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Documente Profesional
Documente Cultură
Pulsul
Pulsul reprezintă expansiunea ritmică a arterelor ce se comprimă pe un plan dur,
osos şi este sincronă cu sistola ventriculară.
Scop: evaluarea funcţiei cardiovasculare.
Se apreciază:
ritmul,
amplitudinea,
frecvenţa,
celeritatea.
Măsurarea pulsului
Loc de măsurare: oricare arteră accesibilă palpării şi care poate fi
comprimată pe un plan osos:
• artera temporală superficială (la copii);
• carotidă;
• regiunea apicală (vârful inimii);
• a.humerală;
• a.radială;
• a.femurală;
• la nivelul regiunii poplitee;
• a.tibială;
• a.pedioasă.
Tehnică
Materiale necesare:
• pix culoare roşie;
• ceas cu secundar.
Tehnica
• pregătirea psihică;
• se asigură repaus fizic şi psihic 10-15 minute;
• reperarea arterei;
• fixarea degetelor index, medius şi inelar pe traiectul arterei;
• se exercită o uşoară presiune cu vârful degetelor asupra peretelui
arterial până la perceperea zvâcniturilor pline ale pulsului;
• se numără pulsaţiile timp de 1 minut.
Consemnarea valorii pulsului
Amplitudinea (volumul)
• este determinată de cantitatea de sânge existentă în vase;
• este mai mare cu cât vasele sunt mai aproape de inimă;
• la arterele simetrice, volumul pulsului este egal.
• Modificări de amplitudine a pulsului
o puls filiform - volum redus, abia perceptibil;
o puls asimetric – volum diferit al pulsului la artere simetrice
Frecvența
Frecvenţa
o n.n. 130-140 p/m
o copil mic 100-120 p/m
o la 10 ani 90-100 p/m
o adult 60-80 p/m
o vârstnic >80-90 p/m
• Scopul= obtinerea de informatii necesare pentru stabilirea diagnosticului si urmarirea evolutiei bolilor
tubului digestiv si glandelor anexe acestuia.
Patologic: Patologic:
albiciaosa ca argila (icter mecanic), brun-inchis (icter foarte fetid (in cancerul colonului si rectului).
hemolitic);
neagra ca ”pacura”, moale, lucios, cu miros de
motorină (in cazul unor hemoragii in portiunea
superioara a tubului digestiv, manifestată prin
melenă);
rosie (in cazul hemoragiilor din portiunea inferioara a
tubului digestiv, care poartă numele de rectoragie).
8.Aspectul
Fiziologic: pastos-omogen
Patologic:
zeama de pepene sau supa de linte (in febra tifoida);
zeama de orez(in intoxicatii, sau holera)
9.Elemente patologice
mucus, puroi, sânge (in colite ulceroase, pseudomembranoase, cancer rectal sau intestinal, dizenterie);
resturi de alimente nedigerate (in pancreatite cronice);
grasimi nedigerate, paraziti intestinali, cazurile vor fi imediat raportate medicului
10. Notarea scaunelor
Scaun normal: I
Moale: /
Diareic: -
Mucus: X
Cu puroi: P
Cu sange: S
Grunjos: Z
Daca un scaun contine mai multe elemente ( de exemplu in acel scaun se observa atat mucus cat si sange)
atunci se noteaza XS si se incercuiesc cele doua litere pt. a stii ca este vorba de un scaun care contine doua
elemente , nu de doua scaune.
MĂSURAREA
DIUREZEI ȘI
NOTAREA GRAFICĂ
DEFINITIE: Diureza reprezinta cantitatea de urina emisa in 24 de ore.
SCOP:
Obtinerea datelor privind starea morfo-functionala a aparatului renal si asupra altor afectiuni;
Urmarirea bilantului circulatiei lichidelor in organism (intrari/iesiri sau ingestie/excretie);
Efectuarea unor determinari calitative si anume analize biochimice din cantitatea de urina emisa.
Materiale necesare:
• Vase gradate spalate si clatite cu apa distilata pentru a
nu modifica compozitia urinei.
Procedură:
• Colectarea incepe dimineata la o anumita ora (ex: ora 8:00) si se termina in ziua urmatoare la
acceasi ora.
• Bolnavul este informat asupra necesitatii si importantei colectarii corecte a urinei si asupra tehnicii
(ex: se educa bolnavul sa urineze numai in urinar si sa nu arunce urina);
• Asistenta se spala pe maini cu apa si sapun, imbraca manusile de protectie, la bolnavul imobilizat la
pat se roaga sa urineze inainte de defecare, se arunca urina dupa prima emisie, apoi se colecteaza
in vasele gradate toate urinile emise pana a doua zi la aceeasi ora.
• Daca bolnavul se poate deplasa, acesta este rugat sa urineze dimineata la ora fixa, prima emisie sa o
arunce, iar restul emisiilor de urina sa le colecteze in decurs de 24 de ore.
• Asistenta medicala dezbraca manusile, se spala pe maini cu apa si sapun, noteaza in foaia de
temperatura urina colectata, trece la reorganizarea locului de munca.
• Vasele in care se face colectarea sunt etichetate cu numele bolnavului,a salonului, a patului și sunt
tinute la racoare si ferite de lumina pentru a preveni descompunerea urinei.
Volumul urinii
Valori fiziologice:
femei: 1000-1400ml urina/24h
barbati:1200-1800ml urina/24h.
Valori patologice:
peste 3000 ml uirna /24h (poliurie).
sub 1000 ml/24h (oligurie).
absenta urinei in vezica/24h (anurie).
Aspectul urinii
Fiziologic: culoare galben deschis sau brun inchis (urina
concentrata), aspect hiperstenuric.
Patologic:
Culoare brun inchisa si spuma – icter;
Culoare rosie deschisa pana la rosu inchis – hematurie;
Culoare albastru verzui, dupa un tratament cu albastru
de metil;
• Dacă nu sunteți de acord cu furnizarea datelor personale, Spitalul Clinic .... prin
intermediul direcțiilor/serviciilor/birourilor/secțiilor /compartimentelor/
laboratoarelor/ unitatea de primiri urgențe din structura sa,
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Urinary Catheter
Dr. Frederick Foley
• Developed in the 1920s
by Dr. Frederick Foley
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What is a urinary catheter
A urinary catheter
is any tube placed
in the body to
drain and collect
urine from the
bladder
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INDICATIONS FOR CATHETERISATION
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Specific indications
Monitor urinary output
Healing after lower urinary tract surgery/trauma
Evacuate the bladder when the urine contains particulate
matter, especially in combination with simultaneous
irrigation (post transurethral resection, blood
clot/purulent material evacuation)
Collect of microbiologic clean urine (uncooperative
patients because of age or mental status or comorbidities
that prevent voluntary voiding)
Measure postvoid residual urine volume (PVR) for
diagnostic purposes
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Specific indications
Provide access to the bladder for urinary tract imaging
studies such as cystography, which requires the
instillation of radiographic contrast material
Urodynamic testing for physiologic assessment of voiding
function requires a pressure monitoring urinary catheter
Instillation of pharmacologic agents for local therapy of
some bladder pathologies such as:
chemo/immunotherapy for non muscle invasive bladder
cancer (mitomycin, BCG),
interstitial cystitis (dimethyl sulfoxide – DMSO)
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Matters to consider for Catheterization
- Documentation
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Catheter selection
The size and type of urinary catheter used depends on the
indication for catheter insertion, age of the patient, and type
of fluid expected to be drained.
Catheter size is measured in the Charrière/French scale,
whereby one Fr or Ch is equal to 0.33 mm. This
measurement indicates the total diameter of the catheter
and not the lumen size (lumen usually ½).
As a general rule, catheter size should be the smallest
size that can accomplish the desired drainage:
• 6 - 10 Fr pediatric catheters (age dependent)
• 12 - 16 Fr for clear urine, no urologic conditions
• 16 - 18 Fr standard for urinary retention in men
• 20 - 26 Fr for thick pus or blood-filled urine (postop)
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Color code of catheters – better/quicker choice
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CATHETER MATERIAL
Modern urinary catheters are most frequently made of
latex, rubber, silicone, and polyvinylchloride (PVC).
Rubber and latex catheters are often chosen for
short-term drainage.
Silicone catheters are indicated when there is
rubber/latex sensitivity or allergy and are particularly
suited for patients requiring a longer indwelling time.
Silicone is relatively inert with less tissue reaction,
and is associated with less bacterial adherence than
other catheter materials - lower incidence of UTI
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CATHETER COATING
Bacterial coating catheters as a method of reducing
catheter-associated urinary tract infection (CAUTI) by
bacterial interference is a novel approach that has
shown promise involving the use of Escherichia coli –
coated catheters.
The rationale is based on natural competition by
nonpathogenic bacteria over-powering pathogenic
bacteria that may enter the urinary tract.
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CATHETER NO OF CHANNELS
SINGLE LUMEN: simple
bladder drainage or
irrigation/instillation
DOUBLE LUMEN: used to
permit addition of an inflatable
retention balloon
TRIPLE LUMEN: for
simultaneous drainage and
irrigation (to drain thick fluids
like pus or blood)
24-Fr three-way catheter has a smaller internal drainage diameter than a 24-
Fr two-way, which has a narrower lumen than a 24-Fr one-way catheter !!!
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CATHETER TIP SHAPE
BLUNT STRAIGHT TIP:
most common (Foley)
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TECHNIQUE OF CATHETER INSERTION
POSITION OF PATIENT
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LOCAL ANESTHETIC ???
Lidocaine based hydro-soluble gels
Not always required – only if
difficult/repeated procedure is expected
Requires 5-10 min of mucosa exposure,
sufficient volume (min 10 mL) and slow
instillation time (> 3 - 10 seconds) to
have the best effect.
Cooling the gel to 4° C diminishes the
discomfort of lidocaine gel instillation,
probably due to a cryo-analgesic effect.
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ANATOMIC CONSIDERATIONS
MALE: FEMALE:
18 to 20 cm in length 3.5 to 4 cm long
Variable diameter 6-7 mm Larger diameter 8-9 mm
Sigmoid shape with a Slight posterior inclination
proximal curve at the
peno-bulbar junction and a
distal curve at the bulbo-
membranous junction
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Structure of Foley Catheter
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PROCEDURE – patient positioning
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hand preparation/gloving
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site cleaning/disinfection
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site sterile draping
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Lubricant/anesthetic gel insertion
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gentle catheter insertion
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urine flows through catheter
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inflating the retention baloon
with 10 cc sterile saline
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foreskin repositioning
(to avoid paraphimosis)
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securing urine bag tube
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Gravity will help Bladder Draining
Gravity is important for drainage and the
prevention of urine backflow.
Ensure that catheter bags are always draining
downwards, do not become kinked and are
secured and below thigh level.
Metal or plastic hangers should be attached to the
side of the bed (not on the floor !!!).
Cloth bags tied to the bed to support the bags are
also available
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Rapid draining leads to Complications!
Rapid drainage of large
volumes of urine from
the bladder may result in
hypotension and/or
haemorrhage!
Clamp catheter if the
volume drained is
1000mls or greater!
After 20 minutes release
the clamp and allow
urine to drain again.
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Collection of urine from catheterised patients
The process of obtaining a sample of urine from a
patient with an indwelling urinary catheter must be
obtained from a catheter sampling port. The sample
must be obtained using an aseptic technique.
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Care of Indwelling Catheters
Indwelling catheters should be removed/replaced no latter
than 3 weeks! Urine bags should be replaced weekly
Care must be taken that catheter bags always drain downwards,
do not become kinked and are secured and below thigh level
Urine flow must be assessed permanently as catheters/tubing
may become obstructed by clots, crusts, kinks etc.
Good personal hygiene prevents the accumulation of bacteria,
reduces the risk of infection, and prevents odour
Every day, patient/nurse should wash around the catheter and
perineum with soap and water, rinse and dry these areas well.
Patient may shower while wearing the catheter. Sitting in the
tub, however, is not recommended.
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DIFFICULT CATHETERIZATIONS
Should be expected in old males with long urologic history
(BPH, strictures, surgery etc). Preparation !!!
To avoid urethral lesions, gentle insertion of the catheter
should always be performed!
If the catheter does not pass:
check patient positioning
use more lubricant
change catheter size (thin catheters are also less rigid!)
change catheter type (silicone is more rigid)
use curved tip catheters (Tiemann)
use hydrophilic guidewires and open tip catheters
Perform suprapubic cystostomy if no option is valid or if
patient has significant urethral bleeding!
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COMPLICATIONS - CAUTI
UTIs account for 40% of all nosocomial infections. The
major risk factor is the use of urethral catheters, which are
responsible for up to 80% of UTIs in the hospital setting
(CAUTI)
Risk factors for CAUTIs:
patients requiring more than 6 days of catheterization,
female gender (large caliber urethra)
active non-urinary infection sites
preexisting medical conditions (e.g.: diabetes)
malnutrition
renal insufficiency
non-sterile catheter insertion
drainage tubing/bag elevated above bladder level.
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COMPLICATIONS
Indwelling catheters
Hematuria,
Urethral and meatal strictures
Urethral perforation
Allergic reactions including anaphylaxis (rare – latex).
Malignant neoplasms (2.3% to 10%)
Stone formation (46% to 53%),
Bladder neck and urethral erosions.
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COMPLICATIONS
Inability to remove catheter from the bladder (rare)
due to:
Catheter encrustations
Entrapment by sutures
Inability to disengage/deflate the retaining balloon
Management:
Gentle traction if mild encrustations
Endoscopic management of severe encrustations/sutures
Inability to deflate the retaining balloon:
cut the inflating valve/port
insert a rigid guide-wire through the valve inflation lumen
ultrasound-guided needle puncture of the balloon
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SUPRAPUBIC
CYSTOSTOMY
Used if an individual is unable to empty his or her bladder
appropriately and urethral catheterization is either
undesirable or impossible.
Cystostomy for the purpose of suprapubic catheterization
may be performed in 2 ways, as follows:
Open approach, in which a small infraumbilical incision is
made above the pubic symphysis (rarely used)
Percutaneous approach, in which the catheter is inserted
directly through the abdominal wall, above the pubic
symphysis, with or without ultrasound guidance or
visualization through flexible cystoscopy
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SUPRAPUBIC CYSTOSTOMY
Indications
Acute urinary retention in which a urethral catheter
cannot be passed:
prostatic enlargement secondary to BPH
prostatitis,
urethral strictures
false urethral passages,
bladder neck contractures secondary to previous surgery
Urethral trauma
Management of a complicated lower UTI
Requirement for long-term urinary diversion
(eg, because of neurogenic bladder)
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SUPRAPUBIC CYSTOSTOMY
Contra-indications
The bladder is not distended, is not easily palpable, or
cannot be localized with ultrasonographic assistance
The patient has a history of bladder cancer
Coagulopathy
Previous lower abdominal or pelvic surgery (adhesions)
Pelvic cancer, with or without a history of irradiation
Placement of orthopedic hardware for pelvic fracture
repair – Although some reports suggest that suprapubic
tubes leading to infection of hardware is a relatively rare
complication,
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SUPRAPUBIC CYSTOSTOMY
Sterile gloves Equipment
Sterile drapes
Antiseptic solution/applicators
1% lidocaine (5 mL)
22-gauge, 7.75-cm spinal needle tip
Scalpel
10 mL of sterile water in a syringe (to inflate the balloon)
Skin tape or 3-0 nylon suture (to secure the catheter)
Surgical instruments (tissue forceps, needle holder).
Tube-securing device
Catheter drainage bag
Suprapubic catheter kit – Many choices exist
(contains: trocar, catheter, ±guidewire and other accessories)
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SUPRAPUBIC
CYSTOSTOMY
Kits
44
SUPRAPUBIC CYSTOSTOMY
patient preparation
Local anesthesia should be used for a percutaneous
suprapubic cystostomy. Light sedation may also be
beneficial for patient comfort.
For the percutaneous technique, the patient should be
in supine position. Also, the patient should always be
in the Trendelenburg position. This allows the
bowels to fall cranially, decreasing the likelihood of
puncturing the gastrointestinal tract during catheter
placement.
Patient will be placed in a dorsal lithotomy position,
if a cystoscope is being used.
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SUPRAPUBIC CYSTOSTOMY
procedure
The abdominal wall should be cleaned and shaved.
Prepare the surgical site with an antiseptic solution.
Create a surgical field with 4 sterile towels, ensuring that the
pubic symphysis can be visualized and palpated.
Ensure that the patient has a full and palpable bladder.
Mark the cystostomy site at 2 fingerbreadths above the pubic
symphysis in the midline (avoid natural skin creases).
Fill a 10-mL syringe with anaesthetic and use a 22-G spinal
needle. Infiltrate the subcutaneous tissue and rectus abdominis
fascia, aiming at a 10-20° angle toward the pelvis.
Advance the needle in this direction, while aspirating the
syringe; urine should be easily aspirated when the bladder is
entered.
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SUPRAPUBIC CYSTOSTOMY
procedure - continued
Remove the syringe from the needle, and advance a guide wire
through the needle into the bladder.
Carefully remove the needle over the wire, leaving the wire in place.
Directly posterior to the wire, make a stab incision through the skin
and subcutaneous tissue.
Pass the trocar sheath into the bladder over the wire.
Remove the guide wire leaving the trocar sheath inside the bladder.
Pass a catheter (of appropriate size) through the intravesical sheath
and into the bladder.
Inflate the catheter balloon with 10 mL of sterile water/saline,
Gently withdraw the trocar sheath from the bladder and abdominal
wall, spliting the sheath into 2 parts, leaving the catheter in place.
Connect the indwelling suprapubic catheter to a drainage bag.
Secure the suprapubic catheter to the skin using tape or suture
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7/30/2021 48
SUPRAPUBIC CYSTOSTOMY
Complications/Adverse events
gross hematuria,
inadvertent urethral catheterization,
intraperitoneal/extraperitoneal extravasation,
bowel/organ perforation,
recurrent UTI
stone formation (catheter encrusting)
latex allergy,
overgranulation at the cystostomy entry site,
obstruction of tubing (by blood, mucous, or kinking),
loss of the cystotomy tract/access if the tubing comes out,
altered body image.
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SUPRAPUBIC CYSTOSTOMY
Monitoring and Follow-up
The first catheter replacement should take be performed after
4-6 weeks to allow time for a tract to form.
If the catheter is intended for long-term use, it can be changed
monthly, with upsizing (to a lumen of 22-24 Fr) .
Any lumen smaller than 16 French in diameter is at high risk for
obstruction (with sediment or mucus) over time.
Repeated catheter blockage should be investigated with
cystoscopy.
Long-term indwelling catheters are associated with chronic
inflammation of the urothelium, with an increased risk of
bladder cancer (cystoscopy).
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Other types of catheters
ureteral stents – simple/JJ
nephrostomy
drainage
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