Download - Urinary Retension
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Post-Operative Retention
Sandra Whytock RN MSN GNC(C) NCA
Clinical Nurse Specialist, Elder Care ProgramProvidence Health CareFebruary 2006
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Retention: Agenda
PredictionPrevention
DetectionManagement
…….. but first ………
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Foley Catheters: Consequences
Polymicrobial bacteriuria (universal by 30days)
Febrile episodes (1 per 100 patient days)
Nephrolithiasis,
Bladder stones
Chronic renal inflammationPyelonephritis
Reduced Mobility
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Indications for Foley Catheter
Short term decompression of acuteretentionWhen retention can’t be managedsurgically or medicallyWhen wounds need to kept clean
Comfort in terminal illnessPatient insistence despite knowing
risks
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Bladder Function:
Conditions for emptyingThe bladder must contract effectively
Urethra must relax and must permitunobstructed flow
The bladder & urethra must be
coordinated
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Retention: the Danger
If low bladder wall compliance or outletobstruction, urine flow from ureters isimpededRisk of hydronephrosis and/or reflux frombladder into uretersPossible effect on upper urinary tract:
Kidney damage
Infection from mixing urine from ureters withhigher level of bacteria with urine frombladder)
Possible UTI d/t stasis of urine in bladder
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Retention:
A predictable problem
Who is at risk?
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More Causes of Retention
Diuresis with sudden bladder overdistention (diuretics, alcohol toxicity,hyperglycemia)
Vit B12 deficiency
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What about Surgery: Factors
Contributing to Risk of Retention?
Bladder procedures, anorectalprocedures
AnaestheticsAnicholinergic medications
OpiatesPeri-operative fluid volume
Constipation/reduced mobility
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Patients at Risk for Retention
Neurological disease (MS, Parkinson’s,chronic alcohol, diabetic neuropathy)Trauma: spinal cord injury, pelvic #,
Bladder outlet obstruction (BPH, prostatecancer, uterine/bladder prolapse,impaction)
Iatrogenesis (medications, anaesthetics,radiation, large volume replacement)Elderly (detrusor hyperactivity with
impaired contractility)
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Can Retention be Prevented?
Not always but ………
Often … by avoiding transient causes:Prevent or resolve constipationPrevent or resolve bladder infection
Patient is up. Mobility helps
Toilet or commode are best
Upright, avoid bedpan
Adequate intake (minimum 1500 mL)
Void in response to urge not requestDiscontinue anticholinergic meds if possible ASAP (e.g.loxapine). Can take as much as 2 – 3 weeks to recoverfrom effects.
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Detecting Retention:
Doing a Post Void Residual
Who should have a PVR?Anyone who:has difficulty voiding or inability to voidis incontinenthas recently had a catheter removed
has repeated urinary tract infectionshas unexplained agitationhas unexplained distention
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Method for Measuring PVR
In & Out Catheterization or Bladder ScannerProcedure:Have patient void in as close as possible to
“ideal position”. Toilet or commode;Measure the void.Measure residual no later than 15 to 30 minutespost voidNote: Bladder will empty best following naturalurge rather than when asked to void; ideallyfirst void in the morning
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Interpreting PVR Results
< 50 mL – normal at most ages< 100 mL – normal for elderly
Between 50 and 199 mL – use clinical judgement to determine impact onindividual (e.g frequent UTIs)
> 200 mL inadequate emptying – report tophysician/refer to urologist if continues
> 400 mL – requires In and Out catheter
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You Have Discovered Retention.
Now What?Get and order for In and Out catheter for residual > 400
mL & PRN (for discomfort)Avoid Foley if possible because far more likely to causeinfection than I & O
Look for & manage transient causes:
Delirium (medications)Constipation, impactionAnticholinergic medicationsInfection
Restricted mobilityConsider putting Foley in for 7 days to decompress thebladder and/or until the patient mobile/until transientcauses removed
Then do trial of voidingMay try medications especially for men
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Removal of Foley: Voiding Trials
Before taking Foley out ensure ideal conditionsfor voiding
No constipation !!!!No bladder infection
Patient is up. Mobility helpsToilet or commode are bestUpright, avoid bedpanAdequate intake (minimum 1500 mL)
Void in response to urge not requestDiscontinue anticholinergic meds if possible (e.g.loxapine). Sometimes need as much as 2 – 3 weeks torecover from effects.
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In and Out Catheterization for
Trial of voiding
Purpose:To retrain bladder/restore bladdercapacity after Foley
To prevent reflux or hydronephrosis kidney damage
Goal:To maintain total bladder volume (voidplus residual) less than 500 mL
Schedules for In and Out
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Schedules for In and OutCatheterization for Trial or forRetention
Start with scan q.i.d. Do in and out for residual
volumes > 400 mL (or as physician orders)When residuals consistently between 200 &300 mL reduce cath to BIDWhen PVR under 200 mL - daily cath. usuallyat hs
When consistently between 100 & 200 mLcheck once per weekAs long as bladder has less than 200 mL at
least once per day risk of infection is lowered
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Schedule Needs Revision If:
Patient is uncomfortable (feeling ofbladder fullness between caths)Patient leaks urine between In & Out
caths.Patient has bladder spasmsVoid plus residual is > 500 mL . Use chart
to determine time of day and add an extracath.Spread out intake over day
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Documentation
Chart void timeVoid amount
Residual measurement time
Residual amount
Catherization time
Catheterization amount
NB times and volumes are all important
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Post-Op Retention Retention
Is Predictable – expect itIs Preventable – avoid transientcontributors
Is detectable – In and out cath. orbladder scanner. Follow procedure
Can be managed in a timely andevidence-based way – follow protocol.Include prevention