Urinary Catheterization

Define terms:

Catheter a rubber or plastic tube inserted through the urethra used for injecting or removing fluids. Micturition synonymous with voiding and urination, which refers to the process of emptying the bladder. It is an involuntary reflex act, but its control can be learned. Urinary retention is the marked accumulation of urine in the bladder as a result of the inability of the bladder to empty. Urinary catheterization involves introducing a rubber or plastic tube through the urethra into the bladder for the purpose of withdrawing urine. - It is considered the most common cause of nosocomial infection. Urgency in urination refers to the feeling of need to void immediately. Urinary incontinence is the involuntary loss of urine that is sufficient to be a problem that may be caused by increased abdominal pressure. Residual volume urine volume that remains in the bladder after voiding(>100 ml)

Anatomy and physiology of the urinary system in males and females

Kidneys: -paired, reddish brown, bean-shaped organs that lie on either side of the vertebral column posterior to the peritoneum and against deep muscles of the back -Normally the left kidney is 1.5-2 cm (6/10-8/10 inch) higher than the right because of the anatomical position of the liver. -Each kidney typically measures approximately 12 by 7 cm (5 by 3 inch) and weighs 120 to 150 g. Functions: kidneys have both regulatory and hormonal functions Responsible for maintaining a normal RBC volume by producing erythropoietin Ureters: -urine enters the renal pelvis from the collecting ducts. Measuring 25-30 cm (10-12 inch) in length and 1.25 cm (1/2 inch) in diameter in the adult. Function: transport of urine from the renal pelvis. Bladder: -a hollow, distensible, muscular organ that is both a reservoir for urine and the organ of excretion. -the capacity is approximately 600 ml of urine, although a normal voiding is about 300 ml The wall of the bladder has four layers : -The inner mucous coat

-sub mucous coat of connective tissue -muscular coat -outer serous coat Function: sphincter prevents escape of urine from the bladder and is under voluntary control.

URETHRA: -urine travels from the bladder through the urethra and passes outside of the body through the urethral meatus. normally the turbulent flow of urine through the urethra washes it free of bacteria. In women, the urethra is approximately 4-6.5 cm (1 to 2 inches) long 20 cm (8 inches) in male the male urethra has three sections: -prostatic urethra -membranous urethra -penile urethra

Steps of urine formation

FILTRATION: -Non selective, passive process -eliminated that is normal by our body TUBULAR SECRETION: -reabsorption in reverse

-eliminated nitrogenous waste One of the more significant functions of the kidneys is to maintain the composition and volume of body fluids. They perform this function in a selective manner by filtering and excreting blood constituents that are not needed and retaining those that are. It is estimated that the total blood volume passes through the kidneys for waste removal approximately every half hours. Despite varying kinds and amounts of foods and fluids ingested, body fluids remain relatively stable if there is proper kidney functioning. The waste product that the kidneys excrete contains organic, inorganic, and liquid wastes and is called urine.

Characteristics of normal urine

CHARACTERISTICS

NORMAL FINDINGS -A freshly voided specimen is pale yellow, strawcolored, or amber, depending on its concentration.

ABNORMAL FINDINGS -Urine is darker than normal when it is scanty and concentrated . Urine is lighter than normal when it is excessive and diluted. -Certain drugs , such as cascara, L-dopa, and sulfonamides, alter the color of

Color

urine Odor Normal urine smell is aromatic. As urine stands, it often develops an ammonia odor because of bacterial action. Some foods cause urine to have a characteristic odor; for example, asparagus causes urine to have a strong, musty odor. -urine high in glucose content has a sweet odor. -urine that is heavy infected has a fetid odor. Turbidity Fresh urine to be clear or translucent; as urine stands and cools, it becomes cloudy Cloudiness observe in freshly voided urine is abnormal and maybe due to the presence of red blood cells, white blood cells, bacteria, vaginal discharge, sperm, or prostatic fluid. -A high protein diet causes urine to become excessively acid. -certain foods tend to produce alkaline urine, such as citrus

Ph

Normal ph is about 6.0, with a range of 4.6-8. Urine becomes alkaline in standing when carbon dioxide diffuses into the air.

fruits, dairy product and vegetables, especially legumes. -certain foods tend to produce acidic urine, for example meat and cranberry juice. -certain drugs influence the acidity of urine; for example, ammonium chloride produces acidic urine, and potassium citrate and sodium de carbonate produce alkaline urine. Specific Gravity This is a measure of concentration of dissolve solids in the urine. The normal range is 1.010 to 1.025. concentrated urine will have a higher than normal specific gravity and diluted urine will have a lower than normal specific gravity. In the absence of the kidney disease, a high specific gravity usually indicates dehydration and below specific gravity indicates

over hydration. Constituents Organic constituents of urine include urea, uric acid, creatinine, hippuric acid, indicant, urine pigments, and undetermined nitrogen. Inorganic constituents are ammonia, sodium, chloride, traces of iron, phosphorus, sulfur, potassium, and calcium. Abnormal constituents of urine include blood, pus, albumin, glucose, ketone bodies, casts, gross bacteria, and bile.

Different factors affecting voiding Disease conditions: primarily affect renal function. 3 types: Prerenal conditions- alterations are outside of the urinary system. Renal conditions- result from factors that cause injury directly to the glomeruli or renal tubule, interfering with their normal filtering, reabsorptive and secretory functions. Postrenal conditions result from obstruction to the urinary collecting system. Growth and development: infants and young children cannot effectively concentrate urine. Their urine thus appears light yellow or clear while aging impairs micturition.

Sociocultural factors: Cultural norms vary on the privacy of urination. North Americans expect toilet facilities to be private, whereas some European cultures accept communal toilet facilities. Social expectations (school recesses) influence the time of urination. Psychological Factors: Anxiety and emotional stress may cause a sense of urgency and increased frequency of urination. Muscle Tone: Weal abdominal and pelvic floor muscles impair bladder contraction and control of the external urethral sphincter. Fluid Balance: The kidneys maintain a sensitive balance between retention and excretion of fluids. If fluids and the concentration of electrolytes and solutes are in equilibrium, an increase in fluid intake causes an increase in urine production. Surgical procedures: The stress of surgery initially triggers the general adaptation syndrome. Medications: Diuretics prevent reabsorption of water and certain electrolytes to increase urine output. Urinary retention may be caused by use of anticholinergics, antihistamines, antihypertensives, or beta-adrenergic blockers.

Alterations in urinary elimination

Oliguria: diminished capacity to form urine (usually <400 ml/24hr) Anuria: inability to produce urine Nocturia: excessive urination at night

Polyuria: excessive output of urine Bacteriuria: presence of bacteria in urine Dysuria: pain or burning sensation during urination Hematuria: blood-tinged urine Urgency: Feeling of need to void immediately Frequency: voiding at frequent intervals (<2 hr) Hesitancy: Difficulty initiating urination Dribbling: Leakage of urine despite voluntary control of urination Incontinence: involuntary loss of urine Retention: accumulation of urine in the bladder, with inability of bladder to empty fully Residual urine: volume of urine remaining after voiding (>100 ml) Proteinuria: presence of large protein in the urine

Principles involved in catheterization Anatomy and physiology: proper knowledge on the urinary
system of both male and female promotes proper technique on catheter insertion, choosing the proper catheter for a patient and it enables one to understand deviations from normal.

Body mechanics: proper body positioning of both patient and

nurse helps prevent unnecessary strains and promotes ease of insertion. The supine and dorsal recumbent are the required positions for both male and female in doing catheterization.

Environment: sanitary environment is necessary since

catheter insertion is an invasive procedure and is the most common cause of nosocomial infection.

Microbiology: nurse must be knowledgeable about the normal

micro flora of the urinary system to detect any deviations from normal that are currently present in the urine.

Time and energy: catheterization must be done quickly but

effectively to conserve time and energy and to avoid prolonged sensation of pain felt by the patient.

Purpose or importance of catheterization

-To relieves urinary retention. -To obtain a sterile urine specimen. -To provide intermittent and contains bladder drainage and irrigations. -To empty the bladder completely prior to surgery. -To facilitate accurate measurements of urinary output that needs to be monitored. -To monitor a critically ill patients

Indications:
Intermittent Catheterization -Relief of discomfort of bladder distention, provision of decompression

-Obtaining sterile urine specimen -Assessment of residual urine after urination -Long-term management of clients with spinal cord injuries, neuromuscular degeneration, or incompetent bladder. Short-term Indwelling Catheterization -Obstruction to urine outflow -Surgical repair of bladder, urethra, and surrounding structures -Prevention of urethral obstruction from blood clots -Measurement of urinary output in critically ill patients -Continuous or intermittent bladder irrigations Long-term Indwelling Catheterization -Severe urinary retention with recurrent episodes of UTI -Skin rashes, ulcers, or wounds irritated by contact with urine -Terminal illness when bed linen changes are painful for clients

Contraindications:
-Patients with uremic reflux (backflow) into the kidney. -Patients with urethral trauma. -Patients with prostatitis. -Patients with previous urethral surgery. -Patients with urethral obstructions

Types of catheter

Straight single-use catheter: has a single lumen with a

small opening about 1.3 cm or inch from the tip. Urine drains from the tip, through the lumen and to a receptacle.

Indwelling Foley catheter: has a small inflatable balloon

that encircles the catheter just below the tip. When inflated, the balloon rests against the bladder outlet to anchor the catheter in place. It has 2 or 3 lumens within the body of the catheter. One lumen drains urine through the catheter to a collecting tube. A second lumen carries sterile water to and from the balloon when it is inflated or deflated. A third (optional) lumen may be used to instill fluids or medications into the bladder.

Coud catheter: is used on male clients who may have

enlarged prostates that partly obstruct the urethra. It is less traumatic during insertion because it is stiffer and easier to control than the straight-tip catheter.

Suprapubic catheter: used for continuous drainage. It is

surgically inserted through a small incision above the pubic area.

Condom catheter: it is a soft, pliable device made of plastic

or rubberized material applied externally to the penis when voluntary control of urination is not possible for male patients. It is an alternative to an indwelling catheter.

Methods of catheterization Intermittent technique: makes use of a straight single-use

catheter that is introduced long enough to drain the bladder (5 to 10 minutes). When the bladder is empty, the nurse immediately withdraws the catheter.

Indwelling Retention Catheterization: remains in place

for a longer period until a client is able to void completely and voluntarily or as long as accurate hourly measurements are

needed. It may be necessary to change indwelling catheters periodically.

Condom Catheterization: it is another method done when

voluntary control of urination is not possible for male patients.

Male and Female Methods of Catheterization Size of the catheter

Male no. 18-20 Female no.16-20 or 14-16

Position of the patient during catheterization

Male: Assist to supine position with thighs slightly abducted Female: Assist to dorsal recumbent position (supine with knees flexed)

Length/area of lubrication applied on the catheter

Male: 15-18 cm (6-7 inches) Female: 1-2 inches of catheter tip

length of catheter insertion

Male: 7.5-10 cm (3-4 inches) Female: 5-7.5 cm (2-3 inches)

Method of catheterization
Male: intermittent or straight catheter

Female: indwelling urethral catheter

Materials needed for catheterization

-sterile gloves -lubricant -disposable bag -prefilled syringe -flashlight or lamp -sterile drapes or towel -antiseptic solution -cotton ball or gauze -velcro leg strap or tape -straight indwelling catheter -urine collection and drainage -water proof bag -specimen container

Guidelines to be observed during and before catheterization

-take into consideration the clients level of comfort. -assess the clients normal patterns of urination -assist the patient to the required position.

-know the average output range for the client. -Clean the perineal area properly before catheter insertion -do not leave the patient alone if there are any questions about safety. -maintain sterile techniques in doing the procedure -the catheter size should be determined by the size of the clients urethral canal. -The expected time required for the catheterization will determine the catheter material selection. -Plastic catheters are suitable only for intermittent use due to their inflexibility. -Latex and rubber catheters are recommended for use up to 3 weeks. -balloon size is also important in selecting an indwelling catheter. -only sterile water should be used to inflate the balloon as saline may crystallized, resulting in incomplete deflation of the balloon at the time of removal -if leakage should occur around the catheter, a change in lumen size or use of antispasmodic medication may be warranted.

Nursing responsibilities before, during, and after catheterization

BEFORE: -Assess status of clients -review clients medical records including physicians order and nurses notes

-assess clients knowledge of the purpose of the catheterization -explain procedure to the client -begin monitoring input and output -perform medical hand washing -provide privacy -prepare the materials needed DURING: -position client - drape client -clean the area with betadine solution -open catheterization kit according to directions, keeping bottom of container sterile -apply sterile gloves -organize supplies of sterile fields -lubricate the catheter for women and for men -insert the catheter slowly AFTER: -Anchor catheter -assist client in a comfortable position -remove gloves, and dispose of equipments, drapes, and urine in the proper receptacles -perform medical hand washing -palpate bladder

-ask about clients comfort -do after care