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Post-Operative Retention

Post-Operative Retention Sandra Whytock RN MSN GNC(C) NCA Clinical Nurse Specialist, Elder Care Program Providence

Sandra Whytock RN MSN GNC(C) NCA Clinical Nurse Specialist, Elder Care Program Providence Health Care February 2006

Retention: Agenda Prediction Prevention Detection Management …… but first ………

Retention: Agenda

PredictionRetention: Agenda Prevention Detection Management …… but first ………

PreventionRetention: Agenda Prediction Detection Management …… but first ………

DetectionRetention: Agenda Prediction Prevention Management …… but first ………

ManagementRetention: Agenda Prediction Prevention Detection …… but first ………

……

but first ………

Foley Catheters: Consequences Polymicrobial bacteriuria (universal by 30 days) Febrile episodes (1 per 100 patient

Foley Catheters: Consequences

Polymicrobial bacteriuria (universal by 30 days) days)

Febrile episodes (1 per 100 patient days)Polymicrobial bacteriuria (universal by 30 days) Nephrolithiasis, Bladder stones Chronic renal inflammation

Nephrolithiasis,by 30 days) Febrile episodes (1 per 100 patient days) Bladder stones Chronic renal inflammation Pyelonephritis

Bladder stonesFebrile episodes (1 per 100 patient days) Nephrolithiasis, Chronic renal inflammation Pyelonephritis Reduced Mobility

Chronic renal inflammationby 30 days) Febrile episodes (1 per 100 patient days) Nephrolithiasis, Bladder stones Pyelonephritis Reduced Mobility

PyelonephritisFebrile episodes (1 per 100 patient days) Nephrolithiasis, Bladder stones Chronic renal inflammation Reduced Mobility

Reduced Mobilitydays) Febrile episodes (1 per 100 patient days) Nephrolithiasis, Bladder stones Chronic renal inflammation Pyelonephritis

Indications for Foley Catheter Short term decompression of acute retention When retention can’t be managed

Indications for Foley Catheter

Short term decompression of acute retention retention

When retention can’t be managed surgically or medically surgically or medically

When wounds need to kept cleanWhen retention can’t be managed surgically or medically Comfort in terminal illness Patient insistence despite

Comfort in terminal illnesscan’t be managed surgically or medically When wounds need to kept clean Patient insistence despite knowing

Patient insistence despite knowing risks risks

NORMAL BLADDER FUNCTION

NORMAL

BLADDER

FUNCTION

NORMAL BLADDER FUNCTION
Bladder Function: Conditions for emptying The bladder must contract effectively Urethra must relax and must

Bladder Function:

Bladder Function: Conditions for emptying The bladder must contract effectively Urethra must relax and must permit

Conditions for emptying

The bladder must contract effectivelyBladder Function: Conditions for emptying Urethra must relax and must permit unobstructed flow The bladder &

Urethra must relax and must permit unobstructed flow unobstructed flow

The bladder & urethra must be coordinated coordinated

Retention: the Danger If low bladder wall compliance or outlet obstruction, urine flow from ureters

Retention: the Danger

If low bladder wall compliance or outlet obstruction, urine flow from ureters is impeded obstruction, urine flow from ureters is impeded

Risk of hydronephrosis and/or reflux from bladder into ureters bladder into ureters

Possible effect on upper urinary tract:outlet obstruction, urine flow from ureters is impeded Risk of hydronephrosis and/or reflux from bladder into

Kidney damageinto ureters Possible effect on upper urinary tract: Infection from mixing urine from ureters with higher

Infection from mixing urine from ureters with higher level of bacteria with urine from bladder) higher level of bacteria with urine from bladder)

Possible UTI d/t stasis of urine in bladdertract: Kidney damage Infection from mixing urine from ureters with higher level of bacteria with urine

Retention: A predictable problem Who is at risk?

Retention:

A predictable problem

Who is at risk?

Causes of Retention Neuropathy or Neurological damage Constipation & fecal impaction Anticholinergic Medication

Causes of Retention

Neuropathy or Neurological damageCauses of Retention Constipation & fecal impaction Anticholinergic Medication Antispasmotics Antiparkinsonian agents

Constipation & fecal impactionCauses of Retention Neuropathy or Neurological damage Anticholinergic Medication Antispasmotics Antiparkinsonian agents

Anticholinergic Medicationor Neurological damage Constipation & fecal impaction Antispasmotics Antiparkinsonian agents Antipsychotics -

Antispasmotics& fecal impaction Anticholinergic Medication Antiparkinsonian agents Antipsychotics - especially the

Antiparkinsonian agentsfecal impaction Anticholinergic Medication Antispasmotics Antipsychotics - especially the older ones Tricyclic

Antipsychotics - especially the older onesMedication Antispasmotics Antiparkinsonian agents Tricyclic antidepressants Calcium channel blockers and

Tricyclic antidepressantsagents Antipsychotics - especially the older ones Calcium channel blockers and narcotics may precipitate

Calcium channel blockers and narcotics- especially the older ones Tricyclic antidepressants may precipitate retention when administered with another

may precipitate retention when administered with another anticholinergic with another anticholinergic

More Causes of Retention Diuresis with sudden bladder over distention (diuretics, alcohol toxicity, hyperglycemia) Vit

More Causes of Retention

Diuresis with sudden bladder over distention (diuretics, alcohol toxicity, hyperglycemia) distention (diuretics, alcohol toxicity, hyperglycemia)

Vit B12 deficiencyMore Causes of Retention Diuresis with sudden bladder over distention (diuretics, alcohol toxicity, hyperglycemia)

What about Surgery: Factors Contributing to Risk of Retention? Bladder procedures, anorectal procedures Anaesthetics

What about Surgery: Factors Contributing to Risk of Retention?

Bladder procedures, anorectal procedures procedures

AnaestheticsRisk of Retention? Bladder procedures, anorectal procedures Anicholinergic medications Opiates Peri-operative fluid

Anicholinergic medicationsBladder procedures, anorectal procedures Anaesthetics Opiates Peri-operative fluid volume Constipation/reduced

Opiatesanorectal procedures Anaesthetics Anicholinergic medications Peri-operative fluid volume Constipation/reduced mobility

Peri-operative fluid volume Constipation/reduced mobility Constipation/reduced mobility

Patients at Risk for Retention Neurological disease (MS, Parkinson’s, chronic alcohol, diabetic neuropathy) Trauma:

Patients at Risk for Retention

Neurological disease (MS, Parkinson’s, chronic alcohol, diabetic neuropathy)Patients at Risk for Retention Trauma: spinal cord injury, pelvic #, Bladder outlet obstruction (BPH, prostate

Trauma: spinal cord injury, pelvic #,(MS, Parkinson’s, chronic alcohol, diabetic neuropathy) Bladder outlet obstruction (BPH, prostate cancer,

Bladder outlet obstruction (BPH, prostate cancer, uterine/bladder prolapse, impaction) cancer, uterine/bladder prolapse, impaction)

Iatrogenesis (medications, anaesthetics, radiation, large volume replacement) radiation, large volume replacement)

Elderly (detrusor hyperactivity with impaired contractility) impaired contractility)

Can Retention be Prevented? Not always but ……… Often … by avoiding transient causes: Prevent

Can Retention be Prevented? Not always but ………

Can Retention be Prevented? Not always but ……… Often … by avoiding transient causes: Prevent or

Often … by avoiding transient causes:

Prevent or resolve constipationalways but ……… Often … by avoiding transient causes: Prevent or resolve bladder infection Patient is

Prevent or resolve bladder infectionavoiding transient causes: Prevent or resolve constipation Patient is up. Mobility helps Toilet or commode are

Patient is up. Mobility helpsor resolve constipation Prevent or resolve bladder infection Toilet or commode are best Upright, avoid bedpan

Toilet or commode are bestor resolve bladder infection Patient is up. Mobility helps Upright, avoid bedpan Adequate intake (minimum 1500

Upright, avoid bedpanPatient is up. Mobility helps Toilet or commode are best Adequate intake (minimum 1500 mL) Void

Adequate intake (minimum 1500 mL)helps Toilet or commode are best Upright, avoid bedpan Void in response to urge not request

Void in response to urge not requestbest Upright, avoid bedpan Adequate intake (minimum 1500 mL) Discontinue anticholinergic meds if possible ASAP (e.g.

Discontinue anticholinergic meds if possible ASAP (e.g. loxapine). Can take as much as 2 – 3 weeks to recover from effects. loxapine). Can take as much as 2 – 3 weeks to recover from effects.

Detecting Retention: Doing a Post Void Residual Who should have a PVR? Anyone who: has

Detecting Retention:

Doing a Post Void Residual

Who should have a PVR? Anyone who:

a Post Void Residual Who should have a PVR? Anyone who: has difficulty voiding or inability

has difficulty voiding or inability to void is incontinent is incontinent

has recently had a catheter removedhas difficulty voiding or inability to void is incontinent has repeated urinary tract infections has unexplained

has repeated urinary tract infectionsinability to void is incontinent has recently had a catheter removed has unexplained agitation has unexplained

has unexplained agitationvoid is incontinent has recently had a catheter removed has repeated urinary tract infections has unexplained

has unexplained distentionvoid is incontinent has recently had a catheter removed has repeated urinary tract infections has unexplained

Some “Normals” You Will Need to Know Normal Bladder capacity: 400 – 600 mL Desire

Some “Normals” You Will Need to Know

Normal

Bladder capacity:Some “Normals” You Will Need to Know Normal 400 – 600 mL Desire to void at

400 – 600 mL

Desire to void atWill Need to Know Normal Bladder capacity: 400 – 600 mL 250 – 300 mL –

250

– 300 mL

– 400 mL per300

300

void

With changes of Aging

Bladder capacity 250 – 300 mL 300 mL

Same or lessvoid With changes of Aging Bladder capacity 250 – 300 mL Total volume voided per void

Total volume voided per void decreases per void decreases

Residual < 100 mL300 mL Same or less Total volume voided per void decreases Up to 2/3 voided volume

Up to 2/3 voided volume after 2000 volume after 2000

No straining, pain, or post-void dribble post-void dribble

Residual < 50 mLvolume after 2000 No straining, pain, or post-void dribble 1/3 voided volume at night No straining,

1/3 voided volume at night night

No straining, hesitation, pain or post-void dribble hesitation, pain or post-void dribble

Method for Measuring PVR In & Out Catheterization or Bladder Scanner Procedure: Have patient void

Method for Measuring PVR

In & Out Catheterization or Bladder Scanner Procedure:

Have patient void in as close as possible to “ideal position”. Toilet or commode; “ideal position”. Toilet or commode;

Measure the void.as possible to “ideal position”. Toilet or commode; Measure residual no later than 15 to 30

Measure residual no later than 15 to 30 minutes post void post void

Note: Bladder will empty best following natural urge rather than when asked to void; ideally first void in the morning urge rather than when asked to void; ideally first void in the morning

Interpreting PVR Results 50 mL – normal at most ages < 100 mL – normal

Interpreting PVR Results

50 mL – normal at most agesInterpreting PVR Results < 100 mL – normal for elderly < Between 50 and 199 mL

<

100 mL – normal for elderlyInterpreting PVR Results 50 mL – normal at most ages < < Between 50 and 199

<

Between 50 and 199 mL – use clinical judgement to determine impact on individual (e.g frequent UTIs) judgement to determine impact on individual (e.g frequent UTIs)

> 200 mL inadequate emptying – report to physician/refer to urologist if continues physician/refer to urologist if continues

> 400 mL – requires In and Out catheterindividual (e.g frequent UTIs) > 200 mL inadequate emptying – report to physician/refer to urologist if

You Have Discovered Retention. Now What? Get and order for In and Out catheter for

You Have Discovered Retention. Now What?

Get and order for In and Out catheter for residual > 400 mL & PRN (for discomfort) Avoid Foley if possible becaus e far more likely to mL & PRN (for discomfort) Avoid Foley if possible because far more likely to cause infection than I & O

Look for & manage transient causes:becaus e far more likely to cause infection than I & O Delirium (medications) Constipation, impaction

than I & O Look for & manage transient causes: Delirium (medications) Constipation, impaction
Delirium (medications)

Delirium (medications)

Constipation, impaction

Constipation, impaction

Anticholinergic medications

Anticholinergic medications

Infection

Infection

Restricted mobility

Restricted mobility

Consider putting Foley in for 7 days to decompress the bladder and/or until the pati ent mobile/until transient causes r 7 days to decompress the bladder and/or until the patient mobile/until transient causes removed

Then do trial of voidingthe bladder and/or until the pati ent mobile/until transient causes removed May try medications especially for

May try medications especially for mendays to decompress the bladder and/or until the pati ent mobile/until transient causes removed Then do

Removal of Foley: Voiding Trials Before taking Foley out ensure ideal conditions for voiding No

Removal of Foley: Voiding Trials

Removal of Foley: Voiding Trials Before taking Foley out ensure ideal conditions for voiding No constipation

Before taking Foley out ensure ideal conditions for voiding

No constipation !!!!taking Foley out ensure ideal conditions for voiding No bladder infection Patient is up. Mobility helps

No bladder infectionensure ideal conditions for voiding No constipation !!!! Patient is up. Mobility helps Toilet or commode

Patient is up. Mobility helpsfor voiding No constipation !!!! No bladder infection Toilet or commode are best Upright, avoid bedpan

Toilet or commode are best!!!! No bladder infection Patient is up. Mobility helps Upright, avoid bedpan Adequate intake (minimum 1500

Upright, avoid bedpanPatient is up. Mobility helps Toilet or commode are best Adequate intake (minimum 1500 mL) Void

Adequate intake (minimum 1500 mL)helps Toilet or commode are best Upright, avoid bedpan Void in response to urge not request

Void in response to urge not requestbest Upright, avoid bedpan Adequate intake (minimum 1500 mL) Discontinue anticholinergic meds if possible (e.g.

Discontinue anticholinergic meds if possible (e.g. loxapine). Sometimes need as much as 2 – 3 weeks to recover from effects. loxapine). Sometimes need as much as 2 – 3 weeks to recover from effects.

In and Out Catheterization for Trial of voiding Purpose : To retrain bladder/restore bladder capacity

In and Out Catheterization for Trial of voiding

Purpose:

In and Out Catheterization for Trial of voiding Purpose : To retrain bladder/restore bladder capacity after

To retrain bladder/restore bladder capacity after Foley

To prevent reflux or hydronephrosis kidney damage Goal: kidney damage Goal:

To prevent reflux or hydronephrosis kidney damage Goal: To maintain total bladder volume (void plus residual)

To maintain total bladder volume (void plus residual) less than 500 mL

Schedules for In and Out Catheterization for Trial or for Retention Start with scan q.i.d.

Schedules for In and Out Catheterization for Trial or for Retention

Start with scan q.i.d. Do in and out for residual volumes > 400 mL (or as physician orders) When residuals consistently between 200 & 300 mL reduce cath to BID When PVR under 200 mL - daily cath. usually at hs When consistently between 100 & 200 mL check once per week As long as bladder has less than 200 mL at least once per day risk of infection is lowered

Schedule Needs Revision If: Patient is uncomfortable (feeling of bladder fullness between caths) Patient leaks

Schedule Needs Revision If:

Patient is uncomfortable (feeling of bladder fullness between caths) bladder fullness between caths)

Patient leaks urine between In & Out caths. caths.

Patient has bladder spasmscaths) Patient leaks urine between In & Out caths. Void plus residual is > 500 mL

Void plus residual is > 500 mL . Use chart to determine time of day and add an extra cath. to determine time of day and add an extra cath.

Spread out intake over dayhas bladder spasms Void plus residual is > 500 mL . Use chart to determine time

Documentation Chart void time Void amount Residual measurement time Residual amount Catherization time Catheterization

Documentation

Chart void timeDocumentation Void amount Residual measurement time Residual amount Catherization time Catheterization amount NB times and

Void amountDocumentation Chart void time Residual measurement time Residual amount Catherization time Catheterization amount NB times

Residual measurement timeDocumentation Chart void time Void amount Residual amount Catherization time Catheterization amount NB times and volumes

Residual amountChart void time Void amount Residual measurement time Catherization time Catheterization amount NB times and

Catherization timetime Void amount Residual measurement time Residual amount Catheterization amount NB times and volumes are all

Catheterization amountvoid time Void amount Residual measurement time Residual amount Catherization time NB times and volumes are

NB times and volumes are all important

Post-Op Retention Retention Is Predictable – expect it Is Preventable – avoid transient contributors Is

Post-Op Retention Retention

Is Predictable – expect itPost-Op Retention Retention Is Preventable – avoid transient contributors Is detectable – In and out cath.

Is Preventable – avoid transient contributors contributors

Is detectable – In and out cath. or bladder scanner. Follow procedure bladder scanner. Follow procedure

Can be managed in a timely and evidence-based way – follow protocol. Include prevention evidence-based way – follow protocol. Include prevention