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t & science continence focus

Developing and implementing


a new bladder irrigation
chart
Cutts B (2005) Developing and implementing a new bladder irrigation chart. Nursing
Standard. 20, 8, 48-52. Date of acceptance: June 20 2005.

Summary
Continuous bladder irrigation is a widely used
procedure following urological surgery. Nurses
monitor patients to minimise complications and to
provide an accurate record of fluid input and output.
Through observation in practice and discussion with a
ward team, it was identified that the documentation
in use for recording fluid balance was inadequate.
This resulted in inconsistencies and omissions in
documentation, which led to inaccuracies in fluid
balance. Development of a new chart has attempted
to address these issues. It has been developed as a
result of concerns identified in practice and adapted
to meet the needs of the clinical area.

Author
Beverley Cutts is a lecturer (adult nursing) at the
Institute of Health and Social Care Studies, Le
Vauquiedor, St Martins, Guernsey.
Email: bcutts@hssd.gov.gg

Keywords

CONTINUOUS BLADDER irrigation after


transurethral resection of prostate and
bladder tumours is a well established
and widely used technique (Ng 2001).
This treatment is required because of
the vascular nature of the prostate and
the bladder and the potential for these
areas to bleed in the immediate postoperative period (Scholtes 2002). It may
also be used to remove heavily
contaminated material from a diseased
urinary bladder (Dougherty and Lister
2004).
Bladder irrigation is used primarily to
reduce the risk of clot formation and

the prostate area and cause the rare


complication of transurethral resection
syndrome.
Nurses are responsible for ensuring a
continuous flow of irrigation fluid to keep
the urine light pink or colourless (Weaver
2001). The colour will be partly
dependent on the patients blood loss
which, if heavy, will increase the risk of
clot formation (Scholtes 2002). In cases
of heavy blood loss, irrigation should run
quickly and be adjusted to a slower rate
when the urine becomes less blood
stained (Fillingham and Douglas 1997).
retention (Fillingham and
Douglas 1997, Scholtes
2002, Dougherty and Lister
2004). Continuous bladder
irrigation is achieved via a
three-way catheter that
permits continuous flushing
and drainage of the bladder
(Ng 2001) (Figure 1). Sodium
chloride 0.9% is the solution
of choice because it is
isotonic. Water should never
be used because, owing to
osmosis, it may be readily
absorbed from

Minimising risk
Maintenance of fluid balance is important, and when
monitoring bladder irrigation it is necessary to
identify the patients urine output and to monitor the
amount of irrigating fluid to ensure that total output
exceeds input (Fillingham and Douglas 1997,
Scholtes 2002). If output
decreases it may indicate that the catheter is
blocked. The patient will present with symptoms
similar to acute urinary retention, such as
experiencing abdominal pain and a sensation of
bladder fullness. There may also be leakage around
the catheter (Weaver 2001). In this instance, bladder
irrigation should be turned off to prevent any further
discomfort and the tubing should be examined for
kinks. If the clot cannot be dislodged by milking the
tubing, a bladder washout will be required to remove
the clot mechanically. This should be considered only
48 november 2 :: vol 20 no 8 :: 2005
undergoing bladder irrigation is an
important nursing intervention to
identify and prevent complications
associated with this therapy. It is
imperative that nurses document fluid
balance correctly and have an
underpinning knowledge to minimise
risk to patients. This can be problematic
in general wards and where nurses may
not have the necessary skills and
experience to care for urology patients
(Ng 2001).
Clinical assessment Working on an acute
surgical ward at Princess Elizabeth
Hospital, Guernsey, for patients following
urological surgery, observation and
discussion with colleagues revealed that
fluid balance for patients with bladder
irrigation was being managed and
documented ineffectively. The chart
being used was designed for universal
use and, although the columns for intake
were labelled, the columns for output
were blank. Thus, when the chart was
used for bladder irrigation, nurses had to
label the columns themselves. It was
often unclear how much bladder
irrigation a patient had received, making
accurate monitoring of output
problematic. Two key issues were
identified:
Inconsistencies in documentation and
the use of abbreviations that had not
been defined.
Inaccurate documentation leading to
inaccuracies in fluid balance
monitoring. For example, not all staff
recorded the time when a new bladder
irrigation unit was set up or
completed, making it difficult to
account for changes in a patients
condition.

as a last resort and performed aseptically


to minimise associated complications of
introducing infection (Fillingham and
Douglas 1997).
Irrigation can be absorbed into the
bloodstream following prostatic surgery.
This occurs when pressure within the
prostatic vessels is lower than that of
the bladder, resulting in circulatory
overload and hyponatraemia. This is
referred to as transurethral resection
syndrome. Patients may present with
mental confusion, bradycardia, nausea
and vomiting, hypertension or
hypotension and cardiac arrest
(Fillingham and Douglas 1997, Scholtes
2002).
Monitoring fluid balance in patients

NURSING STANDARD
Identification of monitoring problems needs to be
considered with respect to professional and clinical
issues:
Professional issues focus on the role and
responsibility of the nurse with respect to standards
of care and identifying risk to provide safe and
competent care (Nursing and Midwifery Council
(NMC) 2004).
Clinical issues relate to the skills and knowledge
required to manage patients undergoing bladder
irrigation.
To address some of these problems and achieve best
practice, the surgical ward team decided to develop a
document that would provide a complete record of a
patients input and output while receiving bladder
irrigation (Figure 2).

Record keeping
Having identified problems with existing documentation,
it was clear that the documentation contributed to
ineffective monitoring of a patients condition. The
NMCs (2005) Guidelines for Records and Record
NURSING STANDARD

Keeping emphasises this point:


Quality of record keeping is
also a reflection of the standard
of
your professional practice.
The guidelines
describe how good
record keeping helps to
protect the welfare of
patients by promoting
high standards of
clinical care and better
communication and
dissemination of
information between
members of the
interprofessional
healthcare team (NMC
2005). Good record
keeping also enables
nurses to detect
problems or changes in
a patients condition at

an early stage. This is particularly


relevant to the care of patients
undergoing bladder irrigation, as a key
aspect of their care is monitoring input
and output, and identifying early
changes in fluid balance to prevent the
onset of further complications.
Although effective documentation
should alert nurses to changes in the
patients condition, nurses also need a
clear understanding of the common
complications that may occur and how
to identify early signs and symptoms.
Ng (2001) identified that patients with
continuous bladder irrigation are often
cared for on general wards, and that
attention should be directed at
examining nursing procedures and
nurses knowledge of practice.

november 2 :: vol 20 no 8 ::
2005 49

FIGURE 1
Bladder irrigation system

Irrigation solution

Clamps
Bladder
Three-way
irrigation catheter

Giving set

Clamp

Urine
drainage bag

50
FIGURE 2
no
Bladder irrigation chart
er
vol
no
FLUID/BLADDER IRRIGATION CHART
2005
DATE:
Oral
intake

ar
Affix label

Intravenous (IV)
Oral

Runnin
g total

IV

Runnin
g total

Bladder irrigation

Time

Fluid type

1630
1700

Sodium chloride 0.9% (1


litre)
Water

200

200

1730

Tea

150

350

1820

1830

Water

150

500

1825

2030

Sodium chloride 0.9% (1


litre)
Hartmans solution (1 litre)

2030

&

WARD:

Commen d
ce

1000 1000
Commen d
ce

(A)
Time

1700

(B)
Volum
e put
up

(C)
Volum
e run
in

Urine

2000

1800

Other

&
science

500
2000

200
0

1905
1925

(D)
Total
volum
e out

Outpu
t
Urine
runnin
g
total

1600

100

1000
200
0

1600

600

700

NURSING
ST

24 hour total:

24 hour total:

(Adapted from Dougherty and Lister 2004)

Method of development

Searches were undertaken on the Cumulative Index of Nursing and Allied Health
Literature (CINAHL) and Cochrane databases as well as other electronic sources.

Key words used were bladder irrigation and transurethral


resection of prostate. Only documents written in English
and published within the past five years were considered.
The search revealed limited research in the area of bladder
irrigation. Articles generally referred to broader issues
associated with bladder irrigation, such as prostate and
bladder surgery. Literature reviewed did not provide
research- based evidence to help nurses develop
documentation specifically for bladder irrigation. While the
literature search was not without its limitations, the key
aim was to develop a document that was appropriate for
practice within a set time limit and literature search was
limited to comply with this.
To develop a record document, reference was made to
The Royal Marsden Hospital Manual of Clinical Nursing
Procedures (Dougherty and Lister 2004), relevant texts
related to urology and documents produced by the
NMC, such as The NMCCode of Professional Conduct
(NMC 2004), and Guidelines for Records and Record
Keeping (NMC 2005).
Discussion with nursing colleagues and the consultant
urologist took place regarding the type of chart that
would be appropriate for recording bladder irrigation. A
chart which reflected a patients total fluid balance was
determined as being the most appropriate and effective
method of record keeping in practice.
The key requirements of a chart were that it would
provide a complete record of a patients fluid balance,
including oral intake, intravenous
(IV) therapy, input and output of bladder irrigation, and
urine output. The format had to be clear and easy to
follow. With reference to the Royal Marsden Hospital
Manual of Clinical Nursing Procedures (Dougherty and
Lister 2004), which partially met our requirements, a draft
chart was devised with the assistance of the quality
department within the health and social services
department.
Once the format of the document had been devised,
discussions took place between ward and theatre staff
about when the chart should become operational during
the patients stay. It was agreed that use of the chart
should start in the recovery room.
Following the development stage, it was decided that
staff using the document would require education about
how to use the chart and how to record fluid balance
accurately. Teaching sessions were devised to address
these needs and written guidelines were supplied to
support

NURSING STANDARD

verbal advice (Box 1). Short teaching


sessions took place at handover times to
reach as many staff as possible in the ward
and recovery areas.

Trial period and audit


The chart was trialed for a period of six
months. An audit tool was designed to
measure whether the chart was being
completed accurately, particularly with
regard to recording the times when
irrigation was set up and completed. Ten
randomly selected charts were reviewed
24 hours after surgery. It was felt that this
would enable any inconsistencies to be
identified in the recovery and the ward
areas.
An initial audit, completed by a nurse
who had a knowledge of urology but no
longer worked in this particular ward area,
identified that the chart was not being
completed accurately, primarily in
recording the times when a volume of
irrigation was put up and when it had run
in. It was unclear when either had
occurred. This resulted in problems with
establishing patients fluid balance. These
problems indicated that staff had not

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changed the way in which they recorded fluid irrigation but


continued with previous practice. This was because of a lack of
understanding, despite educational sessions conducted at the
introduction of the new bladder irrigation chart, and also because
of a high turnover of staff.
The issues highlighted were discussed with senior members of
the ward team and the findings from the initial audit on how to
complete the charts correctly and the importance of this were
disseminated to the entire team.
The written guidelines were reviewed and re-formulated to
provide a more structured approach to the management of
bladder irrigation (Box 1).
The changes to the guidelines and the discussions that took
place resulted in a favourable outcome. A second audit showed
that charts were being completed correctly. There was evidence
that bladder irrigation was being recorded when it was set up and
completed. Oral and IV fluids were also recorded correctly and,
therefore, accuracy in fluid balance was maintained. This was in
contrast to the first audit when it could not be clearly identified
that accurate monitoring of bladder irrigation was taking place.
Staff involvement Opinions of the staff using the chart were also
sought and these have been favourable. Minor changes, such as
making the chart double sided, have been incorporated in
response to suggestions made by those using it.
It has generally been stated that the new documentation (Figure
2) is an improvement on previously used charts and there is
evidence of accurate fluid balance monitoring for this group of
patients. As a result, the ward team believes

t & science continence focus


that the standard of care has improved. This was evident in the
recovery and ward areas, because bladder irrigation is now
recorded more accurately and there is consistency of
documentation throughout the patients stay.
To educate staff further about the care of patients undergoing
bladder irrigation, teaching sessions have been provided on the
broader issues of prostate disease and surgery, as well as the
correct use of the bladder irrigation chart.
There will always be a need to revisit training requirements
because the surgical unit has a high turnover of staff and is a
training area for students.

Conclusion

november 2 :: vol 20 no 8 :: 2005 51


Bladder irrigation is a widely used technique.
Accurate maintenance of fluid balance is
essential to ensure that complications are
prevented or minimised. The development of
a chart that records all aspects of a patients
fluid balance and is simple to use helps
nurses to meet

those responsibilities and also the requirements of the wider healthcare


team NS
Acknowledgement
I wish to acknowledge the support and
co-operation of my colleagues on Giffard ward at Princess Elizabeth Hospital, Guernsey,
without whom this project would not have been successful.

References
Dougherty L, Lister S (Eds) (2004) Royal Marsden Hospital Manual of Clinical Nursing Procedures.
Sixth edition. Blackwell Publishing, Oxford.

Fillingham S, Douglas J (Eds) (1997) Urological Nursing. Second edition.


Baillire Tindall, London.
Ng C (2001) Assessment and intervention knowledge of nurses in managing
catheter patency in continuous bladder irrigation following TURP. Urologic
Nursing. 21, 2, 97, 98, 101-107, 110-111.
Nursing and Midwifery Council (2004) The NMC Code of Professional Conduct:
Standards for Conduct, Performance and Ethics. NMC, London.
Nursing and Midwifery Council (2005) Guidelines for Records and Record
Keeping. NMC, London.
Scholtes S (2002) Management of clot retention following urological
surgery. Nursing Times. 98, 28, 48-50.
Weaver J (2001) Combating complications of transurethral surgery.
Nursing. 31, 7, 32hn 1-2, 32hn 4.

BOX 1
Bladder irrigation chart: guidelines for use
Indications for use
Bladder irrigation is required to:
Prevent the formation and retention of clots, for example, following bladder or prostatic surgery.
Remove heavily contaminated material from a diseased urinary bladder.
Aim of the bladder irrigation chart
To provide an accurate record of a patients input and output during a period of bladder irrigation.
Recording bladder irrigation section (see Figure 2)
1.

Record the time (column A) and the fluid volume in each bag (column B) of irrigating fluid as it is put

up.

2.

When the irrigating fluid has run into the bladder, record the time in column A and the original volume in the bag in column C.

3.
The catheter bag should be emptied whenever a bag of irrigating fluid is empty or as necessary. The amount should be recorded in
column D.
4.
When each bag of fluid has run through, add up the total volume drained by the catheter in column D. Subtract this from total volume
run in (column C) to find urine output. Total volume out (column D) minus volume run in (column C) equals urine output.
5.
If a bag of irrigating fluid is discontinued, the volume run in can be calculated by measuring the volume left in the bag and
deducting this value from the original volume. This should be recorded in column C.
Oral intake and intravenous infusions can be recorded on the same chart to provide one record and enable accurate fluid balance to be
measured.
Adapted from The Royal Marsden Hospital Manual of Clinical Nursing Procedures (Dougherty and Lister 2004).

52 november 2 :: vol 20 no 8 :: 2005

NURSING STANDARD