CBI Flashcards
what are the two types of catheter irrigation
closed and open irigation
what does closed irrigation involve
• Closed = intermittent or cont of urinary caether w/o disrupting sterile connection b/t catheter + drainage sys
what does intermittent irrigation entail
• Intermittent – insertion of sterile catheter into catheter port to irrigate a bolus of fluid
what is CBI
• Continuous Bladder (CBI) = continuous infusion of sterile soln into bladder, usually using 3-way irrigation sys w triple=lumen cath; used post GU sx to keep bladder clear + free of clots
can you do open cath irrigation continuously
what is it
no
• Open = only used when intermittent. Involves breaking or opening closed drainage sys at connection b/t cath + drainage sys.
should open irrigation be practied routinely even if no evidence of obstr
This should be avoided unless irrigation needed to relieve or prevent obstr; strict asepsis to prevent UTI,
aside from removing clots why might closed or open irrigation be used
to infuse meds
would single, double or triple lumens be used with open or continuous
triple=continuous or intermittent. continuous could also be double lumen
double or single=open
what to check in medical record before starting procedure
• Verify order: method (cont or intermit), type (NS or medication soln) + amount of irrigant; type of catheter in place
what to physically assess before starting procedure
- Palpate bladder for distension + tenderness (to see if blocked)
- Abd pains + spasms, sensation of fullness in bladder or cath bypassing (leaking) – shows if blockage, gets baseline to see tx effectiveness
- Urine for colour, amount, clarity, presence of mucus, clots, sediment (shows if pt bleeding or sloughing, requiring inc irrigation rate
IF CBI
should pt have higher input or ouptut. why? what to check?
output.
if input isnt > than input suspect cath obstr (clots, kinked tubing), irrigation stopped, prescriber notified
what would expected outcomes or goals of care be
- Urine output greater than irrigating soln instilled (if CBI)
- Pt reports relief from bladder pain/spasm
- Urine output dec w absence of blood clots + sediment (urine will be bloody following sx, gradually lighter + blood tinged in 2-3d)
- Absence of fever, lower abd pain, clour or foul-smelling urine
when closed irrigation and fresh post op how often miht you empty bag
1-2hrs
closed irrigation. what determines how fast you make the flow rate
the color of the output.
if output is red with clots what do you do (from closed continuous irrigation)
inc rate until pink
closed continuous irrigation procedure
a. Hang bag of irrigating soln to IV pole, prime
b. Connect to drainage port of Y-connector on cath
c. Adjust clamp to desired rate (if bright red irrigation, inc rate until pink)
d. Observe for outflow, ensure no bladder distension; Empty drainage bag as needed
supplies nec for closed intermittent irrigation
sterile container
sterile 30-60ml irrigation syringe
syringe to access system
screw clamp or rubber band (to occlude cath)
supplies for closed continuous irigation
irrigtion tubin w clamp to reg flow rate
y connector (optional)
IV pole
supplies for open intermittent
disposable sterile irrigation kit that has soln container, collection basin, drape, sterile gloves, 30-60ml irrigation syringe
sterile cath plug
sterile gloves
closed intermittent irrigation procedure
a. Pour prescribed sterile irrigation into container
b. Draw prescribed amount (usually 30-50ml) into syringe using aseptic technique. Place sterile cap on top of syringe
c. Clamp cath below soft injection port w screw clamp (or fold + secure w rubber band) – allows irrigation soln to enter cath
d. Clean cath port (specimen port) with antiseptic swab
e. Inject soln using even pressure – minimize trauma to baldder mucosa
f. Remove syringe + open up clamped tubing - some may be required to remain in bladder for prescribed time (such as medications)
i. Do not leave clamped cath unattended
open intermittent irrigation method
a. May need sterile gloves
b. Prep sterile tray
c. Sterile drape under cath
d. Aspirate soln into syringe (usually 60mL)
e. Move sterile collection basin close to pt thigh
f. Wipe connection port b/t cath + drainage tubing before disconnecting
g. Disconnect cath from drainage tube. Cover open end of drainage tube w sterile protective cap + pos tubing so coiled on top of bed w end on sterile drape
h. Instill soln
i. Remove syringe + allow soln to drain into collection basin ; if ordered repeat instillation until drainage clear of clots + sediment
j. Clean end of drainage tubing + reinsert into cath
heidi says no one drains it into basins
what might you remove at the start of cath irrigation that you would reapply after
possibly the cath securement device
to irrigate do you use push pause
much force
continuous P?
what to do if firm resistanc
gentle pressure to prevent trauma to bladder
dont force. the cath may be completely ocluded and need to be changed
how to det urine output
• Meaures urine output (total vol drained – total instilled)
what do you eval after bladder irrigation
- Meaures urine output (total vol drained – total instilled)
- Review I+O sheet
- Inspect urine for blood clots + sediment, ensure tubing not clogged or kinkede
- Eval pt comfort level
- Signs + symptoms of infect
how much oral intake should pt have (unless contra)
2l
how long do you expect bright red tinged urine postop
48hrs
what to do if Irrigating soln does not return (intermittent) or is not flowing at prescribing rate (CBI)
Examine tube for clots, sediment, kinks
Notify HCP if irrigant does not flow freely from bladder, pt complains of pain, or bladder distension occurs
Drainage output < irrigation infused
what to do?
Examine tube for clots, sediment, kinks
Inspect urine for presence of or inc of blood clots + sediment
Eval pt for pain + distended bladder
Notify HCP
Bright-red bleeding with irrigation (CBI) infusion wide open what to do
Assess for shock
Leave wide open + notify HCP
Pt experiences pain w irrigation what to do?
Examine for occlusion
Eval urine for clots
Eval distended bladder
Notify HCP
pt presents with signs of infect what to do?
Notify HCP, monitor vitals + characteristics of urine
post trans urethral resection of the prostate what med might they give to help keep cath patent
• Lasix may be prescribed to promote urine flow + prevent obstruction
what is the danger with cath obstr and TURP
• After TURP, obstructed cath = distension of prostatic capsule + hem
what colour shift indicates reduced bleeding post TURP
from pink to amber
what is a major risk for TURP pt and what do you consequently monitor
hemorrhage
monitor for HoTN, reg shock stuff
if pt complains of pain post TURP what to do
check tubing, check pt, irrigate (ensuring you get the same amount backt hat you put in
why is it bad to let bladder overdistend
it can induce 2’ hemorrhage by stretching the coagulated blood vessels in the prostatic capsule
why does pt still get urge to void with cath in
from presence of cath and from bladder spasms
do you infuse 60 x 2??
yes. the first is a cushion (see later)
how many L are irigation bags
hang just one for CBI?
3l
have two running at same rate
do you run CBI through the pump?
reg with clamp?? acording to handout
t or f your returns are unequal in your CBI setup. You should check the pt for bladder distention and then manually irrigate
F always check the tubing and system before breaking the system as this opens them up to infection
CBI
how often to palpate abd/bladder and when to do this more often
q1-2h and if bleeding then more often
stopped page 2 of handout now ppt
indicatiosn for CBI
To prevent formation of and to remove blood clots in the patient’s bladder
To instill medication (eg for severe bladder infection)
To prevent venous hemorrhage following genitourinary surgery
Continuous irrigation can also be used to treat an irritated, inflamed or infected bladder lining.
-post GU sx eg TUPR removal of bladder tumour
who inserts triple lumen cath and how much are they gen inflated with
surgeon in OR does it and often uses 30ml to inflate
when the urine is what color can the CBI be removed
who can do this
what might be done before removal and why
rose colored output. still require order
nurse can remove
Prior to discontinuing a triple lumen catheter often you will see that the Dr. will order to clamp the CBI for a few hours while the nurse is to observe the patients urine. Doing so allows the nurse to see if the patient begins to bleed without the irrigation of the CBI fluid running (which would cause catheter obstruction).
When the urine is light pink to clear it is a good sign. when clamped for an hr and then opened ad the new drainage darkens to mod sanguineous tinge recommence CBI and clamp again in 1hr
what type of bleeding requires traction post TURP. what fx does this serve
arterial bleed which is bright red and has clots. venous gen doesnt need traction.
it prevents hemorrhage
pt requires traction post TURP how is this done and
If bleeding occurs the catheter is applied with traction (usually adhered to the upper thigh in some way) so that the catheter remains in the prostatic fossa (the area that had prostate and is now empty).
To apply traction the specialized nurse firmly grasps the catheter approximately 6 inches above the 3-way junction (with a Dr.’s order) and pulls firmly until catheter is taut. The catheter is then taped.
with traction during TURP what are your concerns
Once traction is placed, blood pressure and pulse will be taken regularly. The effectiveness of the traction will be assessed.
Check policy for frequency of these assessments. Traction time is limited as traction can cause necrosis of tissue
pt is fresh post op with CBI going when do you dec the freq of your checks. what freq do you use initially
how freq do you check output
Assess drainage system q30 minutes until flow is consistently pink to clear in color, then q4H for duration of CBI
Assess urinary & irrigant output q2h
Returns - irrigant used = urinary output
beyond assessing output and the char of drainage what are you assessing and how regularly (if no abn)
Assess Q4H & PRN:
VS q4H
Patient comfort r/t instillation of fluid
Patency of systems
Assess q8H & PRN: For fluid leaking around the catheter Condition of urinary meatus Inflow obstruction/outflow obstruction Bladder distension
what are the potential problems of CBI
Over-distension of the Bladder – Due to clot formation and obstruction of drainage system. May lead to increased bleeding/pain/rupture of bladder
Bleeding and Hemorrhage – Related to surgical process. Can be caused by over-distension of bladder
Pain – Meatal trauma due to tension on catheter. Bladder spasm related to over-distension
Infection – Nosocomial infections
how clear should the returns be
clear enough to see your finger through the tubing
if you see old red returns what do you do
irrigation might be nec
. If flow does not return after irrigating with 30-50mls what to do
may need to aspirate for clots
what is nec to dec pain
cath MUST be taped in place with stat lock device
antispasmodics…opioids
make sure bladder doesnt overdistend
what is TUR syndrome
direct result of either absorption of irrigating fluid used during the sx procedure through venous sinuses opened by the resecion of prostate tissue and sometimes as a result of breaching of the prostatic capsule w fluid ollecting in the retroperitoneal space and absorbed from there
how much vol of fluids is absorbed in TUR syndrome
why does this happen
10-30 ml per minute irrigating soln’ can be absorbed.
R/T prolonged resection time, increased volume of irrigation fluid, larger resected amount of prostatic tissue & elevation of height of irrigation bag
early signs and symptoms of TUR syndrome
late mnfts
Uneasy/vague apprehension Headache & dizziness N & V, abdominal distension Hypertension Bradycardia Lethargic
late: Hypotension, Angina, Dyspnea, Hypoxia, Cardiovascular collapse, Neuromuscular disturbances, transient blindness, cerebral edema & coma.
what should be reported to dr
1 Urine output is less than 30ml/hr over 2 consecutive hours
2 Dislodged urinary catheter (may need to be reinserted by surgeon)
3 Catheter obstruction (could be from a large clot) Try and clear catheter first by irrigating it (if orders permit) prior to calling physician
4 Excessive leakage around catheter
5 Unresolved bladder distension (could indicate clot blocking urine flow in catheter)
6 Onset of chills, shaking (could indicate hemorrhage, shock)
7 Severe, continuous bladder spasms
8 Neurological changes in lower extremities
9 If irrigant does not return
10 Bright red drainage continues with increased flow rate
11 Sudden change in color of urine
12 Abdominal pain
13 Change in VS
what might excess leakage around cath indicate
(could indicate clot blocking urine flow in catheter)
spasm
obstr
why might pt have continuous bladder spasms
(surgery to the lower abdominal area may weaken the bladder or pelvic floor muscles, or cause damage to the nerves that control the bladder.
Bladder surgery (a common cause of bladder spasms in both children and adults) Prostatectomy (prostate removal) Other lower abdominal surgery
how should bed be for pt if CBI
highest position to promote drainage
what to document after irrigation
Time irrigation started Amount and type of irrigating solution Character and changes in character of urinary returns I&O Urinary returns – irrigant = urinary output Tolerance of procedure Bladder spasms Pain ,
disharge teaching at home
Monitor for Complications at Home:
Infection:
Fever, chills, diaphoresis, myalgia, dysuria, urinary frequency & urgency
Bladder distension R/T spasms, UTI, clots:
Abdominal pain & bladder spasms, changes in urinary flow, dysuria.
pg 2 handout
when getting a pt back from OR what do you assess in relation to CBI
what may not have been switched in OR
BAD
bag–make sure NS and not glycine. if glycine switch right away and fill out incident report.
abdm–palpate for distention
drainage–want to see fingers through tubing
what does it mean to provide a cushion according to VIHa policy
instill 60ml, pinch off, instill 60more then withdraw 60…likely someone infused 60 then tried to withdraw from empty bladder and got some tissue caught. now we provide cushion toprevent this
what is a challenge and when is this done
what happens
When catheter drainage light pink to clear clamp for 1 hour. Open clamp and if drainage light pink d/c and attach catheter to straight drainage bag.
o If drainage darkens to moderate sanguineous tinge recommence CBI and clamp again in 1 hour
symptoms of bladder spasm
sudden urge to void o bearing down sensation o catheter bypassing o urge to have BM o low abd/bladder discomfort o penile discomfort
pts with which sx require extreme caution for hand irrigating, you should consult w urologist befrehand
transurethral resection of bladder tumour–> might perforate the bladder
irrigation bags should never be >___ above pt
3ft (higher can contribute to TUR syndrome)
what PPE would you need? other supplies?
gloves, gown, face shield
alcohol swabs for between irrigating and accessing
waterproof pad for under pt
sterile basin and syringe
250ml or so sterile NS
sterile drape for under catheter (not sure if it comes in package)
sterile cap for the catheter bag that you disconnect when irigating
clamp
? maybe more
