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Artificial Urinary Sphincter
AORN J O U R N A L
APRIL 1986, VOL. 43, NO 4
Artificial Urinary Sphincter RESTORING CONTINENCE
Jeanne P. Sant, RN
T
he lives of many patients with urinary incontinence revolve around indwelling or external catheters, plastic bed coverings, absorbent pads or briefs, clamps, or diapers. The pain, social isolation, and psychological effects associated with urinary incontinence can be lessened with the artificial urinary sphincter. It is a reliable and acceptable method of restoring continence and provides the patient with the opportunity for a more normal life.
Anatomy and Physiology
T
he bladder is composed of three parts. The body, made of detrusor muscle, forms the reservoir for the urine and is the propulsive force for emptying the bladder. At the base of the bladder is the trigone, a small triangular area on the inner surface of the bladder located between the openings of the two ureters and the internal urethral opening. The bladder neck is the third part, and is surrounded by two sphincters. The internal urethral sphincter is controlled by the autonomic nervous system, and the external urethral sphincter is controlled by the pudendal nerve. When the bladder expands to between 200 mL and 400 mL, the intrabladder pressure activates stretch receptors, parasympathetic nerve endings in the bladder wall. These receptors transmit afferent impulses to the spinal cord, initiating both a conscious desire to void and a micturition reflex. The reflex originates in the lower tip of the spinal cord and is transmitted by the afferent pathway to the bladder wall and the internal 866
urethral sphincter. The bladder wall then begins small contractile waves and the internal sphincter relaxes. When the voluntary choice to void is made, the external sphincter is relaxed by an inhibiting impulse to that sphincter through the pudendal nerve; the bladder contracts, and urination occurs. Normally, both sphincters are contracted so that urine cannot flow out of the bladder. Incontinence is a symptom of an underlying condition, not a disease. Causes of incontinence include: (1) cerebral clouding as a result of old age or coma, (2) infections of the genitourinary tract, (3) central nervous system disturbances from brain trauma or cerebral embolism, (4) urethrobladder reflex disturbances such as those caused by spinal cord injury, and (5) tissue damage such as perineal tissue relaxation or sphincter injury.' Candidates for implantation of the artificial urinary sphincter include patients with incontinence associated with spina bifida, myelomeningocele, spinal cord injury, pelvic trauma, and postradical prostatectomy incontinence and female stress incontinence? Patients with incontinence associated with senility are not good candidates for the artificial sphincter.3 Jeanne I! Sant, RN, MEd, is clinical coordinator, operafing room, Naval Hospitai, Oakland Caig She has a masters degree in education from National University, San Diego, and a BSN from the University of New Mexico, Albuquerque. The views expressed in this article are those of the author and not of the US Navy.
AORN JOURNAL
APRIL 1986, VOL. 43, NO 4
Fig 1. The artificial urinary sphincter device. (Photograph courtesy of American Medical Systems, Minnetonka, Minn)
Female stress incontinence is caused when increased intra-abdominal pressure permits the uncontrolled passage of urine through the urethra. This pressure increases when straining, sneezing, or coughing. One underlying factor can be relaxed pelvic structures due to weakening during childbirth. This allows the bladder and urethra to slip down and the urethra shortens, eliminating the ability of the urethral sphincter to close. Another factor can be urethral atrophy due to decreased estrogen levels postmenopause.
The Artificial Sphincter
T
he artificial urinary sphincter is made of silicone rubber and has a cuff, pressure regulating balloon, and pump (Fig 1). The cuff, a detachable band about the size of an adhesive bandage, is placed around the bladder
neck in either males or females, or around the bulbus urethrae in the male. The cuff is filled with fluid and exerts sufficient pressure on the tissue to prevent urine flow from the bladder through the urethra. The pressure balance is important because it must be enough to close the urethra without impairing circulation to the tissue, which could result in tissue necrosis and infe~tion.~ The balloon reservoir is placed in the prevesical space and holds the fluid for this hydraulic system, while exerting pressure on the cuff to close the urethra. When the patient wants to void, he/she squeezes the deflation pump located either in the scrota1 or labial skin (Figs 2 and 3). The fluid flows out of the cuff to the balloon reservoir, relieving presure on the tissue and permitting the passage of urine from the bladder through the urethra. The cuff refills automatically within a few minutes, again preventing the flow of urine?
AORN JOURNAL
APRIL 1986, VOL. 43, NO 4
Fig 2. Placement of the artificial urinary sphincter with the cuff around the bladder neck in the male. (Adapted from drawings dktribuled by American Medical Systems, Minnetonka, Minn)
Preoperative Care
T
he decision to implant an artifical urinary sphincter is made after the patient has had an extensive workup and been taught about the device. The patient must have a normal upper urinary tract and the intelligence and manual dexterity to operate the device. The requirements for children are the same as for adults, but a high level of motivation and a supportive family are also needed. Preliminary testing and evaluation include a complete history and physical, and a complete urological workup to determine whether the bladder is able to store and empty urine. Tests may include a cystometrogram to evaluate muscle tone and pressure of the bladder, an electromyogram to evaluate sphincter tone, measurement of flow rate, urethral pressure profile, cystogram, micturition study, stress testing, and cystourethroscopy.6 Preoperative assessment includes conferences with the surgical team, review of the patient’s chart, 870
interviews with the family, and physical assessment. Fluid intake and output are recorded, as well as the frequency of voiding and appearance of the urine. The patient is observed for the ability to follow instructions and for support from family members or significant others. Two negative urine cultures are necessary before surgery to ensure that the patient is free of any urinary tract infection. The most serious complication of this procedure is infection leading to erosion of the cuff or pump into the surrounding tissue. If urinalysis indicates that an infection is present, surgery is postponed and the patient is placed on antibiotic therapy for five to seven days.’ In addition to the risks (eg, inadvertent entry into the vagina or rectum, perforation of the bladder neck and bulbus urethrae, and infection) and benefits of the surgical procedure, the patient must understand that the artificial urinary sphincter can mechanically fail through leaking, kinking, or broken tubing. Other complications can include stress incontinence, erosion of the cuff into the urethra, and erosion of the pump into the labial
APRIL 1986. COL. 43. NO 1
AORN JOURNAL
-~
Fig 3. The artificial urinary sphincter in place in the female. (Adapted from druwit1g.s disrributcld by American Medical Systems, Minnetonka, Minn)
or scrota1 skin.* There is no rejection reaction. If infection occurs, the device can be removed and after allowing the tissue to heal for one year, a new device can be im~lanted.~ During the preoperative interview, the nurse explains the need for the preoperative procedures to the patient and his family. These include an enema the night before surgery, insertion of a heparin lock for administration of antibiotics preoperatively, povidone-iodine showers, and application of antiembolism stockings before the patient is taken to the OR. If the patient will have spinal anesthesia, the nurse should explain that the skin shave and scrub prep will be performed in the operating room just before the surgical procedure begins.
Intraoperative Care
T
he primary goal of the operating room staff for this procedure must be to decrease the chance of infection by maintaining meticulous aseptic technique. Surgeons sometimes
request that a protocol for this procedure be developed similar to that used for total joint surgery. This routine may include strictly limiting traffic in and out of the room, requiring all team members to wear hoods and double glove, and performing the skin shave on the patient on the OR table. Our urologists ask for a 10 to 15 minute povidone-iodine scrub. In addition, surgeons may spray their arms and hands with povidone-iodine before donning gloves and require that an antibiotic solution be added to the irrigating fluid. Use of laminar airflow or an isolation bubble to reduce airborne contamination has also been suggested.I0 Following administration of spinal or general anesthesia, the patient is placed in a lithotomy or modified lithotomy position with heels and legs padded and supported to protect tissue from pressure areas and stress on joints. Extra padding may be required at the sacrum. If the patient is awake during surgery, a quiet environment should be maintained; minimal talking and abbreviated, purposeful movements 871
APRIL IYX6, VOL 43, NO 4
AORN JOURNAL
Primary activation may not take place at the time of surgery, depending on the age and sex of the patient and the surgeon's preference. can help accomplish this. When the nurses act in a calm, confident manner and speak in quiet voices, the patient who is anxious will feel reassured. After prepping the patient from the umbilicus to the perineum, the patient is draped and the surgeon inserts a Foley catheter into the urethra to act as a landmark for it. If the cuff is to be placed around the bulbus urethrae in the male patient, the primary incision site is in the perineum. For placement around the bladder neck, which can be done for either male or female patients, the primary incision site is the lower abdomen. The catheter is removed when the bulbus urethrae is exposed. A sizing cuff is placed around the urethra to determine the proper dimension for the implanted cuff. Once the cuff is in place in the male patient, a low transverse incision is made above the pubis. The entire device can be implanted in female patients through a single incision in the abdomen. The rectus fascia is then divided and dissection is performed down to the prevesical space. The balloon is positioned after the correct size and appropriate pressure range are determined, and the balloon and cuff are connected and pressurized. A channel is tunneled from the abdominal incision to the base of the scrotum or labia, and the pump control device is placed in a superficial dependent position. All tubing is then aligned, trimmed, and connected. After the incisions are closed, another Foley catheter is inserted, and a dressing using a bulky abdominal pad covered with hypoallergenic tape is applied. The surgery takes between 60 and 90 minutes.
Posloperative Care
P
atients remain in the hospital for between two and 10 days. Postoperative studies generally include an x-ray of the pelvis for
confirmation of device position, urinalysis. and urine culture and sensitivity. The operative site is checked frequently to ensure that tissue vascularity is not compromised as a result of a dressing that is too tight. The most-used artificial urinary sphincter can be activated or deactivated by the patient or the physician by using a button on the top of the control pump, This button will fill the cuff with fluid to activate the device, or will empty the cuff of fluid to deactivate the device for extended periods. Primary activation may not take place at the time of surgery, depending on the age and sex of the patient and the surgeon's preference. The Foley catheter is removed when the device is activated. In primary deactivation, the cuff is left open. or empty, and is activated at a later time. This deactivation technique eliminates the need for manipulation of the pump until the tissue swelling and pain have subsided." Primary activation, if not done at the time of surgery, can be done between two and 12 weeks postoperatively.'* Some research indicates that primary activation may be a predisposing factor in cuff erosion as a result of tissue edema.I3 Before being discharged, the patient should understand the technique for activating the device, as well as proper hand-washing technique. When the device is activated, the patient is given a schedule instructing him to squeeze the pump flat every two hours during the day and once in the middle of the night for three weeks following surgery. After that time, the patient is instructed to pump only when there is a sensation of bladder fullness. The patient should also be advised to wear a medical alert bracelet that instructs the care giver to deflate the device every four to six hours to empty the bladder if the patient is unable to care for himself. The success rate for the artificial urinary 873
APRIL 1986, VOL. 43, N O 4
sphincter is between 80%and 90%, making it a viable solution for urinary incontinence. Successful treatment with the artificial urinary sphincter provides the patient with an opportunity for a more normal life, free from embarrassment and inconvenience. This device is the most efficient means currently available to obtain urinary continence. 0 Notes I , Wilma J Phipps et al, Shafer’s Medical-Surgical Nursing, 7th ed (St Louis: C V Mosby, 1980) 197; R Lawrence Kroovand, “The artificial sphincter for urinary incontinence,” Developmental Medicine and Child Neurologv 25 (August 1983) 521. 2. T P Stephenson et al, “Preliminary results of AS 791 1792 artificial sphincter for urinary incontinence,” British Journal of Urology 55 (December 1983) 684; Ananias C Diokno et al, “Long-term follow-up of the urinary sphincter,” Journal of Urology 131 (June 1984) 1084. 3. Kroovand, “The artificial sphincter,’’521. 4. “Curbing urinary incontinence with a sphincter implant,”American Journal of Nursing 3 (March 1985) 234. 5. Ibid, 520; F Brantley Scott, “The use of the artificial sphincter in the treatment of urinary incontinence in the female patient,” Urologic Clinics ofNorth America 12 (May 1985) 305. 6. Kroovand, “The artificial sphincter,” 521; Scott, “The use of the artificial sphincter in the treatment of urinary incontinence,” 308; Diokno, “Long-term follow-up of the urinary sphincter,’’1084. 7. Scott. “The use of the artificial sphincter in the treatment of urinary incontinence, 308. 8. Ibid. 308; A Ami Sidi et al, “Treatment of urinary incontinence with an artificial sphincter: Further experience with the AS 791/792 device,” Journal of Urologv 131 (May 1984) 891-892; Kroovand, “The artificial sphincter for urinary incontinence,” 522. 9. Kroovand, “Curbing urinary incontinence with a sphincter implant,” 234. 10. Scott, “The use of the artificial sphincter in the treatment of urinary incontinence,” 309. 11. Diokno, “Long-term follow-up of the urinary sphincter,” 1084-1085. 12. J Keith Light, “The artificial urinary sphincter in children: Experience with the AS 800 series and bowel reconstruction,” Urologic Clinics of North America 12 (February 1985) 1055. 13. Sidi. “Treatment of urinary incontinence with an artificial sphincter,” 891-892.
AORN JOURNAL
Aging Can Disrupt Quality of Sleep The aging process can have a detrimental affect on sleeping patterns, according to an article in the January/February issue of Geriatric Nursing. Factors associated with age that can disrupt sleep are alterations in the sleep-wake patterns, physical illness, psychological factors, and medications. Any of those factors can disrupt the nonrapid eye movement (NREM) and rapid eye movement (REM); both are crucial to a satisfying sleep. NREM is a deep sleep where muscles relax, pulse rate slows, temperature decreases, and there is little movement of the body. By the time a person reaches full NREM sleep, he/she has passed through four stages of sleep, about 40 minutes, and is difficult to arouse. He/she is in the last stages of NREM sleep for 15 to 30 minutes, and then moves into REM sleep. REM sleep lasts 10 minutes and is thought to be important to learning, memory, and adaptation. A person becomes more active in this phase-the pulse, respiration, blood pressure, and metabolic rate increase-and dreams vividly. He/she is even more difficult to arouse than when in NREM deep sleep. The first cause of poor sleep is altered sleepwake patterns. Though the total sleep time in a 24-hour period may not decrease by more than an hour over a lifetime, the duration and quality of sleep are altered because the proportion of REM and NREM sleep time changes with age. Physical illness is the second cause of sleep disruption. Approximately two thirds of the population over 65 has one or more chronic illnesses. Psychological factors such as loss of job and family members and diminished physical capabilities can disrupt sleep, Depression occurs, which may result in a delay in falling asleep or frequent awakening. Sleep disorders can be studied by keeping a sleep-wake diary for two weeks. If the disorder is severe (ie, sleep-apnea syndrome or nocturnal myoclonus), the patient may be referred to a specialist for a formal sleep laboratory evaluation.
APRIL 1986, VOL. 43, NO 4
AORN J O U R N A L
NOVAFlL” (MonofilamentPolybutestw Suture) (NonabsabableSurgicalSuture, US P) (Clearor Blue)
A Brief Summary INDICATIONS NOVAFIP is indicatedfor use in all types of soft tissue approximation, including use in cardiovascular and ophthalmlc surgery.but not in microsurgeryand neural tissue. It is recommendedfor use where the possibilityof reduced suture reaction is desired CONTRAINDICATONS There are no known contraindications PRECAUTIONS Since any foreian material in the presenceof bacterial contaminationmay enhance bactenal infectivity, standardsurgicalpractlce should be followed with respect to drainageand closure of infected wounds NOVAFIPdid not enhance infection in animal or in in vrtro studies ADVERSE REACTIONS As with any foreign body, transitory local inflamma tory reactionscouM occur WARNINGS Do not resterilize Discard open, unused sutures CAUTION Federal Law restricts this device to sale, distribution and use by or on the order of a physician or veterinarian
American Cyanamld Company Wayne, New Jersey 07470 Q Registeredtrademark American CyanamldCompany
Patient Badge Triggers Doorway, Public Alarm An electronic alarm system that alerts the nursing station when a patient wanders from a restricted ward or roams out of a nursing home is being tested in a Toronto hospital. Advocacy groups are claiming that such surveillance would violate patients’ rights. The system consists of a centrally located computer terminal, several infrared doorway monitoring stations, and transmitter badges for 10 patients. When a badge-wearing patient goes through a monitored doorway, an alarm sounds in the nursing station and the terminal screen displays the patient’s room number, description, and the time the patient passed the doorway. The system can be programmed to indicate up to 10 priority levels for hospital staff response, and an optional printer can be added to provide a hard copy of the alarm message. During its trial run at Riverdale Hospital, a 784-bed chronic care and general rehabilitation 878
facility, nurses were used to test the system. Two drawbacks were discovered. One, the monitoring function ceases to operate while new patient information is being entered into the computer. Two, the system was not designed to pinpoint the patient’s whereabouts. Its developer objected to advocacy groups referring to the system as a move in the direction of “Big Brother.” One group, however, says it provides a means of controlling behavior in a way that is invisible to the casual observer. The alarm system was reported in the Feb 10 issue of Medical World News.
How DRGs Affect Home Health Care Delivery When New Jersey implemented DRGs in 19801983, it was presumed that a reimbursement system favoring earlier hospital discharge would cause an increase in home care referrals. However, in a follow-up study, a direct effect of DRGs on home health care providers was dificult to establish. This is reported in the November/December 1985 issue of Nursing Outlook. One hypothesis is that DRGs produced an episodic increase in referrals of chronically ill and acutely ill patients to home health care agencies; the majority were referred as DRGs were being implemented. Those patients needed to recuperate from the acute illness that caused their hospitalization in the first place. Based on New Jersey’s experience, tightening the reimbursement system will permit a shorter episode of home care services than in the past few years. Health care agencies will have to change to provide more nursing care and less home health aide service as the trend of discharging sicker patients continues. Changes include providing seven-day, 24-hour service and frequent, closely spaced visits in the first two weeks of service. However, justifying the seven-day intervention to the Medicare program will be more difficult. The trend to separate chronically ill maintenance patients and acutely ill restorative patients will sharpen.
APRIL 1986, VOL. 43, NO 4
Artificial Urinary Sphincter RESTORING CONTINENCE
Jeanne P. Sant, RN
T
he lives of many patients with urinary incontinence revolve around indwelling or external catheters, plastic bed coverings, absorbent pads or briefs, clamps, or diapers. The pain, social isolation, and psychological effects associated with urinary incontinence can be lessened with the artificial urinary sphincter. It is a reliable and acceptable method of restoring continence and provides the patient with the opportunity for a more normal life.
Anatomy and Physiology
T
he bladder is composed of three parts. The body, made of detrusor muscle, forms the reservoir for the urine and is the propulsive force for emptying the bladder. At the base of the bladder is the trigone, a small triangular area on the inner surface of the bladder located between the openings of the two ureters and the internal urethral opening. The bladder neck is the third part, and is surrounded by two sphincters. The internal urethral sphincter is controlled by the autonomic nervous system, and the external urethral sphincter is controlled by the pudendal nerve. When the bladder expands to between 200 mL and 400 mL, the intrabladder pressure activates stretch receptors, parasympathetic nerve endings in the bladder wall. These receptors transmit afferent impulses to the spinal cord, initiating both a conscious desire to void and a micturition reflex. The reflex originates in the lower tip of the spinal cord and is transmitted by the afferent pathway to the bladder wall and the internal 866
urethral sphincter. The bladder wall then begins small contractile waves and the internal sphincter relaxes. When the voluntary choice to void is made, the external sphincter is relaxed by an inhibiting impulse to that sphincter through the pudendal nerve; the bladder contracts, and urination occurs. Normally, both sphincters are contracted so that urine cannot flow out of the bladder. Incontinence is a symptom of an underlying condition, not a disease. Causes of incontinence include: (1) cerebral clouding as a result of old age or coma, (2) infections of the genitourinary tract, (3) central nervous system disturbances from brain trauma or cerebral embolism, (4) urethrobladder reflex disturbances such as those caused by spinal cord injury, and (5) tissue damage such as perineal tissue relaxation or sphincter injury.' Candidates for implantation of the artificial urinary sphincter include patients with incontinence associated with spina bifida, myelomeningocele, spinal cord injury, pelvic trauma, and postradical prostatectomy incontinence and female stress incontinence? Patients with incontinence associated with senility are not good candidates for the artificial sphincter.3 Jeanne I! Sant, RN, MEd, is clinical coordinator, operafing room, Naval Hospitai, Oakland Caig She has a masters degree in education from National University, San Diego, and a BSN from the University of New Mexico, Albuquerque. The views expressed in this article are those of the author and not of the US Navy.
AORN JOURNAL
APRIL 1986, VOL. 43, NO 4
Fig 1. The artificial urinary sphincter device. (Photograph courtesy of American Medical Systems, Minnetonka, Minn)
Female stress incontinence is caused when increased intra-abdominal pressure permits the uncontrolled passage of urine through the urethra. This pressure increases when straining, sneezing, or coughing. One underlying factor can be relaxed pelvic structures due to weakening during childbirth. This allows the bladder and urethra to slip down and the urethra shortens, eliminating the ability of the urethral sphincter to close. Another factor can be urethral atrophy due to decreased estrogen levels postmenopause.
The Artificial Sphincter
T
he artificial urinary sphincter is made of silicone rubber and has a cuff, pressure regulating balloon, and pump (Fig 1). The cuff, a detachable band about the size of an adhesive bandage, is placed around the bladder
neck in either males or females, or around the bulbus urethrae in the male. The cuff is filled with fluid and exerts sufficient pressure on the tissue to prevent urine flow from the bladder through the urethra. The pressure balance is important because it must be enough to close the urethra without impairing circulation to the tissue, which could result in tissue necrosis and infe~tion.~ The balloon reservoir is placed in the prevesical space and holds the fluid for this hydraulic system, while exerting pressure on the cuff to close the urethra. When the patient wants to void, he/she squeezes the deflation pump located either in the scrota1 or labial skin (Figs 2 and 3). The fluid flows out of the cuff to the balloon reservoir, relieving presure on the tissue and permitting the passage of urine from the bladder through the urethra. The cuff refills automatically within a few minutes, again preventing the flow of urine?
AORN JOURNAL
APRIL 1986, VOL. 43, NO 4
Fig 2. Placement of the artificial urinary sphincter with the cuff around the bladder neck in the male. (Adapted from drawings dktribuled by American Medical Systems, Minnetonka, Minn)
Preoperative Care
T
he decision to implant an artifical urinary sphincter is made after the patient has had an extensive workup and been taught about the device. The patient must have a normal upper urinary tract and the intelligence and manual dexterity to operate the device. The requirements for children are the same as for adults, but a high level of motivation and a supportive family are also needed. Preliminary testing and evaluation include a complete history and physical, and a complete urological workup to determine whether the bladder is able to store and empty urine. Tests may include a cystometrogram to evaluate muscle tone and pressure of the bladder, an electromyogram to evaluate sphincter tone, measurement of flow rate, urethral pressure profile, cystogram, micturition study, stress testing, and cystourethroscopy.6 Preoperative assessment includes conferences with the surgical team, review of the patient’s chart, 870
interviews with the family, and physical assessment. Fluid intake and output are recorded, as well as the frequency of voiding and appearance of the urine. The patient is observed for the ability to follow instructions and for support from family members or significant others. Two negative urine cultures are necessary before surgery to ensure that the patient is free of any urinary tract infection. The most serious complication of this procedure is infection leading to erosion of the cuff or pump into the surrounding tissue. If urinalysis indicates that an infection is present, surgery is postponed and the patient is placed on antibiotic therapy for five to seven days.’ In addition to the risks (eg, inadvertent entry into the vagina or rectum, perforation of the bladder neck and bulbus urethrae, and infection) and benefits of the surgical procedure, the patient must understand that the artificial urinary sphincter can mechanically fail through leaking, kinking, or broken tubing. Other complications can include stress incontinence, erosion of the cuff into the urethra, and erosion of the pump into the labial
APRIL 1986. COL. 43. NO 1
AORN JOURNAL
-~
Fig 3. The artificial urinary sphincter in place in the female. (Adapted from druwit1g.s disrributcld by American Medical Systems, Minnetonka, Minn)
or scrota1 skin.* There is no rejection reaction. If infection occurs, the device can be removed and after allowing the tissue to heal for one year, a new device can be im~lanted.~ During the preoperative interview, the nurse explains the need for the preoperative procedures to the patient and his family. These include an enema the night before surgery, insertion of a heparin lock for administration of antibiotics preoperatively, povidone-iodine showers, and application of antiembolism stockings before the patient is taken to the OR. If the patient will have spinal anesthesia, the nurse should explain that the skin shave and scrub prep will be performed in the operating room just before the surgical procedure begins.
Intraoperative Care
T
he primary goal of the operating room staff for this procedure must be to decrease the chance of infection by maintaining meticulous aseptic technique. Surgeons sometimes
request that a protocol for this procedure be developed similar to that used for total joint surgery. This routine may include strictly limiting traffic in and out of the room, requiring all team members to wear hoods and double glove, and performing the skin shave on the patient on the OR table. Our urologists ask for a 10 to 15 minute povidone-iodine scrub. In addition, surgeons may spray their arms and hands with povidone-iodine before donning gloves and require that an antibiotic solution be added to the irrigating fluid. Use of laminar airflow or an isolation bubble to reduce airborne contamination has also been suggested.I0 Following administration of spinal or general anesthesia, the patient is placed in a lithotomy or modified lithotomy position with heels and legs padded and supported to protect tissue from pressure areas and stress on joints. Extra padding may be required at the sacrum. If the patient is awake during surgery, a quiet environment should be maintained; minimal talking and abbreviated, purposeful movements 871
APRIL IYX6, VOL 43, NO 4
AORN JOURNAL
Primary activation may not take place at the time of surgery, depending on the age and sex of the patient and the surgeon's preference. can help accomplish this. When the nurses act in a calm, confident manner and speak in quiet voices, the patient who is anxious will feel reassured. After prepping the patient from the umbilicus to the perineum, the patient is draped and the surgeon inserts a Foley catheter into the urethra to act as a landmark for it. If the cuff is to be placed around the bulbus urethrae in the male patient, the primary incision site is in the perineum. For placement around the bladder neck, which can be done for either male or female patients, the primary incision site is the lower abdomen. The catheter is removed when the bulbus urethrae is exposed. A sizing cuff is placed around the urethra to determine the proper dimension for the implanted cuff. Once the cuff is in place in the male patient, a low transverse incision is made above the pubis. The entire device can be implanted in female patients through a single incision in the abdomen. The rectus fascia is then divided and dissection is performed down to the prevesical space. The balloon is positioned after the correct size and appropriate pressure range are determined, and the balloon and cuff are connected and pressurized. A channel is tunneled from the abdominal incision to the base of the scrotum or labia, and the pump control device is placed in a superficial dependent position. All tubing is then aligned, trimmed, and connected. After the incisions are closed, another Foley catheter is inserted, and a dressing using a bulky abdominal pad covered with hypoallergenic tape is applied. The surgery takes between 60 and 90 minutes.
Posloperative Care
P
atients remain in the hospital for between two and 10 days. Postoperative studies generally include an x-ray of the pelvis for
confirmation of device position, urinalysis. and urine culture and sensitivity. The operative site is checked frequently to ensure that tissue vascularity is not compromised as a result of a dressing that is too tight. The most-used artificial urinary sphincter can be activated or deactivated by the patient or the physician by using a button on the top of the control pump, This button will fill the cuff with fluid to activate the device, or will empty the cuff of fluid to deactivate the device for extended periods. Primary activation may not take place at the time of surgery, depending on the age and sex of the patient and the surgeon's preference. The Foley catheter is removed when the device is activated. In primary deactivation, the cuff is left open. or empty, and is activated at a later time. This deactivation technique eliminates the need for manipulation of the pump until the tissue swelling and pain have subsided." Primary activation, if not done at the time of surgery, can be done between two and 12 weeks postoperatively.'* Some research indicates that primary activation may be a predisposing factor in cuff erosion as a result of tissue edema.I3 Before being discharged, the patient should understand the technique for activating the device, as well as proper hand-washing technique. When the device is activated, the patient is given a schedule instructing him to squeeze the pump flat every two hours during the day and once in the middle of the night for three weeks following surgery. After that time, the patient is instructed to pump only when there is a sensation of bladder fullness. The patient should also be advised to wear a medical alert bracelet that instructs the care giver to deflate the device every four to six hours to empty the bladder if the patient is unable to care for himself. The success rate for the artificial urinary 873
APRIL 1986, VOL. 43, N O 4
sphincter is between 80%and 90%, making it a viable solution for urinary incontinence. Successful treatment with the artificial urinary sphincter provides the patient with an opportunity for a more normal life, free from embarrassment and inconvenience. This device is the most efficient means currently available to obtain urinary continence. 0 Notes I , Wilma J Phipps et al, Shafer’s Medical-Surgical Nursing, 7th ed (St Louis: C V Mosby, 1980) 197; R Lawrence Kroovand, “The artificial sphincter for urinary incontinence,” Developmental Medicine and Child Neurologv 25 (August 1983) 521. 2. T P Stephenson et al, “Preliminary results of AS 791 1792 artificial sphincter for urinary incontinence,” British Journal of Urology 55 (December 1983) 684; Ananias C Diokno et al, “Long-term follow-up of the urinary sphincter,” Journal of Urology 131 (June 1984) 1084. 3. Kroovand, “The artificial sphincter,’’521. 4. “Curbing urinary incontinence with a sphincter implant,”American Journal of Nursing 3 (March 1985) 234. 5. Ibid, 520; F Brantley Scott, “The use of the artificial sphincter in the treatment of urinary incontinence in the female patient,” Urologic Clinics ofNorth America 12 (May 1985) 305. 6. Kroovand, “The artificial sphincter,” 521; Scott, “The use of the artificial sphincter in the treatment of urinary incontinence,” 308; Diokno, “Long-term follow-up of the urinary sphincter,’’1084. 7. Scott. “The use of the artificial sphincter in the treatment of urinary incontinence, 308. 8. Ibid. 308; A Ami Sidi et al, “Treatment of urinary incontinence with an artificial sphincter: Further experience with the AS 791/792 device,” Journal of Urologv 131 (May 1984) 891-892; Kroovand, “The artificial sphincter for urinary incontinence,” 522. 9. Kroovand, “Curbing urinary incontinence with a sphincter implant,” 234. 10. Scott, “The use of the artificial sphincter in the treatment of urinary incontinence,” 309. 11. Diokno, “Long-term follow-up of the urinary sphincter,” 1084-1085. 12. J Keith Light, “The artificial urinary sphincter in children: Experience with the AS 800 series and bowel reconstruction,” Urologic Clinics of North America 12 (February 1985) 1055. 13. Sidi. “Treatment of urinary incontinence with an artificial sphincter,” 891-892.
AORN JOURNAL
Aging Can Disrupt Quality of Sleep The aging process can have a detrimental affect on sleeping patterns, according to an article in the January/February issue of Geriatric Nursing. Factors associated with age that can disrupt sleep are alterations in the sleep-wake patterns, physical illness, psychological factors, and medications. Any of those factors can disrupt the nonrapid eye movement (NREM) and rapid eye movement (REM); both are crucial to a satisfying sleep. NREM is a deep sleep where muscles relax, pulse rate slows, temperature decreases, and there is little movement of the body. By the time a person reaches full NREM sleep, he/she has passed through four stages of sleep, about 40 minutes, and is difficult to arouse. He/she is in the last stages of NREM sleep for 15 to 30 minutes, and then moves into REM sleep. REM sleep lasts 10 minutes and is thought to be important to learning, memory, and adaptation. A person becomes more active in this phase-the pulse, respiration, blood pressure, and metabolic rate increase-and dreams vividly. He/she is even more difficult to arouse than when in NREM deep sleep. The first cause of poor sleep is altered sleepwake patterns. Though the total sleep time in a 24-hour period may not decrease by more than an hour over a lifetime, the duration and quality of sleep are altered because the proportion of REM and NREM sleep time changes with age. Physical illness is the second cause of sleep disruption. Approximately two thirds of the population over 65 has one or more chronic illnesses. Psychological factors such as loss of job and family members and diminished physical capabilities can disrupt sleep, Depression occurs, which may result in a delay in falling asleep or frequent awakening. Sleep disorders can be studied by keeping a sleep-wake diary for two weeks. If the disorder is severe (ie, sleep-apnea syndrome or nocturnal myoclonus), the patient may be referred to a specialist for a formal sleep laboratory evaluation.
APRIL 1986, VOL. 43, NO 4
AORN J O U R N A L
NOVAFlL” (MonofilamentPolybutestw Suture) (NonabsabableSurgicalSuture, US P) (Clearor Blue)
A Brief Summary INDICATIONS NOVAFIP is indicatedfor use in all types of soft tissue approximation, including use in cardiovascular and ophthalmlc surgery.but not in microsurgeryand neural tissue. It is recommendedfor use where the possibilityof reduced suture reaction is desired CONTRAINDICATONS There are no known contraindications PRECAUTIONS Since any foreian material in the presenceof bacterial contaminationmay enhance bactenal infectivity, standardsurgicalpractlce should be followed with respect to drainageand closure of infected wounds NOVAFIPdid not enhance infection in animal or in in vrtro studies ADVERSE REACTIONS As with any foreign body, transitory local inflamma tory reactionscouM occur WARNINGS Do not resterilize Discard open, unused sutures CAUTION Federal Law restricts this device to sale, distribution and use by or on the order of a physician or veterinarian
American Cyanamld Company Wayne, New Jersey 07470 Q Registeredtrademark American CyanamldCompany
Patient Badge Triggers Doorway, Public Alarm An electronic alarm system that alerts the nursing station when a patient wanders from a restricted ward or roams out of a nursing home is being tested in a Toronto hospital. Advocacy groups are claiming that such surveillance would violate patients’ rights. The system consists of a centrally located computer terminal, several infrared doorway monitoring stations, and transmitter badges for 10 patients. When a badge-wearing patient goes through a monitored doorway, an alarm sounds in the nursing station and the terminal screen displays the patient’s room number, description, and the time the patient passed the doorway. The system can be programmed to indicate up to 10 priority levels for hospital staff response, and an optional printer can be added to provide a hard copy of the alarm message. During its trial run at Riverdale Hospital, a 784-bed chronic care and general rehabilitation 878
facility, nurses were used to test the system. Two drawbacks were discovered. One, the monitoring function ceases to operate while new patient information is being entered into the computer. Two, the system was not designed to pinpoint the patient’s whereabouts. Its developer objected to advocacy groups referring to the system as a move in the direction of “Big Brother.” One group, however, says it provides a means of controlling behavior in a way that is invisible to the casual observer. The alarm system was reported in the Feb 10 issue of Medical World News.
How DRGs Affect Home Health Care Delivery When New Jersey implemented DRGs in 19801983, it was presumed that a reimbursement system favoring earlier hospital discharge would cause an increase in home care referrals. However, in a follow-up study, a direct effect of DRGs on home health care providers was dificult to establish. This is reported in the November/December 1985 issue of Nursing Outlook. One hypothesis is that DRGs produced an episodic increase in referrals of chronically ill and acutely ill patients to home health care agencies; the majority were referred as DRGs were being implemented. Those patients needed to recuperate from the acute illness that caused their hospitalization in the first place. Based on New Jersey’s experience, tightening the reimbursement system will permit a shorter episode of home care services than in the past few years. Health care agencies will have to change to provide more nursing care and less home health aide service as the trend of discharging sicker patients continues. Changes include providing seven-day, 24-hour service and frequent, closely spaced visits in the first two weeks of service. However, justifying the seven-day intervention to the Medicare program will be more difficult. The trend to separate chronically ill maintenance patients and acutely ill restorative patients will sharpen.