Skill 12-10

Administering a Continuous Closed Bladder or Catheter Irrigation

Routine intermittent irrigation of long-term catheters is not recommended (Gould et al., 2019). Unless obstruction is anticipated, as might occur with bleeding after prostatic or bladder surgery, bladder irrigation is not recommended and should be avoided (Gould et al., 2019; SUNA, 2015). In these situations, sediment or debris, as well as blood clots, might block the catheter, preventing the flow of urine out of the catheter. Irrigations might also be used to instill medications that will act directly on the bladder wall.

Irrigating a catheter through a closed system is preferred to opening the catheter because opening the catheter could lead to contamination and infection (Gould et al., 2019). Closed-system irrigation via a triple-lumen catheter (Figure 1) is suggested to prevent obstruction and maintain a closed system (Figure 2 on page 764) and is recommended to prevent the introduction of pathogens into the bladder (Gould et al., 2019).

Delegation Considerations

The administration of continuous closed bladder irrigation is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, administration of continuous closed bladder irrigation may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile irrigating solution (at room temperature or warmed to body temperature)
Sterile tubing with drip chamber and clamp for connection to irrigating solution
IV pole
IV pump (if bladder is being irrigated with a solution containing medication)
Three-way indwelling catheter in place in patient's bladder
Indwelling catheter drainage setup (tubing and collection bag)
Alcohol or other disinfectant swab
Bath blanket
Disposable gloves
Additional PPE, as indicated

Assessment

Verify the prescribed intervention in the health record for continuous bladder irrigation, including type and amount of irrigant or irrigation parameters. Assess the catheter to ensure that it has an irrigation port (if the patient has an indwelling catheter already in place) (three-way indwelling catheter). Assess the characteristics of urine present in the tubing and drainage bag. Review the patient's health record for, and ask the patient about, any allergies to medications. Before performing the procedure, assess the bladder for fullness either by palpation or with a handheld bladder ultrasound device. Assess for signs of adverse effects, which may include pain, bladder spasm, bladder distention/fullness, or lack of drainage from the catheter.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired urination
Infection risk

Outcome Identification and Planning

The expected outcomes to achieve are that the irrigation is administered without adverse effect, and the patient exhibits free-flowing urine through the catheter. Initially, clots or debris may be noted. These should decrease over time, with the patient ultimately exhibiting urine that is free of clots or debris. Other outcomes may include that the continuous bladder irrigation continues without adverse effect, drainage is greater than the hourly amount of irrigation solution being placed in the bladder, and the patient exhibits no signs and symptoms of infection.

Implementation

Action	Rationale
1. Confirm the prescribed intervention for continuous catheter irrigation in the health record, including infusion parameters. If irrigation is to be implemented via gravity infusion, calculate the drip rate. Often, titration to keep the urine clear of blood or clots is prescribed.	Verifying the prescribed intervention ensures that the correct intervention is administered to the right patient. The solution must be administered via gravity at the appropriate rate as prescribed.
2. Gather equipment.	Assembling equipment provides for an organized approach to the task.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient.	This ensures the patient's privacy. Discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care.
6. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and prevents unnecessary stretching and twisting of muscles on the part of the nurse.
7. Adjust the bed to a comfortable working height (VHACEOSH, 2016).	Having the bed at the proper height prevents back and muscle strain.
8. Empty the catheter drainage bag and measure the amount of urine, noting the amount and characteristics of the urine.	Emptying the drainage bag allows for accurate assessment of drainage after the irrigation solution is instilled. Assessment of urine provides a baseline for future comparison.
9. Assist the patient to a comfortable position and expose the irrigation port on the catheter setup. Place a waterproof pad under the catheter and irrigation port.	This provides adequate visualization. The waterproof pad protects the patient and bed from leakage.
10. Prepare the sterile irrigation bag for use as directed by the manufacturer. Clearly label the solution as “Bladder Irrigant.” Include the date and time on the label. Hang the bag on the IV pole 2.5 to 3 ft above the level of the patient's bladder. Close the tubing clamp and insert the sterile tubing with drip chamber to the container using aseptic technique (Figure 3). Release the clamp and remove the protective cover on the end of the tubing without contaminating it. Allow the solution to flush the tubing and remove air (Figure 4). Clamp the tubing and replace the end cover.	Proper labeling provides accurate information for caregivers. Sterile solution not used within 24 hours of opening should be discarded. Aseptic technique prevents contamination of solution irrigation system. Priming the tubing before attaching irrigation clears air from the tubing that might cause bladder distention.
11. Put on gloves. Cleanse the irrigation port on the catheter with an alcohol swab. Using aseptic technique, attach the irrigation tubing to the irrigation port of the three-way indwelling catheter (Figure 5).	Aseptic technique prevents the spread of microorganisms into the bladder.
12. Check the drainage tubing to make sure the clamp, if present, is open.	An open clamp prevents accumulation of solution in the bladder.
13. Release the clamp on the irrigation tubing and regulate the flow at the determined drip rate, according to the prescribed rate (Figure 6). If the bladder irrigation is to be done with a medicated solution, use an electronic infusion device to regulate the flow.	This allows for continual gentle irrigation without causing discomfort to the patient. An electronic infusion device regulates the flow of the medication.
14. Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Positioning and covering provide warmth and promote comfort and safety. Hand hygiene prevents the spread of microorganisms.
15. Assess the patient's response to the procedure and the quality and amount of drainage.	Assessment is necessary to determine the effectiveness of the intervention and to detect adverse effects.
16. Remove equipment. Remove additional PPE, if used. Perform hand hygiene.	Proper disposal of equipment prevents transmission of microorganisms. Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.
17. As the irrigation fluid container nears empty, clamp the administration tubing. Do not allow the drip chamber to empty. Disconnect the empty bag and attach a new full irrigation solution bag.	This eliminates the need to separate the tubing from the catheter and clear air from the tubing. Opening the drainage system provides access for microorganisms.
18. Put on gloves to empty the drainage collection bag as each new container is hung. Record initiation of the new container and volume of drainage.	Gloves protect against exposure to blood, body fluids, and microorganisms. Accurate recording of the volume of the irrigation solution infused and catheter drainage allows for accurate calculation of urinary output.

Evaluation

The expected outcomes have been met when the irrigation has been administered without adverse effect, the patient has exhibited free-flowing urine through the catheter, the continuous bladder irrigation has continued without adverse effect, drainage from the catheter has been greater than the hourly amount of irrigation solution being placed in the bladder, and the patient has exhibited no signs and symptoms of infection.

Documentation

Guidelines

Document the baseline assessment of the patient. Document the amount and type of irrigation solution used and the patient's tolerance of the procedure. Record the urine amount emptied from the drainage bag before the procedure and the amount of irrigant used on the intake and output record. Record the amount of urine and irrigant emptied from the drainage bag.

Subtract the amount of irrigant instilled from the total volume of drainage to obtain the volume of urine output.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Continuous bladder irrigation begins, and hourly drainage is less than amount of irrigation being given: Palpate for bladder distention. If the patient is lying supine, rolling them onto their side may help increase the amount of drainage. Check to make sure that the tubing is not kinked. If return flow remains decreased, notify the health care team.
Bladder irrigation is not flowing at prescribed rate, even with clamp wide open: Check the tubing for kinks or pressure points. Raise the bag slightly and then check the flow of the irrigation solution. Frequently check the flow rate of the irrigation solution.

Special Considerations

Patients with long-term indwelling urinary catheters and their health care providers should monitor the “life” of the patient's catheter to anticipate and preempt blockage from encrustation, crystalline formation, sediment, and debris, often related to formation of biofilms to avoid the need for irrigation (Dean & Ostaszkiewicz, 2019; Pelling et al., 2019).

EVIDENCE FOR PRACTICE

Prevention of Catheter-Associated Infections

Practice Guideline

Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2019 [update]). Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention, 31(4). https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf

These guidelines provide evidence-based recommendations to guide care for patients requiring catheterization of the urinary bladder to prevent CAUTI.

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Skill 12-10

EVIDENCE FOR PRACTICE