflation; if pain occurs, discontinue
the procedure, deflate the balloon, and insert the catheter
farther into the bladder.
15. Gently pull the catheter until the retention balloon is
snuggled against the bladder neck (resistance will be met)
16. Secure the catheter to the abdomen or thigh.
17. Place the drainage bag below the level of the bladder.
18. Remove gloves, dispose of equipment, and wash hands.
19. Help client adjust position.
20. Assess and document the amount, color, odor, and quality
of urine.
13. Ensures retention of the balloon;
up to twice the recommended volume
of fluid may be inserted safely into the
retention balloon if needed.
14. Pain or pressure indicates inflation
of the balloon in the urethra; further
insertion will prevent misplacement
and further pain or bleeding.
15. Maximizes continuous bladder
drainage.
NOTE:
•Male catheterization uses bigger size catheters than
female.
•The bigger the number the bigger the size.
•The average catheter size used by adult men range from 14fr to
16fr, and most men use 14fr catheters.
•The average catheter size used by adult women range from
10fr to 12fr, and most women use 12fr catheters.
•Male catheterization uses bigger size catheters than
female.
•The bigger the number the bigger the size.
•The average catheter size used by adult men range from 14fr to
16fr, and most men use 14fr catheters.
•The average catheter size used by adult women range from
10fr to 12fr, and most women use 12fr catheters.
A urine bag with a urinary
catheter attached
catheter attached
3. Condom catheter
Applying a condom catheter
Equipment
•Bedpan (regular or fracture)
•Toilet paper
•Disposable gloves
•Washcloth and towel
•Bedpan cover
Equipment
•Bedpan (regular or fracture)
•Toilet paper
•Disposable gloves
•Washcloth and towel
•Bedpan cover
Applying a condom catheter
Action Rationale
1. Wash hands and apply gloves.
2. Select an appropriate condom
catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for
excessive hair.
5. Inspect the penis for altered skin
integrity.
1. Reduces risk of contamination.
2. The condom catheter must be sized correctly
(refer to manufacturer’s recommendations),
contain a distal tip that resists twisting and
occlusion, and contain an adhesive that prevents
leakage; latex condom catheters are avoided in
men who are allergic to latex.
3. Reduces surface dirt and pathogens.
4. Excessive penile hair is shaved to provide a
watertight seal when the condom is applied.
5. Small lesions may be protected by the use of a
skin sealant.
Action Rationale
1. Wash hands and apply gloves.
2. Select an appropriate condom
catheter.
3. Cleanse the penile shaft.
4. Inspect the penile shaft for
excessive hair.
5. Inspect the penis for altered skin
integrity.
1. Reduces risk of contamination.
2. The condom catheter must be sized correctly
(refer to manufacturer’s recommendations),
contain a distal tip that resists twisting and
occlusion, and contain an adhesive that prevents
leakage; latex condom catheters are avoided in
men who are allergic to latex.
3. Reduces surface dirt and pathogens.
4. Excessive penile hair is shaved to provide a
watertight seal when the condom is applied.
5. Small lesions may be protected by the use of a
skin sealant.
Applying a condom catheter
Action Rationale
6. Stretch the shaft of the penis and
unroll the condom to the base of the
penis.
Follow product directions for the
application of the sealant.
7. Attach the condom to the drainage
apparatus, either a leg bag or bedside
drainage bag.
8. Remove gloves and wash hands.
9. Remove and reapply the condom
catheter every 24 to 48 hours, or when
leakage occurs.
6. The condom is applied over the
entire penile shaft to maximize a
watertight seal; the adhesive may be
built into the wall of the condom, or a
dual-sided sealant strip may be used to
prevent leakage.
7. Ensures adequate urine
containment.
8. Reduces the risks of contamination.
9. Regular reapplication allows routine
inspection of the penile skin and
avoids bacterial over-growth and
altered skin integrity under the
condom.
Action Rationale
6. Stretch the shaft of the penis and
unroll the condom to the base of the
penis.
Follow product directions for the
application of the sealant.
7. Attach the condom to the drainage
apparatus, either a leg bag or bedside
drainage bag.
8. Remove gloves and wash hands.
9. Remove and reapply the condom
catheter every 24 to 48 hours, or when
leakage occurs.
6. The condom is applied over the
entire penile shaft to maximize a
watertight seal; the adhesive may be
built into the wall of the condom, or a
dual-sided sealant strip may be used to
prevent leakage.
7. Ensures adequate urine
containment.
8. Reduces the risks of contamination.
9. Regular reapplication allows routine
inspection of the penile skin and
avoids bacterial over-growth and
altered skin integrity under the
condom.
Unroll condom catheter to the
base of the penis.
base of the penis.
Secure the condom catheter
with a strap
with a strap
4. Catheterisation of a
patient with a supra-pubic
catheter
Insertion of a catheter into the bladder through the anterior wall
of the abdomen using an aseptic technique.
Caution
• Previous difficulties that have required medical assistance
• Blood clotting disorder
patient with a supra-pubic
catheter
Insertion of a catheter into the bladder through the anterior wall
of the abdomen using an aseptic technique.
Caution
• Previous difficulties that have required medical assistance
• Blood clotting disorder
Suprapubic catheter
• When it is not possible for a urethral catheter to be inserted
e.g. stricture
• Where limb contractures make urethral catheter insertion and
management difficult
• Improved patient comfort for wheelchair dependent patients
and easier management of catheter change
• Minimises urethral trauma and development of mega urethra
• May be more acceptable in patients who are sexually active
• Can improve lifestyle of patient
• Where it is patients preferred choice
• Post operatively for bladder drainage or to monitor residual
urine volume
Indications for supra-pubic
catheterisation
e.g. stricture
• Where limb contractures make urethral catheter insertion and
management difficult
• Improved patient comfort for wheelchair dependent patients
and easier management of catheter change
• Minimises urethral trauma and development of mega urethra
• May be more acceptable in patients who are sexually active
• Can improve lifestyle of patient
• Where it is patients preferred choice
• Post operatively for bladder drainage or to monitor residual
urine volume
Indications for supra-pubic
catheterisation
• To relieve acute urinary obstruction where a urethral catheter
cannot be inserted into the bladder eg. urethral stricture
• To relieve chronic urinary retention eg enlarged prostate
• Relieve chronic retention of the neurogenic bladder
• For clients who require long-term catheterisation, who are
sexually active, in a wheelchair, or have persistent problems with
urethral catheters.
• During and following pelvic or urological surgery
cannot be inserted into the bladder eg. urethral stricture
• To relieve chronic urinary retention eg enlarged prostate
• Relieve chronic retention of the neurogenic bladder
• For clients who require long-term catheterisation, who are
sexually active, in a wheelchair, or have persistent problems with
urethral catheters.
• During and following pelvic or urological surgery
Documentation
The procedure is documented in the child's medical record. The
documentation should be signed by the person inserting the
catheter. Documentation should include:
•Indication for catheterization
•Time and date of procedure
•Type of catheter.
•Size of catheter
•Expiry date of catheter
•Amount of water in balloon
•Any problems with insertion
The procedure is documented in the child's medical record. The
documentation should be signed by the person inserting the
catheter. Documentation should include:
•Indication for catheterization
•Time and date of procedure
•Type of catheter.
•Size of catheter
•Expiry date of catheter
•Amount of water in balloon
•Any problems with insertion
•Procedure and time done.
•Size of catheter.
•Amount of urine output.
•Color and character of urine.
•Client’s response and how tolerated.
•Description of urine, colour and volume
•Specimen collected
•Review date
•Size of catheter.
•Amount of urine output.
•Color and character of urine.
•Client’s response and how tolerated.
•Description of urine, colour and volume
•Specimen collected
•Review date
Ongoing Catheter care
Ongoing nursing management
1. Measure urine output hourly and document
Normal urine output is 0.5-1ml/kg/hr. Report any variation from this
If oliguric ensure catheter is not blocked
No routine change of urinary catheter or drainage bag is necessary.
Change for clinical indicators if infection, obstruction or if system
disconnects or leaks. Replace system and/or catheter using aseptic
technique and sterile equipment
2. Maintain unobstructed urine flow. Gravity is important for drainage and
prevention of urine backflow. Ensure the drainage bag is below the level
of the bladder, is not kinked and is secured
Urine for urinalysis or culture should be collected fresh from sampling
port of catheter tubing (not drainage bag). Clean port with
disinfectant first
3. Drainage system
Adherence to a sterile continuously closed method of urinary drainage
has been shown to markedly reduce the risk of acquiring a catheter
associated infection
1. Measure urine output hourly and document
Normal urine output is 0.5-1ml/kg/hr. Report any variation from this
If oliguric ensure catheter is not blocked
No routine change of urinary catheter or drainage bag is necessary.
Change for clinical indicators if infection, obstruction or if system
disconnects or leaks. Replace system and/or catheter using aseptic
technique and sterile equipment
2. Maintain unobstructed urine flow. Gravity is important for drainage and
prevention of urine backflow. Ensure the drainage bag is below the level
of the bladder, is not kinked and is secured
Urine for urinalysis or culture should be collected fresh from sampling
port of catheter tubing (not drainage bag). Clean port with
disinfectant first
3. Drainage system
Adherence to a sterile continuously closed method of urinary drainage
has been shown to markedly reduce the risk of acquiring a catheter
associated infection
4. Infection surveillance
•Consider daily the need for the indwelling catheter to
remain insitu. Remove as soon as no longer required to
reduce risk of UTI
•Cloudy, offensive smelling or unexplained blood stained
urine is not normal and needs further investigation
•Full Ward Test (dipstick) should be done each day. This test
can detect urinary protein, blood, nitrates
•Specimen collection
•Large volumes e.g. 24hr collection, can be collected from
drainage bag
Record fluid balance.
•Consider daily the need for the indwelling catheter to
remain insitu. Remove as soon as no longer required to
reduce risk of UTI
•Cloudy, offensive smelling or unexplained blood stained
urine is not normal and needs further investigation
•Full Ward Test (dipstick) should be done each day. This test
can detect urinary protein, blood, nitrates
•Specimen collection
•Large volumes e.g. 24hr collection, can be collected from
drainage bag
Record fluid balance.
5. Cleaning the genitals.
•The genital areas should first be cleansed with mild soap and
water.
•For men, retract the foreskin of the penis and clean away from
the tip of the penis.
•For women, separate the labia and always clean from front to
back.
•Remember to dry genitals gently using aseptic cloths.
•The genital areas should first be cleansed with mild soap and
water.
•For men, retract the foreskin of the penis and clean away from
the tip of the penis.
•For women, separate the labia and always clean from front to
back.
•Remember to dry genitals gently using aseptic cloths.
6 . Cleaning the catheter
•While cleaning the catheter, hold it firmly at the point it enters
the urethra so that it will not get pulled out.
•Start cleaning the catheter from the same point and move
down the tube in the direction that is away from the body.
•Rinse the catheter with soap and water and dry it with a
separate cloth.
•The catheter is attached to the body using either tape or cath-
secure.
•Replace with new adhesive tape or cath-secure once the old
one is removed.
•While cleaning the catheter, hold it firmly at the point it enters
the urethra so that it will not get pulled out.
•Start cleaning the catheter from the same point and move
down the tube in the direction that is away from the body.
•Rinse the catheter with soap and water and dry it with a
separate cloth.
•The catheter is attached to the body using either tape or cath-
secure.
•Replace with new adhesive tape or cath-secure once the old
one is removed.
7. Changing drainage bag.
•A drainage bag is used to collect the urine. It is an extension of
the catheter which can be removed and replaced by the
caregiver. When changing the drainage bag, place an aseptic
cloth or gauze piece under the connection point of the
catheter.
•Tightly press on the catheter with your fingers and slowly
disconnect the drainage bag.
•Clean the tip of the catheter and connector with separate
alcohol pads. Connect the new bag to the catheter and then
release your fingers. Dispose the used drainage bag.
•Make sure that there are no kinks or twists in the catheter and
drainage bag.
•A drainage bag is used to collect the urine. It is an extension of
the catheter which can be removed and replaced by the
caregiver. When changing the drainage bag, place an aseptic
cloth or gauze piece under the connection point of the
catheter.
•Tightly press on the catheter with your fingers and slowly
disconnect the drainage bag.
•Clean the tip of the catheter and connector with separate
alcohol pads. Connect the new bag to the catheter and then
release your fingers. Dispose the used drainage bag.
•Make sure that there are no kinks or twists in the catheter and
drainage bag.
Complications of
catheterization
•Inability to catheterize
•Urethral injury from trauma sustained during insertion or
balloon inflation in incorrect position
•Haemorrhage
•False passage
•Urethral strictures following damage to urethra. This may be a long term
problem
•Infection
•Psychological trauma
•Paraphimosis due to failure to return foreskin to normal
position following catheter insertion
•Discomfort
•Urine incontinence
•Renal failure incase of catheter blockage
catheterization
•Inability to catheterize
•Urethral injury from trauma sustained during insertion or
balloon inflation in incorrect position
•Haemorrhage
•False passage
•Urethral strictures following damage to urethra. This may be a long term
problem
•Infection
•Psychological trauma
•Paraphimosis due to failure to return foreskin to normal
position following catheter insertion
•Discomfort
•Urine incontinence
•Renal failure incase of catheter blockage
Emptying the urinary Drainage
Bag
Indications
1. To dispose of urine
2. To monitor urinary output
3. To prevent reflux to kidneys. (Leg bag should be emptied when
two third full)
Requirements
• Disposable plastic apron
• Non-sterile disposable gloves as per Glove Guidelines
• Clean container for urine (KEPT FOR THIS PURPOSE ONLY) e.g.
Measuring jug/urinal
• Tissue/Paper towel
• Disposal bag as per Clinical Waste Guidelines
Bag
Indications
1. To dispose of urine
2. To monitor urinary output
3. To prevent reflux to kidneys. (Leg bag should be emptied when
two third full)
Requirements
• Disposable plastic apron
• Non-sterile disposable gloves as per Glove Guidelines
• Clean container for urine (KEPT FOR THIS PURPOSE ONLY) e.g.
Measuring jug/urinal
• Tissue/Paper towel
• Disposal bag as per Clinical Waste Guidelines
Emptying the Drainage Bag
•This should be done wearing non-sterile gloves and via the
drainage tap at the bottom of the bag. When the bag is empty,
the tap should be closed securely and wiped with a tissue.
•If the bag does not have a tap, then replace it when full. Do
not disconnect the bag to empty and then reconnect it.
•Wash and dry hands thoroughly after touching the drainage
bag.
•With proper handling, drainage bags with taps can be left in
situ for long periods and are more cost-effective in the long
run.
•A separate urine bag-collecting receptacle must be used for
each patient and each bag should be emptied separately as
required.
•Hand hygiene and cleaning of periurethral area before
insertion of a sterile catheter.
• Maintenance of a closed drainage system.
• Hand hygiene before and after emptying bags
•This should be done wearing non-sterile gloves and via the
drainage tap at the bottom of the bag. When the bag is empty,
the tap should be closed securely and wiped with a tissue.
•If the bag does not have a tap, then replace it when full. Do
not disconnect the bag to empty and then reconnect it.
•Wash and dry hands thoroughly after touching the drainage
bag.
•With proper handling, drainage bags with taps can be left in
situ for long periods and are more cost-effective in the long
run.
•A separate urine bag-collecting receptacle must be used for
each patient and each bag should be emptied separately as
required.
•Hand hygiene and cleaning of periurethral area before
insertion of a sterile catheter.
• Maintenance of a closed drainage system.
• Hand hygiene before and after emptying bags
Procedure of Changing Urine Bag
Requirements
Trolley with:
•Top shelf
•Urine bag
•Artery forceps
•Recording charts
Bottom shelf
Bucket
Requirements
Trolley with:
•Top shelf
•Urine bag
•Artery forceps
•Recording charts
Bottom shelf
Bucket
Procedure
•Explain the procedure to the patient
•Wash hands and put on gloves
•Kink the catheter using the artery forceps
•Remove the new bag from its case
•Disconnect catheter from urine bag and place the bag in a
bucket
•Fix the tubing of the new bag to the catheter and unclamp the
catheter
•Secure the bag and leave the patient comfortable
•Dispose off the old bag after draining urine in the sluice
•Explain the procedure to the patient
•Wash hands and put on gloves
•Kink the catheter using the artery forceps
•Remove the new bag from its case
•Disconnect catheter from urine bag and place the bag in a
bucket
•Fix the tubing of the new bag to the catheter and unclamp the
catheter
•Secure the bag and leave the patient comfortable
•Dispose off the old bag after draining urine in the sluice
Removal of Indwelling
Catheter
Requirements
•Gloves
•Swabs
•Bucket
•20 cc syringe
•Mackintosh and draw sheet
•Steps
•Explain the procedure to the patient
•Place mackintosh and draw sheet under buttocks of the
patients
Catheter
Requirements
•Gloves
•Swabs
•Bucket
•20 cc syringe
•Mackintosh and draw sheet
•Steps
•Explain the procedure to the patient
•Place mackintosh and draw sheet under buttocks of the
patients
•Remove adhesives anchoring the catheter
•Using syringe, gently draw solution from the balloon to deflate
it
•Remove catheter gently and inspect for completeness and put
it in the bucket
•Dry the perineum and leave the patient comfortable
•Drain the urine in the sluice and dispose the catheter + the
bag
•Document
•Using syringe, gently draw solution from the balloon to deflate
it
•Remove catheter gently and inspect for completeness and put
it in the bucket
•Dry the perineum and leave the patient comfortable
•Drain the urine in the sluice and dispose the catheter + the
bag
•Document
Measuring Residual Urine
•Residual urine is urine remaining in the bladder at the end of
micturition, as in cases of prostatic obstruction or bladder
atony.
•Determined by passing a catheter into the bladder
immediately after a patient voids
•A post-void residual urine greater than 50 ml is a significant
amount of urine and increases the potential for recurring
urinary tract infections.
•Residual urine is urine remaining in the bladder at the end of
micturition, as in cases of prostatic obstruction or bladder
atony.
•Determined by passing a catheter into the bladder
immediately after a patient voids
•A post-void residual urine greater than 50 ml is a significant
amount of urine and increases the potential for recurring
urinary tract infections.
Bladder Training
•Involves training or enabling the bladder to hold urine normally
in case of incontinence after prolonged catheterization
•The catheter is clamped using artery forceps and is unclamped
at regular intervals
•Involves training or enabling the bladder to hold urine normally
in case of incontinence after prolonged catheterization
•The catheter is clamped using artery forceps and is unclamped
at regular intervals
Bladder irrigation
Bladder washout, irrigation
and
instillation
• “manual washout or bladder lavage” is defined as the
washing out of the bladder with sterile fluid and “bladder
irrigation” as the continuous washing out of the bladder with
sterile fluid.
•One indication of Bladder instillations is to prevent or treat
catheter blockages.
•Instillation treatments are not limited to saline or citric acid
solutions; there are some others such as chemotherapy drugs
(i.e. mitomycin-C or epirubicin) or antiinflammatory drugs (i.e.
hyaluronic acid), to reduce toxicity of brachytherapy or
vesicoureteral reflux.
and
instillation
• “manual washout or bladder lavage” is defined as the
washing out of the bladder with sterile fluid and “bladder
irrigation” as the continuous washing out of the bladder with
sterile fluid.
•One indication of Bladder instillations is to prevent or treat
catheter blockages.
•Instillation treatments are not limited to saline or citric acid
solutions; there are some others such as chemotherapy drugs
(i.e. mitomycin-C or epirubicin) or antiinflammatory drugs (i.e.
hyaluronic acid), to reduce toxicity of brachytherapy or
vesicoureteral reflux.
Bladder Irrigation/Washout
Procedure
•Indicated in bladder inflammation or infection
Requirements
•A clean Trolley arranged a follows
•Top Shelf
•Sterile Catheterization tray with:
•Larger bowl
•Mackintosh
•Dressing towel
•Spigot
•Graduated jug
•Small hand towel
Procedure
•Indicated in bladder inflammation or infection
Requirements
•A clean Trolley arranged a follows
•Top Shelf
•Sterile Catheterization tray with:
•Larger bowl
•Mackintosh
•Dressing towel
•Spigot
•Graduated jug
•Small hand towel
•A pair of gloves
•Large kidney dish
•3 way indwelling catheter
•2 way indwelling catheter
Bottom Shelf
•Medication additives if ordered
•A pair of clean gloves
•Urine bag
•Basin of warm water
•Soap
•Flannel/wash cloth
•Large kidney dish
•3 way indwelling catheter
•2 way indwelling catheter
Bottom Shelf
•Medication additives if ordered
•A pair of clean gloves
•Urine bag
•Basin of warm water
•Soap
•Flannel/wash cloth
•Bath towel
•Mackintosh
•Draw sheet
•Betadine or Hibitane
•The ordered solution for irrigation
•Strapping
•Receiver and used swabs
•Receiver with decontaminant for used equipment
•Mackintosh
•Draw sheet
•Betadine or Hibitane
•The ordered solution for irrigation
•Strapping
•Receiver and used swabs
•Receiver with decontaminant for used equipment
Procedure
•Clean and disinfect the trolley
•Arrange items appropriately on the trolley
•Explain the procedure to the patient
•Provide privacy
•Wash hands and glove
•If catheter is not already in situ, then perform the
catheterization
•Remove catheter – tip – syringe cap and place it in the sterile
tray
•Ask the assistant to pour irrigation solution into the bowl
•Clean and disinfect the trolley
•Arrange items appropriately on the trolley
•Explain the procedure to the patient
•Provide privacy
•Wash hands and glove
•If catheter is not already in situ, then perform the
catheterization
•Remove catheter – tip – syringe cap and place it in the sterile
tray
•Ask the assistant to pour irrigation solution into the bowl
•Fill the catheter tip syringe with the solution
•Insert tip securely into the catheter
•Slowly infuse irrigation into the catheter until full amount of
ordered fluid has been infused or until patient says he/she can
not tolerate additional fluid infusion
•Clamp catheter by bending end above syringe tip and remove
syringe to let fluid flow into the kidney dish
•Disinfect the catheter end with Betadine (or available anti –
microbial agent)
•Block the catheter with a sterile spigot or attach urine bag as
necessary
•Insert tip securely into the catheter
•Slowly infuse irrigation into the catheter until full amount of
ordered fluid has been infused or until patient says he/she can
not tolerate additional fluid infusion
•Clamp catheter by bending end above syringe tip and remove
syringe to let fluid flow into the kidney dish
•Disinfect the catheter end with Betadine (or available anti –
microbial agent)
•Block the catheter with a sterile spigot or attach urine bag as
necessary
•Note: If spigotted, open after every five minutes, to let fluid
flow into the kidney dish and clamp end with Betadine
•Repeat irrigation as frequently as ordered
•Clear equipment and leave the patient comfortable
•Record and report
flow into the kidney dish and clamp end with Betadine
•Repeat irrigation as frequently as ordered
•Clear equipment and leave the patient comfortable
•Record and report
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