Fund Exam 3 - Module 15 & 18 urinary catherization
normal WBC
0-4
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 you to give the patient? 1. This is a normal occurrence after having a catheter in place for more than several days 2. it sounds like you have an UTI, I will contact HCP 3. I will need to inspect your perineal area and wash/dry it 4. if these symptoms continue I will contact HCP to see if we can re-insert the catheter
1
During change of shift report the nurse states that a patient has early renal failure and that your should be alert to this when administering medications. Why would this be a concern? 1. kidneys assist with detoxification of medication metabolites 2. patient may not be able to absorb medication 3. bladder acts as a filter 4. kidneys primary site for medication metabolism
1
The nurse is catheterizing a male 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? 1. Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to reinflate 2. have the patient take slow, deep breaths 3. lift penis to position perpendicular to patient's body 4. advance catheter to bifurcation
1
The nursing assistive personnel (NAP) reports leakage around a patient's urinary catheter. What action should the nurse take first? 1. attempt to reinflate the balloon 2. increase patient fluid intake 3. remove the catheter and replace with smaller size 4. obtain urine specimen
1
When obtaining a sterile urinary catheter specimen, the sterile specimen container should be opened and the lid: 1. placed with the inside up 2. placed with the inside down 3. held because placing it down could cause contamination 4. loosened but left on the container
1
You are inserting an indwelling Foley catheter in a male patient. You have asked the patient to bear down as if to void, and you slowly insert the catheter through the urethral meatus. You advance the catheter and meet resistance. What is your best initial action at this time? 1. Ask the patient to take slow deep breaths while you insert the catheter slowly 2. withdraw the catheter and notify HCP 3. apply more force as you insert the catheter forward 4. remove catheter, apply more lubricant, and reinsert
1
Reasons for lack of urine after inserting a straight catheter include: select all that apply 1. catheter outside the bladder 2. catheter inserted into vagina 3. prostate preventing urine from leaving bladder 4. urethral spasms preventing urine from exiting body
1, 2
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? Select all that apply 1. 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; 2. The nurse lubricates the catheter and places it back into the sterile tray when it recoils and touches the bed; 3. After the nurse cleans the labia, the labia becomes slippery and closes as the nurse attempts to obtain a clear view of the urethra 4. the nurse advances the catheter another 1-2 inches after urine appears 5. the nurse uses forceps and a new cotton ball when cleansing the area
1, 2, 3
You are informing your patient that his physician has ordered a urine test for culture and sensitivity that you will obtain from his indwelling Foley catheter. Which statement(s), if made by the patient, indicate that further instruction is needed? Select all that apply 1.That's ok; you can just get a sample out of my urinary drainage bag 2. I think my catheter comes apart from the tubing that goes to the collection bad. We can take it apart and hold a cup at the end of the catheter until you get enough urine for the test 3. After you clamp my tubing, I'm probably going to need some pain medication 4. It won't hurt me when you get the urine 5. the doctor is checking to see if I have a UTI 6. You will have to insert a new catheter to get a sterile specimen
1, 2, 3, 6
Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? 1. An elderly female carries her urinary drainage bag like a purse under her arm as she ambulates 2. As a patient is being transferred in a wheelchair, he places the drainage bag in his lap 3. patient drinks entire pitcher of water in one day 4. The NAP places a patient's drainage bag on a lowered side rail or on the floor 5. female patient keeps catheter secured to thigh with tape
1, 2, 4
You have a sterile urinary catheter and sterile gloves. Choose the remaining equipment you will need to insert a straight urethral catheter. Select all that apply 1. sterile cotton balls 2. antiseptic solution 3. sterile urinary collection bag 4. water-soluble lubricant 5. clean cotton balls 6. sterile forceps 7. sterile water in syringe
1, 2, 4, 6
You are teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following would you include in the teaching? 1. It is relatively safe and noninvasive; 2. ensures complete bladder emptying 3. It is a convenient method of draining urine; 4. It is used for male patients who are incontinent; 5. It may remain in place for several days or weeks 6. It carries less risk of developing a UTI than an indwelling catheter
1, 3, 4, 6.
Which of the following are true regarding the impact of aging related to urinary elimination? 1. Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone 2. elderly are better able to concentrate urine than middle-aged adult 3. aging less likely to experience urinary frequency 4. it is a normal part of aging to become incontinent 5. The elderly are at increased risk of UTI because of retained urine in the bladder
1, 5
Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag 1. catheter slipped out of bladder 2. patient severely dehydrated 3. patient's kidneys are damaged/injured 4. patient has an UTI
1,2,3
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 your best response? 1. What medications are you taking, and when? 2. have you tried to restrict your fluid intake? 3. your high blood pressure is affecting your kidneys 4. it sounds like you may have an UTI
1.
catheter removal supplies
1. 10-mL or larger syringe without needle—information on balloon size (mL) is printed directly on balloon inflation valve 2. Graduated cylinder to measure urine 3. Toilet, bedside commode, urine "hat," urinal, or bedpan 4. Bladder scanner (if indicated) 5. Washcloth and warm water to perform perineal care after removal
if patient complains of bladder discomfort and the catheter is patent as evidenced by adequate urine flow.
1. Check catheter to ensure that there is no traction on the catheter. 2. Notify health care provider. Patient may be experiencing bladder spasms or symptoms of a urinary tract infection. 3. Monitor catheter output for color, clarity, odor, and amount.
if more than 500 to 1000 mL of urine drains from the bladder at the time of insertion.
1. Check facility policy before beginning catheterization. Some agencies restrict maximal amount of urine that can be drained at one time to prevent rapid decompression of the bladder with consequent hemorrhage. This amount may vary from 750 to 1000 mL. 2. Report to health care provider. 3. If patient consistently has an increased urine output (polyuria) the health care provider should be notified.
condom catheter kit
1. Condom sheath of appropriate size 2. Skin preparation to protect skin (per manufacturer's directions) 3. Securing device 4. Urinary collection bag with drainage tubing or leg bag and straps
what would you do if bladder discomfort persists after catherization
1. For urethral spasm or bladder spasm, assist patient in relaxation measures, such as breathing in through nose and out through mouth. 2. If bladder discomfort continues, verify that tubing is kink free and notify health care provider. Prescriber may order medication for relief.
to ensure expected outcome of catheter removal was met
1. Inspect the catheter and genital area for soiling, irritation, and skin breakdown. Ask patient about discomfort. 2. Observe time and measure the amount of first voiding after catheter removal. Remember that the patient should void within 6 to 8 hours. The time of removal and the due-to-void time should be recorded and reported to the nurse providing patient care following your shift. 3. Evaluate the patient for signs and symptoms of a UTI.
what would you do if the catheter enters vagina
1. Leave catheter in vagina. 2. Recleanse urinary meatus. Using another catheter kit, reinsert a sterile catheter into meatus (check facility policy). 3. Remove catheter in vagina after successful insertion of second catheter.
what steps should be performed after urinary catherization
1. Palpate bladder for distention or use bladder scan. 2. Ask patient to determine patient's level of comfort. 3. observe character and amount of urine in drainage system. 4. determine that there is no urine leaking from catheter or tubing connections.
expected outcomes of catheter removal
1. Patient voids at least 150 mL with each voiding no more than 6-8 hours after removal. 2. Patient will verbalize a feeling of complete bladder emptying and absence of discomfort. 3. Patient will identify signs and symptoms of UTI.
what is Intermittent straight catheterization used for?
1. Relief of discomfort from acute bladder distention 2. To obtain a sterile urine specimen 3. Assessment of post void residual when a bladder scanner is unavailable. 4. Long-term management of patients with chronic urinary retention from spinal cord injuries, neuromuscular degeneration, or incompetent bladders (Patients perform self-catheterization.) 5. Sometimes used to instill a medication
what are Short-term indwelling catheters used for?
1. Relief of urinary obstruction; for example, by enlarged prostate 2. Perioperatively or postoperatively; for example, spinal anesthesia, bladder surgery, gynecological surgery 3. Prevention of urethral obstruction caused by blood clots; continuous or intermittent bladder irrigation 4. Accurate monitoring of urinary output in critically ill patients
if sterility is broken during catheterization by nurse or patient.
1. Replace gloves if contaminated and start over. 2. If patient touches sterile field but equipment and supplies remain sterile, avoid touching that part of the sterile field. 3. If equipment and/or supplies become contaminated, replace with sterile items or start over with a new sterile kit.
what are long-term indwelling catheters used for?
1. Severe urinary retention 2. Presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence 3. Terminal illness when bed linen changes are painful for the patient
straight catherization supplies
1. Single lumen catheter (commonly 12-14 French) 2. Sterile gloves (extra pair optional) 3. Waterproof drapes (one fenestrated-has an opening in the center of drape) 4. Lubricant cleansing solution incorporated in an applicator or to be added to cotton balls (forceps to pick up cotton balls) 5. Specimen container
indwelling catherization supplies
1. Sterile gloves 2. Double-lumen catheter (Some kits contain a catheter with attached drainage bag; others contain only a catheter, others with no catheter.) 3. Waterproof drapes (one fenestrated - has an opening in the center of drape) 4. Lubricant 5. Cleansing solution incorporated in an applicator or to be added to cotton balls (forceps to pick up cotton balls) 6. Prefilled syringe with sterile water for balloon inflation 7. Sterile drainage tubing with collection bag 8. Receptacle or basin (usually at the bottom of the catheterization tray) 9. Specimen container 10. Sterile drainage tubing and bag (if not included in the kit) 11. Multi-purpose Velcro tube holder or nonallergenic/paper tape
when obtaining a sterile specimen via straight catherization
1. avoid touching sides of specimen cup 2. withdraw catheter slowly and smoothly 3. hold end of catheter over specimen cup to obtain 20-30mL of urine
what would you do if frequency and amount of urination reduced.
1. check for bladder distention. 2. Observe whether urine is pooling at tip of condom and bathing the penis in urine; reapply as necessary. 3. Check for kinks in tubing or in condom catheter.
what would you do if skin around penis is erythematous, ulcerated, or denuded:
1. check for latex allergy, allergy to skin preparation, or adhesive device. Remove condom catheter and notify health care provider. Do not reapply until penis and surrounding tissues are free from irritation. 2. Ensure that condom is not twisted and urine flow is unobstructed after application.
equipment used to obtain a midstream urine specimen
1. commercial kit for clean-voided urine containing: *antiseptic towelettes/cotton balls & sterile specimen container 2. clean gloves 3. soap, water, washcloth, and towel 4. bedpan (for nonambulatory patient), specimen "hat" (for ambulatory patient who needs for all urine to be measured) 5. sterile water or normal saline 6. urine cup 7. completed identification labels with appropriate patient identifiers 8. completed laboratory requisition including patient identification, date, time, name of test, and source of culture 9. small plastic biohazard bag for delivery of specimen to laboratory (or container specified by facility)
what would you do if a condom catheter does not stay on.
1. ensure that the catheter tubing is anchored and that the patient understands to not pull or tug on catheter. 2. Reassess condom catheter. Refer to manufacturer's guidelines for sizing. 3. Observe whether condom catheter outlet is kinked and urine is pooling at tip of condom, bathing the penis in urine; reapply as necessary and avoid catheter obstruction. 4. Assess need for another brand of external catheter (i.e., one that is self-adhesive).
reduce catherization infection by:
1. limit use 2. use smallest catheter possible 3. daily cleansing with soap/water or perineal cleanser
what would you do if penile swelling or discoloration occurs
1. remove external catheter. 2. Notify health care provider. 3. Reassess current condom size. See manufacturer's size chart.
what would you do if enous circulation in leg is impaired from leg bag strap and the patient complains of leg discomfort.
1. remove the leg collection bag and reapply. 2. Assess the leg every 8 hours for circulatory impairment. 3. Apply a bedside drainage bag at night or continuously for a bedridden patient.
Urine culture reveals bacterial growth
1. report findings to health care provider. 2. Administer medications as ordered. 3. Monitor patient for fever and dysuria.
what would you do if you were unable to advance the catheter.
1. retry unless patient is experiencing discomfort. 2. if unable to advance or if patient has discomfort during advancement, consult with health care provider. Patient may have enlarged prostate (male), causing obstruction.
normal specific gravity
1.010 to 1.025
average catheter size
14-16 Fr
what is the average fluid intake per day?
1500 mL/day
If a patient's indwelling catheter is removed by 0900, the patient should be due to void by
1500-1700
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 physician has ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter should you choose? 1. Coude catheter 2. 14 fr, 5 mL balloon, latex catheter 3. 16 fr plastic catheter 4. 18 fr, 5 mL balloon, latex catheter 5. 8 fr, 3 mL balloon, latex catheter 6. 16 fr, 30 mL balloon, silicon catheter
2
The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next? 1. notify HCP 2. check for kinks in catheter tubing 3. have pt take slow, deep breaths 4. lower head of bed
2
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? 1. urinary tract is considered sterile 2. The nurse may use clean technique to insert an indwelling catheter 3. the urge to void is felt at 150-200 mL in an adult 4. the minimum urinary output is 30 mL per hour
2
Which of the following actions associated with Foley catheterization could cause a potential problem? 1. drainage bag attached to bedframe 2. foreskin retracted after catherization 3. failing to test balloon by injecting fluid 4. cleansing the far labial fold
2
what is the time frame for short term catherization
2 weeks or less
You are to collect a sterile urine specimen for culture and sensitivity from your patient's indwelling Foley catheter. Choose the supplies that you will need to carry out the procedure. 1. sterile gloves 2. clean gloves 3. Alcohol or disinfectant swab 4. 5mL Luer Lock syringe 5. 2omL Luer Lock syringe 6. Catheter clamp or elastic band 7. Sterile specimen container 8. Completed laboratory requisition 9. Completed ID label 10. towel/protective barrier 11. bedpan 12. soap, water, washcloth, towel 13. sterile cotton balls
2, 3, 4, 6, 7, 8, 9,
Marsha Roberts is a 48-year-old female who had abdominal surgery. She is two days post surgery and is continuing to have lower abdominal pain and difficulty voiding. Ms. Roberts has an intravenous infusion at a rate of 50 mL per hour because she is only able to tolerate small amounts of food and fluids by mouth due to persistent nausea. She has not voided for the last 8 hours and she complains of a sensation to urinate. She has an order for the insertion of an indwelling urethral catheter. Which size catheter? Select all that apply 1. 10 fr 2. 16. fr 3. 18 fr 4. 14 fr 5. 12 fr
2, 4
The nurse has inserted a catheter 7.5 cm in a female patient and obtains no urine return even though her bladder is distended. What action should the nurse take at this time? 1. remove the catheter 2. leave the catheter in the vagina as a landmark 3. remove the catheter and reinsert into urethra 4. inflate the balloon and reassess in 1 hour
2.
what is the adult average urine output
2200-2700 mL / day ; minimum of 30mL/hr
A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The physician has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient? 1. 8 fr, 3mL balloon 2. 14 fr, 5mL balloon 3. 16 fr, 5 mL balloon 4. 16 fr, 30 mL balloon
3
A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding the anchoring of the catheter would be most accurate? 1. indwelling catheter tube is secured to the female patient's abdomen 2. indwelling catheter tube is secured to the male patient's inner thigh 3. anchor catheter tubing to reduce risk for urethral trauma 4. when securing the catheter tubing, slack should be avoided
3
Which of the following actions, if made by the nurse, could be considered negligence? 1. leaving the drainage tubing below the catheter port clamped for 30 minutes 2. using aseptic techniques to obtain 5mL of urine for culture 3. Obtaining the urine sample at 1030 and transporting it to the lab at 1115 4. labeling the cup but not the lid and transporting the specimen in a biohazard bag
3
Which of the following indicates a reason for notifying the health care provider to get an order for removal of an indwelling catheter? 1. the patient states his bladder is full and hurting 2. catheter has been in place for 3 days 3. The patient's urine appears cloudy with a foul odor 4. patient is drinking less than 1500mL of liquid per day
3
A nurse inserting an indwelling Foley catheter in a female patient advances the catheter and obtains clear yellow urine. What is the next action the nurse should take? 1. inflate the balloon 2. pull gently back on the catheter 3. advance catheter another 1-2 inches to inflate balloon 4. ask the patient to bear down as if voiding
3.
The nursing assistive personnel (NAP) is assisting the nurse to insert a Foley catheter on a male patient. In which position should the NAP place the patient? 1. Sim's position 2. dorsal recumbent 3. supine, legs adducted 4. supine, legs abducted
4
What is the recommended amount of time to leave the catheter clamped when obtaining a urine specimen from an indwelling catheter? 1. 15 minutes 2. 1 hour 3. 2 hours 4. 30 minutes
4
normal pH
4.6-8
children catheter sizes
5-6 Fr for infants; 8-10 Fr for children; and 12 Fr for young girls
balloon size adult
5-mL balloon (filled with 10 mL)
what would you do if, after catheter insertion and urine return, patient continues to complain of discomfort
A spasm, bladder infection, or injury to the urinary tract could cause
inadequate bladder emptying requiring intervention
Abdominal pain and distention, a sensation of incomplete emptying, incontinence, constant dribbling of urine, and voiding in very small amounts
As part of catheter insertion assessment, where should you palpate?
Above the symphysis pubis
what steps should you take before removing fluid from the balloon in a Foley catheter
Attach a 10mL syringe or larger to the balloon port and allow the water to passively fill the syringe; Gently aspirate the syringe plunger if water remains in the balloon
Step 1 for collecting a urine sample from an indwelling catheter
Clamp the drainage tubing below the sampling port of the catheter for 30 minutes. Apply gloves, cleanse the sampling port with a disinfectant swab, and allow to dry
Each laboratory requisition must include:
Date and time specimen is obtained Patient name Patient ID number Name of the test Source of specimen/culture (if appropriate) Initials and title of person who collected specimen
Step 4 for collecting a urine sample from an indwelling catheter
Document the collection of the specimen
elevated glucose
Elevated in diabetes
abnormal WBC
Elevated with UTI
abnormal blood count
Elevated with kidney disease and/or damage, infection, trauma, and surgery
indicators of UTI
Fever, Complaints of pain, Abdominal pressure and discomfort, cloudiness of the urine
indwelling retention catheterization
Foley catheter remains in place until a patient is able to void voluntarily and completely, or as long as accurate measurements are needed.
elevated pH
Indicates acid-base balance
Step 2 for collecting a urine sample from an indwelling catheter
Insert a 21-gauge, 1-inch needle attached to a 3- or 20-mL syringe into the center of the sampling port, or a 3- or 20- mL leurlok syringe to a needleless port. Draw the correct amount of urine into the syringe (3 mL or 20 mL).
catheter care
Perineal care and cleansing of the first 4 inches of the catheter as it exits the urinary meatus should be completed every 8 hours as part of routine perineal care, after bowel incontinence, or if secretions build around the urinary meatus
abnormal bacterial count
Presence indicates UTI
abnormal cast count
Presence indicates kidney abnormality
elevated protein
Presence suggests renal disease and/or damage
elevated ketones
Present during dehydration, starvation, and poorly controlled diabetes
elevation in specific gravity
Reflects urine concentration Increased with dehydration; decreased with overhydration
interventions to reduce risk of CAUTI
Supporting perineal hygiene, preventing catheter related trauma and removal of indwelling catheters
if autonomic dysreflexia is suspected
This is a medical emergency. 1. support patient by elevating the head of the bed. 2. drain urine (i.e., empty bladder by removing any blockage and/or kinks in the catheter tubing). 3. obtain vital signs. 4. Consult with health care provider.
Step 3 for collecting a urine sample from an indwelling catheter
Transfer the urine to the appropriate container. Place the lid on the container. Unclamp the catheter. Discard the gloves and used supplies; perform hand hygiene; attach the identification label to the container and complete the requisition; send the sample to the lab in a biohazard bag.
If the catheter is in the urethra but outside of the bladder or the catheter is in the vagina rather than the urethra then there would be
a lack of urine
The nurse is assisting a patient to obtain a midstream urine specimen. Which of the following would be inaccurate and require correction? a. The nurse brings the patient a clean specimen cup and sterile towelettes. b. The nurse instructs the patient to avoid touching the inside of the cup. c. The patient removes the specimen container before the flow of urine stops and finishes voiding into the toilet. d. The patient initiates the stream of urine before passing the specimen container into the urine stream.
a. A sterile specimen cup should be used when obtaining a midstream urine specimen.
When obtaining a urine specimen from a Foley catheter, what technique is being used? a. Aseptic technique b. Clean technique
a. Aseptic technique means to use sterile technique in order to prevent contamination with microorganisms.
You are going to remove an indwelling catheter. How can you determine what size syringe to obtain to deflate the balloon of the catheter? a. By looking at the size printed on the balloon inflation valve of the catheter b. By looking at another catheter on the supply shelf and reading the label c. By using a standard 10-mL syringe, as most catheters have a 5-mL balloon d. By looking at the size printed on the catheter where it connects to the drainage tubing
a. Information on balloon size can be obtained directly from the balloon inflation valve on the catheter.
You receive an order to obtain a urine specimen for culture and then discontinue the indwelling catheter. Which of the following is correct regarding delegation? a. The NAP can obtain the urine specimen and remove the catheter. b. You should obtain the urine specimen and the NAP can remove the catheter. c. The NAP can obtain the urine specimen and you should remove the catheter. d. You should never delegate either task.
a. Obtaining a urine specimen from an indwelling catheter and removal of a catheter may be delegated to NAP who are familiar with aseptic technique.
When collecting a sterile urine sample, the Foley should be clamped for: a. 30 minutes b. 60 minutes c. 2 hours d. 15 minutes
a. The recommended time frame to allow sufficient urine to accumulate for collection is 30 minutes.
at what levels do adults/children feel the urge to urinate?
adults: 150-200 mL children: 50-100 mL
factors influencing urination
age, sociocultural, psychological, muscle tone, fluid intake, disease, surgical, medications, diagnostics
collect specimens for C&S
as a clean-voided midstream specimen or under sterile conditions from a urinary catheter
indwelling catheter
attached to urinary drainage bag to collect the continuous flow of urine.
autonomic dysreflexia
autonomic response of the sympathetic system that results in dangerously high blood pressure. Spinal cord injury patients who require intermittent catheterization are especially susceptible to dysreflexia.
When should gloves be worn during specimen collection? a. While handling the container to keep it sterile b. When there is a risk of exposure to body fluids
b. Gloves should be worn during specimen collection any time there is a risk of exposure to body fluids to protect yourself from exposure.
The health care provider has ordered a midstream urine specimen for culture and sensitivity. What does the "sensitivity" reflect? a. The patient's allergies to antimicrobials b. Medications that may be effective against pathogens c. The organism (pathogen) that is present in the urine d. The dosage of the current medication being used
b. Routine cultures identify organism(s), and a sensitivity study identifies antimicrobial medications that may be effective against pathogen(s).
You are changing a condom catheter on a male patient. You notice that pubic hair was caught in the elastic adhesive strip. What action should you take when applying a new condom catheter? a. Apply skin preparation to the pubic hair. b. Clip the hair at the base of the penis. c. Avoid the use of the elastic adhesive strip. d. Overlap the tape rather than use the spiral wrap.
b. The hair may be clipped to prevent it from adhering to the condom or getting caught in the condom during application. Do not shave hair because this increases the risk for skin irritation. A hair guard may also be used as an alternative.
What is the primary purpose of immediately reporting any accidental body fluid exposure? a. It follows facility policy. b. It protects your health.
b. The primary purpose of immediate reporting is to protect the health of yourself and others. Following facility policy is a means for fulfilling this purpose.
Mr. Zorn is a 50-year-old patient with an established indwelling Foley catheter. He has been complaining of flank pain and has been running a fever. The urine in his drainage bag appears cloudy with sediment and has a foul odor. The nurse assesses Mr. Zorn's urethral meatus and surrounding skin. There is absence of redness or discharge. What is your best action at this time? a. Remove the catheter. b. Notify the health care provider. c. Continue to monitor the patient. d. Document the assessment.
b. These are symptoms of a urinary tract infection. You should notify the health care provider.
where is the primary sites of catherization
bladder and urethra
the amount of urine that should be collected in a midstream (clean-voided) urine specimen is: a. 10 to 20 mL b. 100 to 150 mL c. 30 to 60 mL d. 60 to 90 mL
c. For analysis of a midstream urine specimen, 30 to 60 mL is a sufficient quantity.
Ms. Freeman tells you that she is menstruating. What should you do? a. Discard the specimen. b. Instruct Ms. Freeman to come back when menstruation is absent. c. Document this information on the laboratory slip. d. Obtain another urine specimen, this time with the nurse performing the procedure.
c. If the patient is menstruating, place this information on the laboratory slip.
what are some issues with using large catheters
can damage the urethra and urinary meatus, increase bladder irritability, and cause urine to leak around a catheter due to spasm
symptoms of UTI infection
can develop 2 to 3 or more days after catheter removal.
bacteria grow rapidly in drainage bags
can give a false measurement of bacteria in the urine
children under 18-24 mths
can not control urination
catheter leakage
change lumen size, use antispasmodic medication
when obtaining urine sample from an established catheter
clean gloves should be worn
urine should appear
clear yellow to amber in color and without a foul or strong odor
what color is normal urine
clear, straw-colored and slightly acidic
what colony count indicates bacterial growth in urine
colony count of more than 10,000 organisms per milliliter
triple lumen catheters
continuous bladder irrigation or when it becomes necessary to instill medications into the bladder. One lumen drains the bladder, a second lumen is used to inflate the balloon, and a third lumen delivers irrigation fluid into the bladder.
The use of powders or lotions on the perineum
contraindicated because of the risk of growth of microorganisms, which may ascend the urinary tract
Mr. Pitts has a condom catheter due to urinary incontinence. His wife calls the nurse and reports that Mr. Pitt's scrotum and penis appear "red and raw." She asks you if she should put some cornstarch on the area. Which of these responses would be appropriate for the nurse to give Mrs. Pitts? a. "Yes, you can put some cornstarch on the area and then reapply a new condom catheter; just make sure the adhesive isn't so tight." b. "It sounds like the tubing must have been kinked. Wash and dry his penis and apply some skin protectant before applying a new catheter." c. "Wash and dry the area well and apply the next-larger-size catheter. You may have to change the catheter more frequently." d. "I will notify the health care provider. Remove the catheter and avoid applying cornstarch or reapplying the catheter until the area is free from irritation."
d. Redness and excoriation around the penis result from pressure of adhesive or contact with urine. They may also suggest a possible latex allergy. The condom catheter should be removed and the health care provider notified. The catheter should never be reapplied until the penis and surrounding tissue are free from irritation.
When performing catheter care, how many inches of the catheter will you cleanse after it exits the urinary meatus? a. 1 inch (2.5 cm) b. 2 inches (5 cm) c. 3 inches (7.5 cm) d. 4 inches (10 cm)
d. This is the optimum distance to reduce the presence of secretions or drainage on the exterior catheter surface.
what effect does renal disease and febrile conditions have on urine production
decrease volume and increase concentration of urine
lab analysis can aid in
determining illness diagnosis, patient response, illness trends
The NAP obtained the urine specimen from the Foley catheter correctly. However, as the NAP was putting the lid on the specimen container, the NAP accidentally touched the inside of the sterile specimen cup. Which action should be taken? a. Send the specimen to the laboratory within 30 minutes. b. Indicate on the label and requisition what occurred. c. Document the incident in the patient's chart. d. Reinsert a new catheter. e. Discard the specimen and collect another. f. Pour the urine into another sterile specimen cup.
e. The specimen was contaminated. The NAP should recollect the specimen.
Condom type external catheters are held in place
either an adhesive coating of the internal lining of the sheath, a double-sided self-adhesive strip, brush-on adhesive applied to the penile shaft, or in rare cases an external strap.
indication of autonomic dysreflexia in patient with spinal cord injury
elevated blood pressure, bradycardia, flushing, diaphoresis
When removing an indwelling catheter
ensure that the catheter balloon is fully deflated to minimize trauma to the urethra
Before sending the urine specimen to the lab
evaluate your patient and the urine : 1.urine color, characteristics, and amount 2. Any discomfort from the patient
drainage bag should be emptied
every 8 hours
true/false: After a patient has had a Foley catheter for 1 week, a urine specimen may be obtained from the bedside drainage bag
false
true/false: Obtaining a sterile urine sample for testing by using a straight catheter can be delegated to NAP
false
true/false: Removal of at least half of the fluid in the catheter balloon will ensure easy removal of the Foley urinary catheter.
false. All fluid must be removed before the catheter can safely be removed.
true/false: An empty bladder is easily palpated.
false. An empty bladder cannot be palpated as it is located below the symphysis pubis. A distended bladder is palpable. A full bladder with inability to void may indicate need to insert a catheter.
true/false: When providing indwelling catheter care, you should clean around the anchor tapes to prevent the catheter from slipping out of the urethra.
false. Anchor tapes must be changed daily and the skin inspected carefully. The balloon in the bladder prevents the catheter from falling out.
true/false: Reduced fluid intake decreases bacterial growth in the urinary system.
false. Decreased fluid intake can lead to an increase in bacteria and possible infection.
true/false: The foreskin must remain retracted following catheterization.
false. Failure to reduce the foreskin following catheterization can result in paraphimosis (constriction of the foreskin).
true/false: Infants and young children are better able to concentrate urine than the adult.
false. Infants and young children are unable to concentrate urine and reabsorb water effectively.
true/false: Two hours have elapsed since the condom catheter was applied. You should verify that the sheath is intact without leakage and that the patient is comfortable.
false. Initial assessment should occur within 30 minutes of application.
true/false: It is normal for older adults to experience increased urinary frequency, retention of urine in the bladder, and incontinence.
false. It is never normal for an older adult to be incontinent.
true/false: Within 6 to 8 hours of urinary catheter removal, patients should be able to void, without difficulty, at least 75 to 100 mL of urine.
false. Patients should be able to void at least 150 mL within 6 to 8 hours of catheter removal.
true/false: Resistance during catheter insertion with a male is always a sign of urethral obstruction.
false. Resistance is felt before the internal sphincter relaxes. Maintain firm pressure against the sphincter for a few seconds and then continue to advance the catheter.
true/false: A patient with an indwelling catheter informs you that her bladder has felt full ever since the night nurse obtained a urine specimen from her. The patient's symptoms are likely the result of an inadequate amount of urine removed for the specimen.
false. The bladder fullness is likely the result of a nondraining catheter. You must assess the patient's bladder and the drainage system to determine the cause of the bladder fullness. It is possible that the night nurse forgot to unclamp the catheter after the specimen was collected.
true/false: The catheter should be inserted at least 17 cm into the urethra of the female patient.
false. The catheter should only be inserted 5 to 7.5 cm (2 to 3 inches) for the female patient.
true/false: The fenestrated drape is placed under the patient's buttocks before the procedure.
false. The fenestrated drape is used to cover the genital and perineal region.
true/false: The skin preparation solution is used to attach the condom sheath to the penis.
false. The skin preparation solution is used to prevent skin irritation.
true/false: A urine sample can be obtained from the urine collection bag as long as it is within the first 24 hours of catheter insertion.
false. The specimen should be obtained from the collection bag immediately after catheter insertion.
true/false: A 48-year-old female patient had abdominal surgery. She is two days post surgery and is continuing to have lower abdominal pain and difficulty voiding. The patient has an intravenous infusion at a rate of 150 mL per hour because she is only able to tolerate small amounts of food and fluids by mouth due to persistent nausea.You expect that she will have a low urinary output (less than 30 mL per hour) because she has only been eating small meals since her surgery.
false. This patient has an intravenous infusion. Her urine output should be at least 30 mL per hour.
what is a retracted penis pouch used for?
for a male patient with a retracted penis
voiding monitored after catheter removal
for at least 24 to 48 hours
silicone catheter
for frequent catheter changes
double lumen catheters
for indwelling catheters, provide one lumen for urinary drainage while a second lumen is used to inflate a balloon that keeps the catheter in place
UTI symptoms
frequency, hematuria, dysuria
nephron
functional unit of kidneys that forms urine
if urine output is less than 30 mL hr for 2 hours
further evaluation is needed
nephron components
glomerulus, Bowman's capsule, proximal convoluted tubule, Loop of Henle, distal tubule, collecting duct
effect of alcohol on urine production
halts antidiuretic hormone, increasing urine production
bladder
holds urine until urination
collected specimen should be enclosed
in biohazard bag
what is the effect of caffeine on urine production
increases urine production
difference between inserting indwelling and single-use catheters, straight, or intermittent catheter
inflation of a balloon to keep the indwelling catheter in place and in providing a closed drainage system.
urinary catherization types
intermittent & indwelling retention
A laboratory requisition
is needed for each specimen to be certain that the appropriate tests are performed on each specimen and to facilitate accurate reporting of the results.
to prevent urine backflow
keep bag below the level of the bladder ; on the bed frame or a chair , below the level of the patient's bladder
proteinuria
large amounts of protein in urine ; indicates glomerular injury
what effect does diabetes have on urine production
large amounts of urine
change catheter
leaking, blockage, before obtaining sterile specimen
what is the time frame for long term catherization
more than 1 month
specimen container, not lid
must also be labeled with the patient's name, identification number, specimen source, collection date, time and initials of the person who collected it, series number (if more than one specimen), and anatomical site if appropriate.
urine culture indicates +30,000 colonies/mL
notify HCP, monitor pt for fever & dysuria
for a patient with an indwelling catheter
observe the urinary drainage system to ensure that it is intact and paten
Diagnostic testing
performed for the purpose of aseptically obtaining samples of tissue, blood, and other body fluids.
culture and sensitivity (C&S) of urine
performed to identify the presence and type of bacteria (culture) and determine the most effective antibiotic for treatment (sensitivity).
diuretics
prevent reabsorption of water and electrolytes, which increases urination
silver / antibiotic coated catheter
reduce CAUTI, short-term use
latex catheter with coating
reduces irritation
what would you do if leakage of urine from around catheter due to improper catheter placement, possible balloon deflation or too small a catheter.
reinflate balloon or replace catheter.
kidneys
remove waste from blood to form urine
older adults
retain urine in bladder because bladder cannot contract fully, resulting in issues with UTI's
indwelling or Foley catheter
separate lumen used to inflate a balloon so the catheter remains in the bladder for short- or long-term use.
normal protein, glucose, ketones, bacteria, casts
should be 0
normal blood count
should be less than 2 RBC per count
straight or intermittent catheter
single-lumen catheter inserted into the bladder through the urethra only to empty the bladder, and then it is removed.
sites at risk for microorganism introduction
site of insertion, drainage bag, spigot on drainage back, junction of tube and bag
external urinary catheter, condom catheter or penile sheath
soft, pliable condom-like sheath that fits over the penis providing a safe and noninvasive way to contain urine.
what is a urinary catheter
sterile procedure ; flexible plastic/rubber tube
intermittent catheterization
straight, single-use catheter is introduced long enough to drain the bladder. This is frequently done to check for residual urine in the bladder and to obtain specimens. When the bladder is empty the catheter is immediately withdrawn.
what is suprapubic catherization
surgically implanted catheter through the abdominal wall
ureters
transport urine from kidneys to bladder
true/false: Obtaining a urine sample from an indwelling catheter requires sterile technique
true
true/false: Ensuring that the patient receives adequate fluids will improve the probability that the patient will void within 6 to 8 hours after catheter removal.
true. Adequate fluid intake will assist the patient in voiding.
true/false: The catheter should be inserted to the bifurcation of the drainage and balloon inflation port in the male patient.
true. Advancement of catheter to the bifurcation of the drainage and balloon inflation port ensures proper placement of catheter through the longer urethra for male patient.
true/false: The patient should receive an explanation of the procedure regardless of their consciousness status.
true. Always explain the procedure before you begin.
true/false: If uncircumcised, the foreskin of the penis must be retracted before beginning urethral catheterization preparation.
true. Always retract the foreskin before beginning urethral catheterization preparation.
true/false: This patient states that she is allergic to materials made from rubber. You select a silicone catheter for her.
true. An allergy to rubber should cause you to suspect a latex allergy as well.
true/false: An 11-month-old is admitted for surgical repair of a cleft palate. You may anticipate the patient having decreased urinary output immediately following surgery.
true. Anesthetics and pain-killing drugs reduce urinary output, and the body will reduce urinary output as a compensatory mechanism to increase circulatory fluid volume.
true/false: Any sign of infection should be reported to the health care provider before removing a Foley catheter.
true. Any unexpected outcome should be reported before proceeding. The health care provider may order a specimen to be obtained prior to removal.
true/false: Having the patient bear down as if voiding will allow for easier passage of the catheter through the urethral meatus.
true. Asking the patient to bear down will help relax the external sphincter and aid catheter insertion.
true/false: A 48-year-old female patient had abdominal surgery. She is two days post surgery and is continuing to have lower abdominal pain and difficulty voiding. The patient has an intravenous infusion at a rate of 150 mL per hour because she is only able to tolerate small amounts of food and fluids by mouth due to persistent nausea.This patient's abdominal discomfort could be due in part to bladder distention as well as her surgery.
true. Bladder distention can cause considerable discomfort, especially following abdominal surgery.
true/false: Catheter care is performed to remove bacteria that could ascend through the urethral canal and lead to an infection
true. Catheter care removes bacteria along the outer surface of the catheter.
true/false: Diuretics inhibit reabsorption of water by the kidneys, resulting in an increased urine output.
true. Diuretics prevent reabsorption of water and some electrolytes, which increases urination.
true/false: The condom catheter should be removed daily to evaluate the penis and surrounding skin for redness and excoriation.
true. Evaluation of skin integrity should be done daily. The catheter should be checked every 4 hours and the patient should be assessed for discomfort.
true/false: A 40-year-old patient is admitted for an intravenous pyelogram due to severe flank pain. After the tests, the patient's fluid intake increases. This patient may have an increased urine output.
true. If fluids, electrolytes, and solutes are balanced, increased fluid intake leads to increased urine production.
true/false: NAP can remove indwelling urinary catheters.
true. If trained and permitted by agency policy, NAP can remove urinary catheters. Remember to review the process with them.
true/false: At least 10 cm (4 inches) of an indwelling urinary catheter that exits the meatus should be wiped with a clean wash cloth during routine care.
true. Moving away from the body in a circular motion is the correct procedure for cleaning the catheter.
true/false: Facility policy may allow some lab studies to be obtained by NAP.
true. NAP are allowed to collect a number of specimens for lab studies. Refer to facility policy for the type of lab studies allowed.
true/false: An 11-month-old lacks voluntary control of urination.
true. Prior to 18 to 24 months, children are unable to control urination.
true/false: Your assessment of the patient should include exploring any history of previous catheterizations.
true. This information may indicate prior difficulty with voiding or prior difficulties with catheter insertion or maintenance.
true/false: The correct position for catheterizing a male patient is supine with legs slightly abducted.
true. This is the correct position for catheterizing a male patient.
true/false: Once the catheter is inserted, you should release labial retraction and hold the catheter close to the urethra.
true. This is the correct procedure to stabilize the catheter.
true/false: NAP can perform catheter care.
true. This procedure can be taught to the NAP if permitted by agency policy.
true/false: Your assessment of a patient following removal of an indwelling urinary catheter should include urinary frequency.
true. This will assist you in determining whether urinary function has returned to normal.
true/false: Obtaining a sample of urine from an indwelling catheter can be delegated to NAP.
true. Verify the competency of the NAP before delegating this procedure.
true/false: When cleansing the perineum, allow for only one pass with each cotton ball during preparation.
true. Wipe in only one direction and use each cotton ball only once.
true/false: When preparing for catheter insertion in a male, cleanse from the urethral meatus to base of glans three times, using a new cotton ball with each cleansing.
true. Wipe in only one direction and use each cotton ball only once.
true/false: When applying a condom catheter to a patient, you should leave 2.5 to 5 cm of space between the tip of the glans penis and the end of the condom catheter.
true. You should allow space to prevent irritation of the glans penis and allow free passage of urine into the collecting tube and drainage bag.
true/false: Swelling, drainage, and irritation of the urethral meatus may indicate localized infection.
true. this should be reported and treated.
An enlarge prostate could cause the nurse to be
unable to advance catheter into the bladder
how much urine in can be held in the bladder
up to 600 mL
to obtain a urine sample from an indwelling urinary catheter for routine urine analysis
use 20 mL syringe
single lumen catheters
used for intermittent catheterization
Coude catheter
used for males with prostate hypertrophy. This catheter is less traumatic during insertion because it is stiffer and easier to control than a Foley catheter.
larger catheter sizes
used in special circumstances such as after urological surgery or in the presence of gross hematuria.
sterile water
used to inflate balloon
urethra
where urine leaves body
Palpation of a full bladder
will cause pain and/or urge to void, indicating a full or overfull bladder.
when should you inspect penis with condom catheter in place
within 15-30 minutes of application