导尿管之选择与护理.ppt

導尿管之選擇與護理,1,.,Incidenceofcatheterization,10%ofpatientsinhospital（Mulhalletal,1988）25%ofpatientsinhospital（Saintetal,1999）4%ofpatientsreceivingnursingservicesathome（GetliffeandMulhall,1991）,2,Indicationsforuseofurinarycatheters,Short-termcatheterizationUrologicsurgerySurgeryoncontiguousstructuresCriticallyillpatientsrequiringaccuratemeasureofurinaryoutputAcuteurinaryretention,3,Indicationsforuseofurinarycatheters,Long-termcatheterizationBladderoutletobstructionnotcorrectablemedicalorsurgicallyIntractableskinbreakdowncausedorexacerbatedbyincontinenceSomepatientswithneurogenicbladderandretentionPalliativecareforterminallyillorseverelyimpairedincontinentpatientsforwhombedandclothingchangesareuncomfortablePreferenceofapatientwhohasnotrespondedtospecificincontinencetreatments,4,途徑TransurethracatheterizationTransvesicalcatheterization（suprapubiccatheterization）,5,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,6,suprapubiccatheterization,7,suprapubiccatheterization,8,indicationsforsuprapubiccatheterizattion,UrethratraumaClientswhorequirelong-termcatheterizationandwhoaresexuallyactiveFollowingpelvicorurologicalsurgerySomegynaecologicalconditions,e.g.colposuspensionLong-termcatheterizationforincontinenceClientswhoareunabletotolerateurethralcatheterizationSomewheelchair-boundclients,9,Considersuprapubicorurethralcatheterization,10,Considersuprapubicorurethralcatheterization,11,Considersuprapubicorurethralcatheterization,12,Selectionofcatheters,WhichmaterialForshort-termuse（1-28days）:Latex,PVC,PTFE-coatedlatexfoleycatheterForlong-termuseofupto12weeks,selectoneofthefollowing:hydrogel-coatedlatexfoleycatheterpuresiliconFoleycathetersilicon-coatedlatexFoleycatheter,13,Selectionofcatheters,CathetersizeMale:14-16Ch（length40-45cm）Female:12-14Ch（length20-26cm）Balloonsize5-10mlrecommended30mlsurgeryonly,14,Catheter-relatedproblem,BypassingUTIBlockedcatheterInadvertentcatheterremoval,15,Catheter-relatedproblem-Bypassing,CommoncausesofbypassingConstipationKinkedtubingCathetersizeandlength/balloonDetrusorinstabilityTrigoneirritationblockage,16,Catheter-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）,17,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,18,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,19,Catheter-relatedproblem-UTI,20,Catheter-relatedproblem-UTI,致病菌Extogenousorganisms（e.g.serratiaspp.AndPseudomonasaeruginosa）foundintheenvironmentandonhandEndogenousfaecalorurethralmicroorganisma（e.g.Gram-positivecocciandKlebesiella）,21,Complicationsassociatedwithurinarycatheters,Short-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,22,Complicationsassociatedwithurinarycatheters,Long-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Providentiastuartii及M.morganii,23,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,24,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,25,Maintainingaclosedurinarydrainagesystem,DONTDontallowanytensiononthetubingthatcoulddislodgethecatheterordamagetheurethraDontallowtubingtoloopbelowthedrainagebagDontattachthedrainagetoabedrailorallowittorestonthefloorDontallowthepatienttolieonthetubing,26,Maintainingaclosedurinarydrainagesystem,27,Maintainingaclosedurinarydrainagesystem,28,Maintainingaclosedurinarydrainagesystem,DOMaintaingravitydrainagebykeepingthedrainagebagbelowthelevelofthepatientsbladderatalltime.keepthetubingfreefromkinksandobstructionsMakessurethatthesystemiswellsealedandthebagsemptyingportisclosed.checkforleaksatconnectionsitesForapatientinbedoronastretcher,suspendthedrainagebagfromthebedorstretcherframe,usingthehookorstrapprovidedIfthepatientisinachairnearthebed,keepthedrainagebagonthebedframewiththebedinalowpositionorattachthebagtothechair,29,Maintainingaclosedurinarydrainagesystem,30,Maintainingaclosedurinarydrainagesystem,31,Maintainingaclosedurinarydrainagesystem,32,Urinarycathetersecurement,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。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，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。,33,Urinarycathetersecurement,膠布是最古老的固定方法，將尿管黏貼於大腿或腹部，採chevronmethod，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：易脫落常引起皮膚不同程度的反應重複的膠布使用，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。,34,Maintainingaclosedurinarydrainagesystem,35,Urinarycathetersecurement,導尿管固定帶DaleFoleyCatheterHolder,36,Urinarycathetersecurement,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。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DaleFoleyCatheterHolder可分#316大腿固定帶及#330腰部固定帶,37,Urinarycathetersecurementtapemaybetheoldestmethod,butitsnottheonlyone,ThestatlockFoleydevice,anadhesiveanchorforurinarycatheters,38,Urinarycathetersecurement,TTheStatlockFoleyPediatricdevicestabilizestheurinarycatheterviaateddybear-shapedadhesiveanchor,39,Urinarycathetersecurement,TTheFlexi-Trakdevice,amutipurposeanchor,canbeadjustedtosecureevenlarge-diameterdrainagetubing,40,CDCGuidelinesforpreventionofCatheter-AssociatedUTI,Category1.stronglyrecommendedCatheterizeonlywhennecessaryEducatepersonnelincorrecttechniquesofcatheterinsertionandcareEmphasizehandwashingInsertcatheterusingaseptictechniqueandsterileequ