2/25/14

Inserting a Retention (Indwelling) Catheter

Retention (Foley) Catheter Contains a second, smaller tube through out its length on the inside this tube is connected to a balloon near the insertion tip.

Purpose
• To manage incontinence
• To provide for intermittent or continuous bladder drainage and irrigation
• To prevent urine from contacting an incision after perineal surgery (prevent infection)
• To measure urine out put needs to be monitored hourly

Procedure
• Explain the procedure to the patient
• Prepare the equipment like:
Retention catheter
Syringe
├ Sterile water
├ Tape
├ Urine collection bag and tubing

• After catheter insertion, the balloon is inflated to hold the catheter in place with in the bladder.
♦ The out side end of the catheter is bifurcated i.e., it has two openings, one to drain the urine, the other to inflate the balloon.
♦ The balloons are sized by the volume of fluid or air used to inflate them 5 ml – 30 ml (15 commonly) indicated with the catheter size 18 Fr – 5 ml.

• Test the catheter balloon
• Follow steps as insertion straight catheter
• Insert the catheter an additional 2.5 – 5 cm (1-2 in) beyond the point at which urine began to flow (the balloon of the catheter is located behind the opening at the insertion tip) this ensures that the balloon is inflated inside the bladder and not in the urethra (cause trauma)
• Inflate the balloon with the pre filled syringe
• Apply slight tension on the catheter until you feel resistance: resistance indicates that the catheter balloon is inflated appropriately and that the catheter is well anchored in the bladder
• Release the resistance
• Tape the catheter with tape to the inside of a females thigh or to the thigh or a body of a male client

├ Restricts the movement of the catheter and irritation in the urethra when the client moves
├ When there is increased risk of penile scrotal excoriation

• Establish effective drainage
• The bag should be off the floor – the emptying spout does not become grossly contaminated
• Document pertinent data

Removal
• Withdraw the solution or air from the balloon using a syringe
• And remove gently

Study Questions
1. Define gastric lavage.
2. Mention indications of gastric lavage.
3. Define Enema.
4. State how the mechanism of action of soap solution enema exerts its function.
5. Mention conditions that differentiate between male and female catheterization.
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Catheterization Using a straight catheter

Purpose
• To relieve discomfort due to bladder distention
• To assess the residual urine
• To obtain a urine specimen
• To empty the bladder prior to surgery

Equipment
I. Sterile
• Kidney dish
• Galipot
• Gauze
• Towel
• Solution
• Lubricant
• Catheter
• Syringe
• Water
• Specimen bottle
• Gloves

II. Clean
• Waste receiver
• Rubber sheet
• Flash light
• Measuring jug
• Screen

Procedure
• Prepare the client and equipment for perennial wash
• Position the patient – dorsal recumbent (pillows can be used to elevate the buttocks in females).
• Drape the patient.
• Wash the perennial area with warm water and soap
• Rinse and dry the area
• Prepare the equipment
• Create a sterile field
• Drop the client with a sterile drape
• Clean the area with antiseptic solution.
• Lubricate the insertion tip of the catheter (5-7 cm in)
• Expose the urinary meatus adequately by retracting the tissue or the labia minora in an upward direction – female
• Retract the fore skin of uncircumcised mal.
• Grasp the penis firmly behind the glans and hold straighten the down ward curvature of vertical it go to the body – male hole the catheter 5 cm from the insertion tip
• Insert the catheter into the urethral orifice
• Insert 5 cm in females and 20 cm in males or until urine comes
• Collect the urine – for specimen (about 30 ml)
• Pinch previous leakage
• Empty or drain the bladder and remove the catheter
• For adults experiencing urinary retention an order is needed on the amount to urine to be expelled

Note.
• If resistance is encountered during insertion, do not force it – forceful pressure can cause trauma. Ask the client to take deep breaths - relaxes the external sphincter (slight resistance is normal)

• Dorsal Recumbent
Female - for a better view of the urinary meatus and reduce the risk of catheter contaminate. Male- allows greater relaxation of the abdominal and perennial muscles and permits easier insertion of the tube. Straight Catheter: is a single lumen tube with a small eye or opening about (1.25 cm) from the insertion tip:
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Urinary Catheterization

Definition of catheterization: Is the introduction of a tube (catheter) through the urethra into the urinary bladder

• Is performed only when absolutely necessary for fear of infection and trauma
Note. Strictly a sterile procedure, i.e. the nurse should always follow aseptic technique

Catheter: is a tube with a hole at the tip
Types of Catheter
1. Straight (plain or Robinson)
2. Retention (Foleys, indwelling)

Selecting an appropriate catheter:
• May be made of
♦ Plastic – for 1 week
♦ Latex – 2-3 (rubber)
♦ Silicon – for 2-3 month
♦ Pelyvinylchloride (PVC) – 4-6

1. Select the type of material in accordance with the estimatedlength of the catheterization period:
2. Determine appropriate catheter size
- are determined by diameter of lumen
- graded on French scale or number.

• Catheter size depends on the size of the urethral canal
♦ # 8-10 Fr – children
♦ # 14-16 Fr – female adults
♦ # 18 Fr – adult male
NB. Fr= French Scale

3. Determine appropriate catheter length by the clients gender
• For adult male – 40 cm catheter
• For adult females – 22 cm catheter

4. Select appropriate balloon size
• 5 ml – for adults
• 3 ml – for children
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Passing a Flatus Tube Procedure

Purpose
• To decrease flatulence (sever abdominal distention)
• Before giving a retention enema

Procedure
• Place the patient in left. Lateral position
• Lubricate the tube about 15 cm
• Separate the rectum and insert 12-15 cm in to the rectum and tape it
• Connect the free end to extra tubing by the glass connector
• The end of the tube should reach the (tape H2O) solution in the bowel
• The amount of air passed can be seen bubbling through the solution (a funnel may be connected to free end of tube and placed in an antiseptic solution in bowel)
• Teach client to avoid substances that cause flatulent
• Leave the rectal tube in place for a period or no longer than 20 minute – can affect the ability to voluntarily control the sphincter if placement is prolonged
• Reinsert the rectal tube every 2-3 hrs if the distention has been unrelieved or reaccumulates – allows gas to move in the direction of the rectum.


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Rectal Washout (Siphoning Enema) Procedure

(Colon irrigation or colonic flush)
- Also called enterolysis
- Is the process of introducing large amount of fluid into large bowel for flushing purpose and allow return or wash out fluid

Purpose
• To prepare the patient for x-ray exam and sigmoidoscopy
• To prepare the patient for rectum and color operation

Solution Used
• Normal saline
• Soda-bi-carbonate solution (to remove excess mucus)
• Tap water
• KMNO4 sol. 1:6000 for dysentery or weak tannic acid
• Tr. Asafetida in 1:1000 to relieve distention

Procedure
• Insert the tube like the cleansing enema
• The client lies on the bed with hips close to the side of the bed (client assumes a right side lying position for siphoning)
• Open the clamp and allow to run about 1,000 cc of fluid in the bowel, then siphon back into the bucket
• Carry on the procedure until the fluid return is clear

Note:
• The procedure should not take > 2 hrs
• Should be finished 1 hr before exam or x-ray – to give time for the large intestine to absorb the rest of the fluid
• Give cleansing enema ½ hr before the rectal wash out
• Allow the fluid to pass slowly Amount of solution
• 5-6 liters or until the wash out rectum fluid becomes clear
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Retention Enema

• Administration of solution to be retained in rectum for short or long period
• Are enemas meant for various purpose in which the fluid usually medicine is retained in rectum for short or long period  for local or general effects
E.g. oil retention enema

Antispasmodic enema
1. Principles:
• Is given slowly by means of a rectal tube
• The amount of fluid is usually 150-200 cc
• Cleansing enema is given after the retention time is over
• Temperature of enema fluid is 37.4 c or body (Return flow Enema) Harris fluid

Purpose
• To supply the body with fluid.
• To give medication E.g. stimulants – paraldehyde or antspasmodic.
• To soften impacted fecal matter. Other equipment is similar except that the tube for retention enema is smaller in width.

Procedure
Similar with the cleansing enema but the enema should be administered very slowly and always be preceded by passing a flatus tube

Note
1. Most medicated retention enema must be preceded by a cleansing enema. A patient must rest for ½ hrs before giving retention enema
2. Elevate foot of bed to help patient retain enema
3. The amount of fluid is usually 150-200 cc
4. Temperature of enema fluid is 37.4 oc or at body
5. Kinds of solution used to supply body with fluid are plain H2O, normal saline, glucose 5% sodabicarbonate 2-5%
6. Olive oil 100-200 cc to be retained for 6-8 hrs is given for server constipation
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Cleansing enema procedure

1. High enema
• Is given to clean as much of the colon as possible
• The solution container should be 30-45 cm about the rectum

2. Low enema
• Is administered to clean the rectum and sigmoid colon only

Guidelines
Enema for adults are usually given at 40-43oc and for children at 37.7 oc
Hot – cause injury to the bowel mucous
Cold – uncomfortable and may trigger a spasm of the sphincter muscles

The amount of solution to be administered depends on:
• Kind of enema
• The age of the person and
• The persons ability to retain the solution

Age          Amount
18 month         50-200 ml
18 mon-5 yrs 200-300 ml
5-12 yrs         300-500 ml
12 yrs and older 500-1,000 ml

The rectal tube should be appropriate: is measured in French scale

Age          Size
Infants/small child   10-12 fr
Toddler         14-16 fr
School age child 16-18 fr
Adults 22-30 fr

Purpose
• To stimulate peristalsis and remove feces or flatus (for constipation)
• To soften feces and lubricate the rectum and colon
• To clean the rectum and colon in preparation for an examination. E.g. Colonoscopy
• To remove feces prior to a surgical procedure or a delivery
• For incontinent patients to keep the colon empty
• For diagnostic test
E.g. before certain x-ray exam – barium enema Before giving stool specimen for certain parasites

Procedure
• Inform the patient about the procedure
• Put bed side screen for privacy
• Attach rubber tube with enema can with nozzle and stop cock or clamp
• Place the patient in the lateral position with the Rt. leg flexed, for adequate exposure of the anus (facilitates the flow of solution by gravity into the sigmoid and descending color, which are on the side
• Fill the enema can which 1000 cc of solution for adults
• Lubricate about 5 cm of the rectal tube – facilities insertion through the sphincter and minimizes trauma
• Hung the can = 45 cm from bed or 30 cm from patient on the stand
• Place a piece of mackintosh under the bed
• Make the tube air free by releasing the clamp and allowing the fluid to run down little to the bed pan and clamp open – prevents unnecessary distention
• Lift the upper buttock to visualize the answer
• Insert the tube
♦ 7-10 cm in an adult smoothly and slowly
♦ 5-7.5 cm in the child
♦ 2.5-3.75 cm in an infant

• Raise the solution container and open the clamp to allow fluid to flow
• Administer the fluid slowly if client complains of fullness or pain stop the flow for 30” and restart the flow at a slower rate – decreases intestinal spasm and premature ejection of the solution
• Do not allow all the fluid to go as there is a possibility of air entering the rectum or when the client can not hold anymore and wants to defecate, close the clamp and remove the rectal tube from the anus and offer the bed pan.
• Remove bed pan and clean the rectal tube

Note: if resistance is encountered at the internal sphincter, ask the clients to take a deep breath, then run a small amount of solution (relaxes the internal anus sphincter)
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Enema

Enema: is the introduction of fluid into rectum and sigmoid colon for cleansing, therapeutic or diagnostic purposes.

Purpose:
• For emptying – soap solution enema
• For diagnostic purpose (Barium enema)
• For introducing drug/substance (retention enema)

Solution used:
1. Normal saline
2. Soap solution – sol. Soap 1gm in 20 ml of H2O
3. Epsum salt 15 gm – 120 gm in 1,000 ml of H2O

Mechanisms of some solutions used in enema
1. Tap water: increase peristalsis by causing mechanical distension of the colon.
2. Normal saline solution
3. Soap solution: increases peristalsis due to irritating effect of soap to the lumenal mucosa of the colon.
4. Epsum salt: The concentrated solution causes flow of ECF (extra cellular fluid) to the lumen causing mechanical distension resulting in increased peristalsis.

Classified into:
• Cleansing (evacuation)
• Retention
• Carminative
• Return flow enema
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2 ways of supplying suction

a. Simple suction by the use of a syringe
b. An electric suction machine

The continues method is indicated when it is absolutely necessary and desirable to keep the stomach and duodenum empty and at rest.

Equipment
• Aspiration tube (Ryle's tube)
• Aspiration syringe if this method is used
• Gallipots with lubricant e.g. liquid paraffin or vase line, to lubricate the nostrils
• Gauze swabs in a bowl
• Sodium bicarbonate solution or saline to clean the nostrils
• Litmus paper
• Water in a galipot to test the right position of the tube in the stomach
• Two test tubes and laboratory forms of necessary
• Saline or plain water in a galipot to be injected, in case the stomach content is too thick to come out through the syringe.
• Rubber mackintosh and towel to protect the patient’s chest.
• Receiver for soiled swabs

Procedure
1. Explain procedure to patient, in order to gain her/his cooperation
2. Prop up in an upright position with help of back rest and pillow
3. Cleanse and lubricate the nostrils
4. Lubricate the Ryle's tube with water
5. Insert the tube as directed in nasal feeding and ask the patient to swallow as the tube goes down.
6. Instruct patient to open her or his mouth to make sure the tube is in the stomach
7. After being sure that the tube is in the right position, inject about 15-20 cc. of saline or water in to the stomach.
8. Draw plunger back to with draw the fluid collect specimen, If needed
9. If the Ryle's tube is to be left in site then a spigot or clamp is used to close the end, but if it is for one aspiration and to be removed immediately, it should be withdrawn very gently to avoid irritating the mucous lining.

N.B
1. Special care of the nose and mouth to prevent dryness should be considered
2. Always measure the amount withdrawn accurately noting color, contents and smell
3. Record on the fluid chart properly
4. Report any change in patient condition regarding pulse, Temperature, B.P fluid out put.
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Gastric Aspiration

• Aspiration is to withdrawal of fluid or gas from a cavity by suction

Purpose
1. To prevent or relieve distention following abdominal operation
2. In case of gastrointestinal obstruction, to remove the stomach or gastric contents
3. To keep the stomach empty before on emergency Abdominal operation is done
4. To aspirate the stomach contents for diagnostic purposes

There are two type of gastric Aspiration
1. Intermittent method: - In this case, Aspiration is done as condition requires and as ordered.
2. Continues method: - Attached to a drainage bag
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Gastric Lavage Using a Tube with a Bulb Procedure

Procedure
1. Clamp tubing below bulb.
2. With right hand, squeeze bulb this forcing the air out through the funnel.
3. With left hand, pinch tubing over bulb and at the same time releasing bulb. This creates a suction, which will draw the
stomach contents in to the bulb.
4. Lower funnel and allow excess gastric contents to drain in to the pail.
5. Pour 200c.c - 300c.c of solution into funnel. Before funnel is empty invert it and allow solution to drain.
6. Before solution stops running, turn up funnel and add another quantity of solution
7. Repeat this procedure until returns are clear
8. Gently remove the tube, feel the patient pulse and watch the respiration
9. Document the procedure

N.B.
Record
• Time of treatment
• Amount & kind of solution used
• Nature of returned fluid
• Reaction of patient during and after procedure
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Gastric Lavage Procedure

Definition- This is the irrigation or washing out of the stomach.

Purpose
1. To remove alcoholic, narcotic or any other poisoning, which has been swallowed.
2. To clean the stomach before operation
3. To relive congestion, there by stimulating peristalsis e.g. Pyloric stenosis
4. For diagnostic purposes

1. Gastric Lavage Using a Simple Rubber Tube

Equipment:
Clean trolley.
• Bowel containing large esophageal tube in ice (cold water)
• Rubber tubing with screw or clip and glass connection
• Metal or plastic funnel
• Large Jug (5 litter)
• Solution as prescription/usually to care for acidic poisoning. We use sodium bicarbonate 1 teaspoon to 500 cc. of water at a temperature of 370c - 380c.)
• Small jug to carry solution to the funnel
• Lubricant e.g. liquid paraffin
• Bowl for gauze swabs
• Cape or protective material to put around the patient chest
• Pail to receive returned fluid
• Mackintosh or paper to protect the floor beneath the pail
• Receiver for used esophageal tube
• Paper bag for waste material
• A tray for mouth wash after lavage
• Denature cup.
• A receiver for pt's dentures. If any, and should be labeled with the pt's name
• A receiver containing mount gag, tongue depressor, and tongue forceps if patient is unconscious
• Mackintosh to protect bed linen
• Litmus paper
• Specimen battle. If laboratory test is requires
• Measuring jug

Procedure
1. Explain procedure to the pt and ask him/her to remove artificial dentures, If any.
2. Protect pt with cape or towel
3. Protect bed linen by spreading the mackintosh on the accessible side of the bed.
4. Place mackintosh or paper under the pail to protect the floor
5. Elevate head of the bed it pt is conscious and the condition permits. But if unconscious, place in prone position with head over the edge of the bed or head lower than the body.
6. Measure the tube from the tip of the nose up to the ear lobe and from the bridge of the nose to the end of the sternum. (32 - 36 c.m.)
7. Gently pass the tube over the tongue, slightly to one side of the midline towards the pharynx. (If patient is unconscious, mouth gug may be used)
8. Ask patient to swallow while inserting the tube and allow to breath in between swallowing.
9. If air bubbles, cough and cyanosis are noticed the tube is with drawn and procedure commenced again.
10. After inserting, place funnel end in a basin of water to check if the tube is in the air passage.
11. Fill the small pint measure and power gently until the funnel is empty, then invert over the pail.
12. Take specimen. If required, and continue the process until the returned fluid becomes clear and the prescribed solution has been used.
13. Remove tube gently and give mouth wash
14. Measure the amount of fluid returned and record
15. Report and abnormality e.g. blood stain or clots or pieces of the gut.
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Elimation of Gastrointestinal and Uninary Outputs

Learning Objective
At completion of the unit the learner will be able to:
• Define enema.
• List purposes of gastric aspiration, lavage, enema and catheterization.
• Mention types of enema.
• Provide enema according to its purpose and need.
• Explain mechanism of action of fluids used for enema.
• Explain purpose of catheterization.
• Identify different types of catheters.
• Describe indication of catheterization.
• Demonstrate sterility technique through out the catheterization.
• Intervene the procedure for those in need of it with understanding of both male and female catheterization.
• Identify important precautions of the procedure.

Key Terminology
anuria dysuria       melena projectile vomiting
consitipation enema       micturation          urgency
cystitis        fecal impaction  nocturia urinary  catheter
defecation flatus oliguria urinary frequency
diarrhea         incontinenece polyuria urinary retention
voiding vomitus
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