導(dǎo)尿管之選擇與護理課件

1、導(dǎo)尿管之選擇與護理慈濟技術(shù)學(xué)院 江明珠Incidence of catheterization10% 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 cathetersShort-term catheterizationUrologic surgerySu

2、rgery on contiguous structuresCritically ill patients requiring accurate measure of urinary outputAcute urinary retention途徑Transurethra catheterizationTransvesical catheterization（ suprapubic catheterization ）What is suprapubic catheterization？恥骨上導(dǎo)尿管：在膀胱脹滿水之後由恥骨上正中央插入導(dǎo)引器然後插入導(dǎo)尿管suprapubic catheteriza

3、tionsuprapubic catheterizationConsider suprapubic or urethral catheterizationsuprapubicurethralLong term（including incontinence）Short termSexually active clientsintermittentPost-specific surgery Post-specific surgeryUrethra traumaDifficulties with suprapubicSome wheelchair-bound clientsDifficulties

4、with urethral catheterConsider suprapubic or urethral catheterizationsuprapubicurethral Specific disadvantagesAltered body imageAltered body imagePotential leakage from and around siteImpedes sexual intercourseRequires a registered medical practitioner to insertHigher risk of infectionSelection of c

5、athetersCatheter sizeMale:14-16Ch（length 40-45cm）Female:12-14Ch（length20-26cm）Balloon size5-10ml recommended30ml surgery only Catheter-related problemBypassingUTIBlocked catheterInadvertent catheter removalCatheter-related problem-BypassingCommon causes of bypassingConstipationKinked tubingCatheter

6、size and length/balloonDetrusor instabilityTrigone irritationblockageCatheter-related problem-UTI直接影響導(dǎo)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%

7、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(shù)不良Catheter-related problem-UTICatheter-related problem-UTI致病菌Extogenous organisms（e.g.serratia spp. And Pseudomonas aerugin

8、osa）found in the environment and on handEndogenous faecal or urethral microorganisma（e.g.Gram-positive cocci and Klebesiella） Complications associated with urinary catheters Long-term catheterization菌尿癥是很常見，一般多於6週內(nèi)發(fā)生有癥狀泌尿道感染、發(fā)燒、急性腎盂腎炎、菌血癥、甚至死亡導(dǎo)尿管阻塞、尿路結(jié)石、局部尿道周圍感染、慢性腎炎、腎衰竭、甚至術(shù)年後發(fā)生膀胱癌男性長期導(dǎo)尿管放置可導(dǎo)致尿道炎、尿道

9、廔管、副睪炎、陰囊膿瘍、攝護腺炎或攝護腺膿瘍長期導(dǎo)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(shù)為Providentia stuartii及M.morganii病患留置導(dǎo)尿前之護理評估病患留置導(dǎo)尿的適應(yīng)癥選擇合適的導(dǎo)尿管評估病患留置導(dǎo)尿前的排尿情形病患留置導(dǎo)尿前之護理指導(dǎo)正確置入導(dǎo)尿技術(shù) Maintaining a closed urinary drainage systemDONTDont allow any tension on the tubing that could dislodge the catheter or da

10、mage 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 tubingMaintaining a closed urinary drainage systemMaintaining a closed urinary drainage systemMaintaining a closed urinary drain

11、age systemMaintaining a closed urinary drainage systemMaintaining a closed urinary drainage systemUrinary catheter securement導(dǎo)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(fā)炎尿管滑脫之比例為17%-41%，而不適當(dāng)?shù)墓潭ㄊ侵饕奈ｋU因子，常引起沒有計劃性的尿管拔除。創(chuàng)傷及發(fā)炎與重複導(dǎo)尿管移動及尿道受壓有關(guān)，當(dāng)尿管沒有適當(dāng)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(chuàng)傷及發(fā)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(wěn)定或

12、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(yōu)點：便宜、方便缺點：易脫落常引起皮膚不同程度的反應(yīng)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 systemUrinary catheter securement導(dǎo)尿管固定帶Dale Foley Catheter Holder

13、Urinary catheter securement導(dǎo)尿管固定帶為專利產(chǎn)品，利用容易鬆綁之魔鬼膠帶，將導(dǎo)管固定，避免導(dǎo)管晃動拉扯脫出、感染，適合長期照護，急診手術(shù)後需留置導(dǎo)管病患使用。導(dǎo)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 oneThe statlock Foley device,an adhesive anchor for

14、urinary cathetersUrinary catheter securementTThe Statlock Foley Pediatric device stabilizes the urinary catheter via a teddy bear-shaped adhesive anchorUrinary catheter securementTThe Flexi-Trak device, a mutipurpose anchor,can be adjusted to secure even large-diameter drainage tubing CDC Guidelines

15、 for prevention of Catheter-Associated UTICategory1.strongly recommendedCatheterize only when necessaryEducate personnel in correct techniques of catheter insertion and careEmphasize handwashing Insert catheter using aseptic technique and sterile equipmentSecure catheter properlyMaintain closed ster

16、ile drainageObtain urine specimens aspeticallyMaintain unobstructed urine flowCDC Guidelines for prevention of Catheter-Associated UTICategory 2.Moderately recommendedPeriodically re-educate personnel in catheter careUse smallest suitable catheter boreAvoid irrigation unless needed to prevent or relieve obstructionRefrain from daily meatal careDo not cha