URINARY CATHETERIZATION

• Introduction of a catheter through the TYPES AND SIZES OF CATHETER

urethra into the urinary bladder to drain • Urethral catheters are commonly made
out urine. of rubber or plastics although they may
• It is an aseptic procedure for which sterile be made from latex, silicone or polyvinyl
equipment is required. chloride (PVC).
INDICATIONS: • They are sized by the diameter of the
lumen using the French (Fr) scale: the
1. DIAGNOSTIC higher the number; the larger the lumen.
2. THERAPEUTIC • The size to be used is determined
primarily by the age of the patient.
I. DIAGNOSTIC INDICATIONS • The type of urethral catheter indicated is
• Collection of uncontaminated urine determined by the condition of the
specimen. patient.
• Urine output monitoring • When too small catheter is used, the
• Imaging of the urinary tract urine may leak around the catheter and
II. THERAPEUTIC INDICATIONS the diuresis estimation can be
underestimated.
Acute urinary retention
• When too large catheter is used, it may
• Chronic obstruction that causes
irritate or even injure the sensitive
hydronephrosis
urethral mucosa.
• Initiation of continuous bladder
irrigation.
AGE/ CONDITION URETHRAL
• Intermittent decompression for
CATHETER
neurogenic bladder.
• Hygienic care for bedridden Adults Foley catheter (Fr
patients 16-18)
Adult males with Coude catheter (Fr
CONTRAINDICATIONS: prostate 18)
• Patients with any kind of traumatic injury obstruction
in the lower urinary tract. Adult with gross Foley catheter (Fr
hematuria 20-30) or 3 way
EQUIPMENT: irrigation catheter
(Fr 20-30)
• Povidone- iodine
• Sterile cotton balls CHILD’S AGE SIZE (Fr)
• Water soluble lubrication gel GROUP
• Sterile drapes Newborn 4-6
• Sterile forceps Infants 6-8
• Sterile gloves
Pre- pubertal 10-12
• Urethral catheter children
• Pre-filled 10 ml saline syringe
adolescent 14
• Collection bag
• Lidocaine gel 2%
 CHILD’S BODY SIZE (Fr) • Smaller lumen is used to inflate a
WEIGHT balloon near tip of the catheter to hold
Newborn (3-5 kg) 5-8 the catheter in place within the
bladder.
Infants (6-9 kg) 5-8
Toddler (10-11 kg) 8-10
Small child (12-14 10
kg)
Child (15-18 kg) 10-12
Child (19-22 kg) 10-12
Large child (24-30 12
kg)
FOLEY CATHETER (3-WAY)
• Indicated for patients who require
TYPES OF CATHETER: continuous or intermittent bladder
irrigation.
1. Intermittent catheter
2. Condom catheter • Third lumen is through which sterile
irrigation fluid can flow into the bladder;
3. Indwelling/ Retention catheter
fluid then exits the bladder through the
STRAIGHT CATHETER drainage lumen, along with the urine.
• Single lumen tube with a small eye or
opening from the insertion tip

CONDOM CATHETER
• Also called urinary sheath or external COUDE TIP CATHETER
catheter
• More rigid and has a tapered, curved tip.
• Used for men with BPH because it is
more easily controlled and less
traumatic on insertion.

FOLEY CATHETER (2- WAY)

➢ DOUBLE LUMEN CATHETER
• Larger lumen drains urine from bladder.
 to verify the presence of urine in the
STEP PROCEDURE: bladder).
15. After visualization of urine flow (and
1. Verify doctor’s order. while the proximal ports are at the level
2. Explain the procedure, benefits, risks and of the meatus), inflate the distal balloon
complications and alternatives to the by injection 5-10 ml of sterile water.
patient or significant other. 16. Gently withdraw the catheter from the
3. Do proper hand washing. urethra until resistance is met. Secure
4. Prepare all the materials needed. the catheter.
5. Put all the materials in a tray lined with 17. Establish effective drainage
linen. 18. Discard all supplies in appropriate
6. Place the patient in receptable and wash hands.
appropriate position. 19. Document the procedure.
• Male: supine, thighs slightly
abducted, knees slightly flexed.
• Female: supine with knees flexed, feet
about 2 ft apart, hip slightly externally
rotated.
7. Don the sterile gloves PRIMING IV TUBING
8. Connect the urethral catheter to the PURPOSE OF IV INFUSION:
urine bag
• To provide patient with fluid when
For male patients:
adequate fluid intake cannot be achieved
9. Use non- dominant hand to hold the through oral route.
penis and retract the foreskin (if • When the patient is unable to swallow,
present). e.g. unconscious patient.
10. Use the sterile hand and sterile forceps • When it is undesirable for the patient to
to prep the urethral orifice and glans in take fluids or food by mouth, e.g.
circular motions. postoperative patients.
11. Using a syringe with no needle, instill 510 • To keep the vein open for administration
ml of lidocaine gel 2% into the urethra. of drugs or when waiting for blood
12. Hold the coiled catheter with the sterile transfusion
(dominant) hand and apply generous • To maintain and correct electrolytes of
amount of water soluble lubricant at the the body when the patient is losing fluids
catheter tip. or salts in excess like is persistent
13. Ask the client to take a deep breath and diarrhea and vomiting in severe burns.
slowly and gently introduce the catheter
into the urethra, as the client exhales.
Continue to advance the catheter until PERIPHERAL IV lines inserted in patients to
the proximal Y-shaped ports are the help administer medications, blood products,
meatus. and fluids. They are really an essential device
14. Wait for the urine to drain from the used in the hospitalized patient.
larger port to ensure that the distal end PERIPHERAL IV lines are removed or
of the catheter is in the urethra. If urine discontinued when they need to be changed
return is not visible, withdraw the (about every 3 days, depending on the
catheter and reattempt the procedure hospitals protocols) or when the patient is
(preferably after using ultrasonography being discharged.
 with cover, sterile 2x2 gauze
NOTE: always follow your hospitals or transparent dressing).
protocols for the latest skill guidelines for these 6. Check the sterility and integrity of IV
may change overtime. In addition, make sure solution, IV set and other devices.
you have the proper certification before
7. Place IV label on IV fluid bottle duly
attempting any nursing skill.
signed by the RN who prepared it:
patient’s name, room number,
solution, drug incorporation (if any),
bottle sequence, duration, time and
date.

Part B: Priming IV tubing

1. Perform hand hygiene

2. Open and prepare the infusion set:
Remove tubing from the container and
straighten it out
3. Slide the tubing clamp along the tubing
until it is just below the drip chamber to
facilities its access.
4. Close the clamp
5. Leave the ends of the tubing covered with
the plastic caps.
6. Spike the solution container:
a. Remove the protective cover from
the entry site of the bag.
PROCEDURES:
b. Remove the cap from the spike
PART A: PREPARATION c. Insert the spike into the insertion
site of the bag of bottle.
1. Verify written prescription and make
7. Hang the solution container on the pole.
IV label.
Adjust the pole so that the container is
2. Observe 10 Rs when preparing and suspended about I meter (3 ft.) above the
administering IV fluid. client’s head
3. Explain procedure to reassure patient 8. Partially fill the drip chamber with
and/ or significant others. Secure solution by squeezing the chamber gently
consent if necessary. until it is half full of the solution.
4. Perform hand hygiene.
5. Prepare necessary 9. Prime the tubing:
materials for procedure: a. Remove the protective cap (of the
IV tray with tubing) and hold the tubing over a
solution, administration set; container maintaining sterility of
(materials for inserting tubing and cap.
IV fluid; IV cannula, b. Release the clamp and let the fluid
forceps soaked in antiseptic run through the tubing until all
solution, alcohol swabs bubbles are removed.
or cotton balls soaked in alcohol
 c. Re-clamp the tubing and replace the
tubing cap, maintaining sterile
technique.

Removing a peripheral IV Line

Materials needed:
• Gauze Tape
• Gloves

STEP PROCEDURES:

• 1st, gather the supplies, perform hand

hygiene, and don gloves.
• Next, carefully loosen the surrounding
tape and tegaderm surrounding the IV
insertion site
• Once the tegaderm and tape loose,
take the gauze and place over the IV
insertion site. Then the one smooth motion
pull out the IV cannula. It should slide
out with ease and very quickly.
• Next, apply firm pressure with the
gauze on the insertion site. Be sure to
apply firm pressure to prevent the
seepage of blood under the tissues,
which will lead to bruising. This needs
to be performed for at least 2 mins. (or
longer if the patient is taking
anticoagulants.)
• After the allotted time has passed,
check the site and confirm it has
stopped bleeding and secure the site
with gauze and tape
• Assess the removed IV cannula to
confirm it is fully intact, discard it per
facilities guidelines, doff gloves,
perform hand hygiene, and document.
FLUID VOLUME IMBALANCES MANIFESTATION:
1. Fluid Volume Deficit/ HYPOVOLEMIA • Dry mucous membrane
2. Fluid Volume Excess • Early sign (increased heart rate)
a. Hypertonic Overload • Hypotension (orthostatic)
b. Hypotonic Overload- Water • Young babies: fontanelles sink
Intoxication • Decreased skin turgor
c. Isotonic Overload- Hypervolemia • Refill to capillaries sluggish
3. Alterations in Interstitial Fluid/ Third • Attitude changes
space shift/ EDEMA • Thirsty
• Experience weight loss
FLUID VOLUME DEFICIT: • Diagnostics
A. Water is lost extracellularly or increased
extracellular components (ex. Increase NURSING MANAGEMENT OF
glucose in the blood)
B. Water moves from the ICF to the ECF FLUID VOLUME DEFICIT
• Ex. Poor skin turgor, dry skin and • Measure all fluid that enter and leave
mucous membrane the body
C. Equalizes osmolality of ECG and ICF (but • Check electrolytes, CBC, and urine
osmolality remains abnormal) though specific gravity.
fluid volume remains reduced. • Assess for hypotension and weak
a) Increased serum osmolality pulses.
• Increase hematocrit • Assess respiratory system and tissue
• Increase BUN perfusion.
b) Decreased vascular volume • Check orientation, vision, hearing,
• Decrease CO reflexes and muscle strength.
a. Tachycardia, increase • Check for weight changes
BP then decrease BP • Check for skin breakdown and good oral
postural hypotension, care.
weak, thread pulse Laboratory Values
c) Stimulation of the thirst • Hematocrit (hct)
mechanism (unless impaired) and a. Male (39% - 49%)
the anterior and posterior b. Female (35% - 45%)
pituitary gland by the • Urine specific gravity
hypothalamus. a. 1/010 – 1/020
a) Increase thirst • Osmolality
b) Secretion of ADH and a. 285 – 295 mOsm.kg of water
aldosterone b. 285 – 295 mmol/kg
• Increase sodium and
water reabsorption To replace water and electrolytes- goal
• Decreased urine of treatment
output 1. Find the cause and treat the
• Increase urine cause
osmolality; increase 2. Hydration
urine specific gravity • Oral rehydration (except tea
and coffee)
 • IV Fluid- isotonic, but can used RESPIRATORY:
other types of fluid depending • In severe cases, pulmonary edema can
on the types of dehydration occur
• Shortness of breath/ difficulty of
FLUID VOLUME EXCESS breathing
A. There is increased water extracellularly • Crackles
• Dilutional hyponatremia (unless it
PERIPHERAL:
is caused or accompanied by
• Abdomen can be swollen (ascites)
increase sodium.)
• Nausea
• Increased vascular/ plasma volume
a. Increased hydrostatic pressure • Weight gain
• 1kg (2.2 lbs) = roughly 1 liter of fluid
• Fluid shifts from the
intravascular to the • Swelling/ edema in upper and lower
interstitial space extremities
• Pitting edema in the • Edema may pit
extremities, puffy eyelids, • Skin cool to touch
cerebral edema
(especially in water
intoxication) LABORATORIES AND
b. Increased LVEDP and LAP DIAGNOSTICS
• Increased PCWP
• Pulmonary edema • The patient has a lot of fluid in their
• Dyspnea, cough, rales, body.
shortness of breath • This will dilute and decrease certain labs.
c. > full and bounding pulse and • REMEMBER: everything will be Dilute
> venous distention and Decreased.

SIGNS AND SYMPTOMS

NURSING INTERVENTIONS:
NEURO: • Diuretics
• Monitor for brain swelling, which can
• Restrict fluids/ sodium
lead to mental status changes/
• Assess daily weight
confusion.
• Intake/ output strict measurements
• Patient can experience pressure/
• Na+ levels monitored with other
headache.
electrolytes.
CARDIOVASCULAR:
• Strong, bounding pulse
• High blood pressure/ hypertension
• Jugular venous distention (JVD)
• Sinus tachycardia
EKG/ ECG (NON-INVASIVE) Find and mark correct lead placements
Electrocardiogram for the 12 lead ECG.
- graphic record produced by
electrocardiograph.
Electrocardiograph
- a device used for recording the
electrical activity of the
myocardium by placing leads to
certain points in the chest region.
Electrocardiography
- study of records of electric activity
generated by the heart muscles.

Sinus rhythm
small box-0.04 sec.
big box- 0.20 sec.
V1 Remind
V2 Your
V3 Good
V4 Boyfriend
V5 Before
V6 Valentines

PLACEMENT OF 4 LEAD WIRES

P wave- atrial depolarization (activity

of right ventricle)
- block - Contraction
Q, R, S wave- ventricular
depolarization
- actual heart rate
T wave- ventricular repolarization
- Relaxation
- if T is high, hyperkalemia R – marcos died (red & black)
- (U) if T is low, hypokalemia L – aquino ries (yellow & green)
asystole – no more heartbeat
 BLOOD TRANSFUSION thaw. 1 unit= coagulopathy,
150-250 ml clotting factor
replacement.
TYPE (ABO/Rh) Can receive blood 5% Precipitate Plasma volume
from: ALBUMIN from plasma expanders in
O+ O (+/-) OR 5% acute blood
O- O (-) PLASMA loss.
A+ A(+/-) or O (+/-) PROTEIN
FRACTION
A- A(-) or O(-)
To be transfused in 4-6 hours (or else
B+ B(+/-) or O (+/-) mabangles)
B- B(-) or O(-)
AB+ AB, A, B or O (all Isotonic solutions – blood transfusion
+/-) (GOODS)
AB- AB, A, B or O (all –) Hypertonic – shrinkage
Hypotonic – swelling/edema

PRODUCT DESCRIPTION INDICATIONS Cross matching to check for compatibility

1 unit = 450 ml Acute massive BT set – 15 gtts
FRESH contains RBC, bleeding, open
WHOLE WBC, Platelets heart surgery,
BLOOD - and Plasma neonatal total TRANSFUSION REACTIONS
FWB exchange
(dark red) • Sudden fever
PACKED 1 pack = 250 • Diaphoresis
RBC – PRBC cc • Chills
1 “pack” Active • Hypersensitivity Reactions (hives,
should raise bleeding, wheezing, pruritus)
PLATELETS count by 5- contiguous • Tachycardia
(straw 8000. petechiae • Hypotension
colored) 1 pack= about • Headache
50 ml • Backache
Most WBC Potential renal • Shock
removed to transplant,
LEUKOCYTE- make it less previous
TREATMENT FOR TRANSFUSION REACTION
POOR RED antigenic 1 febrile
CELLS unit = 200-250 transfusion
ml reaction, • STOP!!! The blood product transfusion
leukemia. ASAP!
WBC almost As for • Keep IV line (PNSS) open and monitor V/S
completely leukocyte-poor and urine output carefully
WASHED removed 1 red cells but • Save the blood bag, have the lab verify
RBC unit= 300 ml. very expensive the type and cross-match.
and much • In mild febrile transfusion reactions
more purified. antipyretics can be used
Contains Emergency • With urticarial reactions dipenhydramine
Factors II, VII, reversal of (Benadry) should be given.
FRESH IX, X, XI; labile warfarin
FROZEN V and VII. (Coumadin),
PLASMA About 1 hr to suspected