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BLADDER IRRIGATION, CONTINUOUS
Continuous bladder irrigation can help prevent urinary tract obstruction by flushing out small blood clots that form after prostate or bladder surgery. It may also be used to treat an irritated, inflamed, or infected bladder lining.
This procedure requires the placement of a triple-lumen catheter. One lumen controls balloon inflation, one allows irrigant inflow, and one allows irrigant outflow. The continuous flow of irrigating solution through the bladder also creates a mild tamponade that may help prevent venous hemorrhage. Although typically the catheter is inserted while the patient is in the operating room after prostate or bladder surgery, if the patient is not a surgical patient, the catheter may be inserted at the bedside.
Essential Documentation
Each time a container of solution is completed, the nurse should record the date, time, and type and amount of fluid given on the intake and output record. Include any medications added to the solution. Also, record the time and amount of fluid each time the drainage bag is emptied. Note the appearance of the drainage and any complaints by the patient. Document any changes in the patient’s condition (e.g., a distended bladder, clots, or bright red outflow), the name of the health care provider notified and the time of notification, and actions taken. (See Documenting bladder irrigation, page 38.)
ACCUCHARTDOCUMENTING BLADDER IRRIGATION
As this sample shows, the nurse can monitor the patient’s fluid balance by using an intake and output record.
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Bladder Irrigation
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BLANK SPACES IN CHART OR FLOW SHEET
Blank spaces should not be left in a patient’s chart or flow sheet. The nurse should follow the facility’s policy regarding blank spaces on forms. A blank space may imply that the nurse failed to give complete care or assess the patient fully. Because flow sheets and documentation are often complex, nurses may be required to fill in only those fields or prompts that apply to their patient. It is now common for health care facilities to have a written policy on how to complete such forms correctly. Leaving blank spaces in the nurse’s notes also allows others to add information to the note. If charting electronically, the computer may not allow the nurse to exit from a particular field unless all spaces are documented.
Essential Documentation
If the information requested on a form does not apply to a particular patient, the facility’s policy may require the nurse to write “N/A” (not applicable) or draw a line through empty spaces.
When writing a nurse’s notes, the nurse should draw a line through any blank space after the entry and sign his or her name on the far-right side of the column. If the nurse does not have enough room to sign his or her name after the last word in the entry, the nurse should draw a line from the last word to the end of the line. The nurse then should drop down to the next line, draw a line from the left margin almost to the right margin, and sign his or her name on the far-right side.
Blank Spaces in Charting
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BLOOD TRANSFUSION
A blood transfusion provides whole blood or a blood component, such as packed cells, plasma, platelets, or cryoprecipitates, to replace losses from surgery, trauma, or disease. No matter which blood products are administered, the nurse must use proper identification and crossmatching procedures to ensure that the correct patient receives the correct blood product for transfusion. Be sure to follow facility policy for administering blood products.
Essential Documentation
Before administration of a blood transfusion, the following actions are advised:
Verify that an order for the transfusion exists.
Conduct a thorough physical assessment of the patient (including vital signs) to help identify later changes.
Teach the patient about the procedure’s associated risks and benefits, what to expect during the transfusion, signs and symptoms of a reaction, and when and how to call for assistance.
Patients needing blood transfusions should be told about the risks and benefits of the procedure so that they can give informed consent before it is undertaken.
Obtain informed consent.
Check for appropriate and patent vascular access.
Make sure the necessary equipment is at hand for administering the blood product and managing a reaction, such as an additional free intravenous (IV) line for normal saline solution, oxygen, suction, and a hypersensitivity kit.
The nurse should be familiar with the specific product to be transfused, the appropriate administration rate, and required patient monitoring. Be aware that the type of blood product and the
patient’s condition usually dictate the infusion rate. For example, blood must be infused faster in a trauma victim who is rapidly losing blood than in a 75-year-old patient with heart failure, who may not be able to tolerate rapid infusion.
Know what personnel will be available in the event of a reaction, and know how to contact them. Resources should include the on-call physician and a blood bank representative.
Before hanging the blood product, thoroughly double-check the patient’s identification and verify the actual product. Check the unit to be transfused against patient identifiers, per facility policy. Have a second licensed health care provider double check the patient’s identifying information, type and cross-match data, patient blood group and Rh factor, type and Rh factor of blood to be infused, blood bank identifying information, and expiration date of blood product.
Infuse the blood product with normal saline solution only, using filtered tubing.
Premedication
Premedication may be prescribed. To help prevent immunologic transfusion reactions, the physician may order such medications as acetaminophen and diphenhydramine before the transfusion begins to prevent fever and histamine release. Febrile nonhemolytic transfusion reactions seem to be linked to blood components, such as platelets or fresh frozen plasma, as opposed to packed red blood cells; thus, premedication may be indicated for patients who will receive these products. Such reactions may be mediated by donor leukocytes in the plasma, causing allosensitization to human leukocyte antigens. Cytokine generation and accumulation during blood component storage may play a contributing role.
Time Frame for Administration
The nurse must confirm the window of time during which the product must be transfused, starting from when the product arrives from the blood bank to when the infusion must be completed. Failing to adhere to these time guidelines increases the risk of such complications as bacterial contamination.
Before administering the blood transfusion, the nurse should clearly document that the product matched the label on the blood product and that the following were verified:
patient’s name
patient’s identification number
patient’s blood group or type
patient’s and donor’s Rh factor
crossmatch data
blood bank identification number
expiration date of the product
In addition, the nurse should document that the blood or blood component and the patient were matched by two licensed health care professionals at the patient’s bedside according to facility policy, that both of the health care professionals signed the slip that came with the blood, and that both of the health care professionals also verified that the information is correct.
When the nurse has determined that all the information is correct and matches, the consent form has been signed, and the patient’s vital signs are within acceptable parameters per the facility’s policy, the nurse may administer the transfusion and document the following on the transfusion record:
date and time that the transfusion was started and completed
name and credentials of the health care professionals who verified the information
total amount of the transfusion (at least two health care professionals, registered nurses, or physicians should check to see if all identifying information of the patient and blood type and blood products are accurate and match)
patient’s vital signs before, during, and after the transfusion, according to facility policy
patient’s response to the transfusion
The minimum standards for monitoring patients who are receiving blood transfusion include the following:
Pulse rate, blood pressure, temperature, and respiratory rate no more than 60 minutes before the blood transfusion is started.
Pulse rate, blood pressure, and temperature 15 minutes after the start of each blood component. If these readings are significantly different from the baseline observations, the respiratory rate should also be included.
Pulse rate, blood pressure, and temperature no more than 60 minutes after the end of the transfusion.
Transfusion reactions can occur immediately, within 24 hours of a transfusion, or more than 24 hours after a transfusion.
Nurses should know the signs of a transfusion reaction, when to report signs, and how and to whom they should be reported.
In the nurse’s notes, provide additional information:
type and gauge of the catheter
infusion device used (if any) and its flow rate
blood-warming unit used (if any)
amount of normal saline solution used (if any)
patient teaching regarding transfusion reaction signs and symptoms
If the patient receives autologous blood, document the amount of blood retrieved and reinfused in the intake and output records. Also, monitor and document laboratory data during and after the autotransfusion as well as the patient’s pretransfusion and posttransfusion vital signs. Pay particular attention to the patient’s coagulation profile, hematocrit and hemoglobin, arterial blood gas, and calcium levels.
Blood Transfusion
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BLOOD TRANSFUSION REACTION
During a blood transfusion, the patient is at risk for developing a transfusion reaction. If a reaction develops, immediately take the following steps:
Stop the transfusion.
Take down the blood tubing.
Hang new tubing with normal saline solution running to maintain vein patency.
Notify the health care provider, and follow facility policy for a blood transfusion reaction.
Notify the blood bank and laboratory.
Essential Documentation
The nurse should be sure to document the time and date of the reaction, the type and amount of infused blood or blood products, the time the nurse started the transfusion, and the time the nurse stopped it. Also, record clinical signs of the reaction in order of occurrence, the patient’s vital signs, urine specimen or blood samples sent to the laboratory for analysis, treatment given, and the patient’s response to treatment. Indicate that the nurse sent the blood transfusion equipment (discontinued bag of blood, administration set, attached IV solutions, and all related forms and labels) to the blood bank. Some health care facilities require the completion of a transfusion reaction report that must be sent to the blood bank. (See Transfusion reaction report, pages 45 and 46.) Document any follow-up care provided. Be sure to time each note and avoid block charting. Some facilities may also require the completion of an incident report. (See Avoid block charting, page 47.)
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