TEST 3 - Catheterization Flashcards
Indwelling catheter
Remains in place for an extended period
Intermittent catheter
Involves insertion of a catheter for a one-time bladder emptying
Suprapubic catheter
Surgical insertion into the bladder through the lower abdomen above the symphysis pubis
Indications for Catheterization (7)
Preparation for surgery
Urinary irrigations
Collection of sterile urine specimen
Measurement of residual urine (if no scanner is available)
Measurement of accurate UO
Inability to void on own
Presence of stage III and IV pressure ulcers
Determining Catheter Type and Size FOR INFANTS
Infants: 5-6 Fr
Determining Catheter Type and Size FOR CHILDREN
8-10 Fr with 3 ml balloon
Determining Catheter Type and Size FOR YOUNG GIRLS
12 Fr
Determining Catheter Type and Size FOR ADULT WOMEN
14-16 Fr
Determining Catheter Type and Size FOR ADULT MALES
16-18 Fr
Required distance for females
5-7.5 cm (2-3 inches)
Required distance for males
17-22.5 cm (7-9 inches)
Unexpected outcomes with catheters
Urethral or perineal irritation or trauma is present Client is exhibiting S & S of infection Fever Foul odour of urine Small, frequent voidings Burning or bleeding with micturation Urinary retention
Expected outcomes with catheters
May urinate frequently
b/c of decreased bladder muscle tone
May experience dysuria
Resulting from inflammation of the urethral canal
Catheter Irrigation
Intermittent and continuous “CBIs”
Used post genitourinary surgery to maintain catheter patency ex: TURP
Used in the presence of small blood clots and mucous fragments
Closed irrigation system
Catheter Irrigation
Used to maintain catheter patency
However, continuous irrigation not required
Usually, there are no blood clots or large mucous shreds in the urinary drainage
Closed drainage system is broken therefore strict asepsis is maintained
Open irrigation system
Closed Irrigation System
What must be anticipated?
Anticipate more output vs input to account for urine production
If fluid draining less than amounts going in STOP the irrigation
During Irrigation what temp should the NS be at and why?
NS at room temperature
Prevent bladder spasm
Open Irrigation system
true or false
Technique done under strict sterile condition
TRUE
Open Irrigation System
Steps
Technique done under strict sterile condition
Use sterile irrigation tray
Prepare tray
Don gloves (sterile optional)
Wipe connection point btw catheter and tubing with antiseptic wipe
Disconnect and insert tip of syringe into lumen of catheter
Do not force the irrigation if strong resistance is met
Withdraw syringe, allow solution to drain into basin
Repeat until clear returns are obtained
If no returns obtained, reposition client or gently aspirate solution after reinserting syringe
Once complete, reconnect tubing to catheter
Reanchor catheter to client’s leg
Document accurately
Unexpected Outcomes during open irrigation system
Irrigating solution is not returned or not flowing as planned
Signs of fever or cloudy, foul urine
Increase in bladder spasms
Client may still void naturally when the catheter is clamped
More comfortable than the indwelling catheter
Lower risk of UTI
Less likely to obstruct
Suprapubic Catheter
the discharge of urine
micturition
the sudden need to urinate
urgency
inability to control the voiding of urine
incontinence
involuntary escape of urine due to strain on the orifice of the bladder, as in coughing or sneezing
stress incontinence
complete suppression of urine formation and excretion
anuria
diminished urine production and excretion in relation to fluid intake
oliguria
excessive secretion of urine
polyuria
painful or difficult urination
dysuria
blood (erythrocytes) in the urine
hematuria
pus in the urine
pyruria
excessive urination at night
nocturia
the presence of glucose in the urine
glycosuria
increased excretion of urine
diuresis
: The result of progressive obstruction of the urethra by an enlarging prostate, causing urine to remain in the bladder even after urination
urinary retention
urination at short intervals without increase in daily volume or urinary output, due to reduced bladder capacity
urinary frequency
Definition: a decrease in the force of the stream of urine, often with difficulty in beginning the flow. __________ is usually the result of an obstruction or stricture between the bladder and the external urethral orifice. In men, it may indicate an enlargement of the prostate gland; in women, it may indicate stenosis of the orifice. Cold, stress, dehydration, and various neurogenic and psychogenic factors are common causes of this condition
urinary hesitancy
urine remaining in the bladder after urination
residual urine
What are some possible reasons for leakage of urine from around catheter?
o catheter is too small
o balloon is deflated
o tug a bit
o deflate the balloon
What can be a possibility is there is bladder discomfort that persists despite catheter patency?
o UTI
What if?
No urine is present?
o maybe a result of spasming
o change client’s position
o gentle pressure with massaging on bladder - DO NOT PUSH
What position should be used in patients with arthritis, contractures, and fractures
side lying position used in patients with arthritis, contractures, and fractures
urine specimens must be sent within what time frame? or they may stay in refrigerator for up to ___ ____
urine specimens must be sent within 30 minutes or may stay in refrigerator for up to 2 hours
What if UO ↓ and and. Pain ↑?
o possible obstruction
o possible urinary retention
What symptoms do we assess for in case of a of UTI?
clarity, consistency smell of urine
WBCs
systemic signs: chills, fever, malaise
If dislodgement of suprapubic catheter occurs what steps should be taken?
o report quickly because of potential of peritoneal infection
The nurse is watching a graduate nurse remove an indwelling (Foley) catheter. The nurse should intervene if which action by the graduate nurse is observed?
A) Pericare is performed before the catheter is removed because the patient requested it.
B) The syringe attached to the inflation port is quickly pulled back to empty the balloon.
C) The tape securing the catheter to the thigh is removed before the catheter balloon is deflated.
D) The patient is told to notify the staff when he first voids after the catheter is removed.
B) The syringe attached to the inflation port is quickly pulled back to empty the balloon.
A patient recovering from back surgery has two postvoid residuals: 160 mL and 175 mL. Based on the residual results, what nursing intervention would be expected?
A) Encourage fluids up to 2000 mL daily
B) Insert an indwelling (Foley) catheter
C) Reposition the patient every 2 hours
D) Palpate the bladder every 4 to 6 hours
B) Insert an indwelling (Foley) catheter
The nurse is preparing to change a condom catheter on an uncircumcised patient. Which step in the procedure is most important for the nurse to do?
A) Replace the foreskin over the glans penis
B) Cleanse the urethral meatus in a circular motion
C) Use adhesive tape to secure the condom catheter
D) Lubricate the condom catheter for easier application
A) Replace the foreskin over the glans penis
While reviewing the medical record of a patient receiving peritoneal dialysis, the nurse notes that the patient has a negative balance. What assessment data would the nurse check to validate this entry in the record?
A) The patient’s weight has increased over the past few days
B) The patient’s abdominal girth has increased
C) The serum albumin level is low
D) The patient is losing fluid weight
D) The patient is losing fluid weight
A patient asks about caring for the newly established CAPD site. What patient teaching by the nurse will best help the patient to prevent infection?
A) “Make sure you drink at least 2500 mL daily.”
B) “Check your temperature daily at the same time.”
C) “Change the dressing on a regular basis.”
D) “Use sterile gloves when the dressing is off.”
D) “Use sterile gloves when the dressing is off.”
A female client reports that she is experiencing burning on urination, frequency, and urgency. The nurse notes that a clean-voided urine specimen is markedly cloudy. Which of the following is the probable cause of these symptoms and findings? A. Cystitis B. Renal stone C. Hemorrhage D. Incontinence
A. Cystitis
Hospital-acquired urinary tract infections (UTIs) are often related to poor handwashing and which of the following? A. Poor urinary output B. Poor perineal hygiene C. Use of urinary drainage bags D. Improper catheter care
D. Improper catheter care
Some medications change the colour of the urine. Pyridium changes the urine to which colour? A. Blue B. Brown C. Yellow D. Bright orange to rust
D. Bright orange to rust
To minimize nocturia, when should clients avoid fluids? A. After lunch B. In the late afternoon C. For two hours before bedtime D. For four hours before bedtime
C. For two hours before bedtime
What does maintaining a Foley catheter drainage bag in the dependent position prevent? A. Urinary reflux B. Urinary retention C. Reflex incontinence D. Urinary incontinence
A. Urinary reflux
When a condom catheter is applied, the catheter should be secured on the penile shaft in such a manner that the catheter is which of the following?
A. Tight and draining well
B. Dependent and draining well
C. Secured with adhesive tape applied in a circular pattern
D. Snug and secure but without causing constriction that impedes blood flow
D. Snug and secure but without causing constriction that impedes blood flow
A client undergoes ultrasonography of a kidney. The nurse providing postprocedure care remembers that which of the following is true regarding precautions that should be taken for this procedure?
A. No special precautions must be taken.
B. Each urine specimen must be assessed for blood for 24 hours.
C. All urine must be saved in a radiation-safe container for 12 hours.
D. Contact with the client must be limited to 10 minutes each hour for six hours.
A. No special precautions must be taken.
As a result of the adaptation response to surgery, the nurse expects that for the first one to two days after the client’s surgery, the client’s urine output will do which of the following?
A. Increase
B. Decrease
B. Decrease
A client underwent total knee replacement and was placed on patient-controlled analgesia (PCA). The client has been activating the drug button an average of four times per hour. The nurse has assisted the client on and off the bedpan two or three times an hour for the past two hours. Urine output was about 50 mL with each void. The nurse now begins to suspect which of the following? A. Fluid overload B. Urge incontinence C. Retention overflow D. Urinary tract infection (UTI)
C. Retention overflow
The nurse recognizes that which organism most frequently causes urinary tract infections (UTIs) in women? A. Aspergillus B. Streptococcus C. Escherichia coli D. Staphylococcus aureus
C. Escherichia coli
A client is scheduled for an intravenous pyelogram (IVP). Before the test, the most important assessment the nurse performs is asking about which of the following?
A. Allergies to shellfish
B. Previous experience with IVP
C. Family history of a reaction to IVP
D. Ability to remain still during the procedure
A. Allergies to shellfish
Elimination changes that result from obstruction to the flow of urine in the urinary collecting system may cause which of the following? (Select all that apply.) A. Blood clots B. Dehydration C. Renal damage D. Urinary retention E. Urinary tract infection
C. Renal damage
D. Urinary retention
E. Urinary tract infection
A female client is having difficulty voiding after a vaginal delivery. The nurse implements which of the following interventions to promote voiding? (Select all that apply.)
A. Turning the water tap on
B. Ambulating the client to the bathroom
C. Trickling warm water over the mons pubis
D. Offering the client a large glass of cranberry juice
E. Positioning the client on a fracture bedpan flat in bed
A. Turning the water tap on
B. Ambulating the client to the bathroom
C. Trickling warm water over the mons pubis
A client reports to the nurse that he wakes up early because of a need to urinate. The nurse recommends that the client avoid which of the following liquids after 8 P.M.? (Select all that apply.) A. Tea B. Cola C. Wine D. Coffee
A. Tea
B. Cola
C. Wine
D. Coffee
A client with multiple sclerosis is being taught how to perform self-catheterization. As part of this teaching, the nurse instructs the client to do which of the following? (Select all that apply.)
A. Increase intake of fluids.
B. Always use clean technique.
C. Always use sterile technique.
D. Use petroleum jelly to lubricate the catheter tip.
A. Increase intake of fluids.
B. Always use clean technique.
The urine appears concentrated and cloudy because of the presence of white blood cells or __________________________.
Bacteria
After undergoing transurethral prostatectomy, a client returns to his room with a triple-lumen in-dwelling catheter for continuous bladder irrigation. The irrigation fluid is normal saline delivered at a rate of 150 mL/hour. After eight hours, the nurse empties the drainage bag, which contains a total of 2520 mL. Of the total, _____ mL is urine output.
1320
