urinary retension

8/9/2019 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

urinary retension

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