Situation• You are a staff nurse in an outpatient dialysis facility.• A 50-year-old woman with ESRD is scheduled to be seen in the clinic; it is anticipated that she will need dialysis in the near future. The patient lives alone and will require teaching about the dialysis options.• Develop a teaching plan to explain the different types of dialysis, goals, and level of involvement on the part of the patient.
Preventing Infection in the Patient With an Indwelling Urinary Catheter• Use aseptic technique during insertion of the catheter.• Use a sterile, closed urinary drainage system.• Never disconnect the tubing.• The drainage bag must never touch the floor.• The bag and collecting tubing are changed if contamination occurs, if urine flow becomes obstructed, or if tubing junctions start to leak at the connections.• If the collection bag must be raised above the level of the patient’s bladder, clamp the drainage tube. This prevents backflow of contaminated urine into the patient’s bladder from the bag.
• Ensure a free flow of urine to prevent infection.• To reduce the risk of bacterial proliferation, empty the collection bag at least every 8 hours through the drainage spout—more frequently if there is a large volume of urine.• Avoid contamination of the drainage spout. A receptacle in which to empty the bag is provided for each patient.• Check for inflammation or signs of infection in the area around the catheter. Signs of infection include pus or irritated, swollen, red, or tender skin.• Never irrigate the catheter routinely. If the patient is prone to obstruction from clots or large amounts of sediment, use a three-way system with continuous irrigation.• Never disconnect the tubing to obtain urine samples, to irrigate the catheter, or to ambulate or transport the patient.
• Never leave the catheter in place longer than is necessary.• Avoid routine catheter changes unless problems such as leakage, blockage, or infection.• Avoid unnecessary handling or manipulation of the catheter by the patient or staff.• Carry out hand hygiene before and after handling the catheter, tubing, or drainage bag.• Wash the perineal area with soap and water at least twice a day.• Dry the area well, but avoid applying powder because it may irritate the perineum.• Monitor the patient’s voiding when the catheter is removed.• The patient must void within 8 hours; if unable to void, the patient may require catheterization with a straight catheter.• Obtain a urine specimen for culture at the first sign of infection.
BLADDER TRAINING• The purpose of this procedure is to retrain the bladder to empty at timed intervals and in adequate amounts and to prevent urinary incontinence in case for long periods of catheterization.
GUIDELINES1.This procedure takes a minimum of 4 days to complete.2. Empty the urine collection bag each time the catheter is clamped.3. Each time the catheter is unclamped, measure the urine noting the color, clarity and amount of urine. Record this information in the resident’s medical record.4. The resident should be able to tolerate a minimum of 250cc of urine in the bladder before removing the catheter.
PROCEDURE1. On the first day clamp the catheter closed for 1-2 hours. (Preferably 2 hours if resident can tolerate the full time).2. Empty urine collection bag.3. Check the resident frequently. If the resident complains of pain or cannot tolerate the full 2 hours, shorten the time and then increase it gradually.4. Unclamp the catheter after two hours and allow the bladder to empty.5. Note the amount, color and clarity of the urine.6. Encourage the resident to press down with abdominal muscles to assist in emptying the bladder.7. Leave the catheter unclamped for 15 minutes, then re- clamp for 1-2 hours.8. Continue this process for the first 24 hour period.
9. On day 2 increase clamping time to 2-3 hours, unclamp for 15 minutes and then re-clamp.10. Continue this process for the second 24 hour period.11. On day 3 increase clamping time to 3-4 hours, unclamp for 15 minutes and then re-clamp.12. Continue this process for the third 24 hour period.13. On the fourth day, remove the catheter paying close attention and responding to the resident’s requests for help when toileting.14. Assist the cognitively impaired resident to the toilet every two hours to prevent incontinent episodes.