Introduction
When there is any obstruction in the urethra or bladder outlet due to injuries, strictures, prostatic obstruction, or tumor, several temporary measures such as suprapubic puncture and nephrostomy tube are used to divert the flow of urine from the urethra. It is also called cystostomy. It may be performed at the bedside or in the procedure room, in the operating room, or during cystoscopy.
Definition
Suprapubic bladder drainage is a method of establishing an outlet to drain the urine from the bladder by inserting a catheter or tube through abdominal wall into the bladder through a suprapubic (above the pubis) incision or puncture.
Purposes
- To divert the flow of urine temporarily.
- To treat pelvic fractures.
Indications
Patient contraindicated to urethral catheterization:
- Severely enlarged prostate.
- Urethral strictures.
- Neurogenic bladder.
- Quadriplegia.
- Bladder, prostate, and urethral surgery, or injury.
- Bladder cancer.
Contraindications
- Nondistended bladder.
- Pelvic irradiation.
- Gross hematuria with clots may occlude the catheter.
- Short-term catheter placement.
Types
- Incision method: Small incision is made in the abdomen (suprapubic area) to insert the Foley’s catheter to divert the urine.
- Trocar method: Trocar will be used to divert the urine.
Articles
| Articles | Purpose |
| Sterile tray containing; | |
| Trocar and cannula | To hollow canal helps to divert the urine. |
| Suprapubic catheter (Malecot’s catheter/Foley’s catheter) | To drain the urine. |
| Drainage bag | To collect the urine. |
| Antiseptic solution, for example, povidone-iodine/chlorhexidine or hospital policy | To prepare the site for procedure. |
| No. 11 scalpel blade | To make incision to insert the catheter. |
| Lidocaine (1%) | To give local anesthesia. |
| Syringe and needle | To administer anesthetic. |
| Needle holder | To hold the needle during suturing. |
| Suture material | To hold the drainage tube. |
| Adhesive tape | To secure the tube. |
| Sterile gauze 4 x 4 inches | To prepare the site. |
| Normal saline solution | To irrigate the bladder. |
| Tincture-benzoin | To prevent bleeding. |
Procedure
| Nursing Action | Rationale | |
| 1. | Explain the procedure to the patient. | Allays anxiety and obtains cooperation of the patient. |
| 2. | Obtain informed consent from the patient. | Prevents litigation of the staff. |
| 3. | Place the patient in a supine position with one pillow under head. | Allows access to suprapubic area but reduces muscle tension. |
| 4. | Expose the abdomen. | Locates the bladder. |
| 5. | Before procedure, ask the patient to drink the fluid until the bladder is filled or fill the bladder (if not distended already) with 300-500 ml sterile saline solution via the urethral catheter. | Distention of the bladder makes the bladder easier to locate by the suprapubic route. |
| 6. | Cleanse the insertion site with an ordered antiseptic solution. Mark the puncture point. | Maintains asepsis and prevents entry of microorganisms. Reduces unnecessary stress on cystoscopy. |
| 7. | Infiltrate incision site with lignocaine 1% and make small incision about 2-3 cm above the symphysis pubis, but below the upper edge of the bladder. a No incision is needed if the catheter is inserted via the needle and guided wire set. | An adequate level of local anesthesia is achieved to facilitate catheter introduction. |
| 8. | The catheter is introduced in a guidewire, needle, or cannula through the incision and advanced in a slightly caudal direction. | The needle entry point is in the midline 0.75-1.25 inches (2-3 cm) above the symphysis pubis and directly over the palpable bladder. |
| 9. | The catheter is advanced until the flange is against the skin where it is secured with tape, a body seal system, or sutures. | |
| 10. | The catheter is connected to a sterile drainage system. | To maintain closed drainage system. |
| 11. | Secure the drainage tubing to lateral abdomen with tube. Some suprapubic catheters have a balloon to hold them in place. | To prevent dislodgement of the tube from the position. |
| 12. | If the catheter is not draining properly, withdraw the catheter 1 inch (2.5 cm) at a time until urine begins to flow. Do not dislodge the catheter from the bladder. | |
| 13. | The drainage is maintained continuously for several days, connect the catheter and allow the bladder to empty. | To drain the urine continuously. |
| 14. | If a “trial of voiding” is requested, the catheter is clamped for 4 hours. Have the patient attempt to void while the catheter is clamped. After the patient voids, unclamp the catheter and measure residual urine. Usually, if the amount of residual urine is less than 100 mL on two separate occasions (am and pm), the catheter may be removed. If the patient complains of pain or discomfort or if residual urine is over the prescribed amount, the catheter is usually left open. | To determine the effectiveness of voiding. |
| 15. | When the catheter is removed, a sterile dressing is placed over the site. Usually the tract will close within 48 hours. | |
| 16. | Apply tincture benzoin to the catheter shaft and the abdomen. Secure the catheter to the lateral abdomen with adhesive tape. | Tincture benzoin prevents bleeding. Securing reduces the dislodgement of the tube. |
| 17. | Place the patient comfortably at the bedside. | Makes the patient feel at ease after procedure. |
| 18. | Gently clean and dress the incision site every day. Soap and water or swab with antiseptic may be used to clean the site. Clean the site using circular motion, starting at the incision site and moving outward. Dry the suprapubic site by using gauze. Keep dry gauze piece at the site, if there is any leakage. | Protects the skin and prevents infection. Any leakage can be identified and the site kept dry. |
| 19. | Watch for any sign of complications such as bowel or peritoneal perforation, infection at the insertion site, altered skin integrity around the incision site, and failure of the wound to close, which result in urinary fistula and abdominal wall abscess. Report to the doctor if the patient has; Uncontrolled urine leakage.Skin breakdown.Redness or foul, purulent drainage at the insertion site.Foul-smelling, cloudy, bloody urine.Abdominal pain, fever, and decreased urine output. | Facilitates early initiation of treatment. |
| 20. | Encourage the patient to drink plenty of fluid, 2000 mL a day. | Because the small-bore catheter may easily become obstructed by clots, mucus, or sediment. |
| 21. | Watch the catheter frequently for obstruction caused by twisting or kinking, sediments or clots. | Stasis of urine increases the chance of infection. |
| 22. | Teach regarding clinical manifestation of urinary tract infection (UTI) and to approach physician if they occur. | Early identification and reporting facilitate to intervene immediately. |
| 23. | Document the following: Types of catheters used, indication, condition of the tube, and obstruction in drainage tube, etc., and postprocedure vital signs. Fluids administered, techniques used, and patient’s condition at the end of the procedure. Urine output and color of urine in intake and output (I/O) chart. | Serves as legal evidence and to prevent duplication of care. |
Special Consideration
- Imaging guidance (ultrasound or cystoscopy) may be used to avoid bowel injury
- Balloon catheter is secured in the bladder and connected to a drainage system
- Initial insertion often done in hospital; subsequent changes may be outpatient or home-based
- Pediatrics: Smaller catheters, sedation may be needed, involve caregivers in education
- Elderly: Monitor for cognitive decline, skin fragility, and infection risk
- Spinal cord injury patients: High risk for autonomic dysreflexia monitor closely during care
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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