Note: The following interview was arranged by Future Path Medical.
Sue Powers, RN, of University Hospitals Geneva (Ohio) Medical Center, identifies five of the top urine management issues facing nurses today and suggests solutions that can currently or may one day be able to help overcome these challenges.
1. Full urine bags. This is a challenge caused primarily by a lack of staff, says Ms. Powers. "It's not always accessible for a nurse or aid to get into a room to be able to 'eyeball' how full a bag is," she says. "The reality is that emptying a foley bag usually isn't done until the end of the shift."
Unfortunately by that time a bag may have been full for a significant amount of time. A full urine bag can burst or it can pull on a foley catheter and cause trauma to the urinary tract. Sometimes it can pull the catheter out entirely with the balloon still attached.
"It would be nice to get in [to a patient's room] once or twice a shift to look at the bag and to be able to empty it," Ms. Powers says. "But that doesn't usually happen. It could be a time issue, or it could also be the fact that you have a patient that's putting out urine a lot faster than another patient down a hallway.
Ms. Powers says one possible solution would be the development of technology that identifies the flow rate on a computer monitor or perhaps on a wireless device.
"If you were able to see something on your screen where you're working to let you know a foley bag is getting or not getting full, you would know when to get in there and empty that bag in a timely manner," she says. "Of course, we would all love to see more staff, but we also know that's not always going to happen."
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2. Accurate intake and output. I&O — which is the calculation of how much fluid a patient has taken in and excreted — is usually performed at the end of the shift. And not unlike the challenges presented from only addressing how full a urine bag is at the end of a shift, waiting until then to address I&O can also lead to safety issues — problems that should have been caught earlier in the shift, Ms. Powers says.
"How full a bag is, the appearance, the color, the flow rate — this is all information we're looking for when we're doing our I&Os," she says. "Now you're going to play catch up — for example, if you don't have enough urine output, you're going to increase their fluids to increase the output."
The use of a urimeter — a type of foley bag in which a plastic component fills up and is measured and analyzed hourly — helps with accurate I&O. However, this still presents the challenge of needing enough staff to perform the regular measurement.
"We rely a lot on ancillary staff, our nurses' aids who, along with taking vital signs also check the foley bag, and they're the ones who are usually going into the room when patients say they need to get up," Ms. Powers says. "But now we're, again, relying on staff that's not always available."
Ms. Powers says technology could help provide a solution with this challenge as well. "It would be nice to have something that's on your laptop to give you a print out of flow rates, etc, with the technology to calculate it as well — how much urine they're putting out every hour, with the technology to break it down even further if the doctor needed to test kidney function," she says.
3. Disease-specific foley care. "A lot of people think that if a patient has a foley catheter, then this person does not require a bathroom," says Ms. Powers. "Unfortunately that's the mindset of a lot of healthcare workers. But when you have a disease-specific patient, your foley care and your considerations have to change along with it."
For example, a patient with congestive heart failure or pneumonia may be placed on a Lasix medication program to increase urine output. In increasing that urine flow, patients are going to experience an increase in the need to use the bathroom. Just putting a foley catheter in does not entirely address this change.
"You need to pay close attention to the catheter to make sure the Lasix is working and you're avoiding issues like full urine bags, anything causing trauma, etc.," says Ms. Powers. "Then there are patients who have had [transurethral resection of the prostate (TURP)] — those patients come out of surgery and they're on a continuous irrigation. They have a specific foley catheter in where the water goes into the bladder, it irrigates and it comes out.
"Again, there's a misconception that it doesn't need to be checked as often because the water is going in and the water is coming out," she says. "But how can you accurately say what is urine and what is not urine? That's where it comes in that you have to take special consideration as to how much fluid is going in, how much is coming out, and then you have to calculate how much is actually urine and how much is irrigation."
Ms. Powers says the solution to this problem, even with the development of technology that could indicate output, is education and reeducation about the misconceptions associated with the use of foley catheters.
4. Identifying kinks and positioning issues. This challenge is most often presented with quadriplegic patients and older patients who come to a hospital from nursing homes. One solution Ms. Powers has used is Bard Medical's STATLOCK stabilization device.
"It's like a plumbing guide for the catheter urine tube," she says. "You just stick it on the leg and it keeps the end of the catheter in place instead of tugging and pulling."
For patients who are alert and oriented, the use of this device might not be necessary. But for patients who are unable to feel positioning problems or those who are confused or unable to control themselves physically, the use of such a device to help ensure proper position can avoid kinks, Ms. Powers says.
5. Contamination and infection. Contamination can occur because of overflow and spillage from a full foley catheter. It can also occur when emptying a bag into a beaker to perform a reading, thus placing the urine in an open, exposed container, Ms. Powers says.
"With infection, you can wash your hands repeatedly but it's very unfortunate for a patient in your facility to get a secondary problem of a UTI," she says.
There's also the issue of autonomic dysreflexia (AD), also known as autonomic hyperreflexia, which is seen in spinal cord patients. "It's caused by overfilling of the bladder," Ms. Powers says. "In spinal cord patients, they don't have the neurosensory to tell their blood pressure is going up, or if they're getting goosebumps or their pulse is going down. Some of those patients who are very well in-tuned with their body can sense it but a lot of these patients unfortunately cannot.
"And if the hose is kinked, even in patients that are not spinal cord-injured, you can still get that from urine backup from a full bag," she says. "The sooner you can prevent it or correct it, the better."
The solution to this challenge is working to ensure there is the time and resources to obtain a clear picture — in terms of color and appearance — of a patient's urine. Ms. Powers says technology that determines the gravity and temperature of the urine could help indicate whether the patient is increasing in a fever and potentially catch a problem before it becomes a significant issue.
Another solution, and one that could be applied to all five of the challenges Ms. Powers identifies, is a continued focus on patient education. "You always want to involve your patient and family with education," she says. "A lot of education goes with insertion of foley catheter and discussing things to look for — urine leaking around the catheter, a wet bed, etc. An alert patient will tell you their bag is full. Education is key as far as staffing goes and patients go."
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