BSN205 Hallmark- Urinary Catheterization ISB
A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The health care provider has ordered that the patient be catheterized. Which of the following would be an appropriate-size catheter for this patient?
16 French, 5-mL balloon -The 16 French, 5-mL balloon is an appropriate catheter for an adult male who has never had prostate surgery. The 8 French, 3-mL balloon is a pediatric-size urinary catheter. The 12 French, 5-mL balloon is an appropriate-size catheter for an elderly adult female. The 16 French, 30 mL balloon is an appropriate-size catheter for an adult male who had prostate surgery.
A 68-year-old female patient is admitted for knee replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The health care provider has ordered an indwelling catheter to be inserted preoperatively. Which catheter should the nurse choose?
14 French, 5-mL balloon, latex catheter. -Most adults require a 14 to 16 French catheter; it is usually best to begin with the smaller size. A 5-mL balloon is a common size balloon for the adult. Latex and rubber catheters are recommended for use up to 3 weeks. A Coude (elbowed/curved) catheter is often used for men with prostatic hypertrophy. The 8 French, 3-mL balloon, latex catheter is a pediatric catheter. A 30 mL balloon is for continuous bladder irrigation (CBI).
If a patient's indwelling catheter is removed at 0900, the patient should be due to void by:
1500 to 1700 (3:00 PM to 5:00 PM) -The patient should be due to void in 6 to 8 hours, or by 3:00 to 5:00 PM. If the patient fails to void, nursing measures should be taken (i.e., assess for bladder fullness, provide privacy, assist to normal voiding position, run water). If unsuccessful, the health care provider should be notified.
A nurse is performing preoperative teaching for a patient who is having urological surgery. The nurse informs the patient he will likely require closed bladder irrigation following the surgery. The patient asks what the purpose is for bladder irrigation. What would be a correct response by the nurse?
"Bladder irrigation may be used to instill medication into the bladder." "Irrigating the bladder prevents any clots or sediment from blocking urinary drainage." -Bladder irrigation may be performed to instill medication (usually done as an intermittent irrigation) into the bladder, or to provide a continuous flow to prevent clot formation. Both intermittent and continuous bladder irrigation may be used to maintain patency for urinary drainage.
The nurse is reviewing how to perform a bladder scan for determining postvoid residual (PVR) with nursing assistive personnel (NAP). Which of the following statements, if made by the NAP, indicates understanding?
"I will measure and record the patient's intake and output." "I will apply ultrasound gel above the patient's symphysis pubis." "I should point the scanner head downward toward the bladder." -The NAP should measure and record intake and output (I&O) so urine trends can be assessed. Ultrasound gel is spread on the midline abdomen 2.5 to 4 cm (1 to 1.5 inches) above the symphysis pubis and light pressure is applied to the scanner head as it is pointed in a direction downward toward the bladder (following manufacturer's directions). The patient is instructed to empty the bladder before the scan. There is no restriction in fluid intake for a bladder scan.
The nurse is reviewing urinary catheter care with a newly hired nursing assistive personnel (NAP). Which statement made by the NAP indicates further instruction is needed?
"The bedside drainage bag should only be emptied when it is full." The bedside drainage bag should be emptied when two-thirds full, or at least once every 8 hours. Clean technique is used to perform catheter care, and sterile gloves are unnecessary. Moving the securement device prevents the skin from becoming irritated. After reviewing the signs of infection, characteristics of normal urine, and the proper procedure, this task can be delegated to NAP and/or family members.
The nursing instructor is reviewing the renal system and urinary catheterization with her students. Which statement, if made by a nursing student, indicates that further instruction is needed?
"The nurse may use clean technique to insert an indwelling catheter." -Sterile technique is used whether inserting a straight or indwelling urinary catheter. Patients may use clean insertion technique in the home setting for intermittent catheterization. When the patient is in an acute care or long-term care setting, sterile insertion technique is required because of the high risk for nosocomial infections. The urinary tract is sterile. The desire to urinate can be sensed when the bladder contains a smaller amount of urine (150 to 200 mL in an adult and 50 to 100 mL in a child). Minimum average hourly output is 30 mL.
The NAP is applying a condom catheter to the patient. The patient asks, "What is the purpose of the skin preparation solution?" The NAP correctly responds:
"The skin preparation solution prevents skin irritation and should be dry before the condom catheter is applied."
A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for the nurse to give the patient?
"This is a normal occurrence after having a catheter in place for more than several days." -If the catheter was in place for more than several days, the patient may experience dysuria (painful voiding) resulting from inflammation of the urethral canal. Because of decreased bladder muscle tone, the patient may urinate frequently. These symptoms should subside with time.
A patient returned from urological surgery with closed continuous bladder irrigation. The patient's vital signs are within normal limits. The patient's wife voices concern regarding the "bloody-red" appearance of the drainage. What is the nurse's best response?
"This is normal at this time; the drainage will become lighter and appear blood tinged in 2 to 3 days." -It is most appropriate for the nurse to provide the patient and family caregiver information of what is expected at this time in the patient's recovery. Urine will be bloody following bladder/urethral surgery, gradually becoming lighter and blood tinged in 2 to 3 days. It is nontherapeutic to tell the family caregiver not to worry. Although the drainage is more than blood, telling the patient or family caregiver this does not educate them on what to expect and therefore is not the best response. If the drainage had been bright red and the patient was showing signs of hypovolemic shock (decreased blood pressure, increased pulse), the nurse would need to increase the continuous bladder irrigation (CBI) to a wide open rate and notify the health care provider.
The patient is to have intermittent irrigation of a double-lumen urinary catheter. The patient asks why the nurse is kinking the drainage tubing and putting a rubber band on it. What is the nurse's best response?
"This prevents the irrigating solution from going down into your drainage bag rather than into your bladder." -Occluding the catheter tubing below the point of injection allows the irrigating solution to enter the catheter and flow into the bladder. Clamping the drainage tube is not done as prevention of air or bacteria from entering the bladder. There is no strong evidence that clamping the drainage tube (i.e., "bladder training") will aid in preventing urinary incontinence once an indwelling catheter is removed; there is no mention of the catheter being removed.
A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is the nurse's best response?
"What medications are you taking and when?" -The nurse should first assess the patient's medication history before making any interpretation. The patient may be taking diuretics before going to bed or taking other medications that can change the urine's color.
The nurse works on a surgical unit. For which of the following patients would a nurse expect to perform a bladder scan?
A patient who had an indwelling urinary catheter removed 8 hours ago and voided 30 mL once since it was removed. A patient who complains she is having urinary incontinence and never had this problem before. A patient who is postoperative for urological surgery. -A bladder scanner is used to assess bladder volume whenever inadequate bladder emptying is suspected, such as after the removal of indwelling urinary catheters, in the evaluation of new-onset urinary incontinence, and after urological surgery. Diuretic therapy is not an indication for a bladder scan. A change in urine color requires further assessment because it may be due to a change in medicine, or it could be due to hematuria, but it is not an indication of inadequate bladder emptying.
Four patients had a bladder scan for PVR. For which of the following patients would further investigation be required?
A patient with PVR measurements of 125 mL and 150 mL. -A PVR volume of less than 50 mL is considered normal. Two or more PVR measurements greater than 100 mL require investigation. It would be an expected finding for a PVR volume to be less than the prescan void. Prescan volume is the amount of urine the patient voids attempting to empty the bladder completely before having a PVR measured by either bladder scan or straight catheterization.
Which of the following could be considered negligence?
A regular condom catheter is removed every 3 days.
As part of catheter insertion assessment, where should the nurse palpate?
Above the symphysis pubis. -When empty, the bladder is difficult to locate and palpate; if it is full, it may be palpated as a dome-shaped structure above the symphysis pubis. If the bladder is severely distended, it may extend into the abdomen. The costovertebral angle is formed by the last rib and vertebral column and is a landmark used during kidney palpation. Palpating the kidneys is unrelated to bladder fullness. The nurse may use percussion starting at the right iliac crest and move upward along the miclavicular line to determine the size of the liver. Liver size is unrelated to bladder fullness. The area of the umbilicus is located between the xyphoid process and sumphysis pubis.
A nurse inserting an indwelling urinary catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take?
Advance catheter another 1 to 2 inches and inflate balloon. -The female urethra is short. The appearance of urine indicates that the catheter tip is in the bladder. Advancement of the catheter ensures that the inflation balloon is in the bladder and not the urethra. The nurse pulls back gently on the catheter after the balloon is inflated. The nurse may ask the patient to bear down as if to void when initially inserting the catheter; this maneuver relaxes the external urethral sphincter.
Which of the following are true regarding the impact of aging related to urinary elimination?
Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone. The elderly are at increased risk for urinary tract infection because of retained urine in the bladder. -The very young and very old are less able to concentrate urine, placing them at risk for dehydration. The elderly are at an increased risk of urinary incontinence if they have impaired mobility that prevents them from getting to the bathroom in time or from manipulating buttons and zippers. Weak abdominal and pelvic floor muscles impair bladder contraction. Decreased muscle tone increases the risk for urinary incontinence. However, urinary incontinence is not a normal physiological result of the aging process. Urination frequency increases with age with decreased bladder tone. Because the bladder cannot contract as effectively, an older person often retains urine in the bladder after voiding (residual urine). This places the patient at increased risk for bacterial growth and development of urinary tract infections (UTIs).
The nurse is catheterizing a female patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon, the patient complains of pain and resistance is felt. What is the nurse's best action?
Allow fluid to flow back into syringe and advance the catheter a little more before attempting to reinflate. -If resistance occurs when inflating balloon or the patient verbalizes or shows nonverbal signs of pain, the balloon may not be entirely within the bladder. Stop inflation; allow fluid to flow back into syringe, and advance the catheter a little more before reattempting to inflate. Having the patient take slow deep breaths may help the patient relax but does not help with resistance or pain. Lifting the penis to a perpendicular position and applying light traction is done to straighten the urethra. Advancement of catheter to bifurcation of the drainage and balloon inflation port ensures proper placement of catheter through the longer urethra of the male patient.
Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized?
An elderly female patient carries her urinary drainage bag like a purse under her arm as she ambulates. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. The NAP places a patient's drainage bag on a lowered side rail or on the floor. -The urinary drainage bag should be kept below the level of the bladder to prevent reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the level of the bladder and to secure the drainage bag to the side of the wheelchair below the level of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail because it could accidentally be raised to a height higher than the level of the bladder and urine could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should be encouraged. The catheter should be secured to the patient to prevent trauma to the urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary tract infection.
The nurse is inserting an indwelling Foley catheter in a male patient. The nurse asks the patient to bear down as if to void and slowly inserts the catheter through the urethral meatus. The nurse advances the catheter and meets resistance. What is the nurse's best initial action at this time?
Ask the patient to take slow deep breaths while inserting the catheter slowly. -If there is resistance to catheter insertion, the nurse should have the patient take slow deep breaths to promote relaxation while inserting the catheter slowly. Another technique is to rest the nurse's arm against the patient's leg and ask him to relax. When the leg muscles begin to relax, the nurse may continue the insertion process. If there is persistent resistance to insertion, the patient may have an enlarged prostate. Then it is appropriate to notify the health care provider; a Coudé catheter, with a slightly curved end, may be needed to facilitate insertion.
Which of the following steps should you take before removing fluid from the balloon in an indwelling urinary catheter?
Attach a 10 mL or larger syringe to the balloon port and allow the water to passively fill the syringe. Gently aspirate the syringe plunger if water remains in the balloon. -
Which of the following is the best example of documentation on a patient with a urinary catheter?
Catheter care provided; no encrustation noted. Urinary catheter patent and draining clear yellow urine to bedside drainage bag. -Documentation should include the appearance of the urine whether clear or cloudy or with sediment and color.
The nursing assistive personnel (NAP) reports the patient who is 1 day postoperative from bladder surgery is complaining of lower abdominal pain. The nurse palpates the patient's bladder and finds it is distended and there has not been any change in the amount of urine in the last 2 hours in the drainage bag. The patient's vital signs are within normal limits. What is the nurse's best action?
Ensure there are no kinks in drainage tubing, and if none, notify health care provider for possible bladder irrigation order. -Bladder distention is not a normal finding and may indicate catheter occlusion. Patient reports of pain are also consistent with possible occlusion. If there are no kinks or obvious clots or sediment in the tubing, the nurse should notify the health care provider. Catheter irrigation may help remove an occlusion so the bladder can drain effectively. Increasing fluid intake may help flush the bladder, but if the bladder is not emptying properly, the distention would only worsen. Bladder distention is not a symptom consistent with a urinary tract infection (UTI) and the patient does not have a fever.
Identify the indicators of a UTI:
Fever. Complaints of pain with urination (dysuria). Lower abdominal pain. Cloudiness of the urine. -Fever is an indication of infection. Complaints of pain or burning are indicative of a UTI as urine passes over inflamed tissues. The patient may feel abdominal pressure and discomfort with a UTI. Urine should be clear; cloudy urine may indicate the presence of bacteria or white blood cells in the urine.
The nurse is to determine PVR on a patient who has been experiencing incontinence, but a bladder scanner is unavailable. What is the nurse's best action?
Have the patient void and measure the volume, then perform straight catheterization. -If a bladder scanner is not available, obtain a PVR by measuring urine emptied from the bladder after a straight catheterization.
Which of the following would be inappropriate to delegate to NAP?
Indwelling catheter insertion.
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding anchoring of the catheter would be most accurate?
It is important to anchor the catheter tubing to minimize the risk for urethral trauma and bladder spasms from traction and to prevent accidental dislodgment. -Securing the catheter will minimize the accidental dislodgment of the catheter. It also minimizes the risk for bleeding, trauma, meatal necrosis, and bladder spasms from pressure and traction. In male patients, catheter tubes are attached to the lower abdomen or to top of thigh; in female patients, tubes are attached to the inner thigh. Allow slack in catheter so movement does not create tension on catheter.
The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching?
It is relatively safe and noninvasive. ! It is a convenient method of draining urine. It is used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter.
The nurse is teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following should be included in the teaching?
It is relatively safe and noninvasive. It is a convenient method of draining urine. It is used for male patients who are incontinent. It carries less risk of developing a UTI than an indwelling catheter.
Which of the following actions associated with urinary catheterization could cause a potential problem?
Keeping the foreskin retracted after catheterization. -Failure to reduce the foreskin after catheterization can result in paraphimosis (constriction of the foreskin). The bedside drainage bag should be attached to the bed frame and not the bed rails to avoid accidentally raising the rails (and the collection bag) above the level of the bladder, allowing reflux of urine. Testing the balloon by injecting fluid from the prefilled sterile water syringe into the balloon port is no longer a common practice. Testing the balloon may stretch the balloon and lead to damage, causing increased trauma on insertion. Cleansing the far labial fold, the near labial fold, and directly over the center of urethral meatus using a new swab with each area is the correct procedure for cleaning the female patient.
The nurse has inserted a catheter 7.5 cm (3 inches) in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time?
Leave the catheter in the vagina as a landmark and insert another sterile catheter. -There should be a urine return because the patient's bladder is distended. If no urine appears, the catheter may be in the vagina. If misplaced, the nurse should leave the catheter in the vagina as a landmark where not to insert, and insert another sterile catheter. The nurse may straighten the urethra by inserting one finger of a sterile gloved hand inside the vagina and applying gentle pressure upward; however, a new sterile catheter should be used.
During application of the condom catheter, the adhesive strip falls to the floor. What is the nurse's best action?
Obtain another adhesive strip from condom catheter kit.
The nurse is preparing continuous bladder irrigation. Which of the following actions by the nurse would be appropriate?
Performing hand hygiene and donning clean gloves. Priming the infusion tubing with irrigating solution. Calculating urinary output as the amount of irrigant infused subtracted from the amount in the drainage bag. Monitoring and emptying the drainage bag as needed. -There is no need to clamp the drainage tubing with a continuous bladder irrigation; this is done with intermittent closed catheter irrigation. All other actions are appropriate.
The nurse is assessing the patient's condom catheter. Which of the following most likely indicates the condom catheter should be removed?
Redness and/or excoriation of the penis
The nurse has a sterile urinary catheter and sterile gloves. Choose the remaining equipment the nurse will need to insert a straight urethral catheter:
Sterile cotton balls. Antiseptic solution. Water-soluble lubricant. Sterile forceps. -Straight urinary catheterization requires aseptic (sterile) technique. The nurse will need five to six sterile cotton balls soaked in antiseptic solution, such as Betadine, to reduce the number of microorganisms present on perineal area. Sterile forceps are used to pick up the antiseptic-saturated cotton balls. Water-soluble lubricant is used to ease insertion of the catheter. A sterile urinary collection bag is used for an indwelling catheter. Sterile water or normal saline in a syringe is used to inflate the balloon on an indwelling catheter and is unnecessary for a straight catheter.
Reasons for lack of urine after inserting a straight catheter include:
The catheter is outside of the bladder. The catheter is inserted in the vagina rather than in the urethra of a female patient. -The catheter may be in the urethra ahead of the internal sphincter of the bladder. Catheter malposition may be a cause of lack of urine. Urethral spasms may cause discomfort but will not prevent urine flow with an established catheter. An enlarged prostate may hinder catheter insertion but once inserted does not prevent urine from exiting the body. Bladder distention would indicate a full bladder, which once catheterized should result in urine output.
During change-of-shift report the nurse states that a patient has early renal failure and to be alert to this when administering medications. Why would this be a concern?
The kidneys assist in the detoxification of medication metabolites. -The kidneys detoxify and eliminate by products of medication metabolism. If the kidneys are unable to perform this function, medication toxicity can develop. The nephron, the functional unit of the kidney, forms the urine. The bladder holds the urine until it is excreted. The liver is a primary site for medication metabolism.
A nurse is to perform a bladder scan on a patient to measure PVR. After the patient voids, the nurse measures and documents the volume of voided urine. The nurse returns in 20 minutes and places the patient supine with head slightly elevated, exposing the patient's lower abdomen. The nurse turns on the scanner and sets the gender designation. The nurse applies a generous amount of ultrasound gel above the patient's symphysis pubis, and releases the scan button and then applies the scanner head to the gel, pointing it in a downward direction toward the bladder. The nurse wipes the abdomen of the gel and documents the procedure. What error(s) occurred in the performance of the skill?
The length of time between the patient voiding and performing the bladder scan. The timing of pressing and releasing the scan button. Cleaning of the scanner head. -The nurse should have cleaned the scanner head with an alcohol pad and allow it to air dry before applying it to the patient's abdomen and again after the scan was complete to remove all gel. The nurse was correct to have the patient void before the scan; however, to obtain accurate results, the bladder scan should be performed within 5 to 15 minutes after the patient voids. Positioning of the patient was correct, and a generous amount of ultrasound gel should be applied. The nurse should have waited to press and release the scan button until after the scanner head was in position pointing downward toward the bladder to capture and print the image of the volume of urine within the bladder.
A patient with a double-lumen urinary catheter has an order for closed intermittent catheter irrigation. The nurse performs hand hygiene, applies clean gloves, draws up 50 mL of room temperature irrigating solution into a sterile syringe, and places a sterile cap on the end. The nurse wipes the catheter and drainage tubing junction with an alcohol swab, disconnects the catheter from the drainage tube, inserts the needleless syringe, and gently instills the irrigating solution at an even, steady rate. The nurse reconnects the drainage tubing and observes the fluid return for color and any sediment or clots. What aspect of skill performance, if any, was in error?
The nurse disconnected the drainage tubing from the catheter. -The nurse should not open the urinary catheter system to perform closed intermittent catheter irrigation. Opening the system places the patient at greater risk for developing a urinary tract infection. The nurse should have clamped the drainage tubing below the soft injection port, cleaned the port with an antiseptic swab, connected the sterile needleless syringe, and instilled the irrigating solution. The nurse would then remove the clamp, allowing the solution to drain into the urinary drainage bag.
A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique?
The nurse inserts the urinary catheter, and when urine does not return, removes the catheter and makes a second attempt to locate the urethra with the same catheter. The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. After the nurse cleans the labia, the labia become slippery and closed as the nurse attempts to obtain a clear view of the urethra.
Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter?
The patient's urine appears cloudy with a foul odor. -These are symptoms of a UTI. A UTI may be cause for an indwelling catheter to be removed. The health care provider should be notified as a sterile urine specimen may be ordered before removing the catheter. An indwelling catheter should be removed as soon as possible after insertion because of the risk for catheter-associated urinary tract infection (CAUTI). If the patient states that his bladder feels very full and is starting to hurt it may indicate that the tubing is kinked or the patient may be lying on the tubing preventing drainage. How long a catheter remains in place is determined by several factors, such as the type of material the catheter is made of, facility policy, reason for the catheter, and whether the patient is experiencing any complications. Often catheters intended for long-term use are changed once a month. Patients who are not drinking sufficient amounts of fluid should be encouraged to drink more. Remember to count IV solution in the fluid intake calculation.
A health care provider has ordered an indwelling catheter to be inserted for bedside drainage. Which of the following is NOT an expected indication for catheterization with an indwelling catheter?
To determine urinary retention. -A straight catheter or bladder scan may be used to determine urinary retention and would not be an indication for an indwelling catheter. Indications for an indwelling catheter include preparing for surgery, to obtain accurate output measurements, and for incontinent patients in whom a wound needs to heal.
The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves? The NAP:
stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing. -After routine perineal care is given with soap and water, the catheter is cleansed. While stabilizing catheter with dominant hand and using a clean washcloth, soap, and water, the catheter is cleaned in a circular motion along its length for about 10 cm (4 inches). Cleansing starts where the catheter enters the meatus and down toward the drainage tubing. The application of topical antimicrobial products is not effective in reducing meatal bacterial flora and reducing risk for urinary tract infection (UTI). Do not include them as a part of routine catheter care.
