Bladder Irrigation – hazards,
Types of catheters, Nursing Care,
Purpose, and Method.
Tidal Irrigation
BLADDER IRRIGATION
Bladder irrigation means to flush out the urinary bladder with a liquid. Bladder is a natural reservoir of urine. When the urine does not flow freely from the bladder, it forms a stagnant pool which is an excellent media for the growth of bacteria. This stagnant urine also allows the settling of crystals in the bladder which forms bladder stones. In order to avoid these problems, the urinary flow must be maintained by natural or artificial means by the use of urinary catheters.
HAZARDS OF CATHETERIZATION AND BLADDER IRRIGATION
1. Infection
Urinary bladder is a sterile cavity. It is inherently resistant to infection. The acidity of the normal urine is unfavourable to the growth of microorganisms. The mechanical action of voiding also removes organisms from the urinary tract. However, if an infection is present in one part of the urinary tract, it may travel to other parts because of the continuity of the mucus membranes. The urinary tract also offers a favorable environment for the multiplication of bacteria because it is dark, moist and warm.
The common cause of urinary infection is:
a. Placement of catheter into the bladder: during the introduction of catheter, it may cause injury to the bladder mucosa which is a potential hazard for the growth of bacteria in the bladder. Infection is introduced into the bladder along with the catheters during the catheterization and bladder irrigation. Placement of catheter in the bladder prevents the washing action of voiding.
b. Dehydration of the patient highly concentrated urine and may cause infection.
c. Changing the pH value of urine by medications.
d. Force of the fluid introduced into the bladder during the bladder irrigation can cause injury to the bladder mucosa.
e. Over distension of the bladder due to blockage of the urinary flow.
2. Tissue Trauma
During the insertion of the catheter and procedures applied to the bladder, tissue trauma may take place. Even the slight movements of the catheter can cause tissue trauma and tissue breakdown.
3. Urethral Irrigation
Symptoms of urethral irritation such as burning sensation and pain at the urethral meatus will be experienced especially by the male patients due to indwelling catheters. Presence of catheter induces fibrin reaction which will lead to the urinary tract infection.
4. Muscular Spasms
Bladder spasms may occur due to the balloon of an indwelling catheter resting directly on the bladder neck. Forcing fluid more than what is tolerable by the patient will lead to muscle spasms and pain.
TYPES OF URINARY CATHETERS USED FOR THE BLADDER IRRIGATION
The tubes used to draw urine from any part of the urinary system are called urinary catheters. The types of catheters commonly used are:
1. Straight Catheters
The straight catheter is a single lumen tube which may have single eye or many eyes. It may have a round tip or whistle tip. These catheters are not self retaining, so they are used only for a short period and must be secured with adhesive tapes when utilized as indwelling catheters. These are made up of rubber, plastic or metal.
2. Self Retaining/Indwelling/retention Catheters
Indwelling catheters are inserted with an intention of retaining them in place for several hours to several months or years. They may contain more than one lumen throughout its length on the inside. The indwelling catheter used commonly is:
a. Double Lumen Foley’s Catheter
This is a single eyed round tip catheter with a double lumen. One lumen provides the drainage of the urine, while the other lumen connects to a balloon located just above the drainage eye on the catheter. Once the catheter is placed in the bladder this balloon is inflated with sterile water to fix it in position. Now the balloon is too large to pass into the urethra and keeps the catheter in place. It is important to test the balloon for leakage prior to the insertion, with the sterile water injected into the lumen of the catheter which fills the balloon.
b. Triple Lumen Foley’s Catheter
The malecot and pesser catheters are single lumen catheters with self retaining protuberances at their tips. They must be elongated with a stylet is removed and the protuberance secures the catheter in place.
3. Supra-pubic Catheters
These are inserted directly into the bladder through a incision made on the anterior abdominal wall. Malecot’s and mushroom catheters are used as supra-pubic catheters.
4. Ureteric Catheters
The renal pelvis may be drained by urethral catheter which is passed by means of a cystoscope to the bladder and up into the renal pelvis. CARE OF THE PATIENT WITH INDWELLING CATHETERS
Purpose
1. Maintaining the patency of the catheter and the tube
Nursing Actions:
1. Frequent checking of the urinary drainage will help in the early detection of catheter blockage.
2. Secure the catheter safely to prevent accidental dislodgement of the catheter.
3. Care should be taken not to obstruct the lumen of the tube when securing it to the bed. A rubber band or adhesive plaster around the tubing attached to a safety pin, which is pinned to the bed is convenient and is unlikely to squeeze or kink the tube.
4. See that the patient is not lying over the catheter or tubing and obstructing the urinary flow.
5. The catheters should never be left clamped even for a short period unless ordered by the physician. Occasionally, the nurses may forget to remove the clamp which will lead to retention.
6. Bladder irrigation is indicated when a blockage in the catheter is anticipated with clots, mucus plugs etc. remember that the safest and most effective way of irrigating the urinary system is by internal irrigation, that is by administering plenty of fluids orally or parenterally.
7. Avoid pinching the drainage tubings between the side rails or under the wheel of wheel chairs.
2. Prevention of Infection
1. Practice strict aseptic techniques. Everything that touches the urinary tract should be sterile, namely, the fluid, the catheter, the tubings and other equipments used for the procedures connected with the urinary system.
2. Practice through hand washing before and after the procedures related to catheter.
3. Avoid urinary catheterization and irrigations as far as possible. Repeated catheterization increases the chances of urinary tract infection.
4. Separate the patients with catheters from the patients without catheters.
5. Maintain a closed drainage system whenever an indwelling catheter is put in. A closed drainage system is one in which the entire system from the catheter to the collection bag is closed to the atmosphere. Thus, it is protected from the microbial invasion from the environment.
6. Prevent the back flow of urine from the tubing into the urinary bladder. One of the frequent causes of back flow of urine is the raising of the collection bag above the level of the patient’s bladder. If the bag is raised above the patient’s bladder (e.g., when transferring a patient) apply a clamp or tie the tubing to prevent the back flow of urine.
7. Prevent pooling of the urine in the drainage tube. The drainage tube should be long enough to allow the patient’s movements in bed, but it should not be too long to form loops which increases the chances for collection of urine in the tubing thereby the chances for back flow. Pooling of the urine in the tubing may take place when the tubing is passed over the patient’s thigh. Loops are formed when a long tube runs to the floor and then up into the collection bag. Tubing should run straight from the mattress into the collection bag, without forming loops.
8. It is necessary to empty the collection bag at least every 8 hours or even more frequently. If the urine is left to stand in, it is an excellent media for the growth of microbes.
9. Give the perineal care at least twice a day in order to reduce the number of bacteria on the perineum and prevent their transfer into the bladder along the catheter.
10. Cleaning of the catheter that is lying outside the urethra reduces the chances of urinary tract infection.
11. Increased intake of fluid reduces the chances of urinary tract infection and stone formation. It provides internal irrigation of the urinary system.
12. Maintaining the pH value of urine towards the acidic side decreases the chances of urinary infection.
13. Use of antibiotics and urinary antiseptics prevents urinary tract infection.
14. Every patient and his relatives should be explained about the care of the catheter to prevent urinary tract infection and other disorders.
15. Changing the catheter, drainage tubings and the collection bags at specified intervals reduces the chances of urinary tract infection. The catheters are changed infrequently but the drainage tubings and the bags are changed frequently.
3. Maintaining the comfort and safety of patient
1. Explain the patient what is to be expected during and after the catheterizations and irrigations e.g., they have an urgency of urination for a brief period after the catheter is put in.
2. Teach the patient how to move in bed with the catheter in place.
Instruct the patient to take plenty of fluids especially if he has burning sensations on urination.
3. Teach the patient how to keep the perineum clean and dry.
Use restraints for those patients who are irrational and are continually pulling out the catheter.
4. Proper fixation of the catheter may add to the comfort of the patient. Good tapping prevents constant friction on the neck of bladder and urethra. The catheters may be taped to the inner aspect of the thigh. Taping on the hairy portion of the perineum is to be avoided.
5. If the patient gets bladder spasm and pain, gently manipulate the catheter to change the position of the balloon resting on the neck of the bladder.
6. Never force fluid into the urinary bladder. Use gentle pressure during the bladder irrigation etc.
7. During the catheterization, never force the catheter into the bladder. If any obstruction is experienced, withdraw the catheter a little, rotate it and then introduce it into the bladder.
4. Restoring normal bladder functions.
When the bladder is continually drained with an indwelling catheter, the bladder becomes increasingly flaccid, it loses its tone. It gives rise to retention of urine on removal of catheter. One way of avoiding this is by establishing a bladder training programme. The catheter is clamped for increasing lengths of time and then released at specified intervals to allow the drainage of urine. By this way, the bladder is alternatively stretched and allowed to be empty; thus restoring its normal function. Sometimes a tidal drainage apparatus is used to provide automatic filling and emptying of the bladder.
Purpose of Bladder Irrigation
1. To cleanse the bladder from decomposed urine, bacteria, excess of mucus, pus and blood clots and to maintain the patency of the urinary catheter.
2. To relieve congestion and pain in case of inflammatory conditions by the application of heat.
3. To promote healing.
4. To prevent clot formation in case of bladder surgeries.
5. To prevent or treat infection e.g., cystitis.
6. To arrest bleeding.
Solutions used for bladder irrigations
1. Distilled water
2. Normal saline
3. Glucose solution 5 percent
4. Boric acid 2 percent
5. Potassium permanganate 1 in 10,000
6. Acriflavin 1 in 10,000
7. Silver nitrate 1 in 5000 (astringent)
8. Acetic acid 1 in 400 to treat pseudomonas infection
The solution should be administered at body temperature. In inflammatory conditions, it may be used as hot as 43.3 degree celcius according to the tolerance of the patient.
Methods Used
1. Open Method
Open irrigation means that the closed drainage system must be opened to the environment in order to do the bladder irrigation.
Every time the catheter is disconnected from the drainage tubing to do the procedure, there is a great risk of introducing bacterial contamination into the urinary bladder. There are also increased chances of introducing air. Open irrigation is usually done using as asepto syringe.
2. Closed Method
To avoid the hazard of bacterial contamination present in the open system of bladder irrigation, the closed system of bladder irrigation is practiced at present. Closed system can be a continuous irrigation or an intermittent irrigation. The patient will have a urinary catheter put though the urethra and a suprapubic catheter. The apparatus used for I.V. infusions can be used in this through the urethral catheter and drain out through the suprapubic catheter. Clamp is used to regulate the flow of fluid. When only one catheter is put in, apply clamps for the inflow and outflow tubes. Opening and closing these clamps alternately allows the fluid to get into the bladder and then to drain out of the bladder.
GENERAL INSTRUCTIONS FOR BLADDER IRRIGATION
1. The bladder irrigations should not be done without a specific order. As far as possible, the bladder irrigations are to be avoided for the fear of introducing infection and trauma to the urinary system. Remember the safest and most effective means of irrigating the urinary system is by ‘internal irrigation’, that is by forcing fluid by mouth or parenterally.
2. Patients with dwelling catheters should be kept separate because there is a great risk of microbial transmission between catheterized patients.
3. Vigorous irrigation or introducing fluids with great force will destroy the mucus lining of the bladder and spread infection. If the force is much, it can carry the bladder contents up into the ureters. The fluid should be instilled gently and allowed to drain back by gravity. if the fluid flows readily into the bladder but fails to return, there is a clot acting as a valve over the eye of the catheter. In such situations, no more fluid is introduced into the bladder, but tries to dislodge the clot by milking the tubing. The catheter may be rotated slightly to be sure that it is not occluded by its position in the bladder. If the fluid is retained in the bladder, examine the whole irrigating system to detect any displacement, a blockage, a kink etc. that may obstruct the return flow.
4. Practice strict aseptic technique. All the articles that are used for the irrigation must be sterile and great care must be taken to prevent introduction of infection into the bladder.
5. Wash hands before and after the procedure to prevent cross infection.
6. Maintain accurate records of the amount of fluid used for irrigation and the total amount of urinary drainage. Subtract the total amount of fluid used, from the total amount of urinary drainage to find out the amount of urine secreted by the kidneys.
7. For patients who are on restricted salt intake, use 5 percent, dextrose solution instead of normal saline, because some absorption will take place when the irrigation is constant and the doctor may not wish sodium chloride to be absorbed.
8. Irrigations are carried out until the return flow is clear. The color of the drainage should be checked and recorded. If bleeding takes place, stop the procedure and inform the doctor immediately.
9. Keep the following precautions when an open method of irrigation is used:
a. The part of the equipment that must be kept sterile are the tip and the inside of the irrigating syringe, the irrigating solution, the open ends of the catheter and the drainage tubing.
b. Wash hands thoroughly for a surgical procedure.
c. Cleanse the catheter-drainage tubing junction with an antiseptic solution before they are disconnected to prevent infection entering into the drainage system.
d. Separate the catheter from the drainage tubing, taking care not to contaminate either end. Cover the end of the tubing with a sterile dry gauze and place the tubing safely to prevent it failing off from the bed. The distal end of the catheter is held in hand without contaminating it.
e. Hold the catheter and the irrigation syringe perpendicular to the floor so that no air is injected into the bladder, because; air, if introduced into the bladder causes bladder spasms.
f. Slowly inject the solution into the catheter using either gravity flow or slight pressure on the bulb of the irrigating syringe. No undue force should be applied.
g. Introduce only 75 to 100 ml of solution at a time into the bladder. Never introduce more fluid than what a patient can tolerate without pain. If a drip method is used, introduce fluid at a rate of 40 to 60 drops per minute.
h. After the solution is introduced, pinch the catheter with the fingers and remove the irrigating syringe from the catheter. Hold the end of the catheter over the collection basin for drainage. Never use suction with the syringe to withdraw the fluid from the bladder. It may suck the bladder mucosa into the drainage holes of the catheter and cause trauma to the bladder mucosa.
i. After the irrigation is over, cleanse the end of the catheter with an antiseptic solution and re-connect it to the drainage tubing, taking care to maintain the sterility of the two ends.
10. As far as possible use the ‘closed method of irrigation’. A closed method is used for either intermittent or continuous irrigation. The following precautions are taken when a closed method of irrigation is set up.
a. Regulate the flow of fluid into the bladder at a specified rate – a rate similar to an intravenous infusion.
b. When the intermittent irrigation is set up, apply clamps on the inflowing tubings to regulate the flow of fluid into the bladder and to stop it when a sufficient quantity of fluid is flowed into the bladder.
c. Since a large amount of fluid is used for irrigation, the collection bag will need to be emptied more frequently to avoid reverse flow of drainage fluid into the bladder.
d. When the urethral and supra-pubic catheters are introduced into the bladder, as seen in case of prostatectomy, allow the irrigating fluid enter in the urethral catheter and drain out through the supra-pubic catheter.
e. Do not allow the irrigating fluid to run out completely form the irrigating can and prevent the air entering the bladder.
11. Record the procedure on the nurse’s record with date and time.
Record the following:
a. The purpose of the procedures.
b. Amount and the kind of solution used.
c. Amount and characteristics of the drainage from the bladder.
d. Results of irrigation.
e. Problems encountered during the procedure.
f. Any fluid retained and urine removed before, during and after the procedure.
12. Keep the following points in mind when the indwelling catheters are removed:
a. To remove an indwelling catheter, deflate the balloon first by removing the fluid with a syringe. Ask the patient to take a deep breath to enhance relaxation. Then slowly remove the catheter.
b. Record the time and date on which catheter was removed.
c. After the catheter is removed, clean and dry the perineum. Inspect the meatus for signs of infection, trauma or oedema.
d. The nurse should assess the bladder functions for atleast 24 hours to ensure that there is no retention of urine.
e. The patients should be instructed to take plenty of fluids following the removal of catheter. Patient with adequate fluid intake should void within 6 to 8 hours or even more frequently.
f. For few hours or few days (if the catheter was put in for a long period) the patient may have some dribbling because of the sphincters of the bladder have been dilated. g. Dribbling can be controlled by teaching the patient to do the perineal exercise. Observe the patient whether the dribbling is ‘constant’ or ‘on urgency’.
g. The color and consistency of urine voided should be noted.
TIDAL IRRIGATION
Tidal irrigation also called as tidal drainage, is a mechanically controlled method of gradually filling the bladder with an irrigating solution, in addition to the urine and then periodically emptying it.
Different types of apparatus are available in the market for this purpose which help the operator to control the pressure exerted on the bladder wall and the intervals at which the bladder is emptied.
Tidal drainage may be used as an intermediate step in the rehabilitation of a patient with spinal cord injuries that may interfere with the normal functions of the urinary bladder. If there is incontinence following a spinal cord injury and the bladder is continually emptying itself (incontinence of urine) or if retention exists (retention of urine with or without overflow), some physicians believe that an automatic function can be more rapidly established if tidal drainage with its gradual filling and periodic emptying of the bladder is instituted.
The simplest method of tidal drainage used is the manually controlled intermittent closed drainage followed by a period of bladder training. When irrigating solutions are used, the inlet tube is opened at stated intervals (with the outlet tube clamped) and a certain amount of fluid is allowed to enter the bladder. The inlet is then closed and the outlet is opened, permitting the fluid to drain from the bladder into the drainage bottle. This process is repeated. The nurses should be careful not to introduce the excess of solution into the bladder and thus cause discomfort to the patient.