導(dǎo)尿管之選擇與護(hù)理

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

途徑TransurethracatheterizationTransvesicalcatheterization（suprapubiccatheterization）Whatissuprapubiccatheterization？恥骨上導(dǎo)尿管：在膀胱脹滿水之後由恥骨上正中央插入導(dǎo)引器然後插入導(dǎo)尿管suprapubiccatheterizationsuprapubiccatheterizationindicationsforsuprapubiccatheterizattionUrethratraumaClientswhorequirelong-termcatheterizationandwhoaresexuallyactiveFollowingpelvicorurologicalsurgerySomegynaecologicalconditions,e.g.colposuspensionLong-termcatheterizationforincontinenceClientswhoareunabletotolerateurethralcatheterizationSomewheelchair-boundclientsConsidersuprapubicorurethralcatheterizationsuprapubicurethralLongterm（includingincontinence）ShorttermSexuallyactiveclientsintermittentPost-specificsurgeryPost-specificsurgeryUrethratraumaDifficultieswithsuprapubicSomewheelchair-boundclientsDifficultieswithurethralcatheterConsidersuprapubicorurethralcatheterizationsuprapubicurethraspecificcareStrictasepsisoninsertionStrictasepsisoninsertionspecificadvantagesReducedriskofinfectionNurseabletocarryoutprocedureEnablesexualintercourseConsidersuprapubicorurethralcatheterizationsuprapubicurethralSpecificdisadvantagesAlteredbodyimageAlteredbodyimagePotentialleakagefromandaroundsiteImpedessexualintercourseRequiresaregisteredmedicalpractitionertoinsertHigherriskofinfectionSelectionofcathetersWhichmaterialForshort-termuse（1-28days）:Latex,PVC,PTFE-coatedlatexfoleycatheterForlong-termuseofupto12weeks,selectoneofthefollowing:hydrogel-coatedlatexfoleycatheterpuresiliconFoleycathetersilicon-coatedlatexFoleycatheterSelectionofcathetersCathetersizeMale:14-16Ch（length40-45cm）Female:12-14Ch（length20-26cm）Balloonsize5-10mlrecommended30mlsurgeryonlyCatheter-relatedproblemBypassingUTIBlockedcatheterInadvertentcatheterremovalCatheter-relatedproblem-BypassingCommoncausesofbypassingConstipationKinkedtubingCathetersizeandlength/balloonDetrusorinstabilityTrigoneirritationblockageCatheter-relatedproblem-UTI直接影響導(dǎo)尿管造成感染之因素：放置時(shí)間長(zhǎng)短Detectsignificantmicrobialcounts-3daysaftercatheterization（Bachetal,1990）TheriskofdevelopingbacteriuriaGaribaldietal（1974）：8.1%foreachdayMulhalletal（1988）：5-8%foreachdaySedor（1999）：5%foreachdayBacteriuriaisvirtuallyinevitablewithin3-4weeks（Jewesetaal,1988）Catheter-relatedproblem---UTI危險(xiǎn)因素：引流袋污染糖尿病女性患者抗生素使用頻頻測(cè)量尿輸出量腎功能不良技術(shù)不良Catheter-relatedproblem---UTI致病機(jī)轉(zhuǎn)細(xì)菌由會(huì)陰部或尿袋移生後經(jīng)由導(dǎo)尿管外壁或內(nèi)壁上行女性之感染途徑為經(jīng)由直腸正常菌叢污染尿道周?chē)行灾饕獮楣苈穬?nèi)經(jīng)由外來(lái)細(xì)菌污染尿道口之細(xì)菌可經(jīng)由插入導(dǎo)尿管時(shí)帶入膀胱Catheter-relatedproblem---UTICatheter-relatedproblem---UTI致病菌Extogenousorganisms（e.g.serratiaspp.AndPseudomonasaeruginosa）foundintheenvironmentandonhandEndogenousfaecalorurethralmicroorganisma（e.g.Gram-positivecocciandKlebesiella）ComplicationsassociatedwithurinarycathetersShort-termcatheterizationTraumaandinflammationUrethritisbacteriuria：尿道周?chē)懈锾m氏陰性桿菌及腸球菌移生，80%會(huì)產(chǎn)生菌尿癥，女性病人菌尿癥中70-80%是因?qū)蚬芡獗谂c尿道黏膜空隙之細(xì)菌侵入。導(dǎo)尿管短期置放之菌尿癥通常為單一菌種，但有15%是多菌且同時(shí)為膿尿，E.Coli是常見(jiàn)細(xì)菌

ComplicationsassociatedwithurinarycathetersLong-termcatheterization菌尿癥是很常見(jiàn)，一般多於6週內(nèi)發(fā)生有癥狀泌尿道感染、發(fā)燒、急性腎盂腎炎、菌血癥、甚至死亡導(dǎo)尿管阻塞、尿路結(jié)石、局部尿道周?chē)腥尽⒙阅I炎、腎衰竭、甚至術(shù)年後發(fā)生膀胱癌男性長(zhǎng)期導(dǎo)尿管放置可導(dǎo)致尿道炎、尿道廔管、副睪炎、陰囊膿瘍、攝護(hù)腺炎或攝護(hù)腺膿瘍長(zhǎng)期導(dǎo)尿管之病人尿中有95%為多重菌感染，菌種為E.coli、P.aeruginosa、P.mirabilis，少數(shù)為Providentia

stuartii及M.morganii病患留置導(dǎo)尿前之護(hù)理評(píng)估病患留置導(dǎo)尿的適應(yīng)癥選擇合適的導(dǎo)尿管評(píng)估病患留置導(dǎo)尿前的排尿情形病患留置導(dǎo)尿前之護(hù)理指導(dǎo)正確置入導(dǎo)尿技術(shù)

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

MaintainingaclosedurinarydrainagesystemDON’TDon’tallowanytensiononthetubingthatcoulddislodgethecatheterordamagetheurethraDon’tallowtubingtoloopbelowthedrainagebagDon’tattachthedrainagetoabedrailorallowittorestonthefloorDon’tallowthepatienttolieonthetubingMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemMaintainingaclosedurinarydrainagesystemDOMaintaingravitydrainagebykeepingthedrainagebagbelowthelevelofthepatient’sbladderatalltime.keepthetubingfreefromkinksandobstructionsMakessurethatthesystemiswellsealedandthebag’semptyingportisclosed.checkforleaksatconnectionsitesForapatientinbedoronastretcher,suspendthedrainagebagfromthebedorstretcherframe,usingthehookorstrapprovidedIfthepatientisinachairnearthebed,keepthedrainagebagonthebedframewiththebedinalowpositionor