Elimination .pptx

URINARY CATHETERIZATION and ENEMA
By: Murad U( BSC,MSC Fellow)
4/12/2023 1

OBJECTIVES
After completion of this session you will be able to:
Define catheterization and enema
Discuss types of catheter and enema
Describe Indications, contraindications and complications of
catheterization and enema
 Demonstrate urinary catheterization and offering enema
4/12/2023 2

Urinary catheterization
The introduction/insertion of a catheter/tube via the urethra into
the urinary bladder.
A catheter is a plastic or rubber tube used for injecting or
removing fluids from the body.
NB:- Strictly a sterile procedure, i.e. the nurse should always
follow aseptic technique
4/12/2023 3

Types of catheter
Catheters came in different size, materials and types.
The most common types of catheter are
Indwelling or retention catheter
Straight or plain catheter
4/12/2023
Urinary catheterization cont’d…
4

A) Indwelling catheter
It also called retention or Foley catheter.
It can be differ in the number of lumens
Double lumen catheter- has two lumens
One lumen is used to inflate balloon at the end of the catheter
The other lumen is to drain urine.
4/12/2023
5

Triple lumen catheter – has three lumens.
One lumen drains the urine.
The second lumen holds the sterile water when the catheter is inflated .
The third lumen maybe used to instill medications into the bladder or provide
bladder irrigation.
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4/12/2023 7

 Catheter size depends on the size of the urethral canal
# 8-10 Fr – children
# 14-16 Fr – female adults
# 18 Fr – adult male (Fr: French scale)
 Appropriate catheter length is determined by the clients gender
 For adult male – 40 cm catheter
 For adult females – 22 cm catheter

Purpose:
To manage urinary incontinence
Continuous bladder drainage in post surgery and critically ill
patients
Managing skin ulceration caused by incontinence
Instillation of medication into the bladder
Provide a means to monitor accurate urine output in critically
ill patients
4/12/2023
9

B) Intermittent or straight catheter
A catheter used to drain the bladder for shorter period of time (5-10 min).
Purpose:
To relieve discomfort due to bladder distension
To assess the residual urine
To obtain a urine specimen(about 30ml)
To empty the bladder prior to surgery
4/12/2023
10

C) Alternatives for urethral catheterization
Suprapubic catheterization
It is inserted through a small incision above the pubic area directly
into the urinary bladder.
Purpose:
To divert the flow of urine from the urethra when the urethral route
is impossible
After gynecologic or other abdominal surgery
Occasionally after pelvic fractures
4/12/2023
11

4/12/2023 12

Choosing the appropriate catheter depends on:
The size of the patient’s urethral canal
The expected duration of catheterization
Knowledge of any allergies to latex or plastic.
The indications for catheterizing the patient
4/12/2023
13

Contraindications
Urethral trauma
Pelvic fracture
Scrotal hematoma
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14

Risks/Complications
Infections related to poor sterile technique or long-term
catheterization
Bladder spasms and pain
Urethral trauma
4/12/2023
15

Sterile Set
Retention or Foley catheter
2 Sterile drapes (fenestrated & square
drape)
Sterile gauze
14 Cotton swabs
6 forceps in kidney dish
Receiver (kidney dish)
1 forceps in Sterile urine receptacle (KD)
10 cc Sterile water in galipot
Syringe (usually 10 cc)
Galipot
Sterile gloves
Specimen bottle
Equipment
4/12/2023 16

Clean Set
Cleansing solution (sterile NS)
Urine collection bag & tubing
Bed screen
Soap and 3 washcloths
Warm water in basin
Towel
Rubber sheet
Lubricant
Tape
Disposable gloves
Bath blanket
4/12/2023 17

Procedure
1. Explain procedure to patient.
2. Wash hands, gather equipment and bring to the bed side.
3. Provide privacy by applying bed screen.
4. Adjust the bed to a comfortable Ht and apply bath blanket.
5. Place the pt in an appropriate position
Male: supine position with legs slightly spread and feet together or
dorsal recumbent position.
Female: dorsal recumbent
4/12/2023 18

6. Don disposable gloves and wash perineal area (if not did).
7. Remove disposable gloves.
8. Hang the urinary drainage bag on the side of the bed and
place below the level of bladder.
9. Open the sterile field and:
Pour cleansing solution in one galipot
Place lubricant in one sterile gauze
Open the Foley catheter and place it on the sterile field (if not placed)
4/12/2023 19

10. Apply sterile gloves and fill the syringe with sterile NS (10ml) from galipot.
11. Check balloon for any leakage and symmetry then deflate and leave the syringe
attached.
12. Lubricate 2.5-5 cm of the catheter tip and place on the sterile urine receptacle (kidney
dish).
13. Place square (un-fenestrated) drape b/n thighs or under pt hip.
14. Place sterile supplies on the sterile square drape.
4/12/2023 20

15. Clean the area with 7 swabs and 3 forceps in zigzag fashion.
a) Use one forceps for step 1, 2, and 3.
1) Pubic area
2) Rt groin
3) Lt groin
b)Use one forceps for step 4 and 5
4) Rt labia (Periurethral mucosa)
5) Lt labia
c)Use one forceps for step 6 and 7.
6) From urethral orifice to vaginal orifice
7) From urethral orifice to anal orifice
4/12/2023 21

16. Drying the area using 7 dry cotton balls and 3 forceps in the same
way of cleansing.
17. Place fenestrated drape on the client’s abdomen and thighs.
18. Pick up and hold end of catheter loosely coiled in palm of
dominant hand (still sterile).
19. Expose the urinary meatus adequately by:
Male: holding the penis perpendicular using non-dominant hand.
Female: separate labia using non-dominant hand.
4/12/2023 22

20. Identify the urinary meatus and gently insert:
5cm in females and 20cm in males or
Until urine comes.
21. Clamp the drainage lumen and inflate the balloon using 10cc sterile
NS.
22. Instruct the client to immediately report discomfort or pressure
during balloon inflation; if pain occurs:
Deflate the balloon
Insert the catheter farther into the bladder (1-2 inch)
Inflate the balloon again
23. Gently pull the catheter until the retention balloon is snagged
against the bladder neck (resistance will be met).
4/12/2023 23

24. Remove the fenestrated drape.
25. Connect the catheter with drainage bag tube.
26. Secure the catheter to the abdomen or inner thigh using tape.
27. Clean the perineal area using corners of sterile square drape to remove lubricant
and remove gloves.
28. Reposition the pt and return the bed to lowest position.
29. Wash hands and document the amount, color, odor, and quality of urine.
4/12/2023 24

Removal
Apply clean gloves.
Slightly palpate over the pubic area to check the emptiness of the
bladder.
Withdraw the solution from (deflate) the balloon using a syringe.
Remove catheter gently and discard.
4/12/2023 25

OFFERING ENEMA
Def/n: is the introduction of fluid into the bowels via rectum & sigmoid
colon
4/12/2023 27

Guidelines
 Enema for adults are usually given at 40-43oc and for children at 37.7 c
 Hot – cause injury to the bowel mucous
 Cold – uncomfortable and may trigger a spasm of the sphincter muscles
 The amount of solution to be administered depends on:
Kind of enema
The age of the person and
The persons ability to retain the solution

Offering Enema….
Types of Enema
Depending on the indication
a) Cleansing (evacuation) Enema
Solution (500 – 1000ml)
Tap water
Normal saline
Soap solution -1gm Soap in 20 ml of H2O
4/12/2023 29

Purpose/Indications:
Evacuate/cleanse lower bowel before diagnostic studies or surgery. E.g.
Colonoscopy
To stimulate peristalsis
To keep the colon empty (for incontinent patients)
Offering Enema….
4/12/2023 30

2) Retention Enema
Administration of solution to be retained in rectum and colon for
short or long period of time.
The fluid, usually medicine, is retained in rectum for local or
general effects.
Solution (150 – 200ml)
Emollient (oil)- oil retention enema
Medication- medicative enema
Barium salt suspension- barium enema
Nutrition- nutritive enema
Offering Enema….
4/12/2023 31

Indications
Soften and lubricate stool for easy evacuation
Administration of medication
To supply nutrition
Principles:
It is given/administer slowly.
The amount of fluid is usually 150 -200 cc.
Retention enema must be preceded by a cleansing enema.
A patient must rest for ½ hrs before giving retention enema.
Offering Enema….
4/12/2023 32

3) RECTAL WASHOUT
Also called Siphoning Enema, Colon irrigation or colonic flush.
is the process of introducing large amount of fluid in too large bowel
for flush in purpose and allow return or wash out fluid
Solution Used
Normal saline
Soda-bi-carbonate solution(to remove excess mucus)
Tap water
Offering Enema….
4/12/2023 33

Purpose
To prepare the patient for x-ray exam and sigmoidoscopy.
To prepare the patient for rectum or colon surgery
Offering Enema….
4/12/2023 34

Depending on the amount of solution used
a) Small-volume enemas
Used for the purpose of instilling medications in the rectum and sigmoid
colon only.
These are usually found as pre-packaged solutions, which contain 150 to 240
ml fluid
Offering Enema….
4/12/2023 35

b) Large-volume enemas
which typically contain 500 to 1000 ml fluid
They are administered to cleanse the bowel (as much of the
colon as possible).
Offering Enema….
4/12/2023 36

Complication/risk
Repeated enemas produce:
Irritation of bowel mucosa and perineal area
Fluid and electrolyte imbalance
Offering Enema….
4/12/2023 37

1) Cleansing enema
Equipment
Clean Set
Enema can
Rubber tube
Rectal tube
Stop cock or clamp
IV stand (pole)
Bedpan
Clean gloves
Towel and Rubber sheet
Solution per physician’s
order
Water-soluble lubricant
Tissue paper/gauze
Bed side screen
Receiver
Offering Enema….
4/12/2023 38

Procedure
1. Inform the patient about the procedure.
2. Wash hands and assemble the equipment then bring to the pt’s bed
side.
3. Put bed side screen for privacy.
4. Don clean glove and place the patient in the Sim’s position.
4/12/2023 39
Offering Enema….

5. Place bed protective materials under the bed.
6. Prepare enema can and solution:
a) Attach rubber tube with enema can then attach rubber tube with rectal
tube using stop cock.
b) Fill the enema can with 1000 cc of solution for adults.
c) Make the tube air free by releasing the clamp & allowing the fluid to run
down little to the bed pan and clamp – to prevent distention.
d) Lubricate about 5 cm of the rectal tube – to facilitate insertion through
the sphincter and to minimize trauma.
e) Hung enema can 45 cm from bed or 30 cm from pt on the stand (over
45 cm may cause cramping, discomfort & bowel perforation).
4/12/2023 40
Offering Enema….

7. Lift the upper buttock to visualize the anus.
8. Insert the rectal tube smoothly and slowly:
• 7-10 cm in an adult
• 5 -7.5 cm in the child
• 2.5 -3.75 cm in an infant
9. Open the clamp to allow fluid to flow.
4/12/2023 41
Offering Enema….

10. Administer the fluid slowly:
• If client complains of fullness or pain, stop the flow for 30” and restart
the flow at a slower rate.
• Clamp tubing or lower container if patient has desire to defecate or
cramping occurs
• Do not allow all the fluid to go as there is a possibility of air entering the
rectum.
11. Clamp/Close and remove the rectal tube from the anus and
offer the bed pan when:
• the client cannot hold anymore and wants to defecate
12. Remove bed pan and clean the rectal tube.
4/12/2023 42
Offering Enema….

2) Retention Enema
Equipment:
Other equipment is similar with cleansing enema except that
the rectal tube for retention enema is smaller in width.
Offering Enema….
4/12/2023 43

Procedure:
Similar with the cleansing enema but the enema should be:
Administered very slowly
Preceded by cleansing enema
Note:
Elevate foot of bed to help patient retain solution.
Temperature of retention enema fluid is 37.4oc or at body To.
Kinds of solution used to supply body with fluid are plain H2O,
normal saline, or glucose 5%.
100 -200 cc olive oil to be retained for 6-8 hrs is given for Sever
constipation
Offering Enema….
4/12/2023 44

3) OFFERING RECTAL WASHOUT
Procedure
Insert the tube like the cleansing enema.
The client lies on the bed with hips close to the side of the bed (client assumes a right
side lying position for siphoning).
Open the clamp and allow running about 1000cc of fluid in the bowel then siphon back
into the bucket.
Carry on the procedure until the fluid return is clear.
Offering Enema….
4/12/2023 45

Note:
The procedure should not take > 2hours.
Should be finished 1hour before exam or x-ray to give time for the large intestine
to absorb the rest of the fluid.
Give cleansing enema ½hour before the rectal wash out.
Allow the fluid to pass slowly.
Amount of solution 5-6 liters until the wash out rectum fluid becomes clear.
Offering Enema….
4/12/2023 46

Giving Nursing Care For A Patient With
Colostomy
4/12/2023 47

Giving nursing care for a patient with colostomy
Definition: it is an opening that is made in the colon with surgery.
• After the opening is made, the colon is then brought to the surface of the
abdomen to allow stools to leave your body
• The opening at the surface of the abdomen is called a stoma.
• The pouch is attached to the skin with an adhesive
4/12/2023 48

4/12/2023 49
Giving nursing care for a patient with colostomy....

4/12/2023 50

Indication:
• When feces cannot progress naturally from the colon to the anus
• when the rectum or anus is non-functional
• to divert the fecal flow away from an operative area or an area of inflammation
4/12/2023 51

Types of colostomies
a) Temporary colostomy: may be needed to allow the colon to rest and heal
for a period of time
• may be in place for weeks, months, or years
• will eventually be closed and bowel movements will return to normal
b) Permanent colostomy: is usually needed when a part of the colon must be
removed or cannot be used again.
4/12/2023 52

Related to the place on the colon where the surgery is done.
Ascending colostomy:
• The output (stool) that drains from this stoma is in liquid form.
Transverse colostomy:
• The output that drains from this stoma may be loose or soft.
Descending or sigmoid colostomy:
• The output that drains from this stoma is firm.
4/12/2023 53

Colostomy Pouches
Definition: pouch is a flat, changeable, waterproof, odor-proof & light
weight bag.
Purpose: Uses to collect the stool passed through the stoma.
• A colostomy pouch is normally emptied one or more times daily.
• The pouch itself usually needs to be changed every four to six days.
4/12/2023 54

4/12/2023 55

Types of colostomy pouches:
Open-ended pouch:
• The open end is usually closed with a clamp.
• usually used by people with ascending or transverse colostomies.
• The output from these colostomies is looser and is unpredictable (does not drain at
regular times).
4/12/2023 56

Close-ended pouch:
• This type of pouch is removed and thrown away when the
pouch is filled.
• usually used by people with a descending or sigmoid
colostomy.
• The output from these types of colostomies is firm.
4/12/2023 57

• One-piece pouch:
• contains the pouch and adhesive skin barrier together as one unit.
• Two-piece pouch:
• has two parts: an adhesive flange and pouch. The
• adhesive part stays in place while the pouch is removed
4/12/2023 58

Changing a Colostomy Pouch
Equipment
• Appropriate pouch
• Disposable gloves
• Soap and washcloth
• Warm water
• Skin barrier, if needed
• Pouch clip or rubber band, if needed
• Skin paste, if needed
4/12/2023 59

Procedure
1. Explain the procedure to client and provide for privacy. Include caregivers
in instruction if indicated.
2. Wash hands.
3. Assist client to a standing (preferable) or sitting position and don gloves.
4. Remove the soiled pouch by gently pressing on the skin while pulling the
pouch.
4/12/2023 60

5. Remove the soiled pouch by gently pressing on the skin while pulling
the pouch.
6. Dispose of the pouch in a plastic bag after removing the clip used to
seal the pouch to be thrown away if the pouch is disposable.
Rationale: Minimizes odor associated with the pouch change.
7. Cleanse the skin around the stoma with soap and warm water; pat
your skin dry.
8. Inspect the peristomal skin for redness, altered skin integrity, or
rashes; consult the charged nurse if any problem is there.
9. Remove excessive hair with a safety or electric razor.
4/12/2023 61
Procedure….

10. Inspect the pouch opening and ensure that it fits the stoma
11. Use a pouch that has an opening that is one-eighth (1/8th) of an
inch larger than the stoma.
12. Apply a skin sealant or skin paste if indicated; apply skin barrier
13. Applies adhesive to bag or removes backing from adhesive.
14. Gently apply the pouch and press into place for 30 seconds
4/12/2023 62
Procedure….

15. Seal the inferior opening with the clip or a rubber band.
16. Remove gloves and discard; wash hands.
17. Note type and size of pouch; condition of stoma (drainage
amount and odor; surrounding skin); and client response.
4/12/2023 63
Procedure….

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Elimination .pptx