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Sexually Transmitted Diseases: Summary of 2015 CDC Treatment Guidelines

Sexually Transmitted Diseases: Summary of 2015 CDC Treatment Guidelines

These summary guidelines reflect the 2015 CDC Guidelines for the Treatment of Sexually Transmitted Diseases. They are intended as a source of clinical guidance. An important component of STD treatment is partner management.

Providers can arrange for the evaluation and treatment of sex partners either directly or with assistance from state and local health departments. Complete guidelines can be ordered online at www.cdc.gov/std/treatment or by calling 1 (800) CDC-INFO (1-800-232-4636).

Click here to see Summary of 2015 CDC Treatment Guidelines in PDF

Updated ACOG Recommendations for Human Papillomavirus Vaccine

Updated ACOG Recommendations for Human Papillomavirus Vaccine

Human papillomavirus (HPV) infection is linked to the development of cervical, vaginal, vulvar, penile, anal, and oropharyngeal cancer, as well as genital warts. Vaccination against HPV has been shown to lower the incidence of anogenital cancer and genital warts, and it may also reduce the incidence of oropharyngeal cancer and maternal passage of HPV to infants.

Cervical cytology screening in the United States has shown nearly 2.8 million abnormal Papanicolaou test results each year, with more than 12,000 diagnoses of cervical cancer and nearly 4000 deaths from the disease. The American College of Obstetricians and Gynecologists (ACOG) has issued a Committee Opinion regarding unacceptably low rates of and recommendations for HPV vaccination. This Opinion updates the college’s previous recommendations in March 2014.
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STUDY SYNOPSIS AND PERSPECTIVE

A key role of obstetrician-gynecologists and other healthcare providers is to provide patients and their parents with information on the benefits and safety of the HPV vaccine and to encourage adolescents to receive the HPV immunization, according to updated recommendations published online July 6 by ACOG.

“Current vaccination rates are unacceptably low,” write ACOG’s Committee on Adolescent Health Care and Immunization Expert Work Group. “Studies have shown that physicians’ recommendations play a crucial role in the acceptance of HPV vaccination by patients and parents of patients.”



The committees updated the March 2014 recommendations to include the new 9-valent HPV vaccine, also recommended by the Centers for Disease Control and Prevention (CDC) for girls and boys 11 to 12 years old. Those who do not receive the HPV vaccine during the target age range should undergo catch-up vaccination until age 26 years.

The US Food and Drug Administration licensed the new formulation, Gardasil 9, in December 2014. The new vaccine protects against the original 4 strains in the quadrivalent vaccine, as well as 5 additional strains, all of which are responsible for cervical, vulvar, vaginal, penile, and anal cancers. Another earlier bivalent vaccine protects against strains 16 and 18, which are responsible for the majority of cervical cancers. The 9-strain vaccine is more than 99% effective in reducing HPV disease from strains 6, 11, 16, and 18, and it is 96.7% effective in reducing disease from strains 31, 33, 45, 52, and 58.

Despite existing recommendations for HPV vaccination in adolescents, only approximately 50% of US girls between 13 and 17 years old have received at least 1 dose, and 33% have received all 3 doses. The CDC estimates that an immunization rate of at least 80% would prevent an additional 53,000 cases of cervical cancer during the lifetimes of those currently younger than 12 years.

Neither the CDC’s Advisory Committee on Immunization Practices nor ACOG routinely recommends that anyone receive the 9-strain vaccine if he or she received all 3 doses of the previous vaccine. However, providers can use the 9-strain vaccine to complete any series for boys or girls who received 1 or 2 doses of the earlier vaccines.
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The safety profile of the 9-strain vaccine resembles that of the quadrivalent vaccine, with the exception of greater redness and swelling at the injection site in the newer vaccine. After more than 60 million doses of HPV vaccine administered, “there are no data to suggest that there are any severe adverse effects or adverse reactions linked to vaccination,” the committee writes. “Obstetrician–gynecologists or other providers should counsel patients to expect discomfort after vaccination and that such discomfort is not a cause for concern,” they write, although anyone with a previous life-threatening reaction to the HPV vaccine or its components, including yeast, should not receive the vaccine.

The committee does not recommend routine pregnancy testing or routine HPV testing before a patient receives the vaccine, and those in the target age range who may already have a positive HPV DNA test result should still receive the vaccine. Despite reassuring safety data for HPV vaccination during pregnancy, ACOG recommends that women do not receive the vaccine while pregnant. Lactating women may receive it.




STUDY HIGHLIGHTS

  • The CDC and ACOG recommend that girls and boys routinely receive HPV vaccination.
  • The US prevalence of vaccine-type HPV decreased by 56% among girls 14 to 19 years old from 2006 (when the quadrivalent HPV vaccine was introduced) and 2010.
  • The Advisory Committee on Immunization Practices has subsequently recommended use of the new, nanovalent HPV vaccine.
  • The US Food and Drug Administration licensed this vaccine in December 2014 for use in girls and boys 11 to 12 years old.
  • The nanovalent HPV vaccine protects against the 4 strains originally in the quadrivalent vaccine and 5 additional strains implicated in anogenital cancers.
  • Most cases of all HPV-associated cancer are caused by genotypes 16 and 18, and approximately 90% of cases of genital warts are caused by genotypes 6 and 11.
  • The efficacy of the nanovalent HPV vaccine exceeds 99% for strains 6, 11, 16, and 18 and is 96.7% for strains 31, 33, 45, 52, and 58.
  • Despite the benefits of HPV vaccines in reducing the incidence of anogenital cancer and genital warts, only 33% of US girls in the recommended age group (13 – 17 years) have received all 3 vaccine doses, and only 50% have received at least 1 vaccine dose.
  • ACOG describes US vaccination rates for HPV as “unacceptably low” compared with other vaccines recommended for persons in the same age range.
  • The CDC estimates that if HPV vaccination coverage increases to 80%, an additional 53,000 cases of cervical cancer could be prevented during the lifetime of those younger than 12 years, and for every year that coverage does not increase, an additional 4400 women will go on to have cervical cancer.
  • ACOG states that it is “crucial” that obstetrician-gynecologists and other members of the healthcare team inform their young patients and their parents regarding the benefits and safety of HPV vaccination.
  • The Advisory Committee on Immunization Practices has added use of nanovalent HPV vaccine to its recommendations for girls and boys at the target age of 11 to 12 years, with catch-up vaccination through age 26 years for persons not vaccinated at the target age.
  • The nanovalent vaccine is unnecessary for persons who received all 3 doses of earlier HPV vaccine but may be used to complete any series for persons who received only 1 or 2 doses of previous vaccines.
  • Routinely testing for pregnancy or for HPV DNA is not recommended before HPV vaccination in any group.
  • Patients testing positive for HPV DNA should still undergo vaccination.
  • Pregnant women should not be vaccinated, although safety data for HPV vaccination during pregnancy are reassuring.
  • Breastfeeding women may be vaccinated for HPV.
  • A history of life-threatening reactions to the HPV vaccine, to yeast, or to any of the other vaccine components is a contraindication to vaccination.
  • Compared with the quadrivalent vaccine, the nanovalent vaccine is associated with an increased rate of injection site erythema and swelling, which increases after each successive dose.
  • Otherwise, both vaccines have a similar safety profile, with no reports of severe adverse effects.
  • Immunosuppression is not a contraindication to HPV vaccination, but the immune response may be less robust in these patients.




CLINICAL IMPLICATIONS

  • An ACOG Committee Opinion describes HPV vaccination rates in the United States as “unacceptably low” compared with other vaccines recommended for persons in the same age range.
  • ACOG recommends that girls and boys receive nanovalent HPV vaccine at the target age of 11 to 12 years, with catch-up vaccination for girls and boys through age 26 years if they were not vaccinated at the target age.
  • Implications for the Healthcare Team: The ACOG states that it is “crucial” that obstetrician-gynecologists and other members of the healthcare team inform their young patients and their parents regarding the benefits and safety of HPV vaccination.

‘Walnuts prevent heart attack, lower cholesterol’

‘Walnuts prevent heart attack, lower cholesterol’

By Chukwuma Muanya

TWO handfuls of walnuts a day could help stave off heart disease, a new study has revealed.

The tree nuts lower total cholesterol levels in the body, thus reducing the chances of a person suffering a heart attack.

Researchers said the snack contains important nutrients such as unsaturated fats, protein, vitamins and minerals.

The study is published in the American Journal of Clinical Nutrition.

Dr. Michael Falk, one of the authors from the Life Sciences Research Organisation, said: “Our study results further support the growing body of research that tree nuts, such as walnuts, can reduce the risk of cardiovascular diseases.

“Tree nuts contain important nutrients. Walnuts are the only nut that provide a significant amount – 2.5g per one ounce serving – of alpha-linolenic (ALA), the plant-based form of omega-3.”

Juglans regia commonly known as walnut tree is a well-known member of Juglans genus, constituting an important species of deciduous trees found primarily in temperate areas.

J. regia belongs to the family Juglandaceae which includes three species: J. nigra, J. cinerea, and J. regia.

The African walnut is botanically known as Tetracarpidium conophorum and belongs to the plant family Euphorbiaceae. In southern Nigerian ethnomedicine, it is used as a male fertility agent and the leaves are used for the treatment of dysentery and to improve fertility in males. It is known as ukpa (Igbo) and awusa or asala (Yoruba). African walnut is known in the littoral and the western Cameroon as kaso or ngak.




Falk and his team conducted a systematic review and meta-analysis of 61 controlled trials to arrive at their conclusions.

They found walnuts are effective in lowering total cholesterol, Low Density Lipo-protein (LDL), so-called ‘bad’ cholesterol, and ApoB, the primary protein found in LDL cholesterol.

These are key factors that are used to evaluate a person’s risk of cardiovascular disease.

Falk said the findings show consuming at least two servings – two ounces – of walnuts each day jas stronger effects of total cholesterol and LDL levels.

Additionally, the results showed that tree nut consumption may be particularly important for lowering the risk of heart disease in individuals with type 2 diabetes.

Of 1,301 articles reviewed, 61 trials met the eligibility criteria for Dr Falk’s review – incorporating 2,582 people.

Trials directly provided nuts to the intervention group rather than relying solely on dietary advise to consume nuts.

The dose of nuts varied from five to 100g each day, and most participants followed their typical diet.

More than two decades of research has shown that walnuts may help lower cardiovascular risk factors by decreasing LDL by nine to 16 per cent, and diastolic blood pressure by 2-3mmHg2.

Studies have also shown the tree nuts can reduce total cholesterol, while increasing levels of High Density Lipo-protein (HDL), or ‘good’ cholesterol, reducing inflammation and improving arterial function.

These factors are major contributors to heart disease risk, and reducing them is a critical step toward a healthier heart.

In addition to providing omega-3s, walnuts also deliver a convenient source of fiber (two grams per ounce) and protein (four grams per ounce).

Indeed, previous studies had shown that African walnut prevents heart disease. They suggested eating walnuts at the end of a meal might help cut the damage that fatty food can do to the arteries.

It is thought that the nuts are rich in compounds that reduce hardening of the arteries, and keep them flexible. Phytochemical analysis indicates that African walnuts contain ingredients such as omega-3 fatty acids, antioxidants and phytosterols that may all reduce the risk of the disease.

Most of the studies on the plant have been on the nutritive value of the seeds, which is a snack and delicacy.

Processed meats do cause cancer – WHO

Processed meats – such as bacon, sausages and ham – do cause cancer, according to the World Health Organization (WHO).

Its report said 50g of processed meat a day – less than two slices of bacon – increased the chance of developing colorectal cancer by 18%. Meanwhile, it said red meats were “probably carcinogenic” but there was limited evidence.

The WHO did stress that meat also had health benefits.

Cancer Research UK said this was a reason to cut down rather than give up red and processed meats.
And added that an occasional bacon sandwich would do little harm.

How bad?

The WHO has come to the conclusion on the advice of its International Agency for Research on Cancer, which assesses the best available scientific evidence.
It has now placed processed meat in the same category as plutonium, but also alcohol as they definitely do cause cancer.
However, this does not mean they are equally dangerous. A bacon sandwich is not as bad as smoking.
“For an individual, the risk of developing colorectal (bowel) cancer because of their consumption of processed meat remains small, but this risk increases with the amount of meat consumed,” Dr Kurt Straif from the WHO said.




Estimates suggest 34,000 deaths from cancer every year could be down to diets high in processed meat.

That is in contrast to one million deaths from cancer caused by smoking and 600,000 attributed to alcohol each year.
Red meat does have nutritional value too and is a major source of iron, zinc and vitamin B12.
However, the WHO said there was limited evidence that 100g of red meat a day increased the risk of cancer by 17%.
An eight ounce steak is 225g.

The WHO said its findings were important for helping countries give balanced dietary advice.

Hospital Routines May Be Making Patients Sicker

Hospital Routines May Be Making Patients Sicker

NEW YORK (Reuters Health) – Interrupted sleep and withholding of food can make hospitalized patients sicker, according to three U.S. physicians who say patient safety in hospitals is not just a matter of preventing falls and infections.

In a Viewpoint paper online September 8 in BMJ Quality and Safety, they point out that adequate sleep and nutrition are key to keeping the immune system strong, but noisy hospital conditions and long wait times may be compromising the body’s defenses.

The authors, all from Johns Hopkins Hospital in Baltimore, say poor nutrition, present in up to half of all hospital patients – can contribute to inflammation, muscle breakdown, and organ damage.

Sleep and nutrition have always been an issue in hospitals, but longer wait times make the problem worse, coauthor Dr. Martin Makary, a surgeon, health policy researcher, and author of “Unaccountable,” a book about transparency in medicine, told Reuters Health by email.

Today, “hospitals are busier and as a result we are seeing longer wait-lists for procedures, diagnostic testing, and inpatient transfers such as from the ER,” Dr. Makary said.

The authors give an example of a woman who comes to a hospital with pneumonia. Though she has not been eating well for a few days due to not feeling well, she is placed on a no-food plan in case anesthesia is needed. While she waits to be evaluated, she may spend many hours in a shared room with beeping noises and people talking, resulting in highly interrupted sleep.




She might wait up to 12 hours to get a procedure, only to continue without food in case another procedure is needed. She may not sleep well or receive food for multiple days, eventually breaking her fast with low-quality hospital food. After being discharged in a weakened state, she soon ends up back in the hospital with the same symptoms as before.

Dr. Makary said the standard practice of having patients abstain from eating for at least eight hours before surgery isn’t based on facts.

He called this eight-hour timeline a “myth.” He and his colleagues say current research suggests it’s safe to drink a high-carbohydrate drink two hours before surgery.

“We and several other centers have begun to make this our routine practice as of this year,” he said.

“As for sleep deprivation, there are alarms and devices that make constant noise, which makes sleeping difficult for even a healthy person,” and patients can be woken many times during the night for urine samples or blood cultures, said Dr. Ken Lee, who also studies patient safety and quality of care at Johns Hopkins but wasn’t an author on the paper.

The authors suggest giving patients noise-cancelling headphones and eye masks to reduce the effect of the jarring environment.

“We are so focused on providing the best treatment for our patients’ illness that we often forget their human needs,” added Dr. Lee.

Dr. Makary said patients should be allowed to bring food that they like so that they do not have to rely on hospital food.

He also urges patients: “Ask your hospital about participating in new ERAS (Enhanced Recovery After Surgery) protocols and if they can help make rest a goal during any medical recovery.”

SOURCE: bit.ly/1PCSIg8

BMJ Qual Safety 2015.

Even Doctors and Nurses Don’t Always Have Healthy Lifestyles

NEW YORK (Reuters Health) – Even doctors and nurses don’t always follow the healthy lifestyle choices they recommend for patients to reduce the risk of medical problems like obesity, heart disease and diabetes, a U.S. study suggests.

Although rates of these conditions appeared lower among health care workers than other people, the diseases were still common. They also rose over time at rates similar to increases in the general population, researchers reported in an article online October 5 in Mayo Clinic Proceedings.

The findings suggest that the same societal and environmental factors that can influence the development of chronic diseases for ordinary people also impact clinicians and medical experts, lead author Dr. Anupam Jena, a health policy researcher at Harvard Medical School and physician at Massachusetts General Hospital in Boston, told Reuters Health by email.

“This highlights the notion that nobody is fully immune to the factors that promote unhealthy lifestyle behaviors,” Dr. Jena said.

Dr. Jena and coauthor Dr. Elias Dayoub of the University of Pennsylvania in Philadelphia analyzed data from nationwide surveys conducted from 2002 to 2013, in which respondents were asked about their occupation, health behaviors, and chronic health problems.




About 3% of the roughly 150,000 survey participants were health professionals, including doctors, dentists, chiropractors, pharmacists, physician assistants, therapists, and nurses.

Overall, average rates of obesity, diabetes, and hypertension were lower among the health workers than the rest of the survey participants, but the growth in these problems from 2002 to 2013 was similar between the groups.

Health professionals were less likely to smoke and more likely to exercise than the people in other fields, but they were more likely to report moderate to heavy alcohol consumption.

The fact that growth in disease burden for health professionals often mirrored the general population suggests there may be limits to how effective public education efforts can be in reversing growth in unhealthy behaviors or chronic disease, the authors conclude.

“The take-home message for patients is that healthy lifestyle choices and good health are important but aren’t easy to come by,” Dr. Jena said. “Both take work and even health care professionals find it difficult.”

Shortcomings of the study include its reliance on self-reported survey data as well as the potential for health professionals to be diagnosed with diseases more often than other people because they generally have better access to care, the researchers acknowledge.

It’s also possible that by lumping all health professionals into a single category, the survey data didn’t capture nuances of particular jobs that might influence health behaviors and disease prevalence, Dr. Gal Dubnov-Raz, a sports and exercise medicine specialist at Sheba Medical Center in Tel Hashomer, Israel, told Reuters Health by email.

Shift work and activity levels, for example, might differ by occupation within the health field and influence lifestyle behaviors, noted Dr. Dubnov-Raz, who wasn’t involved in the study.

Even so, doctors, nurses, and other health professionals will set an example that patients may follow, making their lifestyle behaviors important in a public health context, Dr. Erica Frank, a researcher at the University of British Columbia who wasn’t involved in the study, told Reuters Health by email.

“We aren’t just docs, we are still also women and men, and are subject to the same environmental and social influences as are others,” Dr. Frank said. “We tend to preach to patients what we practice ourselves – so we should be thoughtful about that and not compromise patient care because we can’t square it with our behavior.”

SOURCE: http://bit.ly/1OxJ6Ea

Mayo Clinic Proc 2015.

Severity of skin psoriasis linked to blood vessel inflammation, cardiovascular risk

Severity of skin psoriasis linked to blood vessel inflammation, cardiovascular risk
By AMERICAN HEART ASSOCIATION NEWS

People with more psoriasis may also have more inflammation in their blood vessels, according to research published in the American Heart Association journal Arteriosclerosis, Thrombosis and Vascular Biology.

Psoriasis is a chronic inflammatory disease affecting about 3 percent of U.S. adults. It occurs when skin cells grow too quickly, resulting in thick white or red patches of skin.

Previous research suggests psoriasis may be linked with a higher risk of cardiac events and cardiovascular-related death. This may be the first study to examine whether psoriasis severity impacts inflammation in the blood vessels.




In the study, researchers analyzed 60 adults (average age 47) with psoriasis and 20 (average age 41) without psoriasis. All study participants were at low risk for cardiovascular disease based on a traditional risk assessment. They underwent a nuclear scan that measured blood vessel inflammation, and a dermatologist assessed the amount of psoriasis.

Researchers found:

  • Patients had psoriasis ranging from mild (only a few patches, less than 3 percent of the skin surface affected) to severe (when patches cover more than 10 percent of the skin surface).
  • Patients had high levels of inflammation in their blood vessels — even though they were at low risk for cardiovascular disease.
  • The most extensive forms of psoriasis were associated with a 51 percent increase in blood vessel inflammation.
  • The relationship between psoriasis and increased blood vessel inflammation didn’t change much after accounting for other heart disease risk factors.

“The most important observation we made was that the more psoriasis was on the skin, the more inflammation there was in the blood vessels,” said senior study author Nehal N. Mehta, M.D., M.S.C.E., a Lasker clinical investigator in the Cardiovascular and Pulmonary Branch of the National Heart, Lung, and Blood Institute in Bethesda, Maryland. “In other words, what we see on the outside is mirrored on the inside.”

The findings support the idea that the skin disease and cardiovascular disease may share an immune-related underlying mechanism, but it doesn’t prove one causes the other.

“People who have psoriasis — particularly if it is severe — should be assessed by their doctor for cardiovascular risk factors, including diabetes, high cholesterol and obesity,” Mehta said. “They should also maintain an active lifestyle, avoid smoking and follow a balanced diet.”

Waterlow score

Waterlow score

The Waterlow score (or Waterlow scale) gives an estimated risk for the development of a pressure sore in a given patient. The tool was developed in 1985 by clinical nurse teacher Judy Waterlow.

Scoring criteria

The following areas are assessed for each patient and assigned a point value.

  • Build/weight for height
  • Skin type/visual risk areas
  • Sex and age
  • Malnutrition Screening Tool
  • Continence
  • Mobility




Additional points in special risk categories are assigned to selected patients.

  • Tissue malnutrition
  • Neurological deficit
  • Major surgery or trauma

Potential scores range from 1 to 64. A total Waterlow score ≥10 indicates risk for pressure ulcer. A high risk score is ≥15. A very high risk exists at scores ≥20. The reverse side of the Waterlow score lists examples of preventive aids and interventions.

Click HERE to download the Waterlow scale

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Cincinnati Pre-hospital Stroke Scale

The Cincinnati Prehospital Stroke Scale is a system used to diagnose a potential stroke in a pre-hospital setting. It tests three signs for abnormal findings which may indicate that the patient is having a stroke. If any one of the three tests shows abnormal findings, the patient may be having a stroke and should be transported to a hospital as soon as possible.




1. Facial droop: Have the person smile or show his or her teeth. If one side doesn’t move as well as the other so it seems to droop, that could be sign of a stroke.

  • Normal: Both sides of face move equally
  • Abnormal: One side of face does not move as well as the other (or at all)

2. Arm drift: Have the person close his or her eyes and hold his or her arms straight out in front for about 10 seconds. If one arm does not move, or one arm winds up drifting down more than the other, that could be a sign of a stroke.

  • Normal: Both arms move equally or not at all
  • Abnormal: One arm does not move, or one arm drifts down compared with the other side





3. Speech: Have the person say, “You can’t teach an old dog new tricks,” or some other simple, familiar saying. If the person slurs the words, gets some words wrong, or is unable to speak, that could be sign of stroke.

  • Normal: Patient uses correct words with no slurring
  • Abnormal: Slurred or inappropriate words or mute

Interpretation: Patients with 1 of these 3 findings as a new event have a 72% probability of an ischemic stroke. If all 3 findings are present the probability of an acute stroke is more than 85%

References:
1. Hurwitz AS, Brice JH, Overby BA, Evenson KR (2005). “Directed use of the Cincinnati Prehospital Stroke Scale by laypersons”. Prehosp Emerg Care 9 (3): 292–6. doi:10.1080/10903120590962283. PMID 16147478.

2. American Heart Association (2011). Advanced Cardiovascular Life Support Provider Manual. USA: First American Heart Association Printing. p. 137. ISBN 9-781616-690106.

Continuous Bladder Irrigation (CBI)

PURPOSE
To prevent blood clot formation, allow free flow of urine and maintain IDC patency, by continuously irrigating the bladder with Normal Saline

EXPECTED OUTCOMES

  • The urinary catheter remains patent and urine is able to drain freely via the indwelling catheter (IDC)
  • The patients comfort is maintained
  • Clot formation within the bladder or IDC is prevented or minimised
  • The patient’s risk of Urinary Tract Infection is minimised, through use of aseptic technique when connecting bladder irrigation to IDC

EQUIPMENT FOR WARD BASED CONTINUOUS BLADDER IRRIGATION (CBI)

  • 3way catheter
  • 0.9% sodium Chloride irrigation bags as per facility policy
  • Continuous bladder irrigation set and closed urinary drainage bag with anti-reflux valve.
  • Alcohol wipes
  • Non sterile gloves
  • Personal protective equipment (PPE)
  • Underpad (bluey)
  • IV pole





PROCEDURE FOR CBI

1. Explain procedure to the patient and ensure patient privacy
2. Position the patient for easy access to the catheter whilst maintaining patient comfort
3. Ensure that the patient has a three-way urinary catheter.
4. Hang irrigation flasks on IV pole and prime irrigation set maintaining asepsis of irrigation set.

Note: Only one of the irrigation flask clamps should be open when priming the irrigation set otherwise the fluid can run from one flask to another. After priming the irrigation set ensure that all clamps on the irrigation set are closed

5. Don goggles and impervious gown , place underpad underneath catheter connection
6. Attend hand wash and don non-sterile gloves
7. Swab IDC irrigation and catheter ports with alcohol swabs and allow to dry
8. Open the irrigation lumen of the catheter
9. Connect the irrigation set to the irrigation lumen of the catheter, maintaining clean procedure
10. Ensure urine is draining freely before commencing continuous irrigation.
11. Unclamp the irrigation flask that was used to prime the irrigation set and set the rate of administration by adjusting the roller clamp.

Note: The aim of the bladder irrigation is to keep the urine rose’ coloured and free from clots. The rate is determined and varied as required, not run at a set rate.

ONGOING MANAGEMENT

  • Continue irrigation as necessary depending on the degree of haematuria (ensure adequate supply of irrigant nearby)
  • After each flask is complete, empty urine drainage bag. Record urine output on the fluid balance chart, prior to commencement of the next irrigation flask
  • Regular catheter care is required in order to minimise the risk of catheter related urinary tract infection
  • Catheter care provided should be documented in the progress notes and nursing care plan including patient comfort, urine colour/degree of haematuria and urine output. Also presence of clots if any and if manual bladder washout was necessary

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Troubleshooting:

    1. Drainage out is less than irrigation infused

  • Stop the irrigation. Recalculate I & O
  • Ensure that tubing is not kinked or looped below bladder level
  • Palpate bladder for distention. Use bladder scanner if available, to facilitate genitourinary assessment as per your unit’s routine.
  • If obstruction is suspected, gentle manual irrigation may be required as per physician’s orders. Cleanse the
    catheter opening well with chlorhexidine. Use nothing smaller than a 60cc syringe and sterile saline. Use slow,
    even pressure to avoid damaging the bladder wall. Do not force if resistance met. Allow irrigation to flow
    back freely
  • Notify physician if previous measures unsuccessful.
  • 2. Increased bloody drainage or presence of clots.

  • Increase rate of irrigation infusion as per physician’s orders.
  • Irrigation of catheter as outlined in #1 to aid in clot removal may be indicated.
  • If large amount blood or clots persists, notify physician
  • 3. Patient complains of pain: (Complete pain assessment using the 0-10 or visual analogue scale)

  • Palpate bladder to determine presence of distention
  • Check drainage tubing for kinks
  • Observe drainage for adequate amount, presence of clots that might be blocking drainage tube. Evaluate I & O
  • Avoid cold irrigation solution as it may cause bladder spasm.
  • 4. The patient is confused/agitated

  • Assess if patient is orientated to time, place person
  • Notify physician of patient’s change in LOC
  • Have relevant information ready to share with physician i.e. amount of opioids received, amount of CBI received,true urine output, time of onset of alteration in orientation, NA level; in TURP syndrome an overload of fluid through the prostatic sinuses can lead to dilutional hyponatremia, confusion and hypertension
  • 5. Solution Leaks around the foley catheter

  • Assess for bladder spasms
  • Refer to #1 – assessing for obstruction
  • Consider administering antispasmatic i.e. Buscopan





Documentation:
Documentation includes:

  • Patient’s comfort/pain level (how procedure is being tolerated)
  • Colour and type of drainage, presence of clots/fragments
  • Intake and output
  • Interventions required manual irrigation, use of bladder scanner
  • Health teaching done with patient and family
  • Patient concerns/adverse reactions (i.e. continued bladder spasms, decreased total urine output), the nursing actions taken and patient outcomes

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References:
Black et al (2001) Medical-Surgical Nursing, 6th edition, Toronto: W.B.Saunders
Perry, A. & Potter, P. (2002) Clinical Nursing Skills and Techniques 5th edition, St. Louis: Mosby
ACI UROLOGY NETWORK – Nursing Guidelines for bladder irrigation

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