导尿管之选择与护理

1、導尿管之選擇與護理慈濟技術學院 江明珠Incidence of catheterizationn10% of patients in hospital（Mulhall et al,1988）n 25% of patients in hospital（Saint et al,1999）n4% of patients receiving nursing services at home（Getliffe and Mulhall,1991）Indications for use of urinary cathetersShort-term catheterizationnUrologic surge

2、rynSurgery on contiguous structuresnCritically ill patients requiring accurate measure of urinary outputnAcute urinary retentionIndications for use of urinary cathetersLong-term catheterizationnBladder outlet obstruction not correctable medical or surgicallynIntractable skin breakdown caused or exac

3、erbated by incontinencenSome patients with neurogenic bladder and retentionnPalliative care for terminally ill or severely impaired incontinent patients for whom bed and clothing changes are uncomfortablenPreference of a patient who has not responded to specific incontinence treatments 途徑nTransureth

4、ra catheterizationnTransvesical catheterization（ suprapubic catheterization ）What is suprapubic catheterization？n恥骨上導尿管：在膀胱脹滿水之後由恥骨上正中央插入導引器然後插入導尿管suprapubic catheterizationsuprapubic catheterizationindications for suprapubic catheterizattionnUrethra traumanClients who require long-term catheterizat

5、ion and who are sexually activenFollowing pelvic or urological surgerynSome gynaecological conditions,e.g.colposuspensionnLong-term catheterization for incontinencenClients who are unable to tolerate urethral catheterizationnSome wheelchair-bound clientsConsider suprapubic or urethral catheterizatio

6、nsuprapubicurethralLong term（including incontinence）Short termSexually active clientsintermittentPost-specific surgery Post-specific surgeryUrethra traumaDifficulties with suprapubicSome wheelchair-bound clientsDifficulties with urethral catheterConsider suprapubic or urethral catheterizationsuprapu

7、bicurethra specific careStrict asepsis on insertionStrict asepsis on insertion specific advantagesReduced risk of infectionNurse able to carry out procedureEnable sexual intercourseConsider suprapubic or urethral catheterizationsuprapubicurethral Specific disadvantagesAltered body imageAltered body

8、imagePotential leakage from and around siteImpedes sexual intercourseRequires a registered medical practitioner to insertHigher risk of infectionSelection of cathetersWhich material For short-term use （1-28days）:nLatex, PVC, PTFE-coated latex foley catheter For long-term use of up to 12 weeks,select

9、 one of the following:n hydrogel-coated latex foley cathetern pure silicon Foley cathetern silicon-coated latex Foley catheter Selection of cathetersCatheter sizeMale:14-16Ch（length 40-45cm）Female:12-14Ch（length20-26cm）Balloon size5-10ml recommended30ml surgery only Catheter-related problemnBypassin

10、gnUTInBlocked catheternInadvertent catheter removalCatheter-related problem-BypassingCommon causes of bypassingnConstipationnKinked tubingnCatheter size and length/balloonnDetrusor instabilitynTrigone irritationnblockageCatheter-related problem-UTI直接影響導尿管造成感染之因素：直接影響導尿管造成感染之因素：放置時間長短nDetect signific

11、ant microbial counts-3days after catheterization（Bach et al,1990）nThe risk of developing bacteriuria Garibaldi et al （1974）： 8.1% for each day Mulhall et al（1988）：5-8% for each day Sedor（1999）：5% for each daynBacteriuria is virtually inevitable within 3-4 weeks（Jewes et aal,1988） Catheter-related pr

12、oblem-UTI危險因素危險因素：n引流袋污染n糖尿病n女性患者n抗生素使用n頻頻測量尿輸出量n腎功能不良n技術不良Catheter-related problem-UTI致病機轉n細菌由會陰部或尿袋移生後經由導尿管外壁或內壁上行n女性之感染途徑為經由直腸正常菌叢污染尿道周圍n男性主要為管路內經由外來細菌污染n尿道口之細菌可經由插入導尿管時帶入膀胱Catheter-related problem-UTICatheter-related problem-UTI致病菌nExtogenous organisms（e.g.serratia spp. And Pseudomonas aeruginos

13、a）found in the environment and on handnEndogenous faecal or urethral microorganisma（e.g.Gram-positive cocci and Klebesiella）Complications associated with urinary catheters Short-term catheterizationnTrauma and inflammationnUrethritisnbacteriuria：尿道周圍有革蘭氏陰性桿菌及腸球菌移生，80%會產生菌尿症，女性病人菌尿症中70-80%是因導尿管外壁與尿道黏

14、膜空隙之細菌侵入。導尿管短期置放之菌尿症通常為單一菌種，但有15%是多菌且同時為膿尿，E.Coli是常見細菌 Complications associated with urinary catheters Long-term catheterization1. 菌尿症是很常見，一般多於6週內發生2. 有症狀泌尿道感染、發燒、急性腎盂腎炎、菌血症、甚至死亡3. 導尿管阻塞、尿路結石、局部尿道周圍感染、慢性腎炎、腎衰竭、甚至術年後發生膀胱癌4. 男性長期導尿管放置可導致尿道炎、尿道廔管、副睪炎、陰囊膿瘍、攝護腺炎或攝護腺膿瘍5. 長期導尿管之病人尿中有95%為多重菌感染，菌種為E.coli、P.a

15、eruginosa、P.mirabilis，少數為Providentia stuartii及M.morganii病患留置導尿前之護理n評估病患留置導尿的適應症n選擇合適的導尿管n評估病患留置導尿前的排尿情形n病患留置導尿前之護理指導n正確置入導尿技術 病患留置導尿的護理n維持導尿管引流系統的功能n適當固定導尿管，預防拉扯及創傷n預防泌尿道的感染n評估留置導尿管對病患及家庭的影響，並協助處理n預防便秘n尿液滲漏的處理 Maintaining a closed urinary drainage systemDONTnDont allow any tension on the tubing that

16、 could dislodge the catheter or damage the urethranDont allow tubing to loop below the drainage bagnDont attach the drainage to a bed rail or allow it to rest on the floornDont allow the patient to lie on the tubingMaintaining a closed urinary drainage systemMaintaining a closed urinary drainage sys

17、temMaintaining a closed urinary drainage systemDOnMaintain gravity drainage by keeping the drainage bag below the level of the patients bladder at all time.keep the tubing free from kinks and obstructionsnMakes sure that the system is well sealed and the bags emptying port is closed.check for leaks

18、at connection sitesnFor a patient in bed or on a stretcher,suspend the drainage bag from the bed or stretcher frame,using the hook or strap providednIf the patient is in a chair near the bed, keep the drainage bag on the bed frame with the bed in a low position or attach the bag to the chairMaintain

19、ing a closed urinary drainage systemMaintaining a closed urinary drainage systemMaintaining a closed urinary drainage systemUrinary catheter securementn導尿管固定好可降低尿管意外脫落，及由於過拉扯尿管或尿袋所造成的組織損傷及發炎n尿管滑脫之比例為17%-41%，而不適當的固定是主要的危險因子，常引起沒有計劃性的尿管拔除。n創傷及發炎與重複導尿管移動及尿道受壓有關，當尿管沒有適當固定或病人拉扯尿管會造成尿管沒有目的的移動，移動尿管會造成創傷及發炎

20、，使其更容易造成感染、組織壞死、尿道腺體阻塞及膀胱不穩定或痙攣。Urinary catheter securementn膠布是最古老的固定方法，將尿管黏貼於大腿或腹部，採chevron method ，即使臨床研究其固定效果不佳，然在沒有其他選擇下，膠布仍然是主要固定尿管之方法。優點：便宜、方便缺點：1.易脫落2.常引起皮膚不同程度的反應3.重複的膠布使用，使得尿管感覺黏黏的，微生物即容易聚積在上面，而增加管腔外染污之危險性，使微生物進而進入膀胱引起泌尿道感染。Maintaining a closed urinary drainage systemUrinary catheter secure

21、ment導尿管固定帶導尿管固定帶 Dale Foley Catheter HolderDale Foley Catheter HolderUrinary catheter securementn導尿管固定帶導尿管固定帶為專利產品，利用容易鬆綁之魔鬼膠帶，將導管固定，避免導管晃動拉扯脫出、感染，適合長期照護，急診手術後需留置導管病患使用。n導尿管固定帶導尿管固定帶簡易、方便，沒有使用貼膠所引起皮膚的過敏或不舒服nDale Foley Catheter HolderDale Foley Catheter Holder可分#316#316大腿固定帶及#330#330腰部固定帶Urinary cath

22、eter securementtape may be the oldest method,but its not the only onenThe statlock Foley device,an adhesive anchor for urinary cathetersUrinary catheter securementnTThe Statlock Foley Pediatric device stabilizes the urinary catheter via a teddy bear-shaped adhesive anchorUrinary catheter securementnTThe Flexi-Trak device, a mutipurpose anchor,can be adjusted to secure even large-diameter drainage tubing CDC Guidelines for prevention of Catheter-Associated UTICategory1.strongly recommendednCatheterize only when necessarynEducate personnel in correct techniques of catheter insertion and c