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Performing and Managing Bladder Irrigation Through a Three-Way Foley Catheter

Overview: To flush or “wash out” the bladder (intermittent or continuous) using a closed system. To maintain or restore catheter patency.

Preparation
● Use strict aseptic technique if intermittent irrigation is ordered.
● Medications may be added to irrigation solution.
● Isotonic irrigation solutions are used.
● Check prescriber’s order to determine if it is a continuous or intermittent irrigation.

Special Considerations
• Assess bladder for distention, because clots can occur.
• Assess patient for lower abdominal pain and/or cramping.
• Perform manual irrigation as needed to remove clots and reestablish irrigation flow.
• If resistance is met during manual irrigation, do not force irrigation fluid, notify prescriber.

Pediatric, Elderly, and Mentally Challenged Patients
• May need closer monitoring because they may not be able to communicate problems.

Relevant Nursing Diagnoses
● Pain or discomfort related to blood clots obstructing normal irrigation flow
● Potential for injury related to blood clots in bladder and/or urethra and causing distention

Expected Outcomes
● All irrigation solution and debris from bladder drains into catheter drainage bag
● Continuous: Flow rate of irrigant remains constant at prescribed rate, and bags of irrigation solution are added as needed
● Catheter and drainage bag tubing remain patent
● Urinary output is accurately assessed
● Patient experiences no discomfort during or following procedure
● Patient’s questions and concerns are adequately addressed

Implementation
1. Review prescriber’s orders and obtain prescribed irrigation solution from pharmacy (unless solution is already in place at bedside).
Rationale: Determines type, strength, and amount of irrigation solution, as well as frequency and timing of procedure.

2. Place label on irrigation bag if not labeled; include patient’s initials, date, time, room number, type of solution, and any additives.
Rationale: Provides safety and continuity of care.

3. Gather all equipment.
Rationale: Enhances efficiency and patient safety.

4. Check patient’s identification band.
Rationale: Ensures patient safety.

5. Explain procedure and its purpose to patient, and provide privacy.
Rationale: Clear explanations reduce patient’s anxiety and increase cooperation with procedure. Maintains patient’s dignity.

6. Organize equipment within easy reach and drape patient, exposing access to irrigation port on catheter only.
Rationale: Enhances efficiency and patient safety.

7. Don clean gloves, and empty and measure urine present in drainage bag; discard urine and gloves in appropriate receptacles.
Rationale: Decreases transmission of microorganisms, provides pertinent data regarding patient’s urine output, and provides empty drainage bag for accurate measurements following procedure.

8. Wash hands.
Rationale: Decreases transmission of microorganisms.

Infusion Tubing and Irrigation Solution Already in Place

Continuous Irrigation


1. Ascertain that solution is correct as prescribed.
Rationale: Ensures that the irrigation solution already hanging and connected to infusion tubing is the prescribed solution.

2. Open flow clamp on urinary drainage tubing and on infusion tubing.
Rationale: Opening drainage bag flow clamp allows infused irrigation solution to flow from bladder into drainage bag.

3. Adjust flow rate to prescribed hourly rate.
Rationale: Ensures that flow rate is continuous.

Intermittent Irrigation
1. Ascertain that solution is correct as prescribed.
Rationale: Ensures that prescribed solution is in place.

2. Open flow clamp to urinary drainage bag and to infusion tubing.
Rationale: Allows irrigation solution to flow into bladder, then into drainage bag.

3. Allow prescribed amount of irrigation solution to infuse into bladder and then clamp infusion tubing.
Rationale: Ensures that only prescribed amount is instilled into bladder.

Irrigation Solution and Infusion Tubing Not in Place
1. Hang irrigation solution bag on IV pole 24 to 36 inches above bladder.
Rationale: Ensures correct height for effective flow.

2. Connect infusion tubing to irrigation solution, prime drip chamber, and flush tubing with solution.
Rationale: Flushing infusion tubing with irrigation solution prevents air from entering patient’s bladder and causing discomfort.

3. Close infusion tube clamp and connect infusion tubing to irrigation port on three-way Foley.
Rationale: Closing infusion clamp allows only prescribed amount of irrigant to be infused.

4. Open flow clamp on urinary drainage bag.
Rationale: Opening drainage bag flow clamp allows instilled irrigation solution to flow from bladder into drainage bag.

5. Intermittent: Open flow clamp on infusion tubing, allowing prescribed amount of irrigation solution to infuse into bladder; clamp tubing.
Rationale: Opening infusion flow clamp allows prescribed volume of irrigant to be infused. Clamping infusion tubing ensures that only prescribed amount of solution is instilled.

6. Continuous: Open flow clamp on infusion tubing and adjust the prescribed hourly rate. Change or add irrigation solution as needed, maintaining aseptic technique.
Rationale: Ensures continuous flow of solution. Ensures continuous irrigation and change in solution when prescribed.

7. Change infusion tubing every 24 to 48 hours or per facility protocol.
Rationale: Reduces incidence of urinary tract infection.

8. Monitor urine output hourly or as ordered, subtracting the amount of irrigant from the total output from drainage bag.
Rationale: Provides pertinent information about bladder and kidney function and need for additional or change in plan of care.

9. Assess drainage bag frequently and empty as needed.
Rationale: Bag can fill more quickly with irrigation and often needs more frequent emptying.

10. Assess color, clarity, odor, and other characteristics of urinary output during irrigation process and each time drainage bag is emptied.
Rationale: Provides pertinent information about bladder and kidney function and need for intervention.

11. Discard gloves and urine in appropriate receptacles.
Rationale: Reduces transmission of organisms.

Evaluation and follow up activities
● Assess amount, color, clarity, odor, and character of fluid in drainage bag, noting clots, tissue prior to and following irrigation
● Assess accurately urine volume and irrigant volume
● Assess patient’s comfort level during and after procedure
● Address patient’s questions and concerns
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