FN II

• Urinary system


  • Kidneys
  • Ureters
  • Urinary bladder
  • Urinary sphincter muscles
  • Urethra

  
• Male urethra is normally curved, straightened by elevating the penis to position perpendicular to the body
• Female urethra is 1.5-2.5 inches (3-6cm) long, more prone to urinary tract infection (UTI)

  
• Male urethra is ~8 inches (16-20cm) long

  
• Micturition: voiding/urination

  1. Urine collects in the bladder

  2. Pressure stimulates stretch receptors in bladder wall

  3. Stretch receptors transmit impulses to spinal cord voiding reflex centre

  4. Internal sphincter relaxes

  5. External sphincter relaxes

  6. Urine eliminated through urethra at the meatus
• Factors affecting voiding

  • Developmental factors (infants, older adults)
  • Psychosocial factors (stress, privacy)
  • Food & medications (tea, alcohol, drinks with caffeine, diuretics)
  • Physical factors (muscle tone: detrusor muscle of bladder, internal & external sphincter of urethra)
  • Pathological conditions (kidney disease, urinary stone, pain, blockage, infection, Benign prostatic hypertrophy (BPH), surgical/diagnostic procedure, post-anesthetic)
• Indications for urinary catheterization

  • To relieve discomfort: decompression of a distended bladder due to retention of urine
  • To assess residual urine after voiding
  • To obtain sterile urine specimen
  • To empty the bladder completely for surgical intervention
  • To perform bladder irrigation, e.g., draining blood clots in profuse haematuria, instilling medications
• Perform urinary catheterization only if really necessary, as it increases the risk of introduction of microorganisms and infection

  
• Urinary catheters


  • Latex (coated), or polyvinyl chloride (PVC)
  • Silicone (usually for long-term use)
  • Straight catheter for intermittent catheterization or obtaining a urine specimen; single use
  • Indwelling catheter (retention catheter), in place for 7 days or longer
  • 3-way catheter for bladder irrigation
• Latex catheters are flexible but may cause urethral trauma and need to be changed every 14 days
• Silicone catheters are biocompatible with urethra mucosa, resistant to encrustation, hypoallergic, and need to be changed every 30 days
• Complications with urinary catheterization

  • Trauma to urethra &/or bladder
  • Haematuria
  • Urinary tract infection (UTI): catheter associated bacteruria increases by 5-8% each day during the period of catheterization
  • Debris and stone formation

  
• Measures to prevent Catheter-Associated Urinary Tract Infection (CAUTI)

  • Evaluate the need of insertion or continued use of an indwelling catheter
  • Use alternatives: condom catheter, incontinence pads, intermittent catheterization, etc.
  • Perform aseptic catheter placement
  • Maintain closed drainage system and catheter care
  • Carry out appropriate post-insertion nursing interventions
  • Remove catheter as soon as possible
• Intermittent Catheterization (IC)

  Self catheterization
• Assessing volume of urine in bladder

  Bladder Scan
• Performing urinary catheterization


  1. Review past medical history (PMH) and general condition (GC)

  2. Check physician's orders for method of catheterization to be done

  3. Assess purpose of catheterization or urine output monitoring

  4. Verify client's identity

  5. Palpate the client's bladder for distention

  6. Assess the volume of retention of urine (RU) with bladder scan, if indicated

  7. Assess urinary meatus for exudate or inflammation

  8. Assess the client's I & O chart, e.g. Urine output and time of last voiding

  9. Review allergic history e.g. medication/latex/tapes/gel/lubricant

  
• Implementation: Positioning


  1. Female: Assist the client to a dorsal recumbent position with knee flexed, feet apart with legs abducted (frog legs)

  2. Male: Supine with legs extended and thighs slightly abducted
• Implementation: Catheterization


  1. Perform hand hygiene

  2. Verify client identification

  3. Explain the procedure to the client

  4. Provide privacy

  5. Prepare the equipment and open a new urine collection bag and hang it at the client's bedside with a hanger

  6. Ensure the outlet is not touching the floor

  7. Place waterproof sheet under client's buttock to protect the linen

  8. Open sterile catheterization set and add the sterile items into the sterile set

  9. Expose the client's perineum area

  10. Perform hand hygiene

  11. Don sterile gloves

  12. Prepare and allocate sterile items into the sterile set

  13. Test catheter balloon with 10 ml syringe only if necessary

  14. Prepare the swabs soaked with disinfectant

  15. Aspirate 10 ml of sterile water with 10 ml sterile syringe

  16. Connect the syringe to the inflation port of the urinary catheter

  17. Lubricate the first part (~5-10cm ) for female or about 12-17cm (for male) of catheter tip with lubricant (+/ Xylocaine gel for male patient)

  18. Drape sterile towel / field around client's perineum

  19. Bring the tray of disinfectant swabs with a pair of forceps on top of sterile drape

  20. With two pieces of sterile non woven gauze, separate the labia apart with the thumbs and index finger of your non dominant hand in a C shape; maintain position of non dominant hand throughout the procedure

  21. Disinfect the labia and urethral orifice with the disinfectant swabs using sterile forceps

  22. Swab from front to back, one swab once

  23. Put away the tray with the used forceps from the sterile drape

  24. Bring the kidney dish with equipment on top of the sterile drape

  25. With sterile glove on dominant hand, insert catheter gently into meatus 5-6cm or until urine starts to flow, then further insert for 2-5cm (1-2 inches)

  26. Inject 10ml sterile water (or as indicated) with 10ml syringe into the inflation port of the catheter (Keep holding the catheter with non dominant hand)

  27. If client complaints of pain on balloon inflation, aspirate the sterile water immediately

  28. Gently pull the catheter out until resistance is felt

  29. Retract the foreskin (if uncircumcised); then use nondominant hand to gasp penis at shaft just below glans
• Female catheterization

  1. Disinfect the labia and urethral orifice with the disinfectant swabs using sterile forceps

  2. Swab from front to back, one swab once

  3. Put away the tray with the used forceps from the sterile drape

  4. Bring the kidney dish with equipment on top of the sterile drape

  5. With sterile glove on dominant hand, insert catheter gently into meatus 5-6cm or until urine starts to flow, then further insert for 2-5cm (1-2 inches)
• Male catheterization


  1. Retract the foreskin (if uncircumcised); then use nondominant hand to gasp penis at shaft just below glans with a piece of sterile non woven gauze

  2. Hold the shaft of penis at right angle to body, then remain in this position during the procedure

  3. Use the dominant hand to hold the disinfected swab with sterile forceps

  4. Cleanse the urethral orifice and glans by circular stroke with one swab/ stroke once technique, beginning at the meatus and working outward in a spiral motion

  5. Repeat cleansing three times using the disinfected swabs with one swab/stroke once technique

  6. Put away the tray with the used forceps from sterile drape

  7. Bring the kidney dish with equipment on top of sterile drape

  8. Lift penis to a 90° angle perpendicular to body with your dominant hand, exert slight traction by pulling upward

  9. Insert the catheter with dominant hand 17-20cm from tip of catheter or until urine starts to flow, then further insert catheter until near to bifurcation

  10. If resistance, lower angle of penis to 45° and ask client to take a deep breath and continue to insert
• Wound healing

  Restore skin and/ or tissue integrity by a complex process of physiological responses

  
• Phases of wound healing

  • Hemostasis
  • Inflammatory/ reaction phase (0-3 days)
  • Proliferation/ regeneration phase (3-24 days)
  • Maturation/ remodeling phase (24 days – 1 year)

  
• Inflammatory phase


  Secretion of histamine by damaged tissue and mast cells, vasodilation and exudation of serum and white blood cells, leukocytes ingest bacteria, dead cells and debris, attract macrophages and stimulate formation of fibroblasts to promote wound healing
• Modes of Wound Healing

  • Closed with sutures or staples
  • Heal by granulation
  • Leave the wound open to heal

  
• Factors affecting wound healing

  • Aging
  • Chronic illness, e.g. Diabetes Mellitus, anemia, cancer
  • Nutritional status: inadequate intake of protein, carbohydrates, vitamins A, B1, B5, C and minerals (Iron, Copper and Zinc)
  • Obesity
  • Edema
  • Mobility
  • Circulatory insufficiency e.g. Peripheral arterial disease, arterial leg ulcer
  • Medications, e.g. Steroids, anti inflammatory drugs
  • Infection
  • Repeated trauma: pressure, incontinence, poor wound care technique
  • Psychological problem
• Conditions for promoting wound healing

  • Wound dressing with aseptic technique
  • No contamination of wounds
  • Apply appropriate dressing materials
  • Appropriate moisture of wound bed & dry surrounding skin
  • Free of foreign bodies
  • Free of infection
  • Assist in ambulation to enhance circulation
  • Sufficient nutrients and fluid intake
  • Sufficient sleep, rest
  • Positioning to keep pressure off the wound

  
• Common types of wound

  • Abrasion
  • Laceration
  • Skin tears
  • Incision
  • Puncture
  • Stab wound
  • Bites
  • Amputation
  • Ulceration
  • Contusion
  • Pressure injury
  • Cancer wound
• Pressure injury stages

  • Stage 1: Skin intact, non-blanchable redness
  • Stage 2: Partial thickness loss of epidermis & dermis, red pink wound bed
  • Stage 3: Full thickness skin loss, expose subcutaneous tissues
  • Stage 4: Full thickness tissue loss with exposed bone, muscle, etc.
  • Unstageable: Full thickness skin and tissue loss in which the extent of tissue cannot be confirmed, slough or eschar is noted
  • Deep Tissue Injury (DTI): Unknown depth, purple or maroon color, damage of underlying tissue
• Wound Assessment


  • Location
  • Types
  • Size
  • Undermining/Tunneling
  • Wound bed color
  • Peri-wound
  • Exudate
  • Any wound pain
  • Any wound infection/wound packing

  
• Common used dressing materials

  • Gauze with secure tape
  • Transparent Dressing
  • Hydrocolloid Dressing
  • Hydrogel
  • Alginates
  • Hypertonic Dressing (Mesalt)
  • Foam dressing
  • Antimicrobial dressing
  • Drain dressing
• Examples of disinfectants


  • Alcohols
  • Formaldehyde
  • Hydrogen peroxide
• Disinfectants


  • Usually toxic to tissue, used on non-living surfaces
  • Mostly for equipment disinfection
• Common cleansing solutions for wound

  • 0.9% Sodium Chloride
  • Aqueous Hibitane
  • Povidine iodine
• Principles of sterile technique

  • All objects used in a sterile field must be sterile
  • A sterile object remains sterile only when touched by another sterile object
  • Sterile objects that are below the waist or table level are contaminated
  • Sterile objects become contaminated by prolonged exposure to airborne microorganisms
  • Sterile objects out of the range of vision is contaminated
• Principles of sterile technique

  • Fluid flows in the direction of gravity; instruments become contaminated if dirty fluid flows backwards along the instrument (when tip up)
  • Non-waterproof sterile surface comes in contact with wet, contaminated surface, becomes contaminated by capillary action
  • Edges of sterile field are considered non-sterile (1 inch margin)
• Basic turns for roller bandages

  • Circular turn
  • Spiral turn
  • Spiral reverse turn
  • Figure of 8 turn
• Oxygenation


  The process of oxygen diffusing through the lung alveoli into the blood; or Administering oxygen to patient to promote the status of oxygen saturation in the blood

  
• Ventilation

  Movement of air in and out of the lungs; inhalation & exhalation

  
• Gas exchange

  Diffusion of O2 and CO2 between alveoli and pulmonary capillaries

  
• Respiratory Disorders

  • Restrictive airway disease (Pleural effusion, Pulmonary fibrosis, etc.)
  • Obstructive airway disease (Movement of air into & out of lungs, Inflammation or infection of airway, Pneumonia, Tumor or foreign body, Contraction of smooth muscles of bronchi, Asthmatic attack)