上接：
嘔吐止住不需要掛急診處理了 恢復按摩 換鼻胃管成功 建立SOP提升照顧深度與廣度 2015.05.10 8:18AM
https://www.peopo.org/news/275881
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本週二2015-05-12回診泌尿科，驗尿結果還是有發炎現象，但是醫生說不需要再吃抗生素了。這很令人驚訝，從來沒有過白血球已經到了無數個了，醫生還說不要吃抗生素，且還有其他醫生也背書。不過之前都是醫師說吃抗生素就吃，從來就不敢打折扣，只有之前醫生開三天藥，護士說怎可不吃完一個療程，去找醫生又拿了四天藥後，吃到第六天吐，又趕緊找醫師，醫師說第七天的藥不吃了，就這樣護士還一直說我不給老媽將藥吃到完，會怎樣又怎樣，很煩。不過我真的是六神無主了！不過中醫師有將原來一天吃兩次加到三次，但是細菌還是增加到無數個。會不會是綁腿的瞑眩反應？最近綁腿的時間有加長些，這會不會有影響而產生的排毒好現象？我這樣幻想著？最好的證據就是觀察再觀察，看結果會怎樣？既然兩位泌尿科醫師都一致認為不要再吃抗生素了，應該放心。今天問第一次求診的醫生（原熟識醫生請假）,為何同一症狀，有開三天、七天及不開藥的現象呢？他答覆說『醫生是醫人不是醫病』！這和我在自然醫學領域聽到的演講相通！既然如此，就該更加努力的幫老媽作現在正在作的事情：礒谷式力學療法、拉筋拍打、刮痧、氣功。。。
這個結果和一年前2014年2月，發現老媽因為吃神經內科的抗凝血藥，導至便血血紅素掉到6.6差點要輸血，後來神內醫生決定停藥後，吃胃藥半年以上大便檢體才驗不到潛血反應，真是艱辛的過程，其間血紅素一直停留在8多的低水平，潛血反應消除後，胃藥也才停掉，血紅素開始回升到11.多，在沒有潛血反應前最高水準是12多那已經是兩年前的事了。現在可能因為發炎現象，血紅素下降到10多的水準。自從潛血反應沒有後，神內醫生主張不必再吃抗凝血藥至今，神內其他的藥：預防失智的藥（忘記藥名）也同時停掉，擔心又會有什麼副作用產生。心血管科的降血壓藥也停了將近八個月了，一直也控制得很穩定，如果有問題，一定先請醫生查是否又是滿肚子大便，通常灌腸通便後，血壓就降下來了。現在隨時在老媽身邊放著一些天然的排便纖維錠，一有問題就吃一顆，都有很好的效果，不必灌甘油球。
講回到現在尿道發炎不吃抗生素，會有怎樣的結果？這位第一次求診的醫生，我很詳盡的告訴他老媽的病情，他說同意之前醫師建議不要再吃抗生素的建議，但是因為有尿管在，很多時候一定會發炎，只能讓身體與細菌和平相處，等到有狀況發生，例如：發燒、血尿或尿液混濁就要來院處理症狀。積極的作法是拿掉尿管，讓身體內沒有異物，就不會有發炎現象，他的病人很多都是採用這種作法效果很好，國外也是這樣的趨勢。請醫師給相關的資訊，他給了三個英文關鍵字：Clean Intermittent Catheterization，找到這樣的資訊：
Adult Clean Intermittent Catheterization─ Clinical Practice Guidelines
https://www.suna.org/resources/adultCICGuide.pdf
原來這種方式也推廣到患者家庭來採用，是外國很平常的一般保健方式，不需要用到消毒殺菌的設備。
Materials needed to prepare:
• Soap and water to wash hands and the urethral opening.
• Urethral catheter (male or female). The size of the catheter should be the smallest French（查字典是尿導管的的量測單位最小單位是3等於直徑1mm,聯想到導尿管用18號，是否表示是6mm直徑？） to pass easily into the bladder and allow adequate drainage.
• Lubricant (water-soluble jelly).
• Urinal or appropriate collection container (if not emptying into a toilet).
• Mild soap (like Ivory) for cleaning the catheter following catheterization.
• Catheter storage item, either a brown paper bag or a clean towel.
Set up:
• Assemble all the necessary products before beginning the procedure.
• Males and females must be instructed on the location of basic anatomical structures before they attempt the procedure on their own.
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如果決定要這樣做，醫師會教導我們如何處理。按照這裡寫的一天要處理四次左右，還挺麻煩的。還有一個作法就是先作排尿訓練，如果排尿訓練不成功，才需要這樣大費周章吧！至少這是一個可行的途徑，讓老媽不至於一直處在發炎的狀況。
享來老媽真是有福氣，今天碰上之前常看的醫生請人代診，我話說從前，將老媽的情況一五一十的講清楚，他從新的角度出發，給出一個從來沒有想到過的解決方案，就像幫老媽換了六家養護所，有人說為何一直要換？！留在同一家不就好了！對老媽來說，如果不換，怎會有現在這麼理想的養護所呢？這真是天助我們！看醫生也是，幾乎所有的醫生都給我看遍了，結果有這樣新的視野。。。
＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠＠
相關資訊：
Adult Clean Intermittent Catheterization─ Clinical Practice Guidelines
https://www.suna.org/resources/adultCICGuide.pdf
Introduction:
Most people empty their bladder by going to the bathroom four or five
times a day. When the bladder is not emptied, infections or other problems
can occur, such as urine passing backward up into the kidneys. This is called
reflux, which can cause infections or eventually cause damage to the kidneys.
Clean Intermittent Self-Catheterization (CIC) is a safe and effective alternative
method of emptying the bladder. (Lapides, Diokno, Silber and Lowe,
1972; Madersbacher et al., 2002; Rate B). It is used to help protect the kidneys,
prevent incontinence and decrease the number of infections a patient
may aquire by promoting adequate drainage of the bladder while lowering
intravesical pressure. (McQuire, Woodside and Borden, 1983; Rate C). It has
been used successfully for patients with neurological involvement of the bladder,
spinal cord injury or spinal tumors, diabetic neuropathy, multiple sclerosis,
spina bifida, myelodysplasia, bladder outlet obstruction and continent urinary
diversion. It can be used on a short or long term basis depending on the
bladder’s ability or inability to return to normal function.
CIC is performed by intermittently inserting a catheter (a tube to drain the
urine) into the urethral opening (meatus) and advancing it into the bladder to
allow the bladder to empty. Only persons who know the correct technique of
proper insertion and maintenance of the catheter should perform this procedure.
It is recommended that CIC be performed at regular intervals throughout
the day depending on the patient’s fluid intake as directed by the healthcare
provider. The patient’s ability to perform catheterization and adhere to a
schedule is essential to the success of the CIC program. Most individuals in
need of CIC will initiate catheterization every four to six hours to keep their
bladder volumes at a predetermined amount (or less) for each catheterization.
(Joseph, et al., 1998; Linsenmeyer et al., 2006; Rate B). If volumes
exceed this amount (more than 400-500 milliliters) more frequent catheterization
may be necessary or fluid intake will need to be adjusted. If patients have
spontaneous voiding but continue with high residual urine volumes, the interval
of CIC will be determined by their health care provider.
Early clinical guidelines recommended strict sterile technique for intermittent
catheterization to avoid the risk of infection from bacteria entering the
bladder through the catheter. This recommendation limited the use of intermittent
catheterization, since strict sterile technique is costly and must be performed
by someone trained to do the procedure. Recent studies have shown
that clean intermittent catheterization of the bladder does not increase the risk
of urinary tract infection.
Adult Clean Intermittent
Catheterization
Summary, Evidence Report/Technology Assessment: Number 6,
January 1999. Agency for Health Care Policy and Research, Rockville,
MD. (Evidence Levels II & III).
Segal, E.S., Deatrick, J.A., Hagelgans, N.A. (1995). The determinants of successful
self- catheterization programs in children with myelomeningoceles.
Journal of Pediatric Nursing. 10(2), 82-88. (Evidence Level IV).
Sherbondy, A.L., Cooper, C., Kalinowski, S.E., Boty, M.A., & Hawtrey, C.E.
(2002). Variability in catheter microwave sterilization techniques in a single
clinic population. Journal of Urology, 168(2), 562-564. (Evidence
Level III).
Wein, A.J. (2002). Neuromuscular dysfunction of the lower urinary tract and
its management. In Walsh, P.C., Retik, A.B., Vaughan Jr., E.D., Wein, A.J.
(Eds.). Campbell’s Urology (8th Ed., 931-1026). Philadelphia: W.B.
Saunders. (Evidence Levels I, II, II IV).
****Levels of Evidence based on PVA Consortium Neurogenic Bladder
Guideline (August, 2006) regimen for rating evidence:
The Steering Committee on Clinical Practice Guidelines for the care and
treatment of Breast Cancer. Introduction. (1998). Canadian Medical
Association Journal. 158(3). S1-S2.
Harris, R.P., Helfand, M., Woolf, S.H., et.al. (2001). Current methods of the
U.S. Preventive Services Task Force. American Journal of Preventative
Medicine. 20(3S). 21-35.
Sackett, D.I., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (1998).
Evidence-based Medicine: How to Practice and Teach Evidence Based
Medicine. Edinburgh: Churchill Livingstone.
Task Force Members:
Donna Clar, MSN/MBA, RN, CRRN
Angela Joseph, MSN, CNS, CURN
Sue Lipsy, RN, MS, CUNP
Janelle Harris, MSN, GNP, CUNP
Melissa Morrison, RN
In the hospital setting, sterile or clean technique is used depending on the
health care policy of the facility. (Lemke, Kasprowicz and Worral, 2005; Rate
B). In the home setting, clean technique is recommended because individuals
are exposed to bacterial organisms that do not routinely cause them to
have infections. The focus of this guideline is to teach appropriate independent
or directed-care for adult patients requiring CIC in the home setting using
the following steps:
Materials needed to prepare:
• Soap and water to wash hands and the urethral opening.
• Urethral catheter (male or female). The size of the catheter should be the
smallest French to pass easily into the bladder and allow adequate
drainage.
• Lubricant (water-soluble jelly).
• Urinal or appropriate collection container (if not emptying into a toilet).
• Mild soap (like Ivory) for cleaning the catheter following catheterization.
• Catheter storage item, either a brown paper bag or a clean towel.
Set up:
• Assemble all the necessary products before beginning the procedure.
• Males and females must be instructed on the location of basic anatomical
structures before they attempt the procedure on their own.
Instructions for Female Patients:
• Wash hands thoroughly with soap and water.
• Find a comfortable position.
• Spread the labia.
• Clean the entire urethral opening (meatus) area with warm soapy water
and a clean washcloth.
• Have the patient use a mirror initially to aid in the location of the meatal
opening if needed. It is located below the clitoris and just above the vagina
in most females, visually seen as “^”.
• Lubricate the tip of the catheter with the water-soluble jelly. Rotate the tip
to spread the lubricant around the catheter.
• Slowly and gently insert the catheter (2-4 inches) into the meatus until
urine begins to flow.
• If resistance is felt at the internal sphincter, hold firm, gentle, steady pressure
and the muscles should relax allowing the catheter to pass.
• Allow the urine to empty into the collection container or into the toilet.
• When the urine flow stops, slowly withdraw the catheter allowing the lower
parts of the bladder to drain. When there is no further flow of urine,
remove the catheter.
• If requested by the physician, record the amount of urine.
• Clean and store the catheter.
Instructions for Male Patients:
• Wash hands thoroughly with soap and water.
• Find a comfortable position. Some men prefer to stand for the procedure
but it can be done just as easily in the sitting position.
• Hold the penis perpendicular to the body (pointing towards the umbilicus)
and wash the urethral opening (meatus) with soap and a clean washcloth.
For uncircumcised men, retract the foreskin first and clean the meatus in
the same way.
• Lubricate the tip of the catheter with the water-soluble jelly. Rotate the tip
to spread the lubricant around the catheter.
• Slowly and gently insert the catheter into the meatus, approximately 6-8
inches or until urine begins to flow. Often the entire length of the catheter
must be inserted (to the hub, or end of the catheter) for urine flow to occur.
• There may be some resistance to the passage of the catheter at the prostatic
urethra, the portion of the urethra where the prostate lies. If this
occurs, hold firm, gentle, steady pressure and the external sphincter will
fatigue. Muscle relaxation will be felt and the catheter will advance
through this part of the urethra.
• There may also be resistance at the bladder neck, the internal sphincter
(the opening from the urethra to the bladder). Using firm, gentle, steady
pressure should cause the muscles to fatigue and allow the catheter to
pass into the bladder.
• Keep the catheter in place until the flow of urine stops. Slowly and gently
withdraw the catheter allowing for any pockets of urine at the base of
the bladder to drain. When there is no further flow of urine, remove the
catheter.
• If requested by the physician, record the amount of urine.
• Clean and store the catheter.
Maintenance:
• Clean catheters with mild soap and water immediately after use.
• Rinse thoroughly and air dry.
• Store covered in a clean dry towel or in a brown paper bag to allow air to
dry inside the catheter.
• Discard catheters if they become cracked or brittle, have any build up of
sediment or lose their form.
• Catheters should be replaced by prescription from the healthcare provider
on a monthly basis or sooner if indicated.
Nursing considerations:
• Difficulty inserting a catheter or an inability to catheterize may require
evaluation with a Urologist. Complications of CIC include: urethral false
passages, urethral strictures, bladder perforation and silent deterioration
of the upper urinary tracts. (Wein, 2002; Rate A).
• Never force the catheter. If the catheter will not pass and the patient feels
that their bladder is full, they will need to go to their nearest Urgent Care
Center/Emergency Room for appropriate evaluation.
• Patients performing CIC will routinely have an abnormal urinalysis. The
value of regular bacteriological monitoring of catheterized patients as an
infection control measure has not been established. The use of prophylactic
antibiotics is not recommended. Patients should be treated only for
symptomatic urinary tract infections (abdominal/flank pain, malaise, fever
and/or chills). (Linsenmeyer, T., et.al., 2006; Rate B).
• CIC may be contraindicated in the following: uncontrolled incontinence,
history of urethral trauma or pathology, decreased host resistance causing
further potential for a symptomatic urinary tract infection (UTI), other
disease processes or changes in the functional ability of the patient.
(Joseph, et al., 1998; Rate C).
• There has been evidence that disinfecting “red rubber” urethral catheters
in a microwave oven may be a viable option for patients who perform CIC.
(Mervine and Temple, 1997; Rate C). However, there is no supporting evidence
or consensus as to the most efficacious procedure to be used for
microwave disinfection of catheters. (Sherbondy et al., 2002; Rate C).
• For children, physiological, developmental and motivational qualities all
must be present for a successful self-catheterization program. Knowing
when a child is ready to learn and understanding different styles of teaching
CIC to children is of utmost importance. (Segal, E.S., Deatrick, J.A.,
Hagelgans, N.A.; 1995; Rate C). This guideline focuses on the adult
learner.
References
Joseph, A.C., et. al. (1998). Nursing clinical practice guideline: Neurogenic
bladder management. Spinal Cord Injury Nursing, 15(2), 21-56.
(Evidence Level II). Lapides, J., Diokno, A.C., Silber, S.J., & Lowe, B.S.,
(1972). Clean, intermittent self-catheterization in the treatment of urinary
disease. Journal Urology, 107, 458. (Evidence Level III).
Lemke, J.R., Kasprowicz, K., & Worral, S. (2005). Intermittent catheterization
for patients with a neurogenic bladder: Sterile versus clean: Using evidence-based
practice at the staff nurse level. Journal Nursing Care
Quality, 20, 302-306. (Evidence Level II).
Linsenmeyer, T., et.al. (August, 2006). Bladder management for adults with
spinal cord Injury: A clinical practice guideline for health-care providers.
Washington, DC: Paralyzed Veterans of America. (Evidence Levels II &
III).
Madersbacher, H., et.al. (2002). Conservative management in neuropathic
urinary incontinence. In P. Abrams, L. Cardozo, S. Khoury and A. Wein
(Eds.) International Consultation on Continence (2nd Ed, 717). Plymouth,
United Kingdom: Plymbridge Distributors, Ltd. (Evidence Levels II, III &
IV).
McQuire, E.J., Woodside, Jr. R., & Bordon, T.A. (1983). Upper urinary tract
deterioration in patients with myelodysplasia and detrusor hypertonia: A
follow- up study. Journal of Urology, 129, 823-826. (Evidence Level III).
Mervine J. & Temple R. (1997). Using a microwave oven to disinfect intermittent-use
catheters. Rehabilitation Nursing, 6, 318-320. (Evidence Level
III).
Prevention and Management of Urinary Tract Infections in Paralyzed Persons.
• Find a comfortable position. Some men prefer to stand for the procedure
but it can be done just as easily in the sitting position.
• Hold the penis perpendicular to the body (pointing towards the umbilicus)
and wash the urethral opening (meatus) with soap and a clean washcloth.
For uncircumcised men, retract the foreskin first and clean the meatus in
the same way.
• Lubricate the tip of the catheter with the water-soluble jelly. Rotate the tip
to spread the lubricant around the catheter.
• Slowly and gently insert the catheter into the meatus, approximately 6-8
inches or until urine begins to flow. Often the entire length of the catheter
must be inserted (to the hub, or end of the catheter) for urine flow to occur.
• There may be some resistance to the passage of the catheter at the prostatic
urethra, the portion of the urethra where the prostate lies. If this
occurs, hold firm, gentle, steady pressure and the external sphincter will
fatigue. Muscle relaxation will be felt and the catheter will advance
through this part of the urethra.
• There may also be resistance at the bladder neck, the internal sphincter
(the opening from the urethra to the bladder). Using firm, gentle, steady
pressure should cause the muscles to fatigue and allow the catheter to
pass into the bladder.
• Keep the catheter in place until the flow of urine stops. Slowly and gently
withdraw the catheter allowing for any pockets of urine at the base of
the bladder to drain. When there is no further flow of urine, remove the
catheter.
• If requested by the physician, record the amount of urine.
• Clean and store the catheter.
Maintenance:
• Clean catheters with mild soap and water immediately after use.
• Rinse thoroughly and air dry.
• Store covered in a clean dry towel or in a brown paper bag to allow air to
dry inside the catheter.
• Discard catheters if they become cracked or brittle, have any build up of
sediment or lose their form.
• Catheters should be replaced by prescription from the healthcare provider
on a monthly basis or sooner if indicated.
Nursing considerations:
• Difficulty inserting a catheter or an inability to catheterize may require
evaluation with a Urologist. Complications of CIC include: urethral false
passages, urethral strictures, bladder perforation and silent deterioration
of the upper urinary tracts. (Wein, 2002; Rate A).
• Never force the catheter. If the catheter will not pass and the patient feels
that their bladder is full, they will need to go to their nearest Urgent Care
Center/Emergency Room for appropriate evaluation.
• Patients performing CIC will routinely have an abnormal urinalysis. The
value of regular bacteriological monitoring of catheterized patients as an
infection control measure has not been established. The use of prophylactic
antibiotics is not recommended. Patients should be treated only for
symptomatic urinary tract infections (abdominal/flank pain, malaise, fever
and/or chills). (Linsenmeyer, T., et.al., 2006; Rate B).
• CIC may be contraindicated in the following: uncontrolled incontinence,
history of urethral trauma or pathology, decreased host resistance causing
further potential for a symptomatic urinary tract infection (UTI), other
disease processes or changes in the functional ability of the patient.
(Joseph, et al., 1998; Rate C).
• There has been evidence that disinfecting “red rubber” urethral catheters
in a microwave oven may be a viable option for patients who perform CIC.
(Mervine and Temple, 1997; Rate C). However, there is no supporting evidence
or consensus as to the most efficacious procedure to be used for
microwave disinfection of catheters. (Sherbondy et al., 2002; Rate C).
• For children, physiological, developmental and motivational qualities all
must be present for a successful self-catheterization program. Knowing
when a child is ready to learn and understanding different styles of teaching
CIC to children is of utmost importance. (Segal, E.S., Deatrick, J.A.,
Hagelgans, N.A.; 1995; Rate C). This guideline focuses on the adult
learner.
References
Joseph, A.C., et. al. (1998). Nursing clinical practice guideline: Neurogenic
bladder management. Spinal Cord Injury Nursing, 15(2), 21-56.
(Evidence Level II). Lapides, J., Diokno, A.C., Silber, S.J., & Lowe, B.S.,
(1972). Clean, intermittent self-catheterization in the treatment of urinary
disease. Journal Urology, 107, 458. (Evidence Level III).
Lemke, J.R., Kasprowicz, K., & Worral, S. (2005). Intermittent catheterization
for patients with a neurogenic bladder: Sterile versus clean: Using evidence-based
practice at the staff nurse level. Journal Nursing Care
Quality, 20, 302-306. (Evidence Level II).
Linsenmeyer, T., et.al. (August, 2006). Bladder management for adults with
spinal cord Injury: A clinical practice guideline for health-care providers.
Washington, DC: Paralyzed Veterans of America. (Evidence Levels II &
III).
Madersbacher, H., et.al. (2002). Conservative management in neuropathic
urinary incontinence. In P. Abrams, L. Cardozo, S. Khoury and A. Wein
(Eds.) International Consultation on Continence (2nd Ed, 717). Plymouth,
United Kingdom: Plymbridge Distributors, Ltd. (Evidence Levels II, III &
IV).
McQuire, E.J., Woodside, Jr. R., & Bordon, T.A. (1983). Upper urinary tract
deterioration in patients with myelodysplasia and detrusor hypertonia: A
follow- up study. Journal of Urology, 129, 823-826. (Evidence Level III).
Mervine J. & Temple R. (1997). Using a microwave oven to disinfect intermittent-use
catheters. Rehabilitation Nursing, 6, 318-320. (Evidence Level
III).
Prevention and Management of Urinary Tract Infections in Paralyzed Persons.
Summary, Evidence Report/Technology Assessment: Number 6,
January 1999. Agency for Health Care Policy and Research, Rockville,
MD. (Evidence Levels II & III).
Segal, E.S., Deatrick, J.A., Hagelgans, N.A. (1995). The determinants of successful
self- catheterization programs in children with myelomeningoceles.
Journal of Pediatric Nursing. 10(2), 82-88. (Evidence Level IV).
Sherbondy, A.L., Cooper, C., Kalinowski, S.E., Boty, M.A., & Hawtrey, C.E.
(2002). Variability in catheter microwave sterilization techniques in a single
clinic population. Journal of Urology, 168(2), 562-564. (Evidence
Level III).
Wein, A.J. (2002). Neuromuscular dysfunction of the lower urinary tract and
its management. In Walsh, P.C., Retik, A.B., Vaughan Jr., E.D., Wein, A.J.
(Eds.). Campbell’s Urology (8th Ed., 931-1026). Philadelphia: W.B.
Saunders. (Evidence Levels I, II, II IV).
****Levels of Evidence based on PVA Consortium Neurogenic Bladder
Guideline (August, 2006) regimen for rating evidence:
The Steering Committee on Clinical Practice Guidelines for the care and
treatment of Breast Cancer. Introduction. (1998). Canadian Medical
Association Journal. 158(3). S1-S2.
Harris, R.P., Helfand, M., Woolf, S.H., et.al. (2001). Current methods of the
U.S. Preventive Services Task Force. American Journal of Preventative
Medicine. 20(3S). 21-35.
Sackett, D.I., Richardson, W.S., Rosenberg, W., & Haynes, R.B. (1998).
Evidence-based Medicine: How to Practice and Teach Evidence Based
Medicine. Edinburgh: Churchill Livingstone.
Task Force Members:
Donna Clar, MSN/MBA, RN, CRRN
Angela Joseph, MSN, CNS, CURN
Sue Lipsy, RN, MS, CUNP
Janelle Harris, MSN, GNP, CUNP
Melissa Morrison, RN
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