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1、導尿管之選擇與護理,慈濟技術學院江明珠,Incidence of catheterization,10% of patients in hospital（Mulhall et al,1988）25% of patients in hospital（Saint et al,1999） 4% of patients receiving nursing services at home（Getliffe and Mulhall,1991）,Indications for use of urinary catheters,Short-term catheterization Urologic surg
2、ery Surgery on contiguous structures Critically ill patients requiring accurate measure of urinary output Acute urinary retention,Indications for use of urinary catheters,Long-term catheterization Bladder outlet obstruction not correctable medical or surgically Intractable skin breakdown caused or e
3、xacerbated by incontinence Some patients with neurogenic bladder and retention Palliative care for terminally ill or severely impaired incontinent patients for whom bed and clothing changes are uncomfortable Preference of a patient who has not responded to specific incontinence treatments,途徑 Transur
4、ethra catheterization Transvesical catheterization（ suprapubic catheterization ）,What is suprapubic catheterization？,恥骨上導尿管：在膀胱脹滿水之後由恥骨上正中央插入導引器然後插入導尿管,suprapubic catheterization,suprapubic catheterization,indications for suprapubic catheterizattion,Urethra trauma Clients who require long-term cathe
5、terization and who are sexually active Following pelvic or urological surgery Some gynaecological conditions,e.g.colposuspension Long-term catheterization for incontinence Clients who are unable to tolerate urethral catheterization Some wheelchair-bound clients,Consider suprapubic or urethral cathet
6、erization,Consider suprapubic or urethral catheterization,Consider suprapubic or urethral catheterization,Selection of catheters,Which materialFor short-term use （1-28days）: Latex, PVC, PTFE-coated latex foley catheterFor long-term use of up to 12 weeks,select one of the following:hydrogel-coated la
7、tex foley catheterpure silicon Foley cathetersilicon-coated latex Foley catheter,Selection of catheters,Catheter size Male:14-16Ch（length 40-45cm） Female:12-14Ch（length20-26cm） Balloon size 5-10ml recommended 30ml surgery only,Catheter-related problem,Bypassing UTI Blocked catheter Inadvertent cathe
8、ter removal,Catheter-related problem-Bypassing,Common causes of bypassing Constipation Kinked tubing Catheter size and length/balloon Detrusor instability Trigone irritation blockage,Catheter-related problem-UTI,直接影響導尿管造成感染之因素：放置時間長短 Detect significant microbial counts-3days after catheterization（Ba
9、ch et al,1990） The risk of developing bacteriuria Garibaldi et al （1974）： 8.1% for each dayMulhall et al（1988）：5-8% for each daySedor（1999）：5% for each day Bacteriuria is virtually inevitable within 3-4 weeks（Jewes et aal,1988）,Catheter-related problem-UTI,危險因素： 引流袋污染 糖尿病 女性患者 抗生素使用 頻頻測量尿輸出量 腎功能不良 技
10、術不良,Catheter-related problem-UTI,致病機轉 細菌由會陰部或尿袋移生後經由導尿管外壁或內壁上行 女性之感染途徑為經由直腸正常菌叢污染尿道周圍 男性主要為管路內經由外來細菌污染 尿道口之細菌可經由插入導尿管時帶入膀胱,Catheter-related problem-UTI,Catheter-related problem-UTI,致病菌 Extogenous organisms（e.g.serratia spp. And Pseudomonas aeruginosa）found in the environment and on hand Endogenous f
11、aecal or urethral microorganisma（e.g.Gram-positive cocci and Klebesiella）,Complications associated with urinary catheters,Short-term catheterization Trauma and inflammation Urethritis bacteriuria：尿道周圍有革蘭氏陰性桿菌及腸球菌移生，80%會產生菌尿症，女性病人菌尿症中70-80%是因導尿管外壁與尿道黏膜空隙之細菌侵入。導尿管短期置放之菌尿症通常為單一菌種，但有15%是多菌且同時為膿尿，E.Coli是
12、常見細菌,Complications associated with urinary catheters,Long-term catheterization 菌尿症是很常見，一般多於6週內發生 有症狀泌尿道感染、發燒、急性腎盂腎炎、菌血症、甚至死亡 導尿管阻塞、尿路結石、局部尿道周圍感染、慢性腎炎、腎衰竭、甚至術年後發生膀胱癌 男性長期導尿管放置可導致尿道炎、尿道廔管、副睪炎、陰囊膿瘍、攝護腺炎或攝護腺膿瘍 長期導尿管之病人尿中有95%為多重菌感染，菌種為E.coli、P.aeruginosa、P.mirabilis，少數為Providentia stuartii及M.morganii,病患留
13、置導尿前之護理,評估病患留置導尿的適應症 選擇合適的導尿管 評估病患留置導尿前的排尿情形 病患留置導尿前之護理指導 正確置入導尿技術,病患留置導尿的護理,維持導尿管引流系統的功能 適當固定導尿管，預防拉扯及創傷 預防泌尿道的感染 評估留置導尿管對病患及家庭的影響，並協助處理 預防便秘 尿液滲漏的處理,Maintaining a closed urinary drainage system,DONT Dont allow any tension on the tubing that could dislodge the catheter or damage the urethra Dont al
14、low tubing to loop below the drainage bag Dont attach the drainage to a bed rail or allow it to rest on the floor Dont allow the patient to lie on the tubing,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,DO Main
15、tain gravity drainage by keeping the drainage bag below the level of the patients bladder at all time.keep the tubing free from kinks and obstructions Makes sure that the system is well sealed and the bags emptying port is closed.check for leaks at connection sites For a patient in bed or on a stret
16、cher,suspend the drainage bag from the bed or stretcher frame,using the hook or strap provided If the patient is in a chair near the bed, keep the drainage bag on the bed frame with the bed in a low position or attach the bag to the chair,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Maintaining a closed urinary drainage system,Urinary catheter securement,導尿管固定好可降低尿管意外脫落，及由於過拉扯尿管或尿袋所造成的組織損傷及發炎 尿管滑脫之比例為17%-41%，而不適當的固定是主要的危險因子，常引起沒有計劃性的尿管拔除。 創傷及發炎與重複導尿管移動及尿道受壓有關，當尿管沒有適當固定或病人拉扯尿管會造成尿管沒有目的的移動，移動尿管會造成創傷及發炎，使其更容易造成感染、組織壞死、尿道腺體阻塞及膀胱不穩定或痙攣。,
