SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE TITLE: ISSUED FOR: Nursing DATE: REVIEWED: PAGES: 11/78 4/18 1 of 10 RESPONSIBILITY: RN (for chemo), LPN (nonchemo) PURPOSE: OBJECTIVE: To introduce medication or medicated irrigation solution into the bladder for a prescribed period of time. This is also called intravesical instillation. The nurse will perform instillation of medication into the bladder with minimal complications. INDICATIONS: 1. Medication is instilled directly into the bladder for treatment of infections, for providing localized anesthetic (soothing) actions and for the treatment of generalized, diffuse malignant tumors which prohibit surgical resection. 2. Amphotericin B is instilled directly into the bladder for treatment of bladder fungal infections. KNOWLEDGE BASE: 1. Aseptic technique must be maintained throughout the procedure to prevent bacteria from entering the bladder. 2. The bladder should be emptied and/or drained prior to the instillation of medication. 3. Instillation of medication into the bladder requires a physician s order. The order should state the medication, the dosage, and the frequency. If the medication is to be left in the bladder for a period of time, this should also be stated in the order. 4. Medications may be instilled using the following catheters: a. Straight catheter: Select a straight catheter when the patient does not have a catheter present or when the patient s current condition does not require an indwelling catheter. After instillation of the medication, the patient will expel the solution on the next voiding. b. Retention Foley catheter: Select this type catheter when it is already in place or when the medication to be instilled is to be removed via the catheter at a later time. Select a three-way catheter when the medication is to be instilled as a continuous irrigation. 5. If the medication will be administered using a syringe, notify

PAGE: 2 of 10 the pharmacy of type of syringe needed for instillation. a. If the medication will be instilled using a straight catheter and the medication is not a chemotherapeutic agent, request the medication be supplied in a cathetertip syringe. b. If the medication will be instilled using a straight catheter and the medication is a chemotherapeutic agent, request the medication be supplied in a Luer-lock syringe with a closed system transfer device (CSTD) Luer-lock adaptor in place. c. If the medication will be instilled using a retention catheter, request the medication be supplied in a Luerlock syringe. 6. If the medication is supplied in an infusion bag, the infusion bag will be labeled by Pharmacy with fluorescent orange stickers that will say Not for IV Infusion. The infusion bag will be hung from an IV pole placed at the foot of the bed. All procedures for handling intravenous (IV) therapy equipment must be followed. 7. The nurse administering the medication will verify the correct patient, correct drug, correct dose, correct route, correct time, and the expiration dates on the drug(s). KNOWLEDGE BASE: Amphotericin B Instillation 8. Amphotericin B can be ordered as a continuous bladder irrigation (CBI) for a prescribed number of days to treat a fungal infection. Call the Urology Unit regarding CBI of any other non- chemotherapy irrigants. a. The Amphotericin B irrigation solution will be prepared by Pharmacy and will be mixed in sterile water. Amphotericin B is never mixed with normal saline. Never irrigate the catheter with normal saline when instilling Amphotericin B. Use sterile water only. b. Avoid administering Amphotericin B concurrently with WBC (granulocyte) transfusions. c. Bladder instillation of Amphotericin B carries fewer side effects than IV, but may cause hematuria, cramping, discomfort and burning. KNOWLEDGE BASE: Chemotherapy Instillation 9. Only chemotherapy competent Registered Nurses (RNs) should instill chemotherapeutic agents into the bladder, following the established procedure(s) including disposal procedures. a. SMH Nursing Procedures and Oncology Nursing Society (ONS) guidelines for chemotherapy

administration will be maintained. PAGE: 3 of 10 NOTE: Follow hazardous drug safe handling guidelines outlined in nursing procedures Administration of Chemotherapeutic Agents and Biotherapies-Adults (onc01), Handling Excreta from Patient Receiving Chemotherapy (onc07) and Disposing of Chemotherapy Tubings, Solution Bags and Syringes (onc08). b. Chemotherapeutic agents will be prepared and supplied by Pharmacy. Bacillus Calmette-Guérin, thiotepa, mitomycin C, and gemcitabine are most commonly used for bladder instillations. c. Chemotherapeutic agents administered via Luer-lock tubing/syringe are administered utilizing a closed system transfer device (CSTD) system. 1) For administration, the CSTD system consists of a syringe adaptor attached to the chemotherapy tubing/syringe that connects with a Luer-lock adaptor attached to the retention catheter sampling port or straight catheter adaptor. 2) In order to maintain the safety of the CSTD, do NOT disconnect the CSTD equipment from the tubing, syringe or catheter port once connected. If it is necessary to remove the CSTD Luer-lock adaptor, when possible, flush with a flush solution before removing the Luer-lock adaptor. 3) If the CSTD syringe adaptor must be disconnected from the CSTD Luer-lock adaptor for flush administration, a CSTD syringe adaptor must be utilized for access through the CSTD Luer-lock adaptor. d. Chemotherapy agents must be delivered in an appropriate delivery device. 1) Chemotherapy delivered via syringe must be supplied in a Luer-lock syringe. If not return the item to the pharmacy for safe transfer to a Luer-lock syringe with a CSTD in place. 2) Chemotherapy delivered via IV tubing must be delivered with IV tubing attached, primed with diluent for instillation, and a CSTD in place. If not, return the item to the pharmacy. 3) All chemotherapy must have a CSTD syringe adaptor attached. e. Chemotherapeutic agents may be retained for as long as two hours without severe depressant effect on the bone marrow. Depending on the physician order, the

PAGE: 4 of 10 patient will either remain for observation or be discharged home without observation. If the patient remains for observation, make sure the patient voids within either two hours of instillation of medication or the ordered specified timeframe.. Notify the physician if the patient has not voided. PATIENT EDUCATION: 1. Explain the rationale for the procedure and briefly outline the procedure to the patient. 2. If giving chemotherapy, explain the positional routine. Once the medication is instilled, the patient should alternate his/her position (from back to right side to left side to abdomen) every fifteen minutes. The physician may order that the patient ambulate during the time the medication is in the bladder. The physician should prescribe the amount of dwell time. EQUIPMENT: The selection of equipment will vary with the type of catheter being used and the way the medication is supplied. 1. Assemble the following from the nursing unit: a. Medication as ordered by the physician b. Alcohol swabs c. Gloves 2. If instilling medication using a straight catheter: a. Straight urinary catheter b. Catheter adaptor from inpatient Oncology unit (for chemotherapy administration) 3. If instilling medication using a retention catheter: a. #14 or larger two-way or three-way Foley catheter (if not in place) b. Catheter clamp c. Four (4) liter urinary drainage bag (for three-way catheter) d. Catheter plug (for three-way catheter) e. Catheter adaptor from inpatient Oncology unit (for three-way catheter continuous infusion) 4. If instilling medication as an infusion: a. IV pole b. IV tubing c. Dial-a-Flo or electronic pump d. Not for IV Infusion stickers 5. If instilling a chemotherapy agent: a. Ordered dose of chemotherapy with CSTD syringe adaptor attached b. CSTD Luer-lock adaptor c. 20 ml syringe with 20 ml normal saline (NS) or other appropriate flush solution

PAGE: 5 of 10 d. CSTD syringe adaptor (for flush syringe) e. Two (2) pairs of chemotherapy approved gloves f. Chemotherapy approved gown g. Face shield (for risk of splashing) h. Face shield/mask combination for bacillus Calmette- Guérin [BCG]) i. Plastic-backed disposable pad j. 4X4 gauze pads. PROCEDURE: Patient Preparation 1. Perform hand hygiene. 2. If it is necessary to insert the catheter, follow the nursing procedure, Catheterization - Straight and Retention/Care and Management/Removal of Catheter - Adult (cat05). If using a three-way retention catheter, attach the urinary drainage bag to the larger outflow lumen of the catheter and insert the catheter plug into the smaller inflow lumen using aseptic technique. 3. Drain bladder. 4. Position the patient on his/her back, with head of bed as low as tolerated, so that medication instilled will come in contact with as much of the bladder wall as possible. 5. Before accessing the catheter sampling port, infusion port, or CSTD Luer-lock adaptor, scrub the connector, infusion port or adaptor with an alcohol wipe for 15 seconds and allow to air dry. 6. If medication is to be instilled as an infusion: a. Place the IV pole at the foot of the bed. b. The infusion bag will have a sticker that states Not for IV Infusion. Place Not for IV Infusion sticker on the tubing. Pharmacy will send the extra sticker for the tubing along with the solution. PROCEDURE: Instillation of Non-Chemotherapy Medication Instillation of medication to be retained in bladder 7. For medication instillation using a straight-catheter: a. Cleanse catheter tubing with alcohol wipes. Allow to air dry. b. Insert the catheter-tipped syringe into the catheter tubing. c. Instill the medication. d. Remove the catheter. 8. For medication instillation using a Foley two-way or threeway retention catheter: a. Clamp the drainage tubing of the retention catheter between the sampling port and the drainage bag.

PAGE: 6 of 10 b. For medications provided in a Luer-lock syringe: 1) Clean the hub of the retention catheter sampling port, with an alcohol wipe for 15 seconds and allow to air dry 2) connect the medication syringe. 3) Instill the medication. 4) Disconnect the syringe from the sampling port. c. For medications provided in an infusion bag: 1) Connect IV tubing to the infusion bag and hang on the IV pole. 2) Prime the tubing. 3) Clean the hub of the retention catheter sampling port with an alcohol wipe for 15 seconds and allow to air dry 4) Connect the IV tubing. 5) Set the infusion rate on the Dial-a-Flo or electronic pump. 6) Instill the medication. 7) At the conclusion of the infusion, disconnect the IV tubing. 9. Place the call light within reach so that help can be summoned readily if discomfort or difficulties arise. 10. Instruct the patient to retain urine for as long as possible and/or as ordered. Keep retention catheter clamped for the prescribed time, usually one hour, or as long as the patient can tolerate. 11. Check the patient at least every 15 minutes to encourage and/or assist in repositioning, if ordered, as well as to assess his/her reaction, if any, to the treatment. 12. After the ordered dwell time has elapsed, drain bladder. a. For medication instilled using a straight-catheter, instruct the patient to void. If the patient is unable to void within two hours of administration of a chemotherapy agent, notify the physician. b. For medication instilled using a retention catheter, unclamp the catheter and allow medication and urine to drain. When unclamping the catheter at the end of the ordered time interval, make sure the catheter is patent. This type of catheter may remain indwelling so check the physician s orders prior to removal. Instillation of medication as a large volume or continuous infusion Administer large volume or continuous infusions using a threeway retention catheter. Do not clamp the catheter.

PAGE: 7 of 10 7. Connect IV tubing to the infusion bag and hang on the IV pole. 8. Prime the tubing. 9. Using aseptic technique, attach the IV tubing to the Luerlock end of the catheter adaptor while maintaining sterility of the tapered end of the catheter adaptor. 10. Maintaining aseptic technique, remove the catheter plug from the inflow lumen of the catheter. Cleanse the opening of the inflow lumen with alcohol wipes. 11. Insert the tapered end of the catheter adaptor into the lumen. 12. Set the infusion rate on the Dial-a-Flo or electronic pump. 13. Begin the instillation of the medication. 14. Place the call light within reach so that help can be summoned readily if discomfort or difficulties arise. 15. Subtract the previous twelve hours infusion from previous twelve hours output to obtain true urinary output for documentation. 16. Change the IV tubing every 96 hours. 17. At the conclusion of the infusion, disconnect the IV tubing. PROCEDURE: Instillation of Chemotherapy Medication 1. Place a plastic-backed disposable pad under patient s buttocks. 2. Don one pair of chemotherapy gloves, chemotherapy gown, and 2 nd pair of chemotherapy gloves. 3. Don face shield if risk of splashing. 4. Don face shield/mask combination if instilling BCG. 5. For chemotherapy medication instillation using a straight catheter: a. Open catheter adaptor package. Maintaining sterility of the tapered end of the catheter adaptor, attach CSTD Luer-lock adaptor to the Luer-lock end of the catheter adaptor. b. Cleanse catheter tubing with alcohol wipe for 15 seconds. Allow to air dry. c. Insert tapered end of the catheter adaptor into the catheter tubing until the adaptor fits snugly in the tubing.

PAGE: 8 of 10 d. Clean catheter CSTD Luer-lock adaptor, air dry and attach chemotherapy CSTD syringe adaptor. e. Instill the medication. Do not disconnect the CSTD syringe adaptor from the CSTD Luer-lock adaptor. f. Carefully remove the catheter using 4X4 gauze pads to contain any leakage from the catheter tip. 6. For chemotherapy medication instillation using a Foley two-way or three-way retention catheter: a. Clamp the drainage tubing of the retention catheter between the sampling port and the drainage bag. b. Clean the hub of the catheter sampling port with an alcohol wipe for 15 seconds, air dry and attach CSTD Luer-lock adaptor. c. For chemotherapy medications provided in a Luer-lock syringe: 1) Clean catheter CSTD Luer-lock adaptor with an alcohol wipe for 15 seconds, air dry and connect chemotherapy CSTD syringe adaptor. 2) Instill the medication. 3) Disconnect the chemotherapy CSTD syringe adaptor from the catheter CSTD Luer-lock adaptor. 4) When possible, flush catheter CSTD Luer-lock adaptor. a) Attach CSTD syringe adaptor to flush syringe. b) Clean catheter CSTD Luer-lock adaptor with an alcohol wipe for 15 seconds, air dry and connect flush CSTD syringe adaptor. c) Flush with 10-20 ml flush solution as tolerated by patient. d) Disconnect the flush CSTD syringe adaptor from the catheter CSTD Luer-lock adaptor. 5) Remove the CSTD Luer-lock adaptor from the catheter sampling port. d. For chemotherapy medications provided in an infusion bag: 1) Clean catheter CSTD Luer-lock adaptor with an alcohol wipe for 15 seconds, air dry and connect chemotherapy CSTD syringe adaptor. 2) Set the infusion rate on the Dial-a-Flo or electronic pump. 3) Instill the medication. 4) When possible, flush tubing. a) Clean the hub of infusion tubing sidearm port with an alcohol wipe for 15 seconds, air dry and attach flush syringe. b) Flush with 10-20 ml flush solution as tolerated by patient. Leave flush syringe attached to tubing. 5) Disconnect the chemotherapy CSTD syringe adaptor from the catheter CSTD Luer-lock adaptor.

PAGE: 9 of 10 6) Remove the CSTD Luer-lock adaptor from the catheter sampling port. 7. Place the call light within reach so that help can be summoned readily if discomfort or difficulties arise. 8. Instruct the patient to retain urine for as long as possible and/or as ordered. Keep retention catheter clamped for the prescribed time, usually one hour, or as long as the patient can tolerate. 9. Check the patient at least every 15 minutes to encourage and/or assist in repositioning, if ordered, as well as to assess his/her reaction, if any, to the treatment. 10. After the ordered dwell time has elapsed, drain bladder. a. For medication instilled using a straight-catheter, instruct the patient to void. If the patient is unable to void within two hours of administration of a chemotherapy agent, notify the physician. b. For medication instilled using a retention catheter, unclamp the catheter and allow medication and urine to drain. When unclamping the catheter at the end of the ordered time interval, make sure the catheter is patent. This type of catheter may remain indwelling so check the physician s orders prior to removal. 11. Dispose of administration equipment per nursing procedure Disposing of Chemotherapy Tubings, Solution Bags, and Syringes (onc08). 12. Dispose of urine per nursing procedure Handling Excreta from Patients Receiving Chemotherapy (onc07). DOCUMENTATION: 1. Medication Administration Record (emar): Document medication administration. 2. Assessment/Reassessment Flowsheet: Document the procedure, patient s tolerance, and any other pertinent data regarding the patient s condition. 3. Intake &Output Flowsheet: Record intake of solution into bladder and output of urine as indicated. 4. Oncology Flowsheet: Document administration of chemotherapy agent. REFERENCE: 1. Lippincott Williams & Wilkins. (2016). Lippincott s nursing procedures (7 th ed.). 2. 2018 Trueven health Analytics, Micromedex

PAGE: 10 of 10 Solutions, Amphotericin B (2018). http://www.micromedexsolutions.com/micromedex2/libr arian/cs/4abbdc/nd_pr/evidencexpert/nd_p/eviden cexpert/duplicationshieldsync/3a16c5/nd_pg/ evidencexpert/nd_b/evidencexpert/nd_appproduct/evi dencexpert/nd_t/evidencexpert/pfactionid/evidencex pert.intermediatetodocumentlink?docid=2562- a&contentsetid=30&title=amphotericin+b&servicestitle =Amphotericin+B 3. Polovich, M., Olsen, M., & LeFebvre, K. B. (Eds.). (2014). Chemotherapy and biotherapy guidelines and recommendations for practice (4 th ed.). Pittsburgh, PA: Oncology Nursing Society. 4. Sarasota Memorial Hospital Nursing Procedure. Catheterization - Straight and Retention/Care and Management/Removal of Catheter - Adult (cat05). SMH: Author. 5. Sarasota Memorial Hospital Nursing Procedure. Disposing of Chemotherapy Tubings, Solution Bags, and Syringes (onc08). SMH: Author. 6. Sarasota Memorial Hospital Nursing Procedure. Handling Excreta from Patient Receive Chemotherapy (onc07). SMH: Author. REVIEWING AUTHOR(S): Deena Damsky Dell CNS, RN-BC, AOCN, LNC, Oncology APN Barbara Poropat, BSN, RN, OCN, NPD, Oncology APPROVAL: Clinical Practice Council 4/5/18