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,Incidence of catheterization,10% of patients in hospital（Mulhall et al,1988） 25% of patients in hospital（Saint et al,1999）4% of patients receiving nursing services at home（Getliffe and Mulhall,1991）,Indications for use of urinary catheters,Short-term catheterizationUrologic surgerySurgery on contiguous structuresCritically ill patients requiring accurate measure of urinary outputAcute urinary retention,Indications for use of urinary catheters,Long-term catheterizationBladder outlet obstruction not correctable medical or surgicallyIntractable skin breakdown caused or exacerbated by incontinenceSome patients with neurogenic bladder and retentionPalliative care for terminally ill or severely impaired incontinent patients for whom bed and clothing changes are uncomfortablePreference of a patient who has not responded to specific incontinence treatments,途徑Transurethra catheterizationTransvesical catheterization（ suprapubic catheterization ）,What is suprapubic catheterization？,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,suprapubic catheterization,suprapubic catheterization,indications for suprapubic catheterizattion,Urethra traumaClients who require long-term catheterization and who are sexually activeFollowing pelvic or urological surgerySome gynaecological conditions,e.g.colposuspensionLong-term catheterization for incontinenceClients who are unable to tolerate urethral catheterizationSome wheelchair-bound clients,Consider suprapubic or urethral catheterization,Consider suprapubic or urethral catheterization,Consider suprapubic or urethral catheterization,Selection of catheters,Which material For short-term use （1-28days）:Latex, PVC, PTFE-coated latex foley catheter For long-term use of up to 12 weeks,select one of the following: hydrogel-coated latex foley catheter pure silicon Foley catheter silicon-coated latex Foley catheter,Selection of catheters,Catheter sizeMale:14-16Ch（length 40-45cm）Female:12-14Ch（length20-26cm）Balloon size5-10ml recommended30ml surgery only,Catheter-related problem,BypassingUTIBlocked catheterInadvertent catheter removal,Catheter-related problem-Bypassing,Common causes of bypassingConstipationKinked tubingCatheter size and length/balloonDetrusor instabilityTrigone irritationblockage,Catheter-related problem-UTI,直接影響導尿管造成感染之因素：放置時間長短Detect significant microbial counts-3days after catheterization（Bach et al,1990）The risk of developing bacteriuria Garibaldi et al （1974）： 8.1% for each day Mulhall et al（1988）：5-8% for each day Sedor（1999）：5% for each dayBacteriuria is virtually inevitable within 3-4 weeks（Jewes et aal,1988）,Catheter-related problem-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-related problem-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-related problem-UTI,Catheter-related problem-UTI,致病菌Extogenous organisms（e.g.serratia spp. And Pseudomonas aeruginosa）found in the environment and on handEndogenous faecal or urethral microorganisma（e.g.Gram-positive cocci and Klebesiella）,Complications associated with urinary catheters,Short-term catheterizationTrauma and inflammationUrethritisbacteriuria：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,Complications associated with urinary catheters,Long-term catheterization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,Maintaining a closed urinary drainage system,DONTDont allow any tension on the tubing that could dislodge the catheter or damage the urethraDont allow tubing to loop below the drainage bagDont attach the drainage to a bed rail or allow it to rest on the floorDont allow the patient to lie on the tubing,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,DOMaintain gravity drainage by keeping the drainage bag below the level of the patients bladder at all time.keep the tubing free from kinks and obstructionsMakes sure that the system is well sealed and the bags emptying port is closed.check for leaks at connection sitesFor a patient in bed or on a stretcher,suspend the drainage bag from the bed or stretcher frame,using the hook or strap providedIf the patient is in a chair near the bed, keep the drainage bag on the bed frame with the bed in a low position or attach the bag to the chair,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Urinary catheter securement,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。,Urinary catheter securement,膠布是最古老的固定方法，將尿管黏貼於大腿或腹部，採chevron method ，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。,Maintaining a closed urinary drainage system,Urinary catheter securement,導尿管固定帶Dale Foley Catheter Holder,Urinary catheter securement,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Dale Foley Catheter Holder可分#316大腿固定帶及#330腰部固定帶,Urinary catheter securementtape may be the oldest method,but its not the only one,The statlock Foley device,an adhesive anchor for urinary catheters,Urinary catheter securement,TThe Statlock Foley Pediatric device stabilizes the urinary catheter via a teddy bear-shaped adhesive anchor,Urinary catheter securement,TThe Flexi-Trak device, a mutipurpose anchor,can be adjusted to secure even large-diameter drainage tubing,CDC Guidelines for prevention of Catheter-Associated UTI,Category1.strongly recommendedCatheterize only when necessaryEducate personnel in correct techniques of catheter insertion and careEmphasize handwashing Insert catheter using aseptic techniq