bladder function

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bladder function


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Urinary Catheterization : 

Urinary Catheterization Presented by :Bassim Odeh

Anatomy and Physiology : 

Anatomy and Physiology

Bladder - Anatomy : 

Bladder - Anatomy

Neuroanatomy of Voiding : 

Neuroanatomy of Voiding

Neuroanatomy of Voiding : 

Neuroanatomy of Voiding Frontal lobe Micturition center Sends inhibitory signals Pons (Pontine Micturition Center) Major relay/excitatory center Coordinates urinary sphincters and the bladder Affected by emotions Spinal cord Intermediary between upper and lower control

Peripheral Nervous System : 

Peripheral Nervous System Somatic (S2-S4) Pudendal nerves Excitatory to external sphincter Parasympathetic (S2-S4) Pelvic nerves Excitatory to bladder, relaxes sphincter Sympathetic (T10-L2) Hypogastric nerves to pelvic ganglia Inhibitory to bladder body, excitatory to bladder base/urethra

Normal Voiding : 

Normal Voiding SNS primarily controls bladder and the IUS Bladder increases capacity but not pressure Internal urinary sphincter to remain tightly closed Parasympathetic stimulation inhibited PNS Immediately prior to PNS stimulation, SNS is suppressed Stimulates detrusor to contract Pudendal nerve is inhibited  external sphincter opens  facilitation of voluntary urination

Innervations of the Lower Urinary Tract : 

Innervations of the Lower Urinary Tract Function Balance between suprasacral modulating pathways, sacral cord and the pelvic floor Emptying phase: “Voiding Reflex” Series of coordinated events involving outlet relaxation, detrusor contraction Storage phase: “Guarding reflexes” constant afferent input to maintain continence

Bladder Dysfunction : 

Bladder Dysfunction

Functional Classification : 

Functional Classification Failure to store Because of bladder Because of outlet Failure to empty Because of bladder Because of outlet Combination

Pathophysiology of Voiding : 

Pathophysiology of Voiding Brain lesion above pons destroys master control center Ex – stroke, brain tumor, hydrocephalus, CP…. Result – urge incontinence, night incontinence, coordinated sphincter Spinal cord lesion, myelomeningocele, MS Detrusor hyperreflexia Spastic bladder Areflexic bladder

Pathophysiology of Voiding : 

Pathophysiology of Voiding Lumbosacral spinal lesion Ex – spinal tumor, sacral SCI, herniated disc, lumbar laminectomy, radical hysterectomy, pelvic trauma Result – areflexic bladder Peripheral nerve injury Ex – AIDS, diabetes, polio, Result – urinary retention

Medication Options : 

Medication Options

Bladder Management Options : 

Bladder Management Options

Management Options : 

Management Options

Management Options : 

Management Options

Management Options : 

Management Options

Electrical Stimulation : 

Electrical Stimulation

Bladder Augmentation : 

Bladder Augmentation Procedure that increases bladder capacity using intestinal segments Ileum, colon, or stomach are used Goals Decreasing intravesicle pressure Restore urinary continence Preserve upper urinary tracts by alleviating reflux and hydronephrosis Can combine with a continent abdominal stoma Consider in patients with Intractable involuntary bladder contractions causing incontinence Patients who are able and motivated to perform CIC Reflex voiders wishing to convert to CIC Females with paraplegia

Urinary Diversion : 

Urinary Diversion Diverts the urine flow from the bladder Secondary form of bladder management when primary methods have failed Ureters transected just above the bladder and connected to a segment of intestine (terminal ileum) which is in turn brought to the skin of the lower abdominal wall External appliance used as collection device Considered if: Lower urinary complications secondary to indwelling catheters Urethrocutaneous fistulas, perineal decubitus ulcers Urethral destruction in females Hydronephrosis secondary to a thickened bladder wall and for hydronephrosis secondary to vesicoureteral reflux or failed reimplant. Bladder malignancy requiring cystectomy

Recommendations : 


Recommendations : 

Recommendations Recommendation 1: Intermittent catheterization is the preferable method for bladder emptying for men and women who have adequate hand function or a willing caregiver to perform the catheterization and have bladders that do not empty adequately. Recommendation 2: Intermittent catheterization should be ideally performed every 4 to 6 hours to keep bladder volumes below 400ccs.

Recommendations from the PVA Guidelines : 

Recommendations from the PVA Guidelines Recommendation 5: Consider sterile catheterization for those individuals with recurrent symptomatic infections occurring with clean intermittent catheterization. Rationale: Lower infection rates can be achieved with sterile techniques and with pre-lubricated self contained catheter sets

Recommendations from the PVA Guidelines : 

Recommendations from the PVA Guidelines Recommendation 5: Risk of symptomatic infection is at least comparable and may be less in individuals with indwelling catheters than those managing their bladders with clean intermittent catheterization.

Recommendations from the PVA Guidelines : 

Recommendations from the PVA Guidelines Recommendation 6: Patient should be advised of long-term complications of indwelling catheterization, including: Bladder stones Kidney stones Urethral erosions Bladder cancer Epididymitis Recurrent symptomatic urinary tract infections

Genitourinary Assessment of Function : 

Genitourinary Assessment of Function

Assessment of Function : 

Assessment of Function U/a and c & s BUN & Cr if compromised renal function is suspected Postvoid residual urine If high, the bladder may be contractile or the bladder outlet may be obstructed

Renal/Bladder US : 

Renal/Bladder US Advantages Simple Eval kidney, parenchymal loss, abnl echogenicity Eval for hydronephrosis, stones Disadvantages Low sensitivity for small stones Ureters not evaluated well Mainstay of screening in many institutions

Nuclear Renal Scan : 

Nuclear Renal Scan Advantages Functional info No nephrotoxic reactions Low radiation Disadvantage Less anatomic info Cannot detect stones

KUB : 

KUB Historically, routinely used to detect renal and bladder stones Disadvantages Poorly sensitive to stones “KUB not justified in routine f/u of urinary tract in SCI” Tins et al. Spinal Cord 2005

Secondary Conditions : 

Secondary Conditions Increased risk of Bladder infection Kidney infection Hydronephrosis Urethral trauma/laxity

Urinary Stones and SCI : 

Urinary Stones and SCI Higher incidence, especially in first 6 mos 3-6% upper tract 11-15% bladder Etiology Stasis Calcium metabolism Infection Diagnosis CT is gold standard

No Indwelling Catheter For You! : 

No Indwelling Catheter For You!

Ultimately, we do what is right for each of our patients,just like we would treat our own family : 

Ultimately, we do what is right for each of our patients,just like we would treat our own family

UTI : 

UTI Indications to treat - No catheter & three of the following present… Fever (increase in temp >2 degrees F (1.1 degrees C) or rectal temperature >99.5 degrees F (37.5 degrees C) or single measurement of temperature >100 degrees F (37.8 degrees C) );14 New or increased burning pain on urination, frequency or urgency; New flank or suprapubic pain or tenderness; Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or Worsening of mental or functional status (e.g., confusion, decreased appetite, unexplained falls, incontinence of recent onset, lethargy, decreased activity).

UTI : 

UTI Indications to treat – w/ catheter & two of the following Fever or chills; New flank pain or suprapubic pain or tenderness; Change in character of urine (e.g., new bloody urine, foul smell, or amount of sediment) or as reported by the laboratory (new pyuria or microscopic hematuria); and/or Worsening of mental or functional status. Local findings such as obstruction, leakage, or mucosal trauma (hematuria) may also be present.

UTI Follow up : 

UTI Follow up Recurrent UTIs Predisposing Factors structural abnormalities - a referral to a urologist poor perineal hygiene PRIMARY - reconsider the relative risks and benefits of continuing the use of an indwelling catheter.

Neurogenic Bladder : 

Neurogenic Bladder What is a neurogenic bladder? A medical term for overflow incontinence, secondary to a neurologic problem However, this is NOT a type of urinary incontinence

Urinary Catherization : 

Urinary Catherization Equipment: Straight catheters Box of supplies: foley, 3 way foley, cath kits with sterile gloves, drainage bags with urin Bag, Drape and towel Tape Skin so soft lubricant Overbed table Good lighting

Slide 43: 

Complication of catheterization 1. Infection- (primary cause) 2. Uretheral tares 3. Ruptured bladder 4. Bladder spasm 5. Possible allergic reaction to tape or latex

Urinary Catherization : 

Urinary Catherization Purposes of catherization: 1. Relief of discomfort due to bladder distention 2. Assess amount of residual urine 3. Obtain a urine specimen 4. Empty bladder prior to procedure 5. Manage incontinence 6. Provide for bladder irrigation 7. Prevent urine coming in contact with wound 8.facilitate accurate measurement of output in critically ill clients 9. Self catherization for management of neurogenic bladder

Slide 45: 

Types of Equipment: Catheters 1. Sizes – range from 8 to 18 French indicates diameter. 2. Types a. Straight- single use for intermittent catherization ; has 1 opening b. Foley- inflatable balloon (5cc-30cc), known as indwelling or retention catheters, has 2 openings c. Continuous catheter-3 openings or lumens (1 to drain urine, 1 for filling balloon, and 1 for irrigation), used for periodic or continuous bladder irrigation d. Coude’- curved tip, used on male clients with enlarged prostates or for obstruction

Slide 46: 

e. Suprapubic-inserted through abdominal wall over suprapubic bone and into bladder . f. Condom catheter- used for incontinence, also known as a sheath or Texas catheter (pg1098) Drainage Bags: 1. Regular 2. Urometer 3. Leg bag Psychological Implications Maintain privacy Anxiety- need for explainition

Slide 47: 

Cultural Considerations Gender. Explain the procedure to client Meticulous hygiene observed (Muslims use left hand for unclean procedures) Strict Sterile procedure need to be observed

Slide 48: 

A. In and Out Catherization (no ballon) 1. After client voids, I&O cath to determine amount of residual urine after a foley catheter has been removed 2. Use straight catheter 3. If over 200 cc obtained then physician may order retention catheter (foley catheter) B. Indwelling catherization (Foley) has ballon 1. Need for extra lighting 2. Follow procedure as outlined during practice 3. Discuss taping for male and female- pressure on penile- scrotal angle can lead to necrosis 4. Collection of specimen from port on drainage bag tubing 5. If getting no urine, insert catheter a little more 6. After getting urine, insert catheter another inch

Slide 49: 

7. Catheter care- once every 8 hours as outlined by policy (peri-care with soap, water, rinse- for uncircumsized males remember to pull back foreskin for cleaning and return to previous position) 8. Encourage fluid intake 2000cc-3000cc per day ( if not on fluid restriction) in order to maintain catheter patency 9. Removal of indwelling catheter- clean gloves, towel, chux, and syringe to accommodate removal of saline in balloon ( never cut)- instruct client to bear down. Note amount of voiding & time after removal of catheter. 10. Equipment changes- foleys should be changed every 10 to 30 days in order to prevent bladder neck necrosis- change bags as needed.

Slide 50: 

Documentation Size of catheter and balloon Amount ,color, odor and consistency of urine How client tolerated procedure

Slide 51: 

Complications Infection a. Most common b. Sources- identify sites on catheter system 2. Uretheral Trauma 1. Not frequent 2. After catheter removal edema may interfere with urine flow. Obstructed catheter 1. Medications- some may cause precipitation of uric acid crystals 2. Clots- post prostatecomy. May run CBI at a rate so as to reduce clots 3. Tubing kinked- reposition client

Slide 52: 

Bladder Irrigation Open- disconnect catheter from drainage bag and instill irrigating solution or medication (pg 1096) Closed intermittent- need to clamp drainage tubing below port and instill irrigant through port Closed Continuous (CBI)- use 3 way foley catheter, hang irrigating solution on IV pole ( usually NSS for post prostatecomy clients) and adjust flow rate; if catheter clogs during CBI, no drainage will flow but irrigation will continue to run in; How to calculate true urine output- subtract amount of irrigation which has infused from the amount of drainage from the catheter= urine output. (pg 1095)

Slide 53: 

Self catherization Indication: Spinal cord injury- neurogenic bladder Procedure: Knowledge of clean versus sterile Knowledge of anatomy and physiology Children can be taught as young as 6 years Performed every 6-8 hours Controlled fluid intake regimen May reuse catheter if washed and bagged properly

Slide 54: 

Things to Remember 1. Know signs of dehydration and fluid overload 2. Usual output is 30cc/hour;if acutely ill need to measure more frequently 3. Measure output every 8 hours or more if needed 4. Encourage fluid intake of 2000ml/day if not restricted 5. Check most recent serum electrolyte 6. Foley of males to tape on abdomen; females to legs 7. When taping provide slack to more around in bed 8. Foley drainage bag below level of bladder and OFF FLOOR 9. Make sure cleanse uncircumcised males before insertion of catheter 10. Check allergies of client relating to tape, latex, l lubricant, Betadine, shell fish

Slide 55: 

11. Do not drain more than 500 to 1000 cc at one 12. Do Catheter care daily on all clients who have foley catheters 13. Make sure catheter tubing does not kink 15. When aspirating the balloon, if the balloon says 5cc there maybe 10cc in the balloon 16. Check old adults for atypical signs and symptoms of UTI 17. If client is unable to void 6-8 hrs after catheter removal notify MD

Slide 56: 

18. If client voiding around catheter may to have a larger catheter 19 NEVER cut the tubing on the balloon to remove a foley catheter 20 NEVER force the catheter in a child if met resistance wait 20 seconds until sphincter relaxes and then try again 21. If patient has a foley for a long period of time, may have to retrain bladder, this is sometimes done with orthopedic trauma patients 22. Patients who have long term use of foley’s are prone to kidney stones because of small amounts of fluid intake

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