Clinical

Patient care report for feline

patient with urethral obstruction
Further investigations
Abstract It was not possible to manually express the bladder
Urethral obstruction in cats is a potentially life-threatening condition. The admin- so cystocentesis was performed using a 23G butter-
istration of sufficient pain relief and appropriate fluid therapy as part of a well fly catheter for immediate relief of the pressure. The
balanced nursing care plan is vital for the care of these patients. Urinary output urine obtained was examined for crystals under the
must be monitored following the removal of the urethral obstruction and this re- microscope, specific gravity and dipstick, as well as
port discusses the considerations of an indwelling urinary catheter. sent for culture to look for bacterial infection and
sensitivity to antibiotics. Methadone (0.3 mg/kg IV)
Key words: urethral obstruction, IVFT, indwelling urinary catheter, was administered as analgesia, followed by general
monitoring, electrolyte imbalance, metabolic acidosis anaesthesia induction with Alfaxan (0.2 mg/kg IV)
and maintenance with isoflurane while saline was
injected into the urethra to break up any blockages
Signalment or flush them back into the bladder. The bladder was
llSpecies: Feline lavaged and an indwelling urinary catheter, with a
llBreed: Domestic Short Hair closed collection system, was placed for 2 days and
llAge: 3 years then removed. Uroliths were not seen on lateral im-
llSex: Male neutered ages of the urinary tract without contrast radiogra-
llWeight: 5 kg phy.

History Discussions of nursing

The patient was presented with a history of frequent
unproductive squatting in the litter tray for the last interventions
48 hours, off food and vomiting, leading to collapse. Urethral obstruction is a medical emergency asso-
ciated with metabolic acidosis, hyperkalaemia, hy-
Patient assessment pocalcaemia and post renal azotaemia (Drobatz and
On physical examination the patient was collapsed, Cole, 2008). Treatment focuses on analgesia, correct-
tachycardic, hypothermic (36.80C), hypotensive and ing perfusion, metabolic imbalances and relieving
had pale mucous membranes with a delayed capillary urethral obstruction (Drobatz and Cole, 2008). It was
refill time (CRT 2s). His bladder was large, hard and crucial that the hospital environment posed minimal
painful to palpate. stress on the patient and pheromones (Feliway Dif-
fuser, Ceva) were used, as well as all other stressors re-
Initial interventions moved, such as barking dogs and loud noises (Woolf,
A 23G intravenous catheter was placed in the right 2012).
cephalic vein and intravenous fluid therapy (IVFT)
initiated, using Hartmann’s. Blood was taken from Fluid therapy
the jugular vein for complete blood count, serum bio- The type of fluid and the rate it is given has to be care-
chemistry, blood gas analysis and to measure packed fully considered. IVFT was administered to: improve
cell volume (PCV)/total solids (TS). hypovolaemia; correct electrolyte imbalances and
metabolic acidosis; and ‘flush’ the urinary tract of po-
tential obstructions.
Charlotte Brown BSc RVN is the Head Nurse
at a veterinary practice called The Vets in Improving initial hypovolaemia
Salisbury. This article was produced as On presentation the patient was experiencing car-
part of her studies for the Royal Veterinary diovascular collapse. There was no history of heart
College Graduate Diploma in Professional disease and there was no audible murmur. The
and Clinical Veterinary Nursing bradycardia was thought to be associated with the
hyperkalaemia. Two boluses of Hartmann’s were ad-

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and Cole, 2008). However, studies have shown that

Box 1. Fluid therapy plan
there is no difference in the time taken to normalise
1. On admission, hypovolaemic shock evident, with urethral obstruction, no
potassium concentrations in hyperkalaemic patients
evidence of cardiac disease
Plan: shock rate bolus of fluids to improve cardiovascular system, repeat if when using sodium chloride 0.9% compared with
necessary. a balanced electrolyte solution (Drobatz and Cole,
*Note: vigilant monitoring required to avoid over hydration in feline patients 2008).
The use of sodium chloride 0.9% may be less ben-
2. Urethral obstruction relieved and indwelling urinary catheter placed eficial if the patient has metabolic acidosis; the lactate
Plan: high volumes of urine to flush the bladder through
within balanced electrolyte solution is metabolised by
10 ml/kg/hour
10 ml x 5 kg = 50 ml/hour the liver and skeletal muscle into bicarbonate, which
acts a buffer enabling correction of acidosis more rap-
3. Post-obstructive diuresis idly than when sodium choloride is used (Drobatz and
Plan: maintain good hydration through post-obstructive diuresis (classified Cole, 2008; Cunha et al, 2010). The chloride within
as more than 2 ml/kg/hour). More than the maintenance fluid requirement is sodium chloride 0.9% actually worsens acidaemia by
necessary (Francis et al, 2010)
interfering with bicarbonate reabsorption within the
Maintenance fluid rate 50 ml/kg/24 hour proximal tubule (Drobatz and Cole, 2008).
50 ml x 5 kg = 250 ml/24hour = 10.4 ml/hour The electrolyte status of the patient was analysed
using an ISTAT machine every 4 hours once the ob-
2 x maintenance fluid rate = 20.8 ml/hour struction had been relieved to ensure potassium levels
were normal and additional electrolyte abnormalities
did not occur. The dilution effect of the high rates of
ministered at 20 ml/kg over 10 minutes. Heart rate, IVFT was adequate in this patient to reduce potassium
respiratory rate and effort and blood pressure were levels quickly, without the intervention of 10% calcium
closely monitored during the fluid resuscitation for gluconate or insulin and dextrose therapy. Blood glu-
signs of overload. When peripheral pulses resumed cose levels need to be closely monitored when admin-
and mucous membranes were pink with a capillary istering insulin in hyperkalaemic patients to ensure
refill of 1 second the fluid rate was reduced to 10 ml/ they do not become hypoglycaemic (Matthews, 2011).
kg/hours (Box 1). An ECG would have been indicated if these additional
treatments were initiated. Due to the additional loss of
Correcting electrolyte imbalances and potassium through the urine while receiving IVFT the
metabolic acidosis patient was subsequently monitored for hypokalae-
The reduction or cessation of the glomerular filtration mia; this potassium would have been supplemented as
rate (GFR) causes post-renal azotaemia, hyperkalae- required.
mia, hypocalcaemia and metabolic acidosis (Segev et
al, 2011). Hypocalcaemia occurs as a result of calcium Flushing the urinary tract to remove potential
binding to the excess phosphorus in the blood, which obstructions
would normally be excreted by the kidneys (Lee and High IVFT rates aid excretion of waste products that
Drobatz, 2003). Hyperkalaemia is also the product of have accumulated within the blood, as well as physi-
reduced excretion of potassium by the kidneys (Lee cal flushing of potential obstructive material, such as
and Drobatz, 2003). uroliths. Urine output was closely monitored to en-
Potassium builds up in the blood and has deleterious sure there was not a further obstruction.
effects on cardiac muscle, which are evident by elec- High rates of IVFT are essential to resume hypovol-
trocardiogram (ECG) examination (Segev et al, 2011). aemia, electrolyte imbalances and diuresis of waste
Spiked T waves and wide QRS complexes are typical of products, however, the hydration status of the patient
hyperkalaemia (Matthews, 2011). An ECG was not used needs to be closely monitored to prevent overhydra-
for this patient; however, on reflection it would have tion, as well as dehydration, especially if the patient
been beneficial to have carried this out, especially as experiences post-obstructive diuresis, as discussed
the patient presented with bradycardia. below.
A balanced electrolyte solution, such as Hartmann’s,
contains sodium chloride, calcium and potassium as Monitoring urine output
lactate. The amount of potassium in Hartmann’s (5 Monitoring the quality and quantity of urine output
mmol/l) has previously been thought to be detrimen- is an essential part of determining the physiological
tal to the hyperkalaemic patient and sodium chloride state of the patient, ensuring the patient is not re-
0.9% has frequently been the fluid of choice (Drobatz obstructing, nor becoming dehydrated. The urinary

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collection bag was weighed every 2 hours, enabling

the volume of urine to be calculated. Ideally urine Box 2. Potential problems with indwelling urinary catheters
output is between 1–2 ml/kg/hour (Matthews, 2011),
however the phenomenon of post-obstructive diure- llUrinary tract infection (UTI) can be caused as a direct result of introducing bacteria
sis may cause volumes to exceed this. Reduced GFR in to the bladder at the time of catheterisation (Sullivan et al, 2010). The risk is
and therefore tubular function results in excessive therefore increased with repeated catheterisation (Chandler et al, 2007). Daily uri-
urine production (Francis et al, 2010). The fluid ther- nalysis promoted early detection of UTIs and if suspected the catheter would have
apy plan incorporated measuring urine output and been removed immediately and the tip of the catheter sent for culture, although this
exceeding this rate with IVFT to avoid subsequent can take 3 days to receive results (Matthews, 2011). Indicators may have been an
dehydration. altered pH, protein, white blood cells on the dipstick and/or bacteria seen under a
Initially urine will be darker than expected in a microscope. Prophylactic use of antibiotics is not recommended (Segev et al, 2011)
healthy patient due to haematuria from the stretching and the application of aseptic technique when handling the urinary drainage system
and inflammation of the bladder, as well as catheteri- is paramount to minimising the occurrence of UTI’s (Choong et al, 2001).
sation attempts (Segev et al, 2011). This was considered
when reading the urine dipstick because the colour llCystitis is often associated with urinary catheterisation, especially male cats with
distorted the interpretation of the readings. very narrow urethras (Chandler, et al 2007). The patient frequently visited his lit-
ter tray and squatted as if he wanted to urinate while the catheter was in place,
Management of indwelling however this resolved once it was removed.

urinary catheter llBlockage of the catheter is particularly relevant for cats that have obstructed initial-
Attentive management of indwelling urinary cath- ly due to urethral plugs or uroliths (Segev et al, 2011). Urine out-put may reduce
eters is essential for the patient’s wellbeing, especially and eventually cease to flow. This can be distinguished from oliguria by palpation
as there are several complications typically associated of an increasing sized bladder as well as performing an ultrasound to ensure the
with their use (Oosthuizen, 2011). Correct manage- tip of the catheter is positioned in the bladder. It is not recommended to flush the
ment requires knowledge of the potential problems, patient’s catheter unless a blockage is suspected due to the increased risk of UTI.
how to recognise the problem and how to avoid the
problem occurring (Chandler et al, 2007) (Box 2). llSelf removal of the catheter is undesirable due to the potential for re-obstruction,
On reflection, the potential risks associated with trauma to the urethra and the associated risks with re-catheterisation. A buster
urinary catheters were acknowledged throughout the collar was worn by the patient at all times to avoid interference and it was ensured
nursing of this patient. The urine collection system that the tubing of the closed urinary drainage system was not restrictive to the
was handled in a strictly aseptic manner, including patient, for example, it was not caught in the kennel door.
hand washing as per the World Health Organisation
(WHO) guidelines (Allegranzi and Pittet, 2009) and llUrethral damage is particularly applicable in male cats because of the narrow
the application of sterile gloves and a closed urinary urethra (Corgozinho et al, 2007). Care must be taken to gradually advance uri-
system was used. A urinary tract infection (UTI) was nary catheters, particularly when passing the ischial curve (Chandler et al, 2007).
not suspected, however the catheter tip was still sent Damage can manifest from inflammation asa small amount of bleeding, to urethral
for culture, the results of which were negative. rupture and uroabdomen (Corgozinho et al, 2007). The patient was monitored for
A closed urinary drainage system was used to aid signs of deterioration, but this was not applicable to him.
calculation of urine output, avoid urine scald and
minimise the risk of UTI (Oosthuizen, 2011). A study
on dogs by Sullivan et al (2010) reports that the use of wet legs and feel clean due to wearing a buster collar,
an open or closed urinary drainage system does not and therefore a closed urinary system was chosen for
affect the occurrence of nosocomial UTIs. However, this patient.
the terminology used to describe open collection and There are several reports detailing the dangers as-
closed collection drainage systems needs to be care- sociated with urethral catheterisation. For example,
fully interpreted. Bloor (2013) explains how an open Corgozinho et al (2007) discusses the trauma caused
collection system does not necessarily mean one that by urethral catheterisation in male cats. However, the
leaves urine to leak freely, but can mean one where sample group in this report only comprised 15 cats,
the bag is disconnected from the patient, and be- which is relatively few, especially when considering
lieves that the Sullivan study was looking at a simple that feline urethral obstructions is classed as a com-
closed collection drainage system. Ultimately a holis- mon emergency (Segev et al, 2011). Oosthuizen (2011)
tic approach to the care of this patient was important. explains the link between the correct management of
Urine leaking directly from the patient would cause indwelling urinary and avoidance of complications,
urine scald, and the patient was unable to clean his which has been demonstrated by this patient.

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Table 1. Nursing care plan for feline patient post-urethral obstruction

Ability Potential problem Short-term goal Nursing interventions Monitoring

Eat adequate Anorexia Maintain RER (30 x Once anti-emetic taken effect, Q2hr offer food, until eating
amounts Vomiting 5kg)+70 = 220kcal offer prescription lower urinary RER, then reduce to Q4-6hr
diet, but remove if not eaten
within 20 mins. Could try other Q24hr Maropitant (1mg/
Cease vomiting favourite foods initially to get kg) s/c
episodes eating
Q1hr until anti-emetic taken
Administer anti-emetic effect
medication on time
Clean up vomitus immediately
Drink adequate Dehydration Avoid dehydration Maintain IVFT adequate for urine Q2hr check hydration status,
amounts output including blood pressure
Over-hydration Avoid over -hydration Q4hr check renal parameters
Monitor electrolytes (urea and creatinine)
Hypokalaemia following Maintain normal
high fluid rates electrolyte levels Remove IV catheter and replace Q4hr check electrolytes until
if inflammation. Keep bandaged normalised, then Q12hr
Intravenous (IV) Avoid inflammation/ and b/collar to be worn at all Q4hr check heart rate,
catheter site patient interference times. Monitor site/foot for respiratory rate
inflammation with IV site swelling/pain
Q6hr un-bandage and check
IV catheter placement site
Q6hr flush IV catheter with
heparin flush
Urinate normally Post-obstructive diuresis Avoid dehydration Intravenous fluid therapy (IVFT) Q2hr weigh urinary
to meet urine output collection bag, adjust IVFT
Urinary catheter Avoid obstruction accordingly
obstruction Monitor for blockage indicated
Maintain hygiene of by decrease in urine production Q6hr clean entry site
Urinary tract infection urinary catheter of catheter with dilute
Ensure B/collar fitted at all hibiscrub
times, aspetic handling of Q12hr urinalysis and specific
urinary drainage system, e.g. gravity
WHO hand washing, sterile Q12hr empty bag in aseptic
gloves worn manner
Defecate normally Constipation Patient to feel relaxed Replace litter tray as soon as When applicable
enough to defecate soiled. Supply preferential litter
and not hold on e.g. soil if usually goes outside.
Allow ‘private time’.
Maintain body Hypothermia Maintain Maintain cardiovascular Q2hr check rectal temp until
temp normothermia circulation, supply clean/dry normal, then Q6hr
bedding at all times. Active
warming, including Bair Hugger,
until 37ºC to avoid over heating
Groom self B/collar worn, unable to Maintain coat and Groom with soft brush, remove Q24hr groom
groom skin quality and soiled bedding asap
cleanliness
Mobilise Indwelling urinary Urinary tubing should Check line not stuck in kennel Every time open kennel door
adequately catheter minimising be free moving door and it remains firmly
mobility secured to patient with sutures
Could tape line to tail if patient
particularly active
Sleep/rest Painful Adequate analgesia Buprenorphine (20µg/kg IV) Q6–8hr Glasgow Pain Score
administered Q8hr
Express normal Stressed, leading to re- Minimise stress in Remove barking dogs from area, At all times
behaviour obstruction environment advise all staff to be calm and Q2hr check mentation
quiet

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The patient showed frustration with wearing a

buster collar by attempting to scratch it off and rub-
bing it along the kennel bars. This was eased by regu- Key points
lar grooming with a soft brush and allowing super- llFeline urethral obstruction can causes serious metabolic derangements, requiring
vised periods without the collar being worn (Table 1). urgent attention.
llThe most significant electrolyte disturbance is hyperkalaemia, which if severe, can
Conclusion causes life-threatening arrhythmias.
The recognition of potential complications associat- llSpecific monitoring for this condition includes electrocardiogram (ECG), frequent
ed with urethral obstruction and the nursing care in- electrolyte analysis and urinalysis, including urine output.
volved was paramount to the successful treatment of llTreatment comprises fluid therapy and analgesia. Antibiotics are not indicated un-
this patient. Strict aseptic technique when handling less culture is positive.
the urinary collection system and close monitoring of llHolistic care for these patients considers the consequences of urinary catheters,
hydration status is vital. In the absence of early de- for example, a buster collar must be worn meaning the patient is unable to groom.
tection of problems including electrolyte imbalance,
urinary catheter obstruction and over or under hydra- mended to only flush the urinary catheter if there is a
tion, the speed of recovery becomes compromised, as high suspicion of blockage.
does the wellbeing of the patient. Ultimately, it is recommended that a detailed
For future practice it is advisable to initiate an ECG nursing care plan is produced at the start of treat-
at initial presentation and as part of on-going treat- ment which covers all eventualities, and is a docu-
ment to monitor effects of electrolyte imbalances, ment referred to by all those involved with the pa-
in particular potassium on the cardiac muscle, and tient’s care.  VN
to ensure any effects are resumed. It is also recom-
Conflict of interest: none.
References
Allegranzi B, Pittet D (2009) Whitfield H (2001) Catheter obstruction. Am J Vet Res and critical care. Replika pathological characteristics
Role of hand hygiene in associated urinary tract in- 71(1): 840–6 Press, India: Ch 8 and prognosis. J Feline Med
healthcare-associasted in- fection and encrustation. Drobatz K, Cole S (2008) The Lee J, Drobatz K (2003) Char- Surg 13(2): 101–8
fection prevention. Journal Int J Antimicrobial Agents influence of crystalloid type acterisation of the clinical Sullivan L, Campbell V, Onu-
of Hospital Infection 73(4): 17(4): 305–10 on acid-base and electrolyte characteristics, electro-
305–15 ma S (2010) Evaluation of
Corgozinho K, Souza H, Perei- status of cats with urethral lytes, acid-base and renal
open versus closed urine
Bloor C (2013) The use and ra A et al (2007) Catheter- obstruction. J Vet Emerg parameters in male cats
collection systems and de-
management of closed uri- induced urethral trauma in Crit Care 18(4): 355–61 with urethral obstruction.
nary catheters. The Veteri- J Vet Emerg Crit Care 13(4): velopment of nosocomial
cats with urethral obstruc- Francis B, Wells R, Rao S,
nary Nurse 4(5): 264–75 227–33 bacteriuria in dogs. J Am Vet
tion. J Feline Med Surg 9(6): Hackett T (2010) Retrospec-
481–6 Med Assoc 237(2): 187–90
Chandler S, Seymour J, Jeffery tive study to characterize Oosthuizen C (2011) How to
A (2007) General nursing, Cunha M, Freitas G, Carregaro post-obstructive diuresis in place and manage ind- Woolf K (2012) Feline lower
the nursing process and A et al (2010) Renal and cats with urethral obstruc- welling urinary catheters. urinary tract disease: pre-
nursing models. In: Lane D, cardiorespiratory effects tion. J Feline Med Surg 12(8): The Veterinary Nurse 2(5): disposition, causes and
Cooper B, Turner L. BSAVA of treatment with lactated 606–8 266–71 nursing care. The Veterinary
Textbook of Veterinary Ringer’s solution or physi- Mathews KA (2011) Renal and Segev G, Livne H, Ranen E, Nurse 3(7): 406–12
Nursing 4th Edition. Replika ologic saline (0.9% NaCl) urinary tract emergencies. Lavy E (2011) Urethral ob-
Press, India, Ch 15: 264–5 solution in cats with experi- In: King L, Boag A, eds. Ca- struction in cats: predispos-
Choong S, Wood S, Fry C, mentally induced urethral nine and feline emergency ing factors, clinical, clinico-

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