Continuous Bladder Irrigation help

[zacarias, ASN, RN]

Hey all,

Last noc shift was one of the worst of the last two years. Mostly because of this guy who had CBI going and I needed to be in there all the time. He also had blood, pain, elevated troponin, tube feedings, etc...admitted for gross hematuria anemia s/p stroke, lives in nursing home, confused.

OK, so the day nurse explains CBI and that we have it wide open. (3L bag goes in like an hour or less). We have to dump the foley like every 20 minutes. She says that it's still clogging up and so we have to manually irrigate it. I'm scared already thinking about it :imbar

So I start my shift and change the bag and wonder if the foley is occluded. I manually irrigate it (I need another hand because keeping the foley tip sterile while I irrigate is a nightmare)and sometimes I get fluid back and sometimes I just get nothing. He's confused so he can't even tell me when he feels like he has to really urinate!

This goes on for hours, I manually irrigate when I *think* it's clogged and I get clots out occasionally and wonder if I'm making it worse my manually irrigating so often anyway.

Later my charge nurse recommends me turning down the flow of the CBI just to not go through so many bags.

This went on until morning when my prayer was answered and my shift was over. (I had another patient desat to 70% on 2L for no reason but that's a different story that I won't post so don't worry):wink2:

The day nurse who took over said that I should adjust the flow of the CBI according to the urine...so that they're no clots. This made sense to me but then why was I getting clots all night? My question is, was I irritating the bladder even more by manual irrigation and how do I know for sure if it's clogged without just physically flushing manually? If you irrigate with too much pressure or pull on the plunger can you hurt the bladder?

I know these are a lot of questions but I really want to know because this is pretty new to me. I have read the nursing procedure I just want you super nurses to give your expertise.

Also he had what looked like an old elbow fx that wasn't set right (elbow stuck way out). I was wondering, do y'all see that often in nursing home patients or old patients who have weird elbows?

Thanks to all you folks!!

[nursecave]

It has been 5 years since Ihave done a CBI, but yes we adjusted based on UOP. If we flowed in 300mL and there was 350mL in the foley, we had a +50. If we flowed in 300mL and there was 200mL in the foley we were -100. In the latter instance you would slow the irrigation (I think, been a while) and recheck the UOP soon. If no UOP, then irrigate. (again i think). We kept a running chart on a clipboard at the foot of the bed with the policy attached to it. you always want + UOP. I do remember that. Sorry i couldn't be more help.

[SharonH, RN]

You stated that you would manually irrigate it when you thought it was clogged. What made you think it was clogged? If the patient was comfortable and the urine was running clear, then there was no need to irrigate. If you were getting clots, the urine would have been very bloody, the Foley would have clogged off and the patient probably would have began to have spasms which is very uncomfortable for them. The day nurse was right about adjusting the flow to keep the urine free of clots;it sounds like you may have been manipulating it too much. Truly, if you were running the irrigation at a rate to keep it clear, you should have not been getting clots. The catheter tip might have also been in a bad position. Normally, there is no need to manually irrigate it periodically solely to check for clots. Oh and yes, you should irrigate and aspirate gently.

[canuckeh!]

It is also a lot easier on the staff if you put the irrigation solution on a Y-set, so you can open up the second bag while you change the first. Also connect the drainage tubing(there is a special set of tubing for CBI's that has the inflow tubing -narrower- no need to be larger to allow for clots to pass and the outflow tubing-larger so clots won't obstruct the tubing to a 3 Liter drainage bottle(must be vented to alow fluid to displace the air.)

That way you don't need to spend so much time in the room. If you are getting output that equals the amount of irrigation solution plus a reasonable hourly urine output, you have no reason to worry. If less, you need to assess for obstruction.

[UM Review RN, ASN, RN]

I noticed when I had my last CBI patient that the previous shift had slowed the rate down to practically nothing. He was confused, restrained, and he was moaning. His abdomen was distended, and there was no flow to the drainage bag. I irrigated and got small clots and about 700 mls of output in about 3 minutes! I found out later that the drainage bag had last been emptied about 1/2 hour before. I suspect that it was clogged before that.

So no matter what the rate, my advice would be to check these patients pretty frequently, especially if they're confused.

I also do not irrigate when I have flow that approximates the flow of the dripping bag, if you get what I mean. In other words, if I have a patient who has a lot of clots, I want a pretty rapid rate of drip going in there to keep the line from clogging. If I see it running very clear for a couple of hours, I'll empty the drainage bag and turn it down to a moderate rate, so I can tell if the flow is still good.

I don't like to run these really slow because that's usually when there are more clots. I'd really rather empty bags than de-clot the catheter, so I let it run rapidly to moderate unless the patient's been running very nicely without difficulty all night.

[zacarias, ASN, RN]

Thanks for all your suggestions and ideas guys.

Angie, I agree that I feel more comfortable running it fast. There was acouple times on this shift where I thought it was clogged and then when I aspirated some clots, he then drained like 500 ccs each time. That was enough for me to worry a lot about it. I thought to myself, what if I had gotten busy with another patient (which I might have had I not been so worried) and then came back to find the patient with no further urine and a bladder that I can't manually irrigate....I just didn't want that to hapen.

Now you said that his lower abdomen got distended, well I checked my patient and he never seemed to get really distended so I guess I was OK anyway. Maybe even if it did clog and it wasn't fixed for a little while, I would be OK.

An alert and oriented patient would make this process easier definitely!