导尿管之选择与护理

導尿管之選擇與護理慈濟技術學院江明珠Incidenceofcatheterization10%ofpatientsinhospital（Mulhalletal,1988）25%ofpatientsinhospital（Saintetal,1999）4%ofpatientsreceivingnursingservicesathome（GetliffeandMulhall,1991）IndicationsforuseofurinarycathetersShort-termcatheterizationUrologicsurgerySurgeryoncontiguousstructuresCriticallyillpatientsrequiringaccuratemeasureofurinaryoutputAcuteurinaryretentionIndicationsforuseofurinarycathetersLong-termcatheterizationBladderoutletobstructionnotcorrectablemedicalorsurgicallyIntractableskinbreakdowncausedorexacerbatedbyincontinenceSomepatientswithneurogenicbladderandretentionPalliativecareforterminallyillorseverelyimpairedincontinentpatientsforwhombedandclothingchangesareuncomfortablePreferenceofapatientwhohasnotrespondedtospecificincontinencetreatments

途徑TransurethracatheterizationTransvesicalcatheterization（suprapubiccatheterization）Whatissuprapubiccatheterization？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suprapubiccatheterizationsuprapubiccatheterizationindicationsforsuprapubiccatheterizattionUrethratraumaClientswhorequirelong-termcatheterizationandwhoaresexuallyactiveFollowingpelvicorurologicalsurgerySomegynaecologicalconditions,e.g.colposuspensionLong-termcatheterizationforincontinenceClientswhoareunabletotolerateurethralcatheterizationSomewheelchair-boundclientsConsidersuprapubicorurethralcatheterizationsuprapubicurethralLongterm（includingincontinence）ShorttermSexuallyactiveclientsintermittentPost-specificsurgeryPost-specificsurgeryUrethratraumaDifficultieswithsuprapubicSomewheelchair-boundclientsDifficultieswithurethralcatheterConsidersuprapubicorurethralcatheterizationsuprapubicurethraspecificcareStrictasepsisoninsertionStrictasepsisoninsertionspecificadvantagesReducedriskofinfectionNurseabletocarryoutprocedureEnablesexualintercourseConsidersuprapubicorurethralcatheterizationsuprapubicurethralSpecificdisadvantagesAlteredbodyimageAlteredbodyimagePotentialleakagefromandaroundsiteImpedessexualintercourseRequiresaregisteredmedicalpractitionertoinsertHigherriskofinfectionSelectionofcathetersWhichmaterialForshort-termuse（1-28days）:Latex,PVC,PTFE-coatedlatexfoleycatheterForlong-termuseofupto12weeks,selectoneofthefollowing:hydrogel-coatedlatexfoleycatheterpuresiliconFoleycathetersilicon-coatedlatexFoleycatheterSelectionofcathetersCathetersizeMale:14-16Ch（length40-45cm）Female:12-14Ch（length20-26cm）Balloonsize5-10mlrecommended30mlsurgeryonlyCatheter-relatedproblemBypassingUTIBlockedcatheterInadvertentcatheterremovalCatheter-relatedproblem-BypassingCommoncausesofbypassingConstipationKinkedtubingCathetersizeandlength/balloonDetrusorinstabilityTrigoneirritationblockageCatheter-relatedproblem-UTI直接影響導尿管造成感染之因素：放置時間長短Detectsignificantmicrobialcounts-3daysaftercatheterization（Bachetal,1990）TheriskofdevelopingbacteriuriaGaribaldietal（1974）：8.1%foreachdayMulhalletal（1988）：5-8%foreachdaySedor（1999）：5%foreachdayBacteriuriaisvirtuallyinevitablewithin3-4weeks（Jewesetaal,1988）Catheter-relatedproblem---UTI危險因素：引流袋污染糖尿病女性患者抗生素使用頻頻測量尿輸出量腎功能不良技術不良Catheter-relatedproblem---UTI致病機轉細菌由會陰部或尿袋移生後經由導尿管外壁或內壁上行女性之感染途徑為經由直腸正常菌叢污染尿道周圍男性主要為管路內經由外來細菌污染尿道口之細菌可經由插入導尿管時帶入膀胱Catheter-relatedproblem---UTICatheter-relatedproblem---UTI致病菌Extogenousorganisms（e.g.serratiaspp.AndPseudomonasaeruginosa）foundintheenvironmentandonhandEndogenousfaecalorurethralmicroorganisma（e.g.Gram-positivecocciandKlebesiella）ComplicationsassociatedwithurinarycathetersShort-termcatheterizationTraumaandinflammationUrethritisbacteriuria：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

ComplicationsassociatedwithurinarycathetersLong-termcatheterization菌尿症是很常見，一般多於6週內發生有症狀泌尿道感染、發燒、急性腎盂腎炎、菌血症、甚至死亡導尿管阻塞、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長期導尿管之病人尿中有95%為多重菌感染，菌種為E.coli、P.aeruginosa、P.mirabilis，少數為Providentia

stuartii及M.morganii病患留置導尿前之護理評估病患留置導尿的適應症選擇合適的導尿管評估病患留置導尿前的排尿情形病患留置導尿前之護理指導正確置入導尿技術

病患留置導尿的護理維持導尿管引流系統的功能適當固定導尿管，預防拉扯及創傷預防泌尿道的感染評估留置導尿管對病患及家庭的影響，並協助處理預防便秘尿液滲漏的處理

MaintainingaclosedurinarydrainagesystemDON’TDon’tallowanytensiononthetubingthatcoulddislodgethecatheterordamagetheurethraDon’tallowtubingtoloopbelowthedrainagebagDon’tattachthedrainagetoabedrailorallowittorestonthefloorDon’tallowthepatienttolieonthetubingMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemDOMaintaingravitydrainagebykeepingthedrainagebagbelowthelevelofthepatient’sbladderatalltime.keepthetubingfreefromkinksandobstructionsMakessurethatthesystemiswellsealedandthebag’semptyingportisclosed.checkforleaksatconnectionsitesForapatientinbedoronastretcher,suspendthedrainagebagfromthebedorstretcherframe,usingthehookorstrapprovidedIfthepatientisinachairnearthebed,keepthedrainagebagonthebedframewiththebedinalowpositionor