導(dǎo)尿管之選擇與護(hù)理

導(dǎo)尿管之選擇與護(hù)理慈濟(jì)技術(shù)學(xué)院江明珠Incidenceofcatheterization10%ofpatientsinhospital（Mulhalletal,1988）25%ofpatientsinhospital（Saintetal,1999）4%ofpatientsreceivingnursingservicesathome（GetliffeandMulhall,1991）IndicationsforuseofurinarycathetersShort-termcatheterizationUrologicsurgerySurgeryoncontiguousstructuresCriticallyillpatientsrequiringaccuratemeasureofurinaryoutputAcuteurinaryretentionIndicationsforuseofurinarycathetersLong-termcatheterizationBladderoutletobstructionnotcorrectablemedicalorsurgicallyIntractableskinbreakdowncausedorexacerbatedbyincontinenceSomepatientswithneurogenicbladderandretentionPalliativecareforterminallyillorseverelyimpairedincontinentpatientsforwhombedandclothingchangesareuncomfortablePreferenceofapatientwhohasnotrespondedtospecificincontinencetreatments

途徑TransurethracatheterizationTransvesicalcatheterization（suprapubiccatheterization）Whatissuprapubiccatheterization？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suprapubiccatheterizationsuprapubiccatheterizationindicationsforsuprapubic

catheterizattionUrethratraumaClientswhorequirelong-termcatheterizationandwhoaresexuallyactiveFollowingpelvicorurologicalsurgerySomegynaecological

conditions,e.g.colposuspensionLong-termcatheterizationforincontinenceClientswhoareunabletotolerateurethralcatheterizationSomewheelchair-boundclientsConsidersuprapubicorurethralcatheterizationsuprapubicurethralLongterm（includingincontinence）ShorttermSexuallyactiveclientsintermittentPost-specificsurgeryPost-specificsurgeryUrethratraumaDifficultieswithsuprapubicSomewheelchair-boundclientsDifficultieswithurethralcatheterConsidersuprapubicorurethralcatheterizationsuprapubicurethraspecificcareStrictasepsisoninsertionStrictasepsisoninsertionspecificadvantagesReducedriskofinfectionNurseabletocarryoutprocedureEnablesexualintercourseConsidersuprapubicorurethralcatheterizationsuprapubicurethralSpecificdisadvantagesAlteredbodyimageAlteredbodyimagePotentialleakagefromandaroundsiteImpedessexualintercourseRequiresaregisteredmedicalpractitionertoinsertHigherriskofinfectionSelectionofcathetersWhichmaterialForshort-termuse（1-28days）:Latex,PVC,PTFE-coatedlatexfoleycatheterForlong-termuseofupto12weeks,selectoneofthefollowing:

hydrogel-coatedlatexfoleycatheterpuresiliconFoleycathetersilicon-coatedlatexFoleycatheterSelectionofcathetersCathetersizeMale:14-16Ch（length40-45cm）Female:12-14Ch（length20-26cm）Balloonsize5-10mlrecommended30mlsurgeryonlyCatheter-relatedproblemBypassingUTIBlockedcatheterInadvertentcatheterremovalCatheter-relatedproblem-BypassingCommoncausesofbypassingConstipationKinkedtubingCathetersizeandlength/balloonDetrusorinstabilityTrigoneirritationblockageCatheter-relatedproblem-UTI直接影響導(dǎo)尿管造成感染之因素：放置時間長短Detectsignificantmicrobialcounts-3daysaftercatheterization（Bachetal,1990）Theriskofdevelopingbacteriuria

Garibaldietal（1974）：8.1%foreachday

Mulhalletal（1988）：5-8%foreachday

Sedor（1999）：5%foreachdayBacteriuriaisvirtuallyinevitablewithin3-4weeks（Jewesetaal,1988）Catheter-relatedproblem---UTI危險(xiǎn)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-relatedproblem---UTI致病機(jī)轉(zhuǎn)細(xì)菌由會陰部或尿袋移生後經(jīng)由導(dǎo)尿管外壁或內(nèi)壁上行女性之感染途徑為經(jīng)由直腸正常菌叢污染尿道周圍男性主要為管路內(nèi)經(jīng)由外來細(xì)菌污染尿道口之細(xì)菌可經(jīng)由插入導(dǎo)尿管時帶入膀胱Catheter-relatedproblem---UTICatheter-relatedproblem---UTI致病菌Extogenousorganisms（e.g.serratia

spp.AndPseudomonasaeruginosa）foundintheenvironmentandonhandEndogenousfaecalorurethralmicroorganisma（e.g.Gram-positivecocciandKlebesiella）ComplicationsassociatedwithurinarycathetersShort-termcatheterizationTraumaandinflammationUrethritisbacteriuria：尿道周圍有革蘭氏陰性桿菌及腸球菌移生，80%會產(chǎn)生菌尿癥，女性病人菌尿癥中70-80%是因?qū)蚬芡獗谂c尿道黏膜空隙之細(xì)菌侵入。導(dǎo)尿管短期置放之菌尿癥通常為單一菌種，但有15%是多菌且同時為膿尿，E.Coli是常見細(xì)菌

ComplicationsassociatedwithurinarycathetersLong-termcatheterization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、尿道廔管、副睪炎、陰囊膿瘍、攝護(hù)腺炎或攝護(hù)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(hù)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(hù)理指導(dǎo)正確置入導(dǎo)尿技術(shù)

病患留置導(dǎo)尿的護(hù)理維持導(dǎo)尿管引流系統(tǒng)的功能適當(dāng)固定導(dǎo)尿管，預(yù)防拉扯及創(chuàng)傷預(yù)防泌尿道的感染評估留置導(dǎo)尿管對病患及家庭的影響，並協(xié)助處理預(yù)防便秘尿液滲漏的處理

MaintainingaclosedurinarydrainagesystemDON’TDon’tallowanytensiononthetubingthatcoulddislodgethecatheterordamagetheurethraDon’tallowtubingtoloopbelowthedrainagebagDon’tattachthedrainagetoabedrailorallowittorestonthefloorDon’tallowthepatienttolieonthetubingMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemDOMaintaingravitydrainagebykeepingthedrainagebagbelowthelevelofthepatient’sbladderatalltime.keepthetubingfreefromkinksandobstructionsMakessurethatthesystemiswellsealedandthebag’semptyingportisclosed.checkforleaksatconnectionsitesForapatientinbedoronastretcher,suspendthedrainagebagfromthebedorstretcherframe,usingthehookorstrapprovidedIfthepatientisinachairnearthebed,keepthedrainagebagonthebedframewiththebedinalowpositionorattachthebagtothechairMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemUrinarycathetersecurement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(xiǎn)因子，常引起沒有計(jì)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)定或痙攣。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(yōu)點(diǎn)：便宜、方便缺點(diǎn)：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(xiǎn)性，使微生物進(jìn)而進(jìn)入膀胱引起泌尿道感染。MaintainingaclosedurinarydrainagesystemUrinarycathetersecurement導(dǎo)尿管固定帶

DaleFoleyCatheterHolderUrinarycathetersecurement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(hù)，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

DaleFoleyCatheterHolder可分#316大腿固定帶及#330腰部固定帶Urinarycathetersecurement

tapemaybetheoldestmethod,butit’snottheonlyone

ThestatlockFoleydevice,anadhesiveanchorforurinarycathetersUrinarycathetersecurementTThe

StatlockFoleyPediatricdevicestabilizestheurinarycatheterviaateddybear-shapedadhesiveanchorUrinarycathetersecurementTTheFlexi-Trakdevice,amutipurposeanchor,canbeadjustedtosecureevenlarge-diameterdrainagetubingCDCGuidelinesforpreventionofCatheter-AssociatedUTICategory1.stronglyrecommendedCatheterizeonlywhennecessaryEducatepersonnelincorrecttechniquesofcatheterinsertion