IV, Cath, Lavage

PERFORMANCE CHECKLIST LEVEL II
SOLUTION :
Isotonic -
* patient Nonly
STARTING AN INTRAVENOUS INFUSION '
- needs
y rehydration
Definition:
needle if dehydrated
-
→
gaowwigfilyoi.im
may
'M
Provides route for administration of fluids, medication, blood or nutrients
Materials Needed: but it is nurse 's responsibility to
N
Hypertonic -
* cause
shrink;
cell to
BBM drop → start .

maintain , I monitor N fluids .
µ
mas mabiliskapag for cellular
Solution * si
-
doctor ang nagpe -
prescribed overload
either nurse determines the
MIUROSET or
IV cannula or steel-winged needle *
size of cannula Hypotonic -
* cause cell to
"
←
Administration set swell ; for
MACROSET it is the SMALLEST GAUGE that
-
☒
-
:(
cellular
-
IV pole could accumulate N therapy :

dehydration
(• zouggtlml Tourniquet
/
'
inappropriate sa vein ni patient .
walang
- - - -
hindi tayogagamitngmalaki * If the patient needs
needle sa Aseptic swab Kung ang vein ni patient ay more nutrients N
chamber ,
Tape Malik as it will cause phlebitis ,
fluids that contains

PARTS OF AS : Bandage scissors FAB • inflammation carbohydrates inform
Mathis na
CONSIDERATIONS of vein
Spike mahabana Dressing material of of glucose or dextrose .
CANNULA : became
ipapasoksa
Arm board for mechanical * It also has water for
" fluids !
seethe purpose of Nfluids injury hydration & Carbo
-
dehydration 122-27)
Ilah'm ng spike
chamber ↳ g. if blood
-
"
e. ,
Kino
if transfusion (18-20) hydrates to
it neonate ; fragile vein I Remarks provide calories I
-
Roller # control Procedures Done Not

clamp to fasten masyadongmaliit (24-27)
↳ ilalim or slow IF adult 120-24
done energy .
ng the drops
chamber we
give ASSESSMENT * If patient is
WHITE PORT
4¥ dito naga IV push:
-
italian ng roller
1. Review physician’s order admitted w/
clamp PLANNING HYPER EMESIS
1. Wash your hands GRAVID ARUM
2. Choose appropriate equipment
open ng Ad set ang
roller clamp ay
chose
ilapitsa
[⑥ extreme ,
3. Set up IV fluid tubing µ pag
-
,
chamber para madding Mag regulate ; Kasi if

-
naka open e- hinang na ang N fluids magstart

-
,
persistent
4. Take equipment to bedside chamber magflow kapag hindi nilagyan ng fluids any
na ;
nausea J
pistol pistol any fluids tubing -
sa s
↳
,
.
IMPLEMENTATION banal may air ang mapupunta na patient ! sa Vomiting

c-
* because 2- 3mi of air
- - -
cerebral circulation
na
during
1. Identify patient and explain the procedure pumunta could be fatal I. 5 mi
sa
-
l na
pregnancy .
pulmonary vein
pumuhta cardiac sa
y
- - - - -
- - -
2. Wash your hands because if may

arrest can cause
air , it can cause f-
An air embolism, also known as a gas
embolism, is a blood vessel blockage
By
air embolism caused by one or more bubbles of air or
I
.
3. Select a position of comfort for yourself

µpp possible
other gas in the circulatory system.
- - -
- - - - - - -
,
4. Put on gloves. complications

is electrolytes
5. Locate vein. Apply tourniquet 5 to 12 cm. (2-6 inches) above imbalance .
Up
the injection site see N lecture for distended vein ( what to ? )
do
that is why ,
doctor will
6. Prepare site with effective topical antiseptic according to prescribe
hospital policy or cotton balls with alcohol on circular Nfluidswl
electrolytes
motion and allow 30 seconds to dry.
7. Using the IV Cannula: µ e. g.,
has ipiñiiii
0.9%4*-1
Pierce the skin with the needle, positioned on 15-30 Nacl i Nss , i
degree angle, upon flashback visualization, decrease has *

iiaiñgiiiii
1 ,
Naa ,
isolation !
Kia
19 | P a g e has ☒ aoidi
Nach i. II.ng.ee's;
K.ca I
Lactate
the angle, and advance the catheter and stylet into

the vein.
Position the IV catheter parallel to the skin. Hold
stationary and slowly advance the catheter off of the
stylet until the hub meets the puncture site.
Release the tourniquet, remove the stylet while
applying digital pressure over the catheter with one
finger about ½ inch from the tip of the inserted
catheter
Using the Steel-winged needle
Pierce the skin with the needle’s bevel up, position it
on a 5-10 degree angle
With the steel-winged needle parallel on the skin,
enter the vein directly and advance the needle ¼ inch
after successful venipuncture. Check for backflow.
Release tourniquet
8. Attach the infusion tubing and open the roller clamp
enough to allow the fluid to drip.
9. Slip a sterile gauze pad under the catheter hub.
10. Anchor needle firmly in place with tape.
11. Place a transparent tape/dressing directly over the puncture
site.
12. Regulate the flow of infusion according to the physician’s
order.
13. Label the IV fluid bottle
EVALUATION
1. Evaluate, using the following criteria:
Right patient, right solution, right time, right
amount, right rate.
IV secure
Patient’s comfort
DOCUMENTATION
1. Document IV insertion on appropriate chart form.
____________________________ _______________________________ ______________________

Student’s Signature Clinical Instructor’s Date
Printed Name & Signature
20 | P a g e
MAY EFFECT BA IF MASYADONG MATTIAS OR MABABA ANG
FLUIDS SA N POLE ? MERON .
* If masyadong mataas ang N fluids

-
* mas mabilis ang flow ng N fluids because of gravity
* If masyadong mababa
→ mahihirapah i resist
-
ang venous pressure ; mahihirapan ang Fluids na pumasok, mas ma

bag at .
APPROPRIATE : 1m or 3ft above patient

TO OPEN !
takip
ng N fluids ring ilagay maliitna but as ;
* sa takip ,
may parang , ang finger sa
parang ring then snap to open .
Pagtanggal ng , may malaki I
i twist ma dali
i ang maliit na
'
sa ma taking butas ipapasok ang spike butas ay for incorporation ng needle pag maghah along gamot sa N fluids ;
-
papas ok
para mas
Then is a bit ang N bottle , pagkasabit ng N fluids by half ang chamber ikapag meron
ng kalahati tsaka
io open
ang roller clamp
-
.
,
,
• Kapag sumo bra , batik tarin lang then pisilinulit ,

* Ilagay ang N pole N fluids IN tubing s near working station .
babalik fluids saw bottle DAPAT HALF LANG !

, ,
na ang .
↳ dahilkapagpinuno ,
hindi
monitor il
ang drops
na
Mamo Kung .
MAKE SURE :
stylet lneedle) Walang maiiwan needle Kay patient cannula plastic

* Kapagtinanggal ang ,
na ,
tang na .
ang pin aka tubing tsakatatanggalin FLUSH IT FIRST ! THEN REGULATE AS PRESCRIBED BY THE Doctor
* Kapag ipapasok ng ,
.
ayan natin blood sa

1-
p da hit
may
- - na
pin aka cannula da hit possible na A thrombus is a blood clot that forms in a vessel and remains
ng blood clot or thrombus Ba there. An embolism is a clot that travels from the site where it
magkaroon
.
formed to another location in the body. Thrombi or emboli can

blood clot,
B kapag may lodge in a blood vessel and block the flow of blood in that
hindi magpo flow! -
location depriving tissues of normal blood flow and oxygen.

MONITORING AND MAINTAINING AN INFUSION
Definition:
An important responsibility is to monitor an IV infusion so that the flow of the correct
solution is maintained at the correct rate
Materials Needed:
Watch with a second hand
Procedures Done Not Remarks

done
ASSESSMENT
1. Identify whether the patient has IV fluid running.
2. Examine IV record for accuracy and completeness as to:
Number of IV infusing
Ordered contents of the fluid container
Time the IV was hung
Time the IV is to be completed
3. Review information about IV infusing if not familiar with.
4. Identify patient
5. Explain that you are monitoring the IV infusion
6. Check IV container We also have
EXTRAVASATION .
Date and time

* infiltration ; -
Correct solution infusing but the fluids are
The number of IV container is correct / considered vesicant
,
The fluid level in the container and designated time

of completion Bai N complications ,
/
cause
• g. CHEMO
e.
blistering ( ,
.
THERAPEUTIC
-
(* causes
AGENTS
7. Inspect drip chamber -
-
-
Filled to an appropriate level necrosis
e-
or
ulceration
Dripping N tubing sa bed ni patient
Nakalaylay ang
g•
,
Rate is correct
may effect ba Kung baba gal or bibilis
8. Check tubing for kinks or obstruction rate ?
( ang flow
9. Examine IV site for phlebitis or infiltration A MERON BABAGAL dahibmahihirapah
-
-
-
. .
any fluids na umakyatsa insertion
[
Skin color and temperature
site drawl waka dangle
vesicant ay ( NAGA BED DAP AT Pen HINDI dapat
- .
Pain ang fluid na

µp non -
µ
.
Swelling Wala na sa ugat ; Kinks or

tissues nadadaganan ; no
( sa surrounding
uapwpunta na
obstructions
10. If arm board is in use, remove, examine for skin irritation
-
-
.
µ possible IV out !
- - -
na
and circulation impairment and replace dislodge ang

cannula na na
MANAGEMENT ! (BANG MAKI KITA SA INSERTION SITE

inflammation of
cool
the vein
or
•
21 | P a g e :
warm µµ •
may edema
compress
↳
(to provide comfort )
l - - -
µ POSSIBLE CAUSE !
(
• cool to touch
mas mataba ang insertion site compare sa other arm
Assessment : to mechanical injury
lap too big gauge cannula ang yµ MANAGEMENT : &
warm to touch ng facilitate vasolidatioh )
µreabsorption
•
redness ginamit
• warm compress of fluid
hand
•
• chemical irritation •• elevate the

can masyadong matapang ang gamot na ginamit
11. Identify specific problem present

PLANNING
1. Plan an appropriate course of action on the IV problem
noted
IMPLEMENTATION
1. Carry out action planned
EVALUATION
1. Evaluate using the following criteria:
Any problem identified and corrected
Correct IV infusion running at the correct rate
DOCUMENTATION
1. On the flowsheet, note that the correct IV is running, the rate
and the appearance of the site
2. If the problems identified were corrected, note on nurse’s
notes or flow sheet.
____________________________ _______________________________ ________________

22 | P a g e
MAY EFFECT BA IF IT IS TOO FAST OR TOO SLOW ANG FLOW ?
YES MERON !
.
so dapat correct ang regulation !
'
-
-
I Ilapit ang reto sa chamber .
* IF too fast → fluid overload

* IF too slow *
fluid insufficient
* Nabih's ang flow rate, slow it or
regulate ? Slow it ! to avoid fluid overload
* Nab a gal ang flow rate , fasten it or regulate ? REGULATE order ! not fasten it it fluid overload
as
you should as may also cause .
or ask the doctor .

naka set up parin

-
magpapalit
gµ
,
N bottle
CHANGING FLUID CONTAINER tang ng .
(• close roller clamp kink then

, ,
pasok sa bagong N fluids

Definition:
When only a small amount of fluid is left in the neck of the intravenous container and
fluid still remains in the drip chamber, intravenous containers are changed, and usually
tubing is also changed at the same time.
Decreases opportunity for growth of microorganisms by removing possible medium for
infection
Materials Needed:
Correct fluid
Appropriate infusion set
Cotton balls with alcohol
Dressing materials if needed
A syringe with a needle for flushing
Plaster

done
ASSESSMENT
1. Review physician’s order for the type of fluid and infusion
rate
2. Check date of last tubing and dressing
PLANNING
1. Determine equipment you will need
2. Wash your hands
3. Select the correct fluid container
4. Gather materials needed
IMPLEMENTATION
1. Explain the procedure
2. Check the patient’s identity, IV site, and solution to be
changed
3. Close the roller clamp or kink tubing of the administration
set and remove the fluid container from the stand.
4. Remove tubing from the empty container and insert tubing
to the new container while observing the aseptic technique.
5. Hang the new IV fluid to the pole
23 | P a g e
6. Regulate the flow rate based on the duration of infusion.

Remove air bubbles if any
7. Change the IV Solution slip
EVALUATION
Tubing and fluid container changed with no
contamination
Correct IV infusion running at correct rate
DOCUMENTATION
2. Record information in correct location according to your
hospital policy
Time started and stopped, and the exact contents of
IV
Fluid intake from discontinued container
Assessment of IV line and site and patient’s response
____________________________ _______________________________ __________________

24 | P a g e
24 HRS NA NAKA HUNG PERO MAY LAMAN PA PAPA LI TAN BA ?
,
* YES Dahil nagkakarooh ng growth of bacteria To prevent complications, palitan ka hit laman pa
Kapag hrs na
. 24 na , .
may .
* N tubing ay up to 96 hrs ( ideal ) dapatpalitan

1- - - -
* 4 days !
ADMINISTERING MEDICATIONS VIA:

(1) IV PUSH, (2) DRUG INCORPORATION & (3) VOLUMETRIC CHAMBER

done
ASSESSMENT
1. Validate the orders
2. Examine the medication administration record for accuracy
and completeness
3. Review information on the drug, including:
Effects
Dilution
Rate of administration
Potential for incompatibility with other fluids or
medications to be given
4. Assess for what type of IV access is present
PLANNING
5. Determine equipment you will need
6. Wash your hands
7. Select materials needed:
IMPLEMENTATION
8. IV Push
a. Explain procedure (Name of medicine and action)
before administration
b. Check the IV site placement. Check for ANST of the
drug for IV push (if applicable )
c. Disinfect the Y-port using an alcohol swab.
d. Kink tubing, pierce through the Y-injection site and
push prepared drug slowly as ordered
e. Flush IV tubing after drug administration
f. Regulate rate of IVF infusion as ordered
9. Incorporation of drug into IVF
a. Follow procedure a and b on IV push
b. Locate and disinfect the injection port with an
alcohol swab.
c. Close the roller clamp. Remove the IV bottle from the
stand.
d. Incorporate prepared drug aseptically.
25 | P a g e
e. Shake the bottle to mix incorporated medicine with

the IV solution, hang the bottle, regulate flow rate,
and place an IV label
10. Incorporation into the volumetric chamber
a. Follow procedure 1 and 2 on IV push
b. Set up the Volumetric Chamber
c. Open the package and close all the clamps.
d. Spike into the ordered IV fluid.
e. Open the roller clamp above the volumetric chamber
and run down the ordered amount of IV solution.
Close clamp once the amount is reached.
f. Open the roller clamp below the volumetric chamber
to prime the tubing. Close the clamp and attach a
needle at the end of the tubing.
g. Disinfect injection port at the volumetric chamber.
h. Incorporate prepared drug.
i. Clamp tubing from the main IV bottle and attach the
needle of the volumetric chamber to the y-port.
j. Regulate the flow rate of IVF infusion as ordered.
k. Place IV label on the volumetric chamber
EVALUATION
Patients’ rights followed
Correct route used
Effectiveness of medication assessed
Any side effect promptly identified
DOCUMENTATION
1. Record pertinent data in terms of:
Medication dosage
Route of administration
Time of administration
Signature
____________________________ _______________________________ __________________

26 | P a g e
* IF order ni doctor
ng antibiotic via IR route ( faster effect) Magi inject ng medication
,
-
sa white port .
* IF Mag IV push ,
FIRST STEP is tihgnan-ku-ng-i-h-P-afdipawoutl.to make sure na mapupunta doon ang medication .
(µ How to FIND out ?

•
Ibaba ang IV bottle then MakiKita na
may backflow ng blood
] IN PA !
,
MEANS NAKA -
• Or aspirate kink
,
sa part na pa
-
N fluids then aspirate makiKitana may blood
,
* In administering medication clean white port first then administer SLOWLY ( because masakit
, esp antibiotics )
.
INCORPORATION ,
* In DRUG Yung pinata fluids do on ihahato ( Yung
'
bwtas ay for incorporation , do on ipapasok omg needle)
'
sa N Mah it ha
'
bottle
1- - -
• Then ikapag nalagay na ang fluids then hatun in to mix then hung ulit
PWEDE BANG MAGSULAT SA N BOTTLE ?

* BANAL MAGSULAT gamit any pen kapag nag incorporation , pwedengmaglagay ng tag
-
. .
"
"
- -
☒ banal any pentel din ! Dawn possible na ma -
incorporate sa container, Maha halo sa mistiming fluids .
-
B banal ballpen possible ma puncture
any
-
. .
* N TAG ONLY .
- - - - - - - - - - - - - - - - - -
- - - - - - - - - - -
* Gumagamit tayo ng volumetric chambers or son set Ia-pag-kai-a-ga.is centre talaga any solution papuntr
- _
sa patient ; or as ordered by doo na
(Be ganon ang gamitin .
Esp .
if PEDI A
Cpp prone sa fluid overload

discontinue tayo
poor Nagai
-
kapagtapos na ang
DISCONTINUING AN INTRAVENOUS INFUSION N therapy or discharge na
or out ka na ( Wala na sa
Definition: ng at , need ng re -
insertion )
Termination of intravenous infusion when the clients’ oral fluid intake and hydration
status are satisfactory when intravenous routes are no longer required.
Materials Needed:
Sterile cotton balls Plaster
Alcohol swabs Clean gloves
done
ASSESSMENT
1. Check order for IV discontinuation
PLANNING
1. Determine what you will need
2. Wash your hands
3. Gather necessary materials
IMPLEMENTATION
1. Identify patient
2. Explain the procedure to the patient
3. Turn off IV flow
4. Put on gloves.
5. Remove tape and dressing
6. Hold the swab above the entry site
7. Remove cannula by pulling straight out
8. Put pressure on site
9. Elevate patient’s arm for 1 minute, keeping pressure on-site
until bleeding is controlled
10. Remove all equipment
11. Wash your hands
EVALUATION
Intravenous infusion is discontinued
Any bleeding is controlled
Cannula is intact * check if buo A Walang naputol
DOCUMENTATION
1. Document that IV was discontinued with cannula intact,
assessment of site and time.
27 | P a g e
____________________________ _______________________________ __________________

28 | P a g e
WHAT TO REMEMBER ?
discharge
m-u-na-an-g-rotler-damp.GR
turn-off
* If Magdi -
,
make sure no -
if di tinurn I
Because off , open
flowing pa Yun mababasg

'
so
si patient & ang bed niya .
TIP :
* If maglalagdy ng tape , fold ang pinata ditto para ma
dating tanggalin if tapos na
Tayo . Also kapag naka -
gloves, kapag nilalagay kapag

starting ,
do on hahawakan
para hindi masyado nadidikit .
DISCONTINUING :
* Aug hatak ay diretso lang .
maglalagay tang
- - - - -
- ng pressure
-
saw site
-
kapagnatangg.at -
ang cannula
- - - - .
.
(MB
- - - -
-
da hit baka masaktan si patient dahil may cannula

'
pa , so Walang maglalagay
ing pressure hab hinuhugot; also to
ang bleeding
prevent .
'
- - - -
☒ After that , we can ask the patient to elevate the hand para
decrease
any blood flow hindi masyadong may bleed
-
, .
WHAT IF NAPUTOL ANG CANNULA ( see evaluation )

* Kapag naka Kapa pa yung pinakanaputol maglagay ng torniquet then notify physician , tatauggalin siya surgically
'
, ,
.
1- M D ahh
Kapag it napwfob, it will move centrally aakyat you & mahihirapan pahanapin a tanggalin
-
- - '
, .
'
- - - - -
⑧ That's why it is important to check if the cannula is intact .
* REASONS BAKIT NAPUPUTOL :
•
manufacturer defect ( that's why it is nurse 's
responsibility to check expiration date)
Intravenous
Therapy
Concepts
Rhealeen C. Viray-Vicedo, RN, MAN
Table of Contents
01 02 03
Body Fluids IV Fluids Drip Rate
Calculation
04
Electrolytes
01
Body Fluids
Body Fluids and Compartments
Intracellular fluid (ICF) Plasma an fluid part of blood
Fluid inside cells within (blood) is ECF, but
01
or
Accounts for two- 03 accounts04

• •
• for 3L of total
thirds of body fluid body water.
• Links external and
Extracellular fluid (ECF) internal environments
Fluids outside cells;
02 (Figure 15.9)
•
includes blood plasma,

interstitial fluid (IF),
(
lymph, and transcellular
contain within sinovial cavity
fluid •
like CSF , fluids © 2018 Pearson Education, Inc.
"
-
in between cellular compartments ;

-
-
The joint cavity is filled with synovial fluid. The synovial fluid
-
-
→ provides nutrition and lubrication to the articular cartilage that covers
in between intra I extracellular the ends of the articulating bones. The joint is enclosed by a
connective tissue that forms the articular capsule.
Total body water
Volume 40 L
60% body weight
Plasma
Volume
Intracellular fluid (ICF) Interstitial
Volume 25 L fluid (IF)
3 L, 20% of ECF
40% body weight Volume 12 L
80% of ECF
Extracellular fluid (ECF) ~µw IF I Plasma

Volume 15 L
20% body weight
© 2018 Pearson Education, Inc.
Functions of Body Water
ECF – maintains blood volume; vk.ph fluid outside the cells
helps
to deliver nutrients stake
transport system to and from the cell away

the cells
waste
.
products from
ICF – internal aqueous medium for fluids

yo inside the cells helps
to suspend cellular organelles I
cellular chemical function helps to maintain cellular

functions .
Maintenance of normal body → How

BODY TEMPERATURE
BODY MAINTAIN
DOES THE
?
temperature
,
if is hot outside
'
-
-
☒ Ex
-
- it .
,
you pe spire ! in order to

remove heat or cool off
②
if yoiirein a coil ÑMT
- -
-
to chill or Shiver
you tend ,
to heat up cells to produce
Elimination of waste products

more heat within to maintain
body temp .

Factors that Affects Total Body Water
• Age
• Gender
• Input and Output -
µ everything that body eliminates leg urine I vomit )
.
.
(Bµ everything take inside water IN fluids)
Ways for Fluid

we our body (e. g. ,
Output:
• Sensible fluid loss → fluid loss that can be
(e. g.,
urine )
perceived / measured
• Insensible fluid loss -

☒ cannot be perceived
(e. g. , perspiration)
/ measured

Body Water Distribution
• Normal amount of water • Water is necessary for
in the human body many body functions, and
• Young adult levels must be maintained
females = 50% within normal limits
É
.
E
'
• Young adult
males = 60%
EE •
•
Babies = 75%
The elderly =
45%
⑧ that's why if they experience LBM
,
or vomiting
,
they tend to be more prone of

dehydration © 2018 Pearson Education, Inc.
Maintaining Water Balance of the Blood
• Regulation of water intake and output
• Water intake must equal water output if ~µ
that's
we
why
usually
in admitted patients
measure I & 0 and
,
the body is to remain properly hydrated

it should be equal ; if I > 0
meaning you have retained body
water or IV fluids
Sources for water intake

.
• Ingested foods and fluids

• Water produced from metabolic
processes (10%)
• Thirst mechanism is the driving force for
(
water intake
BBB located on our

hypothalamus ,
when mouth is
dry or there is
increased salivation ,
hypothalamus is iner bated thus thirst
mechanism is experienced .
In which we tend to drink water .
Water intake and output.
cells
utilization of
B.
( 100 ml Feces 4%
Metabolism
10% 250 ml Sweat 8%
200 ml
Insensible
Foods
750 ml 700 ml losses via
30%
skin and
2500 ml
lungs 28%
Beverages 1500 ml 1500 ml Urine 60%

60%
Average intake Average output

per day 12,500 )
Mt
per day ( 2,500 my © 2018 Pearson Education, Inc.
Cellular Physiology:
Membrane Transport
❏Membrane Transport Methods of Transport

– movement of • Passive transport npp substances can freely
move
inside or outside of the cells,

No energy is required
vice versa
substance in and out

or
of the cells • Active transport:

Metabolic energy required → for substances to pass through
cellular membrane inside or outside
of the cell ; may consider as a gate up
you needs key .
¥wuEs
!
→ serves a
gate w/o
in
energy is required 1 keys
bop cellular membrane
Passive Transport Diffusion
Processes ● Particles tend to
distribute themselves
evenly within a solution
● Movement is from high

concentration to low
concentration, or down
a concentration
Or Molecules
gradient © 2018 Pearson Education, Inc.
I outside the cell,

- - -
• mas Mataas
they tend to move away
papunta sa cytoplasmic membrane
UM nay dissolve may isa -
sa water ; lwmatsas
papunta sa water I
away kung sawn
sila mas manami
FLU 1 Much
p e.g.
Cpr med for
-
y •
wth
EFFERVESCENT TABLET
to dissolve
'
i -
- - -
• designed
in water, I release
I
,
uh -
ta
concentrated
any substances
so tablet
Diffusion © 2018 Pearson Education, Inc.
Kaya
nagdidissolve sa
water
Types of diffusion
Facilitated
Simple diffusion: Osmosis:
diffusion:
÷ 1 1
I
'
i i ,
l Unassisted process. Solutes l simple diffusion of l

Substances require a
are lipid-soluble materials or l water: Highly polar
l
l
protein carrier for passive
small enough to pass water easily crosses the l
\
l
through membrane pores. \ plasma membrane. transport.
' © 2018 Pearson Education, Inc.
i ' e
simple diffusion he dap at may protein transporter

- -
-
-
•
MB there
-
-
- - are no
para markup ask any substance
-
energy required ; who refers to

membrane
no other processes simple diffusion sa
involved ; substances of water

just passed through
freely .
Active Transport Processes
Transport of substances that are not
able to pass by diffusion because they:
● May be too large
● May be unable to dissolve in the fat of
membranes
● May have to move against a concentration
gradient wrap cellular membrane
(µ to transport
required energy substances
2 Types of Active Transport Process:
Solute pumping
illustrates the ←
movement of kit
Na against the
● Amino acids, some sugars
concentration
membrane and ions are transported
by solute pumping
● ATP energizes protein
carriers, & in most cases,
moves substances against
concentration gradients
(
• in Eui Na is usually
,
no requirument
for protein carrier

higher in concentration to open the gate I
in the inside
compare move Na towards
of the Mlb concentration
higher
in the outside of the
1
cells ( Ict to Ect )
'
-
- - - -
µ same thing goes for K 1h W/o

it weeds ADP for protein carrier
to open the gate I move towards
low to high ( Elt to Ict )
up same as the explanation above
nµBo there is a
protein carrier
that requires energy in the
form of ATP to let substances

such K I Na to pass
as through
Solute Pumping © 2018 Pearson Education, Inc.

means to
go
Bulk transport
outside ; exit
yµ* Mr
outs
movement of
Exocytosis:↳ process STEPS:
process of
=
substances outside the

cells.
●Moves materials out of 1. Vesicle migrates to

the cell. Material is carried plasma membrane
in a membranous vesicle. 2. Vesicle combines with
¥÷ ¥ 3.
plasma membrane
Material is emptied to
¥É?÷
-
www.waneiiiiiiio
;; the outside : °o°
I• vesicles that contains substances

uses into the membrane so

the substances inside the vesicles
can exit I
pass through the
membrane towards the other wells
.
• resins containing substances
f inside the cells exit the
cellular membrane by fishy
into the membrane then
to the outside so that
opening
substances
inside the vesicles can move
outside of the cells .
Exocytosis
Bulk transportroo
to
inside
go • cells • process
✓ [
substances
ay papasok ng
Endocytosis:
=
cells ; still uses vesicles
transport mechanism as a
■ Extracellular substances
are engulfed by being
enclosed in a membrane
vesicle.
Types:
1. Phagocytosis: cell eating
2. Pinocytosis: cell drinking © 2018 Pearson Education, Inc.
towards the cells
-
me substances are engulfed so
they may move
vesicles gets fluid substances that is move inside the cells

PHIN 06410815 •
-
Endocytosis
Mechanisms that Control Body Fluids * measures the pressure
within the blood vessels or
plasma
Thirst ADH RAAS Baroreceptors, ANP

Osmoreceptors
1
Renin – Angiotensin Sensitive cells
A dry mouth Anti-diuretic Atrial Natiuretic
– Aldosterone - that become
due to Hormone
decreased saliva Hormone System more active in
A cardiac hormone
Prevents Angiotensin II reaction to small
also promotes •
which functions to
excessive water causes changes in
↳µ•
the thirst vasoconstriction lower BP and
loss in the urine plasma solute
mechanism and aldosterone controle
and increases concentration
(• contains release electrolyte
in
water Result is increase and blood
the hypothalamus •
pressure. homeostasis
reabsorption in blood volume
and blood
pressure to differences or
to retain µp reacts
µ outs I reabsorb
osmotic
changes in
water within the
might pressure
water ; blood plasma
increase& blood
volume
pressure
of
movement body
tosses
&
smh
Fiuwf¥F%Y
our
outside
Fluid Imbalances
to
refers
water for
• in
the
[ Fluid Volume Fluid Volume

Deficit Excess
there is Na retention may lead to edema
Eg: dehydration, attracts water if
: so
µB
hemorrhage, Eg: sodium and
excessive diuretics, water retention leading to
GI losses (diarrhea, edema
vomiting)
Excess fluid
OTHER
KINDS : Third spacing : infusions
extracellular fluid
volume shift • may lead to
sumo bra
fluid
ang N
volume excess ;
infusions
• Ebt volume is shifted Kung saan
hindi naman si la normally present ;

e. g. , may
occur in parietal cavity ,
causing pleural effusion
A pleural effusion is accumulation of excessive fluid in the pleural space, the potential space that surrounds each lung. Under
normal conditions, pleural fluid is secreted by the parietal pleural capillaries at a rate of 0.01 millilitre per kilogram weight per
hour, and is cleared by lymphatic absorption leaving behind only 5–15 millilitres of fluid, which helps maintaining a functional
no vacuum between the parietal and visceral pleurae. Excess fluid within the pleural space can impair inspiration by upsetting the
functional vacuum and hydrostatically increasing the resistance against lung expansion, resulting in a fully or partially collapsed
lung.
Fluid Concentration
Tonicity Osmotic Pressure
Refers to the Refers to the power
effect of of a solution to
water/solution on draw water across a
the water’s semi-permeable
osmotic pressure membrane (e.g. cell
membrane)
Osmotic Pressure
• ↑ osmotic pressure : ↑ pulling force →• directly proportional
of water
• Cell shrinks if on ↑ osmotic pressure (hypertonic) solution
• Cell swells if on ↓ osmotic pressure (hypotonic) solution
• E.g. Red blood cell: if exposed on hypotonic

solution will swell if exposed on hypertonic
solution will shrink
;
means how !
•
refysnut.tt#jw0fgwfe
Hop I
pA
www.waterI
7*aa
I
less water
unchanged less solute : more sonde
:
in KBO ! RBC smell : RBU shrink ,
movement of just vice versa
water is to high
to low concentration ;
will enter the cellar
RBC causing ith

swell .
02
Intravenous Fluids
Types of IV Fluids
● Crystalloids
● Colloids
● Blood and Blood Products
Crystalloids
• water with electrolytes that
form a solution that can pass
through semi permeable Distinguished by relative tonicity:
membranes Isotonic Solutions
Hypotonic Solutions
can remain in the extracellular Hypertonic Solutions
compartment for about 45
minutes (larger volumes than
colloids are required for fluid
resuscitation)
Tonic Solutions Isolates 1 equal)
game
concentration of water
ISOTONIC SOLUTION
Big
• No fluid movement or change in

volume within the cell
• No change on the cell size
• E.g. Plain NSS or 0.9 NaCl, D5W,

Lactated Ringer’s Solution
• Indication: for intravenous

dehydration
PLAIN NW or 0.9 Nall
Dsw Dsa Nacl
↳ considered both
isotonic & hypotonia;
the
because it dilutes
osmolality of Ect ;
the cell all
used
once
content
the dextrose
-
,
remaining saline
a
the
out Arn
electrolytes Ect
isotonic expanding
,
compartment .
Tonic Solutions
HYPERTONIC
SOLUTION
• ↑solute concentration than
plasma
• When exposed to hypertonic
solution, cells will shrink
• E.g. D5LR, D10W, D5NSS
• Indication: for intracellular
overload
Deo W D 5.9 Natl
DSLR
B- MR Ds IMV B- MM
Colloids
• Also known as volume/plasma expanders
• Colloids contain solutes in the form of large proteins or
other similar sized molecules
• remain in blood vessels longer and increase
intravascular volume
• attract water from the cells into the blood vessels
• Less total volume is required compared to IV fluids.
• indicated for patients in malnourished states and
patients who cannot tolerate large infusions of fluid.
Colloids ,
-
pµ usually in vial
preparation I
• Albumin (plasma y administered via
drip
protein) 4% or 20%
side .
o Keeps fluids in vessels

o Maintains volume (fluid blood or volume)
o Primarily used to replace

protein and treat shock
o WOF: anaphylaxis
(• watch out for this or
generalized allergic
reaction !
µ
administered for
when client
,
Colloids white wasting for blood transfusion
[ needs blood transfusion
instance
wala p any
blood i
infused
pero
• Dextran (polysaccharide)
40 or 70
o Shifts fluids into vessels
results this
o Vascular expansion
&
fluid '
u-
also
B volume
o WOF: fluid overload, increase

I
hypersensitivity,
bleeding
• watch out for this !
Colloids
• Mannitol (alcohol sugar 5%
or 10%)
(
o Oliguric diuresis
o Reduces cerebral edema
o Eliminates toxins
o WOF: fluid overload,
electrolyte imbalance, cellular
dehydration, extravasation
may cause necrosis
1µg if you will administer this , you should check if N cannula is in place ,
because if N line is out of blood vessels or vein ,

then you infuse the
mannitol it can cause necrosis within the vein

.
,
Blood and Blood Products
● Blood is the only fluid tissue,
a type of connective tissue,
in the human body
● Components of blood
○ Formed elements (living cells)
○ Plasma (nonliving fluid matrix)
µ Put in CENTRIFUGE
03
Drip Rate Calculation
IV Orders IV Orders must
specify the ff:
• The prescriber is • Name of the IV
responsible for solution
Name of
writing the order
•
medication to be
added if any
Administering and • Amount (volume)
•
to be
monitoring an IV = administered
nursing responsibility • Time period
during which the
IV is to infuse
IV Drip Factors
● Microdrip = 60 µgtt/mL
● Macrodrip, need to check package ~pµ there is aneedle in the
o 10 gtt/mL drip chamber I
smaller drops compared
15 gtt/mL
ÉÉ o
o 20 gtt/mL
to macro drips .
● To calculate IV drip rates, this

information must be known and is
constant.
IV DRIP CALCULATION
(Method A: Two-Step)
~µ• Kung ilang drops

nalin siya
irregular !
IV DRIP CALCULATION
(Method B: One-Step)
Sample IV Calculation
Calculate the IV flow rate for 1000 mL of NSS to be infused
in 8 hours. The infusion set is calibrated for a drop factor
of 15 gtts/mL.
Using Method A:
1. 1000 mL / 8 hr = 125 ml/hr
2. 125 mL/hr X 15 gtt/mL = 1875 = 31.25 or 31 gtt/min
60 min 60
Calculate the IV flow rate for 1000 mL of NSS to be infused
in 8 hours. The infusion set is calibrated for a drop factor
of 15 gtts/mL.
Using Method B:
1000 ml X 15 gtt/mL = 15000 = 31.25 or 31 gtt/min
8 hr 60min 480
• Order: 1000mL of D5NSS to infuse for 12 hours.
• Available: macrodrip set with 10 gtt/mL and a microdrip set
with 60µgtt/mL.
• Calculate the IV flow rate in drops per minute according to
the IV set given.
Using Method A: MACRODRIP SET

1. 1000 mL / 12 hr = 83.33 ml/hr
2. 83.33 mL/hr X 10 gtt/mL = 13.89 or 14 gtt/min
60 min
with 60µgtt/mL.
the IV set given.
Using Method A: MICRODRIP SET

1. 1000 mL / 12 hr = 83.33 ml/hr
2. 83.33 mL/hr X 60 µgtt/mL = 83.33 or 83 µgtt/min
60 min
with 60µgtt/mL.
the IV set given.
Using Method B: MICRODRIP SET

1000 ml X 60 µgtt/mL = 60,000 = 83.33 or 83 µgtt/min
12 hr X 60min 720
04
Electrolytes
Electrolytes
● Chemical compounds in solution that have the ability to
conduct an electrical current
● Break into charged particles called ions
○ Positively charged ions (CATIONS); negatively charged ions
(ANIONS) µ outside ; most abundant extracellular substance
● Major Extracellular Cation – Na+ (Sodium); Major
Intracellular Anion – Cl- (Chloride)
● Major Intracellular Cation – K+ (Potassium); Major
Extracellular Anion – HPO4- (Phosphate) ↳ inside ; most abundant
intracellular substance
General Functions Electrolytes
❏ Promote neuromuscular activity
❏ Maintain body fluid volume and osmolality
❏ Distribute body water between fluid
compartments
❏ Regulate acid – base balance
Blood Transfusion Components
Indication for Treatment with Blood Components
Component Volume Infusion Indications
Time
Packed Red 200-250 mL 2-4hr Anemia ; hemoglobin <6 g/dL, 6-10 g/dL,
Blood Cells depending on the symptoms
(PRBCs)
Washed Red 200 Ml 2-4hr History of allergic transfusion reactions; Thrombocytopenia is a
Blood Cells Bone marrow transplant clients condition in which you have a
low blood platelet count.
(WBC-poor Be Platelets (thrombocytes) are
colorless blood cells that help
PRBCs) blood clot. Platelets stop
bleeding by clumping and
Platelets Approximately 15-30 min Thrombocytopenia; platelet count <20,000 forming plugs in blood vessel
injuries.
(Pooled) 300 mL
Whole Blood 350 - 450 mL 4 hr (less in Emergent restoration of circulating volume;
high massively bleeding patient
ambient
temperature
)
Blood Transfusion Components
Indication for Treatment with Blood Components
Thrombocytopenia is a condition in
which you have a low blood platelet
count. Platelets (thrombocytes) are
colorless blood cells that help blood
clot. Platelets stop bleeding by
Component Volume Infusion Indications clumping and forming plugs in blood
Time Dong vessel injuries.

Prothrombin time (PT) is a blood test that
measures how long it takes blood to clot. A
Fresh Frozen 200 mL 15-30 Deficiency in plasma coagulation factors; prothrombin time test can be used to check
for bleeding problems. PT is also used to
Plasma min check whether medicine to prevent blood
Prothrombin or partial thromboplastin time 1.5 clots is working.
The reference range for prothrombin time
times normal depends on the analytical method used,
but is usually around 12–13 seconds
Cryoprecipitate 10-20 15- Hemophilia VIII or von Willebrand’s disease;

Boo
7.
mL/unit 30min Fibrinogen levels < 100mg/dL Hemophilia is a disease that
prevents blood from clotting
White Blood 400mL 1 hr Sepsis, neutropenic infection not responding properly. A clot helps stop
bleeding after a cut or injury.
Cells to antibiotic therapy In factor VIII deficiency
(hemophilia A), the body
Volume For severe blood loss (e.g. hemorrhages) or doesn't make enough factor
VIII (factor 8), one of the
expanders loss of plasma (severe burns, which draw substances the body needs to
form a clot.
(Dextran, large amounts of plasma from the bloodstream

Plasma, to burn site) Von Willebrand disease is a
lifelong bleeding disorder in which
your blood doesn't clot well. People
Albumin) with the disease have low levels of
von Willebrand factor, a protein
that helps blood clot, or the protein
doesn't perform as it should.
Neutropenia is when a person has a low level of
DD neutrophils. Neutrophils are a type of white blood cell.
All white blood cells help the body fight infection. • an escape of blood from a
ruptured blood vessel,
Neutrophils fight infection by destroying harmful especially when profuse.
bacteria and fungi (yeast) that invade the body.
Conclusion
IVT cannot be veered away in
the everyday practice of a
nurse. Thus, it is just but right
to be well equiped with
knowledge and skills in the
concepts of intravenous
fluids.
References
Marieb, E. (2018). Essentials of Human Anatomy and
Physiology 12th Edition.Philippines.Pearson Education
South Asia PTE. LTD.
Hinckle, J., and Cheever, K. (2016). Brunner & Suddarth’s
Textbook of Medical-Surgical Nursing. 13th Edition.
Philippines. Wolters Kluwer Health/ Lippincott Williams
& Wilkins
Udan, J. (2017). Medical-Surgical Nursing: Concepts and
Clinical Application. Third Edition. Philippines.Guiani
Prints House
Thanks!
Do you have any questions?
rhealeen.viray@bulsu.edu.ph
CREDITS: This presentation template was created by

Slidesgo, including icons by Flaticon, and infographics
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REASONS FOR BACK FLOW :
change position sa kamay 1 yung blood umaakyat sa tubing)
'
in
(• That's
•
why we
change ang position sa ka
may !
'
kapagfinilush InaWala ang
IF MAY BACKFLOW ?
-
7 pwedeng pronation or supination µ
dislodge ! )
f blood (no need to
- - -
FLUSH OR CHANGE IV
*
Kapag naka in -
pa ang Swan - -
> ibaba
-
ang N fluids or bottle , if may backflow means naka.in Pa -

• open the roller clamp then bibilis ang two
then Mag flush
'
na
yon .
→ kahitbilisanangswenihalos hindi natumutnlo need ng palitan

* Kapag hindi na naka in sa-
ng at , dislodge na
-
,
-
• , also kapag may
possible sa tissues na napupunta any fluids
µ complications such as
phlebitis I
infiltration inflammation
PAAN 0 KAPA G WALANG VIABLE VEIN ? • wfiuidor medication
leak into the surrounding
µ
of vein
* Distal part ! Kaya nagsisimula sa

kamay • para
-
kanitmasira
'
yung distal ( harap) , pwede
'
tissue
pasa likodiipag vice versa hindi pwede Kasi
* pwede n'n sa ulo or paa I usually sa baby) damage na ang mas distal if hindi distal omg inuna .
TIPS FOR CANNULA INSERTION ?

admitted because of dehydration ( masyadongmaliitangugat)
kapag maitimldimakita) Kaya di maKita )
* ,
mataba Club og ang ugat ,
severe
1- - -
µ reasons bakit hindi masweruhan ayad

also dapatdiretso
LB WHAT TO DO ? µ ang vein , not branching ;
and lama any gagamitin na cannula
gauge size
* veins should be distended !
TIP :
'
- -
fragile putukin -
* not or
-15min
Teri
ika-pag-pirs-tti-m-ed-ahan-da-ha-na-ng-pa-g.in tha ☒ 10
- -
use torniquet i stroke ang ugatpataas then pipitikin

, :
-
or
I mataas then backflow I
angle if may ask the
Muna
dugo means has a

ang
ka na ,
ugatiadvance i
Wag
patient
to open I chose the hand
ang vein distention ; if not urgent ,
ing Maldita we can use warm
,-na patusok ,
decrease angle, parallel then advance cannula 1
- i para compress
remove stylet - - - . - - - -
HOW TO PREVENT BACKFLOW ?
* Hindi dapat masyadong ginagamit ang hand (that's why we insert sa non-dominant hand
ng patient )
!
INSERTING A STRAIGHT OR INDWELLING CATHETER TO A MALE PATIENT
Purpose
 To relieve discomfort due to bladder distention or to provide gradual decompression of

a distended bladder
 To assess amount of residual urine if the bladder empties incompletely
 To obtain a sterile urine specimen
 To empty the bladder completely prior to surgery
 To facilitate accurate measurement of urinary output for critically ill clients whose
output needs to be monitored hourly
 To provide for intermittent or continuous bladder drainage and/or irrigation
 To prevent urine from contaminating an incision after perineal surgery
 To manage incontinence when other measures have failed
Equipment
 Sterile catheter of appropriate size (an extra should be on hand)Catheterization kit:

 1-2 pair of sterile gloves
 Waterproof drape
 Antiseptic solution
 Cleansing cotton balls
 Forceps
 Water soluble lubricant
 Urine receptacle
 Specimen container
 For indwelling catheter:
 Syringe prefilled with sterile water in amount specified by the manufacturer
 Collection bag and tubing
 Disposable clean gloves
 Bath blanket for draping the client
 Adequate lighting
Goal
 The patient’s urinary elimination is maintained, with a urine output of at least 30

mL/hour, and the patient’s bladder is not distended.
Criteria Done Not Remarks

done
ASSESSMENT
1. Assess status of client.
a. When client last voided
b. Level of awareness or developmental
stage
c. Mobility & physical limitations
d. Bladder distention
e. Any pathological conditions & allergies
f. Sex & age
2. Review client’s medical record, including
physician’s order.
PLANNING
1. Gather all materials needed.
Page 33 of 46
2. Explain the procedure to the client & provide
privacy.
IMPLEMENTATION
1. Wash hands.
2. Facing client, stand on the left side of the bed if
right handed (right side if left handed). Clear
beside table and arrange equipment.
3. Place the side rail on opposite of the bed.
4. Close the cubicle or room curtains.
5. Place the waterproof pad under patient.
6. Position client. Assist to supine position with
thighs slightly abducted.
7. Drape patient. Drape upper trunk with a bath
blanket and cover lower extremities with bed
sheets, exposing only genitalia.
8. If inserting indwelling catheter, open package
containing draining system. Place drainage bag
over edge of bottom bed frame. Bring drainage
tube up between side rail and mattress.
9. Open catheterization kit according to directions,
using aseptic technique. Place waste receptacle in
accessible places.
10. Don sterile gloves.
11. Organize supplies on sterile field:
 Open sterile package containing catheter; pour
sterile package of antiseptic solution in correct
compartment containing sterile cotton balls.
 Lubricate tip of catheter, remove specimen
container (lid should be loosely placed on top)
and prefilled syringe from collection
compartment of tray and set them aside on
sterile field.
12. Nurse may want to ensure that inflatable balloon of
indwelling catheter is intact by inserting syringe tip
through valve of intake lumen & injecting sterile
fluid until balloon inflates. Then aspirate all fluid
out of the inflated lumen.
13. Apply sterile drape: Apply sterile drape over
thighs just below the penis. Pick up fenestrated
sterile drape and allow it to unfold without
touching any unsterile object. Apply drape over the
penis with fenestrated slit resting over penis.
14. Place sterile tray & contents on sterile drape
between thighs.
15. Determine that catheter tip is properly lubricated.
Male 12.5 – 17.5 cm (5-7 in).
16. Cleanse urethral meatus:
 If patient is not circumcised, retract foreskin
with non-dominant hand.
 Grasp penis at shaft just below glands.
 Retract urethral meatus between thumb and
forefinger.
Page 34 of 46
 Maintain non-dominant hand in this position
throughout procedure.
17. Pick up catheter with gloved dominant hand 7.5-10
cm (3-4 in) from catheter tip. Hold end of catheter
loosely coiled in palm of dominant hand (optional:
May grasp catheter with forceps). Place distal end
of catheter in urine tray receptacle.
18. Insert catheter:
 Lift penis to position perpendicular to client’s
body and apply light traction.
 Ask patient to near down as if to void and
slowly insert catheter through meatus.
 Advance catheter 17.5 to 22.5 cm (7-9 in) in
adult and 5 to 7.5 cm (2-3 in) in young child or
until urine flows out the catheter’s end. When
urine appears, advance catheter another 5 cm
(2in). Do not force against resistance.
 Lower penis and hold catheter securely in non-
dominant hand. Place end of catheter in urine
tray receptacle.
19. Collect urine specimen as needed: fill the specimen
cup to desired level (20-30ml) by holding end of
catheter in dominant hand over cup. With
dominant hand, pinch catheter to stop urine flow
temporarily. Release catheter to allow remaining
urine in bladder to drain into collection tray. Cover
specimen cup & set aside for labeling.
20. Allow bladder to empty fully (about 750-1000ml)
unless institution policy restricts maximal volume
of urine to drain with each catheterization.
21. A. For straight single use catheter: Pinch catheter
& remove slowly but smoothly when urine cease to
flow.
B. For indwelling catheter, inflate balloon of
indwelling catheter.
 While holding catheter with thumb & little
finger of non-dominant hand at meatus,
take end of catheter and place it between
first two fingers of non-dominant hand.
 With free dominant hand, attach syringe to
injection port at end of catheter.
 Slowly inject total amount of solution. If
patient complains of sudden pain, aspirate
back solution and advance catheter further.
 After inflating balloon fully, release
catheter with non-dominant hand and pull
gently to feel resistance.
22. Attach end of catheter to collecting tube of drainage
system. Drainage bag must be below level of
bladder.
23. Tape catheter tubing on top of thigh or lower
abdomen. Allow slack in catheter so movement of
thigh does not create tension on catheter.
Page 35 of 46
24. Be sure there are no obstructions or kinks in tubing.
Place excess coil of tubing on bed & fasten it to
bottom sheet with clip from drainage set or with
rubber band & safety pin.
25. Remove gloves & disposed of equipment, drapes
and urine in proper receptacles.
26. Assist patient to comfortable position. Wash dry
perineal area as needed.
27. Instruct client on ways to lie in bed with catheter:
 side-lying facing drainage system with catheter
& tubing draped over thigh
 Side-lying facing away from the system,
catheter and tubing extended between legs.
28. Caution client against pulling on catheter.
29. Put on clean gloves. Obtain urine specimen
immediately, if needed, from drainage bag. Label
specimen. Send urine specimen to the laboratory
promptly or refrigerate it.
30. Remove gloves and additional PPE, if used.
Perform hand hygiene.
31. Wash hands
EVALUATION
1. Palpate bladder & ask if client remains
uncomfortable
2. Determine that there is no urine leaking from
catheter or tubing connections.
3. Record of procedure, characteristics, amount of
urine in drainage system.
Evaluator
________________________ ________________________ ________________________
Clinical Instructor’s Name Student’s Name and Date

and Signature Signature
Page 36 of 46
ROUTINE CATHETER CARE
Purpose
 To minimize the trauma and infection risk associated with urinary catheters.
Equipment
 Soap and washcloth  Tape

 Anti-infective solution  Measurement container
 Antibiotic ointment  Sterile gloves
 Sterile swabs  Sterile drape
 Forceps
Goal
 The patient’s urinary elimination is maintained, with a urine output of at least 30

mL/hour, and the patient’s bladder is not distended.

done
ASSESSMENT
1. Determine how long catheter has been in place.
2. Observe any discharge or encrustation around
urethral meatus. Assess for complaints of pain or
discomfort.
3. Wash hands.
PLANNING
1. Prepare the necessary equipment and supplies
IMPLEMANTATION
1. Wash hands and close curtains around or close
door to room.
2. Organize equipment for perineal care.
3. Position patient correctly and cover with bath
blanket exposing only perineal area.
 Female – dorsal recumbent
 Male – supine
4. Place waterproof pad under patient.
5. Drape bath blanket on bath clothes so only perineal
area is exposed.
6. Open sterile catheter care kit using sterile aseptic
technique.
7. Put on sterile gloves.
8. Apply sterile drapes over patient’s perineum.
9. Pour antiseptic solution on cotton balls or swabs.
Apply antiseptic ointment on cotton balls (check
patient for allergies to antiseptic).
10. With non-dominant hand:
 Gently retract labia of female client to fully
expose urethral meatus & catheter insertion
site. Maintain position of hand throughout the
procedure.
 Retract foreskin of an uncircumcised male
client and hold penis at shaft below glands.
Page 37 of 46
Maintain position of hand throughout the
procedure.
11. Assess urethral meatus and surrounding tissues for
inflammation, swelling & discharge. Note amount,
color, odor, consistency of discharge. Ask patient if
burning & discomfort is felt.
12. Cleanse perineal tissues:
A. Female client:
 Use separate cotton balls &forceps to
cleanse each labia majora, moving down
toward anus. Repeat process to cleanse each
side.
B. Male client
 While spreading urethral meatus, cleanse
around catheter first, then use clean cotton
ball to wipe in circular motion around
meatus and glans.
13. Reassess urethral meatus for discharge.
14. Get new cotton ball & wipe in circular motion
along length of catheter for about 10 cm (4 inch).
15. Apply antiseptic ointment at urethral meatus along
2.5 cm of catheter.
16. Replace adhesive tape anchoring catheter to client
as necessary. Remove adhesive tape residue from
the skin.
17. Replace urinary tubing and collection bag adhering
to principles of surgical asepsis as necessary but at
least 8 hours.
18. Check drainage tubing. No tube should be coiled,
kinked or clamped.
19. Collection bag is emptied as necessary but at least
8 hours.
20. Assist patient to safe, comfortable position.
21. Dispose of contaminated gloves & supplies & wash
hands.
EVALUATION
1. Inspect condition of urethra, note character of urine
& assess client’s temperature.
2. Record on nurse’s notes when catheter care was
given, assessment of urethral meatus and character
of urine.
Evaluator
________________________ ________________________ ________________________

Page 38 of 46
PERFORMING CLOSED CONTINUOUS CATHETER IRRIGATION
Purpose
 To prevent blood clot accumulation that may occlude the catheter thus the procedure
maintains patency of the catheter and tubing
Equipment
 Sterile irrigating solution, correct bag of solution

 Irrigation tubing with clamp (with or without Y connector
 Metric container
 IV pole
 Antiseptic swab
 Y connector
 Bath blanket
Goal
 The patient exhibits free flowing urine through the catheter.

done
ASSESSMENT
1. Check the patient’s record to determine:
 Purpose of the close bladder irrigation.
 Physician’s order.
 Type of irrigating solution to be used.
 Frequency if irrigation
 Type of catheter used.
 Triple lumen (1 lumen to inflate balloon, 1
to install irrigation solution, and 1 to allow
outflow of urine)
 Double lumen (1 lumen to inflate balloon,
1 to allow outflow of urine)
2. Assess the ff:
 Color of urine & presence of mucus/sediment.
 Patency of drainage tubing
 Closed system:
 Note if fluid entering bladder & fluid draining
from the bladder are appropriate proportions.
 Note amount of fluid remaining in existing
irrigating solution container.
 Check irrigation tubing to ensure it has no
kinks and is opened/clamped according to
3. Review patient’s medical record, including
4. Review I and O record.
PLANNING
Page 39 of 46
1. Develop individualize goals of care for patient
based on nursing diagnoses:
 Maintain patent, free-flowing urinary drainage
system.
 Minimize risk of infection
 Minimize discomfort
2. Collect necessary equipment and supplies
3. Explain the procedure to the client.
IMPLEMENTATION
1. Confirm the order for catheter irrigation in the
medical record. Calculate the drip rate via gravity
infusion for the prescribed infusion rate.
2. Bring necessary equipment to the bedside.
3. Perform hand hygiene and put on PPE, if indicated.
4. Identify the patient.
5. Close curtains around the bed and close the door

to the room, if possible. Discuss the procedure with
patient.
6. Adjust bed to comfortable working height, usually
elbow height of the caregiver (VISN 8 Patient
Safety Center,2009).
7. Empty the catheter drainage bag and measure the
amount of urine, noting the amount and
characteristics of the urine.
8. Assist patient to comfortable position and expose
the irrigation port on the catheter setup. Place
waterproof pad under the catheter and aspiration
port.
9. Prepare sterile irrigation bag for use as directed by
manufacturer.
 Clearly label the solution as ‘Bladder Irrigant.’
 Include the date and time on the label. Hang
bag on IV pole 2.5 to 3 feet above the level of the
patient’s bladder.
 Secure tubing clamp and insert sterile tubing
with drip chamber to container using aseptic
technique. Release clamp and remove
protective cover on end of tubing without
contaminating it. Allow solution to flush tubing
and remove air. Clamp tubing and replace end
cover.
10. Put on gloves. Cleanse the irrigation port on the
catheter with an alcohol swab. Using aseptic
technique, attach irrigation tubing to irrigation port
of three-way indwelling catheter.
11. Check the drainage tubing to make sure clamp, if
present, is open.
12. Release clamp on irrigation tubing and regulate
flow at determined drip rate, according to the
ordered rate. If the bladder irrigation is to be done
Page 40 of 46
with a medicated solution, use an electronic
infusion device to regulate the flow.
13. Remove gloves. Assist the patient to a comfortable
position. Cover the patient with bed linens. Place
the bed in the lowest position.
14. Assess patient’s response to the procedure, and
quality and amount of drainage.
15. Remove equipment. Remove gloves and additional
PPE, if used. Perform hand hygiene.
16. As irrigation fluid container nears empty, clamp
the administration tubing. Do not allow drip
chamber to empty. Disconnect empty bag and
attach a new full irrigation solution bag.
17. Put on gloves and empty drainage collection bag as
each new container is hung and recorded.
EVALUATION
1. Calculate fluid used to irrigate bladder and
catheter and subtract from volume drained.
2. Assess characteristics of output; viscosity, color,
presence of clots & observe catheter patency.
DOCUMENTATION
1. Record amount of solution used as irrigant,
amount returned as drainage, in nurse’s notes and
in I & O sheet..
2. Report catheter occlusion, sudden bleeding,
infection or increased pain to the physician
Evaluator
________________________ ________________________ ________________________

Page 41 of 46
REMOVING AN INDWELLING CATHETER
Equipment
 Syringe same size as volume solution used to inflate balloon

 Waterproof pad
 Sterile specimen container, labeled correctly
 25-gauge 1/2” needle
 Alcohol swab
 non-sterile disposable gloves
Goal
 The catheter is removed without difficulty and with minimal patient discomfort.

done
ASSESSMENT
1. Review patient’s medical record including
physician’s order and note period of time catheter
was in place.
PLANNING
1. Prepare necessary equipment and supplies:
2. Close curtains around the bed and close the door to
the room, if possible. Discuss the procedure with
the patient and assess the patient’s ability to assist
with the procedure.
IMPLEMENTATION
1. Adjust bed to comfortable working height, usually
elbow height of the caregiver (VISN 8 Patient
Safety Center,2009).
2. Stand on the patient’s right side if you are right
handed, and on the patients’ left side if you are left-
handed.
3. Wash hands and don gloves.
4. If bladder conditioning is to be performed:
 Hours before removal, clamp indwelling
catheter for 3 hours.
 Unclamp and drain urine for 5 minutes.
 Repeat clamping for 3 hours and draining for 5
minutes two more times.
5. Provide privacy by closing room door or bedside
curtain.
6. Position patient in supine position.
7. Place water proof pad between female’s thighs or
over male’s thigh.
8. Obtain urine specimen, if required.
9. Remove adhesive tape anchoring catheter; cleanse
any residue from skin.
10. Insert hub of syringe into inflate valve. Aspirate
entire amount of fluid used to inflate balloon.
11. Pull catheter out smoothly and slowly.
Page 42 of 46
12. Wrap contaminated catheter in water proof pad.
Unhook collection bag and drainage tubing from
bed.
13. Reposition patient as necessary. Lower level of bed
and position side rails accordingly.
14. Measure and empty contents of collection bag.
15. Dispose all contaminated supplies properly and
wash hands.
EVALUATION
1. Observe time and amount of first voided specimen
and note any discomfort experienced by the client
when voiding and condition of the skin from
adhesive tape.
DOCUMENTATION
1. Record and report time catheter was removed, time
and amount of next voiding.
Evaluator
________________________ ________________________ ________________________

Page 43 of 46
• Permit the feeding to flow in slowly at the prescribed rate. Raise or lower the syringe
to adjust the flow as needed. Pinch or clamp the tubing to stop the flow for a minute
if the client experiences discomfort.
4. Instill 50 to 100mL of water through the feeding tube.
 Be sure to add the water before the feeding solution has drained from the neck of a
syringe or from the tubing of an administration set.
5. Clamp the feeding tube.
 After the feeding is completed, cover end of the feeding tube with plug and clamp.
 Clamp the feeding tube before all of the water is instilled.
6. Ensure client comfort and safety.
 Secure the tubing to the client’s gown.
7. Ask the client to remain sitting upright in Fowler’s position or in a slightly elevated
right lateral position for at least 30 minutes. .
8. Dispose of equipment appropriately.
9. Remove and discard gloves.
10. Perform hand hygiene.
EVALUATION
1. Perform a follow-up examination of the following:
 Tolerance of feeding (e.g., nausea, cramping)
 Bowel sounds
 Regurgitation and feelings of fullness after feedings
 Weight gain or loss
 Fecal elimination pattern (e.g., diarrhea, flatulence, constipation)
 Skin turgor
 Urine output and specific gravity
 Glucose and acetone in urine
DOCUMENTATION
Document all relevant information:
1. Document the feeding, including amount and kinds of fluids administered (feeding plus
any water used to flush the tubing), duration of the feeding, and assessments of the
client.
2. Record the volume of the feeding and water administered on the client’s intake and
output record.
3. Report significant deviations from normal to the primary care provider.
III. GASTRIC LAVAGE
Purposes:
 To remove unabsorbed poison taken by mouth or those that are excreted

through the alimentary canal regardless of the method of their administration
like opium.
 To diagnose and treat gastric hemorrhage.
 To clean stomach before endoscopic procedure.
 To remove liquid or small particles in the stomach.
12
Equipment
 Pre – packed irrigation set, or large irrigating syringe with an adapter or
asepto syringe
 Large plastic funnel with an adapter to fit gastric tube
 Lavage fluid (saline or prescribed solution) in a graduated cylinder
 Bucket / big emesis basin for aspiration
 Container for specimens
 Stethoscope
ASSESSMENT
1. Assess signs and symptoms that increase risk of tube dislocation (coughing, retching,
others)
2. Review physician’s order.
PLANNING
1. Verify type of lavage fluid / solution, amount, and temperature to be used.
2. Obtain the necessary equipment.
3. Explain the importance of the procedure to the client.

4. Provide privacy to the patient.
5. Position patient. Place patient in sitting position, if conscious. If unconscious, place in
left lateral position with the head, neck, and trunk, forming a straight line.
IMPLEMENTATION
1. Perform hand hygiene and apply gloves.
2. Determine if the tube is in the stomach by auscultating the stomach during injection of
air with a syringe to confirm gastric location. Rationale: This ensures that the irrigating
solution enters the stomach (Kozier and Erb).
3. Aspirate the stomach contents with syringe attached to the tube before instilling
normal saline or antidote. Save the specimen for analysis. Rationale: Aspiration is
performed to remove the stomach contents. Initial gastric aspirates are saved for toxicological
analysis (Lippincott).
4. Insert tip of irrigating syringe or use 50mL syringe into end of NG tube. Remove
clamp. Hold syringe with tip pointed at floor to put lavage solution in gastric tube.
Volume of fluid placed in the stomach should be small. Rationale: Overfilling of the
stomach may cause regurgitation and aspiration of the stomach contents through the pylorus
(Lippincott).
5. Elevate funnel above the patient’s head and pour approximately 150 – 200 ml of
solution to funnel. Rationale: The lavage is left in place about 1 minute and then allowed to
drain (Lippincott).
6. If resistance occurs, check for kinks in tubing. Turn patient onto left side. Report
repeated resistance to health care provider. Rationale: Tip of tube is possibly against
stomach lining. Repositioning on left side helps to dislodge tube away from stomach
lining.
13
7. Lower the funnel and siphon the gastric contents into the bucket or emesis basin.
Rationale: The fluid should flow in freely and drain by gravity (Lippincott).
8. Save samples of first two washings. Rationale: Keep track of fluid input / output to be
sure that most of the fluid is being removed (Lippincott).
9. Repeat lavage procedure until the returns are relatively clean and no particulate
matter is seen. Rationale: This usually requires a total volume of at least 2L; some
clinicians advocate 5 – 20 L (Lippincott).
10. At the completion of the lavage:
 Stomach may be left empty.
 An absorbent / saline cathartic may be instilled in the tube and allowed to remain
in the stomach.
Rationale: Activated charcoal absorbs variety of drugs and toxic agents into the surface
and is used to prevent gastrointestinal absorption of various substances. It renders the
poison inaccessible to the circulation, thereby reducing its toxicity. A cathartic facilitates
the transit of the charcoal and remains of ingested substances through the intestinal tract
(Lippincott).
11. Pinch off tube during removal. Rationale: Pinching of the tube prevents aspiration and
the initiation of the gag reflex. Keeping the patient’s head lower than the body also gives this
protection (Lippincott).
12. Make patient dry and comfortable, dispose equipment, and wash hands
EVALUATION
1. Determine amount and character of contents draining from NG tube. Ask if patient
feels nauseated. Rationale: Determines if tube is decompressing stomach of contents.
2. After palpating patient’s abdomen, note any distention, pain, and rigidity and
auscultate for presence of bowel sounds. Rationale: Determines success of abdominal
decompression and return of peristalsis.
3. Evaluate condition of nares and nose. Rationale: Evaluates onset of skin and tissue
irritation.
4. Observe position of tubing. Rationale: Determines if tension is being applied to nasal

structures.
5. Ask if patient feels irritation on throat. Rationale: Evaluates level of patient’s discomfort.
DOCUMENTATION
1. Document the type, amount, temperature of lavage fluid, characteristics (amount,
color, and consistency) of the gastric contents and response of patient in the nurse’s
notes.
IV. REMOVING A NASOGASTRIC TUBE
Purpose
 After therapeutic nourishment and management via NGT were done.
14
Lesson 10.1: Introduction to
Urinary Elimination
I. Structure and Function of Urinary Elimination

Urinary elimination depends on the function of the kidneys, ureters, bladder,
and urethra. Kidneys remove wastes from the blood to form urine. Ureters transport
urine from the kidneys to the bladder. The bladder holds urine until the urge to
urinate develops. Urine leaves the body through the urethra. All organs of the urinary
system must be intact and functional for successful removal of urinary wastes.
A. Kidneys
⮚ Nephrons – the functional units of the kidneys which remove waste
products from the blood and regulate fluid and electrolyte balance.
⮚ Glomerulus is a cluster of capillaries where the blood is filtered and

urine is formed.
B. Ureters
In adults the ureters are from 25 to 30 cm (10 to 12 inches) long and

about 1.25cm (0.5 in.) in diameter. At the junction between the ureter and the
bladder, a flaplike fold of mucous membrane acts as a valve to prevent reflux
(backflow) of urine up the ureters.
C. Bladder
The urinary bladder is a hallow muscular organ that serves as a

reservoir for urine and as the organ of excretion. When empty, it lies behind
the symphysis pubis. In men, the bladder lies in front of the rectum and above
the prostate gland, in women, it lies in front of the uterus and vagina. The
smooth muscle layers are collectively called the detrusor muscle, it allows
the bladder to expand as it fills with urine, and to contract to release urine to
the outside of the body during voiding.
D. Urethra
The urethra extends from the bladder to the urinary meatus (opening).
In the adult woman, the urethra lies directly behind the symphysis pubis,
anterior to the vagina, and is between 3 and 4cm (1.5 in.) long. The urethra
serves only as a passageway for the elimination of urine. The urinary meatus
is located between the labia minora, in front of the vagina and below the
clitoris.
1
The male urethra is approximately 20 cm (8in.) long and serves as a
passageway for semen as well as urine. The meatus is located at the distal
end of the penis.
E. Pelvic Floor
The vagina, urethra, and rectum pass through the pelvic floor, which
consist of sheets of muscles and ligaments that provide support to the viscera
of the pelvis. The internal sphincter muscle situated in the proximal urethra
and the bladder neck is composed of smooth muscle under involuntary
control. It provides active tension designed to close the urethral lumen. The
external sphincter muscle is composed of skeletal muscle under voluntary
control, allowing the individual to choose when urine is eliminated.
Figure 1: A Neobladder
II. Act of Urination

Micturition, voiding, and urination all refer to the process of emptying
the urinary bladder. Urine collects in the bladder until pressure stimulates special
sensory nerve endings in the bladder wall called stretch receptors. This occurs
when the adult bladder contains between 250 ml and 450 ml of urine. In children,
a considerably smaller volume, 50 to 200 ml, stimulates these nerves.
Table1.1 Average Daily Urine Output By Age

Age Amount (ml)
1 – 2 days 15 – 60
3 – 10 days 100 – 300
10 days – 2 months 250 – 450
2 months – 1 year 400 – 500
1 – 3 years 500 – 600
2
3 – 5 years 600 – 700
5 – 8 years 700 – 1,000
8 – 14 years 800 – 1,400
14 years – adulthood 1,500
Older adulthood 1,500 or less
III. Factors Affecting Voiding

Numerous factors affect the volume and characteristics of the urine produced
and the manner in which it is excreted.
1. Developmental factors
Infants and Children

- An infant may urinate as often as 20 times a day. The urine of the neonate
is colorless and odorless and has a specific gravity of 1.008. Because
newborn and infants have immature kidneys they are unable to
concentrate urine very effectively. Infants are born without urinary control.
Most will develop this between the ages of 2 and 5 years. Control during
the daytime normally precedes night-time control.
- Girls have more UTIs than boys, usually due to contamination of the
urethra with stool. Teach children and parents that they should go to the
bathroom as soon as the sensation to void is felt and not try to hold the
urine in.
Older Adults
- Many older men have enlarged prostate glands, which can inhibit
complete emptying of the bladder, resulting in urinary retention and
urgency that can cause incontinence.
- After menopause women have decreased estrogen levels, which results in
a decrease in perineal tone and support of bladder, vagina, and supporting
tissues. This often results in urgency and stress incontinence and can
even increase the incidence of UTIs.
Interventions that may improve these conditions include:
● Medications or surgery to relieve obstructions in men and strengthen
support for better bladder control.
● Behavioral training for better bladder control.
● Providing safe, easy access to the bathroom or bedside commode,
whether at home or in an institution. Make sure the room is well lit, the
environment is safe and the proper assistive devices are within reach
(such as walkers, canes).
● Habit training, such as taking the person to the bathroom at a regular,
scheduled time. This can often work very well with people who have
cognitive impairments.
2. Psychosocial factors
3
For many people, a set of conditions helps stimulate the micturition
reflex. These conditions include privacy, normal position, sufficient time, and,
occasionally, running water. Circumstances that do not allow for the clients
accustomed conditions may produce anxiety and muscle tension. As a result,
the person is unable to relax abdominal and perineal muscles and the
external urethral sphincter, thus, voiding is inhibited. People also may
voluntarily suppress urination because of perceived time pressures, for
example, nurses often ignore the urge to void until they are able to take a
break. This behavior can increase the risk of UTIs.
3. Fluid and food intake
When the amount of fluid intake increases, therefore, the output

normally increases. Certain fluids, such as alcohol, increase fluid output by
inhibiting the production of antidiuretic hormone. Fluids that contain caffeine
(e.g., coffee, tea, and cola drinks) also increase urine production. Some foods
and fluids can change the color of urine. For example, beets can cause urine
to appear red, foods containing carotene can cause the urine to appear
yellower than usual.
4. Medications
Many medications, particularly those affecting the autonomic nervous

system, interfere with the normal urination process and may cause retention.
Diuretics (e.g., chlorothiazide and furosemide) increase urine formation by
preventing the reabsorption of water and electrolytes from the tubules of the
kidney into the bloodstream. Some medications may alter the color of the
urine.
5. Muscle tone
Good muscle tone is important to maintain the stretch and contractility

of the detrusor muscle so the bladder can fill adequately and empty
completely. Clients who require a retention catheter for a long period may
have poor bladder muscle tone because continuous drainage of urine
prevents the bladder from filling and emptying normally. Pelvic muscle tone
also contributes to the ability to store and empty urine.
6. Pathologic conditions
Some diseases and pathologies can affect the formation and excretion
of urine. Diseases of the kidneys may affect the ability of the nephrons to
produce urine. Abnormal amounts of protein or blood cells may be present in
the urine or the kidneys may virtually stop producing urine altogether, a
condition known as renal failure. Heart and circulatory disorders such as heart
failure, shock, or hypertension can affect blood flow to the kidneys, interfering
with urine production.
7. Surgical and diagnostic procedures
4
Some surgical and diagnostic procedures affect the passage of urine
and the urine itself. The urethra may swell following a cystoscopy, and
surgical procedures on any part of the urinary tract may result in some
postoperative bleeding, as a result, the urine may be red or pink tinged for a
time. Spinal anesthetics can affect the passage of urine because they
decrease the client’s awareness of the need to void.
Common Urinary Elimination Problem: UTI

UTI = Urinary Tract Infections
▪ Most common bacteria: E. coli (from colon)

▪ Causes: improper wiping; frequent sexual intercourse; bubble baths;
residual urine, foley catheter contamination on insertion or lack of peri-
care
▪ Common symptoms: dysuria, urgency, frequency, hematuria
o If spreads to kidneys: fever, flank pain, chills
o Older adult may only show change in mental status
▪ Diagnostic tests: urinalysis; urine culture
▪ Treatment: antibiotics, antispasmodic (Pyridium)
Common Types of Urinary Alterations

Symptoms Descriptions Causes or Associated Factors
Urgency Feeling of need to void Full bladder, bladder irritation or inflammation from
immediately infection, overactive bladder, psychological stress
Dysuria Painful or difficult urination Bladder inflammation, trauma or inflammation of

urethral sphincter
Frequency Voiding at frequent intervals Increased fluid intake, bladder inflammation, increased
(less than 2 hours) pressure on bladder (pregnancy), diuretic therapy
Hesitancy Difficulty initiating urination Prostate enlargement, anxiety, urethral edema
Polyuria Voiding large amounts of urine Excess fluid intake, diabetes melitus or insipidus, use of
diuretics, post obstructive diuresis
Oliguria Diminished urinary output relative Dehydration, renal failure, UTI, increased ADH secretion,
to intake (usually 400 mL/24 hr) heart failure
Nocturia Voiding one or more times at night Excessive fluid intake before bed (especially coffee or
alcohol), renal disease, aging process, prostate
enlargement
Dribbling Leakage of urine despite Stress, incontinence, overflow from urinary retention
voluntary control of urination (e. g., from BPH)
Incontinence Involuntary loss of urine Multiple factors: Unstable urethra, loss of pelvic muscle
tone, fecal impaction, neurological impairment, overactive
bladder
Hematuria Blood in urine Neoplasms of kidney or bladder, glomerulus disease,

infection of kidney or bladder, trauma to urinary structure,
calculi, bleeding disorders
Retention Accumulation of urine in bladder, Urethral obstruction (stricture), decreased sensory activity,
with inability of bladder to empty neurogenic bladder, prostate enlargement, post anesthesia
fully effects, side effects of medications (e. g., anticholinergics,
5
opioids)
Residual urine Volume of urine remaining after Inflammation or irritation of bladder mucosa from
voiding (100 mL) infection, neurogenic bladder, prostate enlargement,
trauma, or inflammation of urethra
NURSING MANAGEMENT
ASSESSING
A complete assessment of a client’s urinary function includes the following:
● Nursing history
⮚ The nurse determines the client’s normal voiding pattern and

frequency, appearance of the urine and any recent changes, any past
or current problems with urination, the presence of an ostomy, and
factors influencing the elimination pattern.
● Physical assessment of the genitourinary system, hydration status, and

examination of the urine
⮚ Complete physical assessment of the urinary tract usually includes

percussion of the kidneys to detect areas of tenderness.
⮚ Palpation and percussion of the bladder are also performed.
⮚ The urethral meatus of both male and female clients is inspected for
swelling, discharge, and inflammation.
⮚ It is important for the nurse to assess the skin for color, texture, and
tissue turgor as well as the presence of edema.
⮚ If incontinence, dribbling, or dysuria is noted in the history, the skin of
the perineum should be inspected for irritation because contact with
urine can excoriate the skin.
● Relating the data obtained to the results of any diagnostic tests and
procedures
Assessing Urine:
Characteristics (color, clarity, odor, hematuria)

Assessing Input/ Output and 24 hour trend
Measuring urine
o Measure in calibrated container from hat, bedpan or catheter

bag
o Normal = approximately 60/hr or about 1,500 ml/ day
o * REPORT * if less than 30 ml/hr
Measuring Residual Urine
o Postvoid residual (PVR) (urine remaining in the bladder

following voiding) is normally 50 to 100 ml. (e.g., enlargement of
6
the prostate gland) or loss of bladder muscle tone may interfere
with complete emptying of the bladder during urination.
Inspection and palpation: presence of bladder distention?

Bladder Ultrasound or “bladder scan”
Frequency, amount, burning with urination?
Diagnostic Tests
Blood levels of two metabolically produced substances, urea and creatinine,
are routinely used to evaluate renal function. The kidneys through filtration and
tubular secretion normally eliminate both urea and creatinine. Urea, the end product
of protein metabolism, is measured as blood urea nitrogen (BUN).
Creatinine is produced in relatively constant quantities by the muscles. The
creatinine clearance test uses 24-hour urine and serum creatinine levels to
determine the glomerular filtration rate: a sensitive indicator of renal function. Other
tests related to urinary functions such as collecting urine specimens, measuring
specific gravity.
Characteristics of Normal and Abnormal Urine

Characteristic Normal Abnormal
Amount in 24 hours 1,200 – 1,500 mL Under 1,200 mL.
(adult) A large amount over intake
Color, clarity Straw, amber Dark amber

Transparent Cloudy
Dark orange
Red or dark brown
Mucous plugs, viscid, thick
Odor Faint aromatic Offensive
Sterility No microorganisms Microorganisms present

Present
pH 4.5 – 8 Over 8
Under 4
Specific gravity 1.010 – 1.025 Over 1.025
Under 1.010
Glucose Not present Present
Ketone bodies Not present Present

(acetone)
Blood Not present Occult (microscopic)

Bright red
DIAGNOSING
NANDA International (Herdman & Kamitsuru, 2014) includes two general diagnostic
labels for urinary elimination:
7
● Impaired Urinary Elimination: dysfunction in urine elimination
● Readiness for Enhanced Urinary Elimination: a pattern of urinary functions
for meeting eliminatory needs, which can be strengthened.
More specific diagnoses

● Functional Urinary Incontinence
● Overflow Urinary Incontinence
● Reflex Urinary Incontinence
● Stress Urinary Incontinence
● Urge Urinary Incontinence
● Risk for Urge Urinary Incontinence
● Urinary Retention
PLANNING
The goals established will vary according to the diagnosis and defining
characteristics. Examples of overall goals for clients with urinary elimination
problems may include the following:
o Maintain or restore a normal voiding pattern.
o Regain normal urine output.
o Prevent associated risks such as infection, skin breakdown, fluid
and electrolyte imbalance, and lowered self-esteem.
o Perform toileting activities independently with or without
assistive devices.
o Contain urine with the appropriate device, catheter, ostomy
appliance, or absorbent product.
IMPLEMENTING
Maintaining Normal Urinary Elimination

Most interventions to maintain normal urinary elimination are independent nursing
functions:
1. Promoting fluid intake
o A normal daily intake averaging 1,500 ml of measurable fluids

o Clients who are at risk for UTI or urinary calculi (stones) should
consume 2,000 to 3,000 ml/ daily.
o Increased fluid intake may be contraindicated for some clients such
as people with kidney failure or heart failure – fluid restriction may
be necessary to prevent fluid overload and edema.
2. Maintaining Normal Voiding Habits
a. Positioning
o Assist the client to a normal position for voiding: standing for male
clients; for female clients, squatting or leaning slightly forward when
8
sitting. The positions enhance movement of urine through the tract
by gravity.
o If the client is unable to ambulate to the lavatory, use a bedside
commode for females and a urinal for males standing at the
bedside.
o If necessary, encourage the client to push over the pubic area with
the hands or to lean forward to increase intra-abdominal pressure
and external pressure on the bladder.
b. Relaxation
o Provide privacy for the client. Many people cannot void in the
presence of another person.
o Allow the client sufficient time to void.
o Suggest the client read or listen to music.
o Provide sensory stimuli that may help the client relax. Pour warm
water over the perineum of a female or have the client sit in a warm
bath to promote muscle relaxation. Applying a hot water bottle to
the lower abdomen of both men and women may also foster muscle
relaxation.
o Turn on running water within hearing distance of the client to
stimulate the voiding reflex and to mask the sound of voiding for
people who find this embarrassing.
o Provide ordered analgesics and emotional support to relieve
physical and emotional discomfort to decrease muscle tension.
c. Timing
o Assist clients who have the urge to void immediately. Delays only
increase the difficulty in starting to void, and the desire to void may
pass.
o Offer toileting assistance to the client at usual times of voiding, for
example, on awakening, before or after meals, and at bedtime.
d. For clients who are confined to bed
o Warm the bedpan. A cold bedpan may prompt contraction of the

perineal muscles and inhibit voiding.
o Elevate the head of the client’s bed to Fowler’s position, place a
small pillow or rolled towel at the small of the back to increase
physical support and comfort, and have the client flex the hips and
knees. This position simulates the normal voiding position as
closely as possible.
3. Assisting with toileting
o The nurse should assist the clients to the bathroom and remain
with them if they are at risk for falling.
9
o For clients unable to use bathroom facilities, the nurse provides
urinary equipment close to the bedside (e.g., urinal, bedpan,
commode) and provides the necessary assistance to use them.
Preventing Urinary Tract Infection. The rate of UTI is greater in women than men
because of the short urethra and its proximity to the anal and vaginal areas.
The following guidelines are useful for everyone:
✔ Drink eight 8-ounce glasses of water per day to flush bacteria and of the
urinary system.
✔ Practice frequent voiding (every 2 to 4 hours) to flush bacteria out of the
urethra and prevent organisms from ascending into the bladder. Void
immediately after intercourse.
✔ Avoid use of harsh soaps, bubble bath, powder, or sprays in the perineal
area. These substances can be irritating to the urethra and encourage
inflammation and bacterial infection.
✔ Avoid tight-fitting pants or other clothing that creates irritation to the urethra
and prevents ventilation of the perineal area.
✔ Wear cotton rather than nylon underclothes. Accumulation of perineal
moisture facilitates bacterial growth. Cotton enhances ventilation of the
perineal area.
✔ Girls and women should always wipe the perineal area from front to back
following urination or defecation in order to prevent introduction of
gastrointestinal bacteria into the urethra.
✔ If recurrent urinary infections are a problem, take showers rather than baths.
Bacteria present in bath water can readily enter the urethra.
Managing Urinary Incontinence

Independent nursing interventions for clients with UI include:
(a) A behavior- oriented continence training program that may consist of
- Bladder retraining
- Habit training
- Pelvic floor muscle exercises (Kegels)
(b) Meticulous skin care
(c) For males, application of an external drainage device (condom-type catheter
device
Bladder Retraining which requires that the client postpone voiding, resist
or inhibit the sensation of urgency, and void according to a timetable rather than
according to the urge to void. The goals are to gradually lengthen the intervals
between urination to correct the client’s frequent urination, to stabilize the
bladder, and to diminish urgency. This form of training may be used for clients
who have bladder instability and urge incontinence. Delayed voiding provides
large volumes and longer intervals between voiding. Initially, voiding may be
encouraged every 2 to 3 hours except during sleep then every 4 to 6 hours. A
vital component of bladder training is inhibiting the urge-to-void sensation. To do
10
this, the nurse instructs the client to practice deep, slow breathing until the urge
diminishes or disappears. This is performed every time the client has a premature
urge to void.
Managing Urinary Retention

▪ Maintain a normal voiding pattern.
▪ The primary care provider may order a cholinergic drug such as bethanechol
chloride (Urecholine) to stimulate bladder contraction and facilitate voiding.
▪ Clients who have a flaccid bladder (weak, soft, and lax bladder muscles)
may use manual pressure on the bladder to promote bladder emptying. This
is known as Crede’s maneuver or Crede’s method. It is not advised without a
primary care provider or nurse practitioner’s order and is used onlyfor clients
who have lost and are not expected to regain voluntary bladder control.
▪ Urinary catheterization
Urinary catheterization is the introduction of a catheter into the urinary
bladder. This is usually performed only when absolutely necessary, because
the danger exists of introducing microorganisms into the bladder.
▪ Bladder irrigation
An irrigation is a flushing or washing – out with a specified solution.
Bladder irrigation is carried out on a primary care provider’s order, usually to
wash out the bladder and sometimes to apply a medication to the bladder line.
Catheter irrigation may also be performed to maintain or restore the patency
of a catheter.
EVALUATION
Using the overall goals and desired outcomes identified in the planning stage,
the nurse collects data to evaluate the effectiveness of nursing activities. If the
desired outcomes are not achieved, explore the reasons before modifying the care
plan.
11
Lesson 10.2: Inserting a Straight or
Indwelling Catheter to a Male Patient
Description
Urinary catheterization is the introduction of a catheter into the urinary

bladder. The catheter provides a continuous flow of urine in patients unable to control
micturition or those with obstructions.
Purposes
● To relieve discomfort due to bladder distention or to provide gradual
decompression of a distended bladder
● To assess amount of residual urine if the bladder empties incompletely
● To obtain a sterile urine specimen
● To empty the bladder completely prior to surgery
● To facilitate accurate measurement of urinary output for critically ill clients
whose output needs to be monitored hourly
● To provide for intermittent or continuous bladder drainage and/or irrigation
● To prevent urine from contaminating an incision after perineal surgery
● To manage incontinence when other measures have failed
Skill 2: Inserting a Straight or Indwelling Catheter to a Male Patient
Assessment
● Determine first the status of the client, level of awareness, mobility & physical
limitations, bladder distention, any pathological conditions & allergies.
● Determine when the client last voided or was last catheterized.
● Assess the client’s overall condition. Determine if the client is able to
participate and hold still during the procedure and if the client can be
positioned supine with the head relatively flat. For female clients, determine if
she can have knees bent and hips externally rotated.
● Use an indwelling/ retention catheter if the bladder must remain empty,
intermittent catheterization is contraindicated, or continuous urine
measurement/ collection is needed.
● If catheterization is being performed because the client has been unable to
void, when possible, complete a bladder scan to assess the amount of urine
present in the bladder.
1
Planning
● Allow adequate time to perform the catheterization.
● Some clients may feel uncomfortable being catheterized by nurses of the
opposite gender. If this is the case, obtain the client’s permission.
● Explain the procedure to the client & provide privacy.
Equipment
● Sterile catheter of appropriate size (an extra should be on hand)
Catheterization kit:
⮚ 1-2 pair of sterile gloves
⮚ Waterproof drape
⮚ Antiseptic solution
⮚ Cleansing cotton balls
⮚ Forceps
⮚ Water soluble lubricant
⮚ Urine receptacle
⮚ Specimen container
● For indwelling catheter:

⮚ Syringe prefilled with sterile water in amount specified by the manufacturer
⮚ Collection bag and tubing
⮚ Disposable clean gloves
⮚ Bath blanket for draping the client
⮚ Adequate lighting
Figure 1. A Closed Indwelling Catheter Insertion Kit
2
Implementation
Policy and Procedure:
● Perform hand hygiene and observe other appropriate infection prevention
procedures.
● Establish adequate lighting.
● Cleanse the meatus. Note: The nondominant hand is considered
contaminated once it touches the client’s skin.
● Place the client in the appropriate position and drape all areas, upper trunk
with a bath blanket and cover lower extremities with bed sheets, exposing
only the genitalia.
o Female: supine with knees flexed, feet about 2 feet apart, and hips
slightly externally rotated, if possible.
o Male: supine, thighs slightly abducted or apart.
● Organize supplies on sterile field:
o Open sterile package containing catheter; pour sterile package of
antiseptic solution in correct compartment containing sterile cotton balls.
o Lubricate tip of catheter, remove specimen container (lid should be
loosely placed on top) and prefilled syringe from collection compartment
of tray and set them aside on sterile field.
● In cleansing the meatus, the nondominant hand is considered contaminated
once it touches the client’s skin. Also, in cleansing the meatus, it should be
considered if:
o Patient is not circumcised, retract foreskin with non-dominant hand.
o Grasp penis at shaft just below glands.
o Retract urethral meatus between thumb and forefinger.
Figure 2. Left. An in-depth anatomy when urinary meatus is exposed.

Figure 3. Right. Cleansing the expose urinary meatus, separating the labia minora
and retract the tissue upward.
3
Figure 4. Left. Actual cleansing of the urinary meatus by retracting the foreskin with
non-dominant hand.
Figure 5. Right. Actual insertion of catheter to a female client.
● In picking up catheter with gloved dominant hand 7.5-10 cm (3-4 in) from
catheter tip, hold end of catheter loosely coiled in palm of dominant hand
(optional: May grasp catheter with forceps). Place distal end of catheter in
urine tray receptacle.
● Insert catheter:
o Lift penis to position perpendicular to client’s body and apply light
traction.
o Ask patient to near down as if to void and slowly insert catheter through
meatus.
o Advance catheter 17.5 to 22.5 cm (7-9 in) in adult and 5 to 7.5 cm (2-3
in) in young child or until urine flows out the catheter’s end. When urine
appears, advance catheter another 5 cm (2in). Do not force against
resistance.
o Lower penis and hold catheter securely in non-dominant hand. Place
end of catheter in urine tray receptacle.
o If urine sample is needed, you can fill the specimen cup at a desired level
(20-30ml) by holding end of catheter in dominant hand over cup. With
dominant hand, pinch catheter to stop urine flow temporarily. Release
catheter to allow remaining urine in bladder to drain into collection tray.
Cover specimen cup & set aside for labeling.
● Secure the Catheter by attaching the end of catheter to collecting tube of

drainage system. Drainage bag must be below level of bladder.
● Tape catheter tubing on top of thigh or lower abdomen. Allow slack in catheter
so movement of thigh does not create tension on catheter.
● Be sure there are no obstructions or kinks in tubing. Place excess coil of
tubing on bed & fasten it to bottom sheet with clip from drainage set or with
rubber band & safety pin.
4
Figure 6. Left. Placement of indwelling catheter and inflated balloon of a closed
system (A-Female client, B-Male client)
Figure 7. Right. Catheter securement devices: (A- non-adhesive device, B-adhesive
device)
Figure 8. Correct position for urine bag and tubing
5
● Instruct client on ways to lie in bed with catheter:
o Side-lying facing drainage system with catheter & tubing draped over
thigh.
o Side-lying facing away from the system, catheter and tubing
extended between legs.
● Caution client against pulling on catheter.
Evaluation
● Notify the primary care provider of the catherization results especially the
initial urine output after catherization.
● Perform a detailed followed-up based on findings that deviated from expected
or normal for the client. Relate findings to previous assessment data if
available.
● Teach the client how to care for the indwelling catheter, to drink more fluids,
and provide other appropriate instructions.
Unexpected Outcomes and Related Interventions

1. Urethral or perineal irritation is present.
✔ Observe for catheter leaking, replace if necessary.
✔ Assess that indwelling catheter is anchored properly.
✔ Perform perineal hygiene and catheter care more frequently.
2. Patient has fever, and/or odor is present, or he or she experiences small

frequent voiding, burning or bleeding on voiding.
✔ Obtain clean-voided urine specimen.
✔ Notify health care provider.
3. Patient experiences urinary retention and is unable to void after you remove the
catheter.
✔ Provide adequate fluid intake and ensure patient privacy.
✔ If patient is unable to void 4 hours following catheter removal, notify health
care provider.
Recording and Reporting

● Report and record type and size of catheter inserted, amount of fluid used to
inflate the balloon, characteristics and amount of urine, reasons for
catheterization, specimen collection if appropriate, and patient’s response to
procedure and teaching concepts.
● Initiate intake and output (I&O) record.
● If catheter is definitely in bladder and no urine is produced within an hour,
immediately report absence of urine to health care provider.
6
Lesson 10.3: Performing Routine
Catheter Care
Indwelling Catheter Care
Nursing care of the client with an indwelling catheter and continuous drainage
largely directed toward preventing infection of the urinary tract and encouraging
urinary flow through the drainage system. It includes encouraging large amounts of
fluid intake, accurately recording the fluid intake and output, changing the retention
catheter and tubing, maintaining the patency of the drainage system, preventing
contamination of the drainage system and teaching these measures to the client.
Specific purposes:
 To prevent infection in the urinary system.
 To maintain the patency and prevent the contamination of the drainage system
Preventing or Reducing the Risk of CAUTIs (Catheter Associated Urinary Tract

Infection)
A. Avoid Unnecessary Use of Urinary Catheters

⮚ Develop criteria for appropriate catheter insertion.
⮚ Consider alternatives to an indwelling catheter such as external condom
catheter.
⮚ Use a bladder scanner to assess for urinary retention.
B. Insert Urinary Catheters Using Aseptic Technique
C. Maintain the Urinary Catheter
⮚ Use hand hygiene and standard precautions during any manipulation of
the catheter or collecting system.
⮚ Maintain a sterile, closed drainage system.
⮚ Maintain unobstructed urine flow.
D. Practices to Avoid
⮚ Irrigation of catheters, except in cases of catheter obstruction.
⮚ Disconnecting the catheter from the drainage tubing.
⮚ Replacing catheters routinely.
⮚ Cleaning the periurethral area with antiseptics.
E. Review Urinary Catheter Necessity Daily and Remove Promptly
⮚ Assess the need for catheter in daily nursing assessments; contact the
primary care provider if criteria not met.
⮚ Develop nursing protocols that allow nurses to remove urinary catheters
if criteria for necessity are not met and there are no contraindications for
removal.
⮚ Implement automatic stop orders for 48 to 72 hours after catheter
insertion. Continue catheter use only with a documented order from the
primary care provider.
1
⮚ Use alerts in chart or computerized charting system to inform the primary
care provider of the presence of a catheter and require an order for
continued use.
Figure 1. Potential sites for introduction of infectious organisms into a urinary

drainage system
Purpose
 To minimize the trauma and infection risk associated with urinary catheters.
Equipment
 Soap and washcloth
 Anti-infective solution
 Antibiotic ointment
 Sterile swabs
 Forceps
 Tape
 Measurement container
 Sterile gloves
 Sterile drape
Goal
 The patient’s urinary elimination is maintained, with a urine output of at least
30 mL/hour, and the patient’s bladder is not distended.
2
Skill 3. Performing Routine Catheter Care
Assessment
 Assess for episode of bowel incontinence or patient discomfort or provide

care per agency routine as part of hygiene measures.
 Observe any discharge or redness around urethral meatus.
 Assess patient’s knowledge of catheter care.
Planning
 Prepare the necessary equipment and supplies
 Determine how long catheter has been in place for possible replacement.
Implementation
Policy and Procedure
 Perform hand hygiene

 Position patient correctly and cover with bath blanket exposing only perineal
area.
o Female – dorsal recumbent
o Male – supine
 Place waterproof pad under patient.
 Drape bath blanket on bath clothes so only perineal area is exposed.
 Open sterile catheter care kit using sterile aseptic technique, put on sterile
gloves and apply sterile drapes over patient’s perineum
 Pour antiseptic solution on cotton balls or swabs. Apply antiseptic ointment on
cotton balls (check patient for allergies to antiseptic).
 With non-dominant hand:
o Gently retract labia of female client to fully expose urethral meatus &
catheter insertion site. Maintain position of hand throughout the
procedure.
o Retract foreskin of an uncircumcised male client and hold penis at shaft
below glands. Maintain position of hand throughout the procedure.
 Cleanse perineal tissues:
o Female client:
 Use separate cotton balls &forceps to cleanse each labia majora,
moving down toward anus. Repeat process to cleanse each side.
o Male client:
 While spreading urethral meatus, cleanse around catheter first,
then use clean cotton ball to wipe in circular motion around
meatus and glans.
3
Figure 2. Left. Actual draping of the client with fenestrated drape.
Figure 3. Right. Cleansing the female perineum, separating the labia minora and
retracting the tissue by using a forceps following the stroke of 7 method.
Figure 4. Cleansing the catheter tube after finishing the female perineum part.
4
 Get new cotton ball & wipe in circular motion along length of catheter
for about 10 cm (4 inch) and apply antiseptic ointment at urethral meatus
along 2.5 cm of catheter.
 Replace adhesive tape anchoring catheter to client as necessary. Remove
adhesive tape residue from the skin.
 Replace urinary tubing and collection bag adhering to principles of
surgical asepsis as necessary but at least 8 hours.
 Check drainage tubing. No tube should be coiled, kinked or clamped as
the collection bag is emptied as necessary but at least 8 hours.
Evaluation
 Inspect condition of urethra and surrounding tissue and ask patient about
discomfort.
 Record on nurse’s notes when catheter care was given, assessment of urethral
meatus and character of urine.

1. Urethral discharge or perineal irritation present
o Observe for leaking from around catheter, catheter may need replacing.
o Increase frequency of indwelling catheter care.
o Monitor color, clarity, odor of urine: at high risk for developing UTI
o Notify health care provider.
2. Accidental catheter dislodgements

o Notify health care provider. Assess for urethral trauma.
o Monitor urine output should be at least 30cc/hour
- If less: check placement, bladder scan
- If still no improvement call the physician as it could be clogged or
could indicate serious condition
Home Care Considerations

● If patient is discharged with indwelling catheter, teach patient and family
catheter care and signs and symptoms to report to nurse or health care
provider.
5
Lesson 10.4: Performing Closed
Continuous Catheter Irrigation
Urinary Irrigations
An irrigation is a flushing or washing-out with a specified solution. Bladder
irrigation is carried out on a primary care provider’s order, usually to wash out the
bladder and sometimes to apply a medication to the bladder lining. Catheter irrigations
may also be performed to maintain or restore the patency of a catheter, for example,
to remove pus or blood clots blocking the catheter. Sterile technique is used.
The closed method is the preferred technique for catheter or bladder irrigation
because it is associated with a lower risk of UTI. Closed catheter irrigations may be
either continuous or intermittent. This method is most often used for clients who
have had genitourinary surgery. The continuous irrigation helps prevent blood clots
from occluding the catheter. A three-way or triple lumen catheter is generally used for
closed irrigations. The irrigating solution flows into the bladder through the irrigation
port of the catheter and out through the urinary drainage lumen of the catheter.
General Purposes
a. To flush clots and debris out of the catheter and bladder.
b. To instill medication to bladder lining.
c. To restore patency of the catheter.
Expected Outcomes
 The urinary catheter remains patent and urine is able to drain freely via the
indwelling catheter (IDC)
 The patient’s comfort is maintained
 Clot formation within the bladder or IDC is prevented or minimized
 The patient’s risk of Urinary Tract Infection is minimized through use of aseptic
technique when connecting bladder irrigation to IDC.
Equipment
 Sterile irrigating solution, correct bag of solution

 Irrigation tubing with clamp (with or without Y connector)
 Metric container
 IV pole
 Antiseptic swab
 Y connector
 Bath blanket
Goal
 The patient exhibits free flowing urine through the catheter.
1
Skill 4: Performing Closed Continuous Catheter Irrigation
Assessment
 Determine first the status of the client, level of awareness, mobility & physical
 Assess the client’s overall condition. Determine if the client is able to
participate.
 Assess the color of urine and presence of mucus/sediment, patency of
drainage tubing, fluid entering bladder and fluid draining from the bladder for
appropriate proportion.
 Frequency of irrigation
o Triple lumen (1 lumen to inflate balloon, 1 to install irrigation solution, and
o Double lumen (1 lumen to inflate balloon, 1 to allow outflow of urine)
Planning
 Explain the procedure to the patient.

 Develop individualize goals of care for patient based on nursing diagnoses:
o Maintain patent, free-flowing urinary drainage system.
o Minimize risk of infection.
o Minimize discomfort
Implementation
Figure 1. Closed Continuous Bladder Irrigation
2
 Confirm the order for catheter irrigation in the medical record. Calculate the
drip rate via gravity infusion for the prescribed infusion rate.
 Check the type of sterile solution, the amount and strength to be used, and
the rate (if continuous)
 Check the type of catheter in place
 Empty the catheter drainage bag and measure the amount of urine, noting the
amount and characteristics of the urine.
 Assist patient to comfortable position and expose the irrigation port on the
catheter setup. Place waterproof pad under the catheter and aspiration port.
 Prepare sterile irrigation bag for use as directed by manufacturer.
o Clearly label the solution as ‘Bladder Irrigant.
o Include the date and time on the label. Hang bag on IV pole 2.5 to 3 feet
above the level of the patient’s bladder.
o Secure tubing clamp and insert sterile tubing with drip chamber to
container using aseptic technique. Release clamp and remove
protective cover on end of tubing without contaminating it. Allow solution
to flush tubing and remove air. Clamp tubing and replace end cover.
 Check the drainage tubing to make sure clamp, if present, is open.
 Release clamp on irrigation tubing and regulate flow at determined drip rate,
according to the ordered rate. If the bladder irrigation is to be done with a
medicated solution, use an electronic infusion device to regulate the flow.
 As irrigation fluid container nears empty, clamp the administration tubing. Do
not allow drip chamber to empty. Disconnect empty bag and attach a new full
irrigation solution bag.
 Put on gloves and empty drainage collection bag as each new container is hung
and recorded.
Evaluation
 Calculate fluid used to irrigate bladder and catheter and subtract from volume
drained.
 Assess characteristics of output; viscosity, color, presence of clots & observe
catheter patency.
Documentation
 Record amount of solution used as irrigant, amount returned as drainage, in
nurse’s notes and in I & O sheet.
 Report catheter occlusion, sudden bleeding, infection or increased pain to the
physician

1. Irrigant or instillation solution not returning or continuous solution not flowing at
prescribed rate, which indicates possible occlusion of catheter
- Stop the irrigation. Recalculate I&O
- Ensure that tubing is not kinked or looped below bladder level
- Palpate bladder for distention. Use bladder scanner if available to facilitate
genitourinary assessment as per your unit’s routine.
3
- If obstruction is suspected, gentle manual irrigation may be required as per
physician’s orders. Cleanse the catheter opening well with chlorhexidine.
Use nothing smaller than a 60cc syringe and sterile saline. Use slow, even
pressure to avoid damaging the bladder wall. Do not force if resistance
met. Allow irrigation to flow back freely.
- Notify physician if previous measures unsuccessful.
2. Increased bloody drainage or presence of clots.

- Increase rate of irrigation infusion as per physician’s orders.
- Irrigation of catheter as outlined in # 1 to aid in clot removal may be
indicated.
- If large amount blood or clots persists, notify physician.
3. Patient complains of pain: (Complete pain assessment using the 0-10 or visual
analogue scale)
- Palpate bladder to determine presence of distention
- Check drainage tubing for kinks
- Observe drainage for adequate amount, presence of clots that might be
blocking drainage tube. Evaluate I&O
- Avoid cold irrigation solution as it may cause bladder spasm.
- Notify the physician
4. Cloudy or foul urine, fever.

- Monitor fever.
- Notify the physician.
- Obtain sterile urine specimen if ordered by health care provider.
5. The patient is confused/ agitated

- Assess if patient is oriented to time, place, person
- Notify physician of patient’s change in LOC
- Have relevant information ready to share with physician i.e. amount of
opioids received, amount of CBI received, true urine output, time of onset of
alteration in orientation, in TURP syndrome an overload of fluid through the
prostatic sinuses can lead to dilutional hyponatremia, confusion and
hypertension
6. Solution leaks around the foley catheter

- Assess for bladder spasms
- Refer to # 1- assessing for obstruction
4
Lesson 10.5: Performing Closed
Intermittent Catheter Irrigation
Purpose
 To flush clots and debris out of bladder

 To instill medication to bladder lining
 To restore patency of the catheter.
Equipment
 Sterile irrigating solution

 Sterile graduated cup
 Sterile 30-50 ml syringe
 Sterile 19-22 gauge, 1 in needle
 Antiseptic swab
 Screw clamp
 Bath blanket
Goal
 The patient exhibits the free flow of urine through the catheter.
Skill 5. Performing Closed Intermittent Irrigation

Assessment
 Determine first the status of the client, level of awareness, mobility & physical
 Assess the client’s overall condition. Determine if the client is able to
participate.
 Assess the color of urine and presence of mucus/sediment, patency of
drainage tubing, fluid entering bladder and fluid draining from the bladder for
appropriate proportion.
 Frequency of irrigation
o Triple lumen (1 lumen to inflate balloon, 1 to install irrigation solution, and
o Double lumen (1 lumen to inflate balloon, 1 to allow outflow of urine)
Planning
 Explain the procedure to the patient.

 Develop individualize goals of care for patient based on nursing diagnoses:
o Maintain patent, free-flowing urinary drainage system.
o Minimize risk of infection.
o Minimize discomfort
1
Implementation
 Confirm the order for catheter irrigation in the medical record.
 Open supplies, using aseptic technique. Pour sterile solution into sterile basin.
Aspirate the prescribed amount of irrigant (usually 30 to 60 mL) into sterile
syringe. Put on gloves.
Rationale: Aseptic technique is vital to reduce the risk of instilling
microorganisms into the urinary tract during the irrigation.
Figure 1. Irrigation Set

 Cleanse the access port on catheter with antimicrobial swab using aspetic
technique.
 Clamp or fold catheter tubing below the access port, then attach the syringe to
the access port on the catheter using a twisting motion. Gently instill solution
into catheter.
 Remove syringe from access port. Unclamp or unfold tubing and allow irrigant
and urine to flow into the drainage bag. Repeat procedure, as necessary.
 Secure catheter tubing to the patient’s inner thigh or lower abdomen (if a male
patient) with anchoring device or tape. Leave some slack in the catheter for
leg movement.
 Secure drainage bag below the level of the bladder. Check that drainage
tubing is not kinked and that movement of side rails does not interfere with
catheter or drainage bag.
Evaluation
 Calculate fluid used to irrigate bladder and catheter and subtract from volume
drained, in which the amount of drainage should must be equal to the amount
of irrigant entering the bladder plus any urine that may have been dwelling in
the bladder by determining the amount of fluid used for the irrigation and
subtract from total output on the client’s I&O record.
 Assess characteristics of output; viscosity, color, presence of clots & observe
catheter patency.
Documentation
 Record amount of solution used as irrigant, amount returned as drainage, in
nurse’s notes and in I & O sheet.
 Report catheter occlusion, sudden bleeding, infection or increased pain to the
physician
2
Lesson 10.6: Removing an Indwelling
Catheter
Removal of a retention catheter requires the use of clean technique. You deflate
the retention balloon before removal. If the retention catheter balloon remains even
partially inflated, its removal will result in trauma and subsequent swelling of urethral
meatus. Always remove an indwelling catheter as soon as possible after insertion
because of risk for catheter – associated urinary tract infection (CAUTI).
If the catheter has been in place for a short time (e.g., 48 to 72 hours), the client
usually has little difficulty regaining normal urinary elimination patterns. Swelling of the
urethra, however, may initially interfere with voiding so the nurse should regularly
assess the client for urinary retention until voiding is reestablished.
Clients who have had a retention catheter for a prolonged period may require
bladder retraining to regain bladder muscle tone. With an indwelling catheter in place,
the bladder muscle does not stretch and contract regularly as it does when the bladder
fills and empties by voiding. A few days before removal, the catheter may be clamped
for specific periods of time (e.g., 2 to 4 hours), then released to allow the bladder to
empty. This allows the bladder to distend and stimulates its musculature. Check
agency policy regarding bladder training procedures.
Skill 6: Removing an indwelling Catheter
Goal
● The catheter is removed without difficulty and with minimal patient discomfort.
Assessment
 Review patient’s medical record including physician’s order and note period of
time catheter was in place.
Planning
 Prepare necessary equipment and supplies.
 Close curtains around the bed and close the door to the room, if possible.
Discuss the procedure with the patient and assess the patient’s ability to
assist with the procedure.
1
Equipment
● Syringe same size as volume solution used to inflate balloon
● Waterproof pad
● Sterile specimen container, labeled correctly
● 25 – gauge, 1/2” needle
● Alcohol swab
● non-sterile disposable gloves
Implementation
(Policy and Procedure)
To remove a retention catheter the nurse follows these steps:
o If bladder conditioning is to be performed:
o Hours before removal, clamp indwelling catheter for 3 hours.
o Unclamp and drain urine for 5 minutes.
o Repeat clamping for 3 hours and draining for 5 minutes two more times.
o Obtain a receptacle for the catheter (e.g., a disposable basin).
o Ask the client to assume a supine position as for a catheterization.
o Optional: Obtain a sterile specimen before removing the catheter. Check
agency protocol.
o Remove the catheter securing device attaching the catheter to the client,
apply gloves, and then place the towel between the legs of the female client
or over the thighs of the male.
o Insert the syringe into the injection port of the catheter, and withdraw the fluid
from the balloon.
o Do not pull the catheter while the balloon is inflated; doing so will injure the
urethra.
o After all of the fluid is removed from the balloon, gently withdraw the catheter
and place it in the waste receptacle.
o Dry the perineal area with a towel.
o Measure the urine in the drainage bag.
o Remove and discard gloves and perform hand hygiene.
o Record the removal of the catheter. Include in the recording:
- the time the catheter was removed
- the amount, color, and clarity of the urine
- the intactness of the catheter
o Provide the client with either a urinal, bedpan, or commode or toilet collection
device (“hat”) to be used with each subsequent unassisted void.
o Following removal of the catheter; determine the time of the first voiding and
the amount voided during the first 8 hours. Compare this output to the client’s
intake.
o Observe for dysfunctional voiding behaviors (i.e., < 100ml per void, which
might indicate urinary retention. If this occurs, perform an assessment of PVR
using a bladder scanner if available. Generally, a PVR greater than 200 ml will
require straight catheterization as needed.
2
Recording and Reporting
 Record in nurse’s notes time of removal of catheter, condition of urethral

meatus, and character and amount of urine.
 Record urine emptied from drainage bag on intake and output form.
UNEXPECTED OUTCOMES RELATED INTERVENTIONS

1. Urethral or perineal irritation is  Observe for leaking from around
present. catheter; catheter may need
replacement
 Make sure catheter (if not removed)
is anchored and secured
appropriately.
2. Patient has fever and / or urine is  Monitor vital signs and urine.
malodorous; patient has small,  Report findings to prescriber,
frequent voidings; or bleeding or because any of these symptoms /
burning occurs with urination after signs indicates a UTI.
catheter is removed.
3. Patient is unable to void after  Assess for bladder distention.
catheter removal or voids in small,  Assist to a normal position for
frequent amounts. voiding.
 Provide privacy.
 Perform bladder ultrasonography to
assess for residual urine. Notify
prescriber if residual volume is
greater than 150 mL.
Catheterization may be indicated.
 If patient is unable to void within 6 to
8 hours of catheter, notify the health
care provider.

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PERFORMANCE CHECKLIST LEVEL II

BBM drop → start .

doctor ang nagpe -

IV pole could accumulate N therapy :

fluids that contains

Roller # control Procedures Done Not

chamber para madding Mag regulate ; Kasi if

naka open e- hinang na ang N fluids magstart

IMPLEMENTATION banal may air ang mapupunta na patient ! sa Vomiting

2. Wash your hands because if may

3. Select a position of comfort for yourself

4. Put on gloves. complications

degree angle, upon flashback visualization, decrease has *

the angle, and advance the catheter and stylet into

____________________________ _______________________________ ______________________

* If masyadong mataas ang N fluids

ang venous pressure ; mahihirapan ang Fluids na pumasok, mas ma

APPROPRIATE : 1m or 3ft above patient

• Kapag sumo bra , batik tarin lang then pisilinulit ,

babalik fluids saw bottle DAPAT HALF LANG !

stylet lneedle) Walang maiiwan needle Kay patient cannula plastic

ayan natin blood sa

formed to another location in the body. Thrombi or emboli can

location depriving tissues of normal blood flow and oxygen.

MONITORING AND MAINTAINING AN INFUSION

Procedures Done Not Remarks

Date and time

The fluid level in the container and designated time

any fluids na umakyatsa insertion

Pain ang fluid na

Swelling Wala na sa ugat ; Kinks or

and circulation impairment and replace dislodge ang

MANAGEMENT ! (BANG MAKI KITA SA INSERTION SITE

• chemical irritation •• elevate the

11. Identify specific problem present

____________________________ _______________________________ ________________

* IF too fast → fluid overload

or ask the doctor .

naka set up parin

(• close roller clamp kink then

pasok sa bagong N fluids

Procedures Done Not Remarks

6. Regulate the flow rate based on the duration of infusion.

____________________________ _______________________________ __________________

* N tubing ay up to 96 hrs ( ideal ) dapatpalitan

ADMINISTERING MEDICATIONS VIA:

Procedures Done Not Remarks

e. Shake the bottle to mix incorporated medicine with

____________________________ _______________________________ __________________

(µ How to FIND out ?

PWEDE BANG MAGSULAT SA N BOTTLE ?

incorporate sa container, Maha halo sa mistiming fluids .

(Be ganon ang gamitin .

Cpp prone sa fluid overload

____________________________ _______________________________ __________________

flowing pa Yun mababasg

gloves, kapag nilalagay kapag

da hit baka masaktan si patient dahil may cannula

WHAT IF NAPUTOL ANG CANNULA ( see evaluation )

* REASONS BAKIT NAPUPUTOL :

Accounts for two- 03 accounts04

includes blood plasma,

in between cellular compartments ;

Extracellular ﬂuid (ECF) ~µw IF I Plasma

____________ _ ________

____________ _ __

____________ _ ____

____________ _ ____

____________ _ ____