Download to the handouts in color.

2/26/2014
The Evidenced-Based
Approach to Managing
Postoperative Urinary
Retention (POUR)
Lara Beth Conner, RN, MSN, ONC
Charla B. Johnson, RN, MSN, ONC
Conflict of Interest
We hereby certify that, to the best of our
knowledge, no aspect of our current personal
or professional situation might reasonably be
expected to affect significantly our views on
the subject on which we are presenting, other
than the following.
Objectives
O Identify three risk factors associated with
POUR
O Discuss the assessment and treatment of
POUR
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Poll Question #1
O The first urge to void is felt at ___cc’s?
O 150
O 200
O 300
O 500
Bladder Function: Normal
Physiology of Urination
O Urinary System
O Bladder fills with urine at approximately
0.5 ml/kg/hour
O The bladder wall is stretched when volume
reached (200-400ml)
O Nerve impulse travels to the spinal cord and to
brain signaling that the bladder is full.
O To empty the bladder, a nerve impulse to
bladder muscle and urinary sphincters
O Detrusor muscles contracts and sphincters open
To brainstem
From brainstem
Sensory afferent
Brain
Sympathetic ganglion
Somatic efferent (tonic)
Sympathetic
postpost-ganglionic (tonic)
Parasympathetic
ganglion
Bladder
Stretch receptor
Sphincters
Int.
Ext.
Urethra
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Steps to the Normal
Voiding Cycle
Definition of POUR
The inability to void with a full bladder
O Acute Urinary Retention
O Acute-on-Chronic Retention
O Chronic Retention
Acute Urinary Retention
O Anatomical Retention
O Functional Retention
O Psychogenic Retention
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Poll Question #2
O Which of the following is not a predisposing
risk factor for POUR?
O Male
O Diabetes
O Immobility
O Age over 50
Risk Factors
O Predisposing- Preoperative risk factors
O Age & Gender
O Age over 50
O Male
Consequences of Aging
Normal
O Bladder capacity: 400 –
600 mL
O Desire to void at 250 –
O
O
O
O
300 mL
300 –400 mL per void
Residual < 50 mL
1/3 voided volume at
night
No straining, hesitation,
pain or post-void dribble
Changes with Aging
O Bladder capacity 250 –
300 mL
O Same or less
O Total volume voided per
void decreases
O Residual < 100 mL
O Up to 2/3 voided volume
after 8 PM
O No straining, pain, or
post-void dribble
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Risk Factors
O Predisposing – Preoperative risk factors
O Co morbidities
O Neurological conditions
O Alcohol intake
O Constipation
O Renal disease
O Urethral strictures
O Chronic UTI
O Diabetes
Risk Factors
O Predisposing – Preoperative risk factors
O Co morbidities
O Medications
O Antipsychotic drugs
O Antidepressants
O Benzodiazepines
O NSAIDS
O Calcium channel blockers
O Anticonvulsants
O Opioids
Risk Factors
O Precipitating – Intraoperative and Postoperative
Factors
O Duration of surgery
O Excessive fluid intake (>750cc)
O Anesthesia
O Analgesia
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Poll Question #3
O Do you routinely use a bladder scanner in
clinical practice?
O Yes
O No
Assessment
O Voiding Status
O Fluid Balance
O Clinical Exams
Voiding Status
O Spontaneous Voiding
O Amount Voided
O Bladder Scanning
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Lower Urinary Tract Storage
&Emptying Symptoms
O
O
O
O
O
O
O
O
O
O
O
Dysuria
Frequency
Incontinence
Pressure
Urgency
Hesitancy
Incomplete Emptying
Intermittent- stream
Post-void dribbling
Straining to void
Weak stream
Ask….
Do you have a feeling or
urge/sensation to void?
Character of the stream?
Strains or bears down
when voiding?
Once on the toilet, can
the patient initiate the
stream within a minute?
Fluid Balance
O Intra-operative
O Oral Intake
O Blood Output
O Urine Output
Clinical Exam
O Frequent Inspection
O Palpation of the Bladder
O Percussion
O Bladder Scanner Technique
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Bladder Scanner Technique
Prepare the patient
Bladder Scanner Technique
Bladder Scanner Technique
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Bladder Scanner Technique
Bladder Scanner Technique
Bladder Scanner Technique
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Bladder Scanner Technique
286 ml
Bladder Scanner Technique
We thank our Model
for allowing us to
demonstrate a
bladder scanning
technique
Poll Question #4
O When would you perform in and out
catheterization?
O Bladder scan equal to or greater than 600 cc
O Patient discomfort
O 8 hours post-op
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Interventions to Assist with
Spontaneous Voiding
O Early Mobilization
O Offering Toileting
O Bedside Commode
O Privacy
O Offering Caffeinated Fluids (if appropriate)
Treatment
Indwelling versus Intermittent
O Initially managed with Indwelling
O Remove quickly as possible
O Intermittent while waiting for voiding function
resolution
Goal:
Allow the bladder to store a reasonable volume
of urine at low pressure, and empty it at
appropriate intervals if the patient is not
adequately voiding.
Poll Question #5
O Does your institution have a risk assessment
tool in place to assess for patients at risk for
POUR?
O Yes
O No
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Best Practice
O Institution Guidelines and Protocols
O Peri-operative Risk Assessment
O Indwelling catheters in high risk patients
O Use of silver alloy catheter
O Insertion technique
O Catheter size
O GU Assessment
O SCIP
Catheter Care
O Aseptic Technique
O Securement Devices
O Perineal Care
O Catheter Removal at 24 Hours
The Key is
Prevention!!!
NAON
Practice
Point
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Case Study #1
O 83 year old male with THA
O PMH: BPH, angina, HTN, diverticulitis, renal
disease, arthritis, TIA, hyperlipidemia
O Intra-op fluids 2400 cc
O BUN, Cr
O Foley cath placed in OR due to high risk
Case Study #1
O Foley removed POD 2, reinserted @ MN
O Foley removed POD 3 @ 12:48 pm
O Foley reinserted POD 4 @ 5:30 am, removed
@ MN
O Flomax; urology consult
What went wrong in this case?
Case Study #1
O Bladder scan not done
O Flomax not started until POD 4
O Indwelling instead of intermittent catheter
O Voiding volumes not recorded
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Case Study #2
O 72 year old female, TKA
O PMH: renal CA/nephrectomy, diabetes, HTN,
hyperlipidemia, urinary retention
O BUN, Cr
O Intra-op fluids 2400 cc
Case Study #2
O Procedure ended @ 8:59 am
O Foley inserted @ 8:30 pm
O Foley removed POD 2 @ 6:40 am
O Bladder scan = 610 cc @ 3:30 pm,
intermittent cath
O Intermittent cath repeated @8:30 = 400 cc
What went wrong in this case?
Case Study #2
O Foley not inserted in OR
O Foley not inserted until > 11 hrs postop
O No bladder scan until 9 hrs after catheter
removal
O No documentation on voiding volumes after
last intermittent cath
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References
O
Fleming, R. (2013). The development of post-operative urinary
guidelines. The Dissector, 40 (4), 22-24.
O
Gallo, S. DuRand, J. & Pshon, N. (2008). A study of naloxone effect on
urinary retention in the patient receiving morphine patient controlled
analgesia. Orthopaedic Nursing, 27 (2), 111-115.
O
Hansen, B.S., Soreide, E., Warland, A.M., & Nilsen, O.B. (2011). Risk
factors of post-operative urinary retention in hospitalized patients. Acta
Anaesthesiologica Scandinavica, 55, 545-548.doi: 10.1111/j.13996576.2011.02416.
O
Johansson, M. & Christensson, L. (2010). Urinary retention in older
patients in connection with hip fracture surgery. Journal of Clinical
Nursing, 19, 2110-2116. doi: 10.1111/j.1365-2702.2010.03261.
O
Johnson, C.B. & Conner, L.B. (2010). Practice Points: Post operative
Urinary Retention (POUR). National Association of Orthopaedic Nursing.
References
O
McVary, K. (2006). Non-steroidal anti- inflammatory drugs and urinary
retention. Retrieved from http://wwwthelancet.com. (367)
O
Miller, A.G., McKenzie, J., Greenky, M., Shaw, E., Gandhi, K., Hozack,
W.,Parvizi, J. (2013). Spinal anesthesia: Should everyone receive a
urinary catheter? The Journal of Bone and Joint Surgery, 95, 14981503. doi:10.2106/JBJS.K.01671
O
Newman, Diane K., Managing Urinary Retentaion in the Acute care
Setting. February 10,
2014. http://verathon.com/portals/0/Uploads/ProductMaterials/_bsc
/0900-0447-08-86.pdf
O
Pavlin, D.J., Pavlin, E.J., Fitzgibbon, D.R., Koerschgen, M.E., & Plitt, T.M.
(1999). Management of bladder function after outpatient surgery.
Anesthesiology, 91, 42-50.
O
Steggall, M., Treacy, C., & Jones, M. (2013). Post-operative urinary
retention. Nursing Standard, 28 (5), 43-48.
Question and Answers
Incorporate Best Practice in your care!!!
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