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Continuous Bladder Irrigation (CBI),

Prepared by: Emmanuel Ryan P. Francisco a continuous infusion of a sterile solution into the bladder, usually by using a three-way irrigation closed system with a triple-lumen catheter. One lumen is used to drain urine; another is used to inflate the catheter balloon, and the final lumen carries the irrigation solution. CBI is primarily used following genitourinary surgery to keep the bladder clear and free of blood clots or sediment Implementation Considerations: A physicians order is required for Foley catheter insertion and continuous bladder irrigation (CBI) Insertion and maintenance of (three way) Foley catheter patency involves a closed drainage system and sterile technique Sterility and patency of CBI system is maintained to avoid infection and occlusions Saline solution for infusion should be stored and infused at room temperature to avoid bladder spasms. Strict Intake & Output is recommended for all patients receiving CBI. Special attention to frail elderly and/or history of pelvic floor or bladder radiation. These patients are at high risk for bladder perforation. Indications: 1.urinary retention 2.bladder spasm 3.blood clot inside the catheter 4.pus inside the catheter 5.after prostate or bladder surgery Contraindication: 1.presence of traumatic injury to the lower urinary tract Complications: 1.Infection (UTI) 2.Bladder Distention blockage of an irrigated bladder rapidlyleads to overdistention 3.Bladder rupture Procedure:

1. Explain procedure to the patient and ensure patient privacy 2. Position the patient for easy access to the catheter whilst maintaining patient comfort 3. Ensure that the patient has a three-way urinary catheter. If not, a three-way catheter needs to be inserted 4. Hang irrigation flasks on IV pole and prime irrigation set maintaining asepsis of irrigation set. Note: Only one of the irrigation flask clamps should be open when priming the irrigation set otherwise the fluid can run from one flask to another. After priming the irrigation set ensure that all clamps on the irrigation set are closed. 5. Don goggles and impervious gown , place underpad underneath catheter connection 6. Attend hand wash and don non sterile gloves 7. Swab IDC irrigation and catheter ports with chlorhexidine swabs and allow drying 8. Remove the spigot from the irrigation lumen of the catheter using sterile gauze and discard spigot 9. Connect the irrigation set to the irrigation lumen of the catheter, maintaining clean procedure 10. Remove spigot or old drainage bag from the catheter lumen using sterile gauze and apply catheter drainage bag maintaining clean procedure. Note: Do not commence Bladder Irrigation until urine is draining freely 11. Unclamp the irrigation flask that was used to prime the irrigation set and set the rate of administration by adjusting the roller clamp Note: The aim of the bladder irrigation is to keep the urine rose coloured and free from clots. Materials/ Equipment Needed: 3 way catheter 0.9% sodium chloride irrigation bags as per facility policy continous bladder irrigation set and closed urinary drainage bag with anti-reflux valve. Chlorhexidane 0.5% with 70% alcohol wipes Non sterile gloves Personal protective equipment Underpad (bluey) IV pole

Implementation Process: Foley insertion as per physicians orders. May use Urojet (sterile xylocaine jelly) Verify physicians order for CBI and note any special instructions eg. Run slowly until clear. (means clear in the tubing, although may appear pink tinged in the bag) Use strict aseptic technique when handling any of the equipment to prevent introduction of microorganisms into the urinary tract.

Troubleshooting: 1. Drainage out is less than irrigation infused

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 units routine). If obstruction is suspected, gentle manual irrigation may be required as per physicians 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 physicians 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.

4. The patient is confused/agitated

Assess if patient is orientated to time, place person Notify physician of patients 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, NA level; in TURP syndrome an overload of fluid through the prostatic sinuses can lead to delusional hyponatremia, confusion and hypertension)

5. Solution Leaks around the foley catheter

Assess for bladder spasms Refer to #1 assessing for obstruction Consider administering antispasmatic i.e. Buscopan

Nursing Responsibilities: Saline flasks for bladder irrigation do not need to be ordered by a Medical Officer Continue irrigation as necessary depending on the degree of hematuria (ensure adequate supply of irrigant nearby) After each flask is complete, empty urine drainage bag and record urine output on the fluid balance chart, prior to commencement of the next irrigation flask

Regular catheter care is required in order to minimise the risk of catheter related urinary tract infection Catheter care provided should be documented in the progress notes and nursing care plan including patient comfort, urine colour/degree of hematuria and urine output. Also presence of clots if any and if manual bladder washout was necessary. Documentation: Documentation includes:

Patients comfort/pain level (how procedure is being tolerated) Colour and type of drainage, presence of clots/fragments Intake and output; use following calculation output CBI infused - foley output = True urine

Interventions required (manual irrigation, use of bladder scanner) Health teaching done with patient and family Patient concerns/adverse reactions (i.e. continued bladder spasms, decreased total urine output), the nursing actions taken and patient outcomes

References: Black et al (2001) Medical-Surgical Nursing, 6th edition, Toronto: W.B.Saunders Perry, A. & Potter, P. (2002) Clinical Nursing Skills and Techniques 5th edition, St. Louis: Mosby Swaeringen, L. & Ross, D.(1999) Manual of Medical-Surgical Nursing Care 4thedition, St. Louis: Mosby