GUIDANCE ON THE MANAGEMENT OF INDWELLING URINARY CATHETERS

Transcription

1 GUIDANCE ON THE MANAGEMENT OF INDWELLING URINARY CATHETERS Version 1.9 (01 st October 2014) (Revised 24/11/14) CLINICAL GUIDELINES ID TAG Title Author Designation Specialty / Division Directorate Date Consulted upon Approved by Review Date (Every 2 years or sooner if required) Clinical Guideline ID Guidance on the Management of Indwelling Urinary Catheters Dr Nizam Damani Associate Medical Director Infection Prevention and Control Microbiology / Infection Prevention and Control Medical Directorate 01/10/2014 YES HCAI Strategic Forum 01/10/2015 CG st October 2014 Guidance on the management of indwelling urinary catheters 1

2 SECTION 1 INDICATIONS FOR URINARY CATHETER CONSIDERATION PRIOR TO CATHETERISATION Catheterisation should only be considered following the completion of a comprehensive patient assessment which includes the following considerations: Does the patient really need the indwelling urinary catheter? Can bladder drainage be obtained by any other means e.g. intermittent catheterisation? If the answer is yes, then agree the most suitable route of catheterisation e.g. urethral or supra-pubic? INDICATIONS FOR THE USE OF INDWELLING URINARY CATHETERS Examples of appropriate uses of indwelling catheters Patient with acute or/and chronic urinary retention or bladder outlet obstruction (NB constipation may cause outlet obstruction) Maintain a continuous outflow of urine for patients with voiding difficulties, as a result of neurological disorders that cause paralysis or loss of sensation affecting urination Need for accurate measurements of urinary output in critically ill patients Perioperative use for selected surgical procedures e.g. patients undergoing urological surgery or other surgery on contiguous structures of the genitourinary tract Anticipated prolonged duration of surgery catheters inserted for this reason should be removed in theatre recovery unit Patients anticipated to receive large-volume infusions or diuretics during surgery or need for intraoperative monitoring of urinary output To assist in healing of open sacral or perineal wounds in incontinent patients Patient requiring prolonged immobilization e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries such as pelvic fractures To improve comfort for end of life care if needed Examples of inappropriate uses Don t use indwelling catheters a substitute for nursing care of the patient or resident with incontinence Don t use as a means of obtaining urine for culture or other diagnostic tests when the patient can voluntarily void Don t use for prolonged postoperative duration without appropriate indications 01 st October 2014 Guidance on the management of indwelling urinary catheters 2

3 SECTION 2 STRATEGIES TO PREVENT CATHETER- ASSOCIATED URINARY TRACT INFECTIONS (CAUTI) Fig 1: The three main sites through which bacteria may reach the bladder of a patient with an indwelling urethral catheter. Please refer to corresponding Table 1 for preventative measures Table 1: Summary of strategies to prevent CAUTI (see Fig 1) 1. EXTERNAL URETHRAL MEATUS AND URETHRA Bacteria carried into bladder during insertion of catheter Ascending colonisation up urethra Use aseptic non-touch technique (ANTT) for insertion Pass catheter when bladder is full (preferably) for wash-out effect. Use bladder ultrasound, if available Before catheterization clean the urinary meatus using (single-use sterile) water/saline or antiseptic solution Use single-use sterile gel. If 2% lignocaine anaesthetic (single-use sterile) gel is used, then inject gel into urethra and hold it for 3-5 min before inserting catheter Use sterile items /equipment (sterile catheter, sterile gloves,single-use sterile solution etc). Use Urinary Catheter Pack, where available Keep peri-urethral area clean and dry. Don t use catheter maintance solution or ointments Secure catheter appropriately to prevent movement in urethra After faecal incontinence, clean perineum as soon as possible. Maintain unobstructed urine flow and ensure that the catheter and drainage bag tubing are free of kinks 2. JUNCTION BETWEEN CATHETER AND DRAINAGE TUBE Do not disconnect catheter unless absolutely necessary for e.g. when replacing the leg bag Closed drainage bag should not be disconnected. If a sample of urine is required for bacteriological examination, it should be obtained from a sampling port using an aseptic technique ( see page 8). 3. TAP AT BOTTOM OF COLLECTION BAG Reflux from bag into catheter Emptying of bag Ensure the drainage bag is never raised above the height of the bladder and keep the catheter and collecting tube free from kinking. Do not hold the bag upside down when emptying. The drainage bag must never touch the floor Empty the bag every 8 hours or when 2/3 full. Use a separate disinfected jug to collect urine from each bag and prevent contact of the drainage spigot with the non-sterile collecting jug/container. Don t instil antiseptic into urinary bag after emptying Always wash or disinfect physically clean hands with an alcoholic hand rub before and after opening tap. 01 st October 2014 Guidance on the management of indwelling urinary catheters 3

4 SECTION 3 URINARY CATHETER BUNDLE INSERTION CARE BUNDLE CATHETER NEEDED? Avoid unnecessary catheterisation. Consider the use of a condom sheath and leg bag or intermittent catheterisation in appropriate patients Use portable bladder ultrasound if available to assess urine volume as this may help to reduce unnecessary catheterizations Ensure that only properly trained and competent persons insert the catheter. Choice of urinary catheter should be based on individual patient assessment. Use smallest catheter size PERSONAL PROTECTIVE EQUIPMENT Wear appropriate Personal Protective Equipment (PPE) e.g. plastic apron, sterile gloves Gloves are single-use items and should be removed and discarded immediately after the care activity. Always decontaminate hands after removal of gloves USE STERILE ITEMS/EQUIPMENT Use sterile items/equipment (sterile catheter, sterile gloves, drapes, swabs, single-use sterile solution, etc.). Use Urinary Catheter Pack, where available. Prior to insertion, clean meatus with single-use sterile solution of normal saline/water or antiseptic solution. Use single use sterile gel. If 2% lignocaine anesthetic gel is used, insert gel into urethra and hold it for 3-5 min before inserting catheter ASEPTIC NON-TOUCH TECHNIQUE (ANTT) & HAND HYGIENE Use aseptic non-touch technique (ANTT) throughout the procedure and always wash or disinfect physically clean hands with alcoholic hand rub using 7 step hand hygiene technique CLOSED DRAINAGE SYSTEM Use closed drainage system After insertion properly secure catheter to prevent movement in urethra Maintain unobstructed urine flow by ensuring that the catheter and drainage bag tubing are free of kinks 01 st October 2014 Guidance on the management of indwelling urinary catheters 4

5 MAINTENANCE CARE BUNDLE (Ongoing care) CATHETER NEEDED? Review the need for the catheter on a daily basis (in hospital and care homes) and if not needed remove as soon as possible Document daily assessment in the Catheter Monitoring Form In community review the catheter as per the catheter management plan. CATHETER HYGIENE AND HAND DECONTAMINATION Encourage patients to wash the catheter daily as part of their usual hygiene using warm soapy water. Advise that the catheter should be washed away from the urethra to reduce risk of infection. Ensure the area is dried gently and thoroughly afterwards. Always wash or disinfect physically clean hands with alcoholic hand rub using 7 step hand hygiene technique before and after each patient contact CATHETER MANIPULATION A new pair of non-sterile gloves should be worn to manipulate a catheter Always wash or disinfect physically clean hands with alcoholic hand rub using 7 step hand hygiene technique before and after manipulation of catheter SAMPLING Don t routinely send sample to the Lab for microbiological investigation; send CSU sample only if clinically indicated Use of dipsticks are not reliable for diagnosis of CAUTI After removal of catheter, don't send catheter tip to the Lab for culture If urine specimen required, take specimen aseptically via the sampling port (see page 8). Don t break the closed drainage system DRAINAGE BAG POSITION Keep the drainage bag above the floor but below bladder level to prevent reflux and contamination. The collection bag must never touch the floor. Always wash or disinfect physically clean hands with alcoholic hand rub using 7 step hand hygiene technique before and after opening tap Use a separate disinfected jug to collect urine from each bag 01 st October 2014 Guidance on the management of indwelling urinary catheters 5

6 SECTION 4 FREQUENTLY ASKED QUESTIONS A. INSERTION OF URINARY CATHETER Q1: What size of catheter should I use? Catheter size relates to the circumference of the catheter. In general, the smallest /size/gauge/ diameter of catheter should be selected to allow free flow of urine as it less likely to be associated with leakage. Larger diameter catheters should be avoided because they can block the urethral gland and put pressure on the urethral mucosa, which may result in ischaemic necrosis. In addition, they are also resistant to bending and are more likely to cause pressure necrosis, especially in males. Urological patients may require larger diameter catheters and these must be used on the advice of the urologist. Q 2: Does routine use of an antiseptic coated catheter prevent Catheter-Associated Urinary Tract Infections (CAUTI)? No. Overall, the evidence suggests that these urethral catheters reduce the risk of bacteriuria, but there is insufficient evidence to indicate whether they reduce the risk of CAUTI. Therefore they must not be used routinely and should be considered only in selected patients with recurrent CAUTI which persists despite the implementation of all the infection prevention and control measures outlined in this guideline. Q 3: What solution should I use to clean urethra before insertion of catheter? Epic3 guideline (2014) expert opinion indicates that there is no advantage in using antiseptic preparations for cleansing the urethral meatus prior to catheter insertion. This is an unresolved issue so use of either sterile saline /water or antiseptic solution (0.015 % chlorhexidine gluconate/ 0.15 cetrimide can be used for meatal cleaning before catheter insertion. Q 4: Is routine administration of prophylactic antibiotic at the time of insertion necessary? No. Routine administration of prophylactic (IV or oral) antibiotics at the time of catheter insertion or removal is not recommended. However, it should be considered in high risk patients e.g. cases of suspected/confirmed UTI and in those who have had a previous episode of bacteremia during catheter change. Don t send a urine sample after catheter removal routinely but a sample must be sent for patients where there is a high degree of suspicion or symptoms suggestive of infection. If antibiotic is considered necessary, it should be based on the previous culture and sensitivity result. If culture and sensitivity are not available then administer single high dose gentamicin (3-5 mg/kg of body weight); teicoplanin or vancomycin can be added if patient is known to be colonised with MRSA. Don t give additional dose of gentamicin until blood levels are available (refer to the Trust intranet for further guidance on monitoring of antibiotics). B. DAILY MAINTENANCE OF URINARY CATHETER Q 5: Why daily monitoring of the catheter is necessary? This is absolutely essential to prevent both infective and non-infective complications. Daily review will allow you and the clinical team to assess the need for catheterisation on a daily basis so that the catheter can be removed promptly if no longer necessary to prevent complications. In addition, it will allow the clinical team to diagnosis CAUTI at an early stage to prevent blood stream infections. Therefore, it is essential that the clinical team review and document the need for catheter on a daily 01 st October 2014 Guidance on the management of indwelling urinary catheters 6

7 basis using the Urinary Catheterisation Insertion and Maintenance form (see Appendix 3, p. 13). This form must be kept at the patient s bedside for the duration of catheterization and then in the medical notes when the catheter is removed. Q 6: Is daily administration of prophylactic antibiotic necessary to prevent CAUTI? No. Long-term oral antibiotic prophylaxis is not recommended to prevent CAUTI as they are not only ineffective due to presence of biofilm on the catheter but also predispose to infection with resistant bacterial and yeast infections and are responsible for causing C.difficle infections. Routine administration of prophylactic (IV or oral) antibiotics is not recommended at the time of catheter removal. However, it should be considered in high risk patients e.g. cases of suspected/confirmed UTI and in those who have had a previous episode of bacteremia during catheter change Q 7: Is daily administration of cranberry juice necessary to prevent CAUTI? No. Recent Cochrane review concludes that use of cranberry juice doesn t prevent UTI. Q 8: Should I use a catheter maintenance solution routinely? No. These solutions should only be used as part of a catheter management plan and after discussion with the Specialist Continence Team. They should not be used to unblock urinary catheters. Q 9: If a patient has a low urinary output should I flush the catheter with sterile water? No, routine flushing in these circumstances is not recommended as breaking the closed drainage system is responsible for causing CAUTI Q 10: How often should I replace the catheter? The optimal time limit for replacing the catheter depends upon individual circumstances and the type of catheter used; please follow manufacturer s recommendations. Q 11: How often should I perform meatal cleaning? Daily routine bathing or showering is all that is needed to maintain meatal hygiene. Meatal cleansing should be performed at intervals appropriate for keeping the meatus free of encrustations and contamination. This is usually performed daily with warm soapy water as part of routine hygiene measures; use of antiseptic solutions is not necessary. Don t apply antibiotic/ antiseptic ointment to the urethral meatus. If faecal incontinence occurs, the perineum must be cleaned as soon as possible. Q 12: How often should I empty drainage bag? As a guide, the drainage bag should be emptied regularly (i.e. 8 hourly or when 2/3 full or earlier if it fills rapidly) via the drainage tap at the bottom of the bag to maintain urine flow and to prevent reflux. The spout from the tap must be completely emptied to minimize a build-up of microorganisms in the stagnant urine. Extreme care must be taken when emptying the drainage bag to prevent cross-infection. Non-sterile single-use gloves should be worn before emptying each bag. Alcohol impregnated swabs may be used to decontaminate the outlet (inside and outside) before and after emptying the bag. When the bag is empty, the tap should be closed securely and wiped with a tissue. If the bag does not have a tap, replace it when the bag is full using aseptic technique. Do not reconnect a used bag. Use a separate disinfected jug/receptacle to collect urine from each bag and avoid contact between the urinary drainage tap and the container. Wash and dry hands thoroughly after touching the drainage bag or disinfect physically clean 01 st October 2014 Guidance on the management of indwelling urinary catheters 7

8 hands with alcoholic hand rub using 7 step hand hygiene technique. In hospital settings, the urine receptacle should be heat disinfected; in community it must be cleaned, and stored dry after each use. Single-use disposable receptacles may be used. Q 13: How often should I replace the drainage bag? The optimal time limit for replacing the drainage bag depends upon individual circumstances and the type of catheter used, please follow manufacturer s recommendations which usually state every five to seven days. However, bags should be changed earlier if they become discoloured contain sediment, smell offensive or are damaged. C. DIAGNOSIS OF CAUTI Q 14: How do I collect a Catheter Specimen of Urine (CSU) if clinical team suspects infection? Use of urine dipstick to diagnose UTI on a catheterised patient is not recommended. If CAUTI is suspected, the specimen must be obtained aseptically using sterile technique by needle aspiration from the proximal drainage tubing/sampling port (see Fig 2) and not from the urine bag. The Closed drainage bag should not be disconnected to obtain a sample as this poses a risk of infection to the patient. Fig 2. How to collect a urine sample If the drainage bag has a needle-free sampling port, first disinfected the port by wiping with a 70% isopropyl alcohol and allow to dry and then insert the barrel of an empty sterile syringe into the sample port and withdraw the desired amount of urine. If the sampling port is not needle-free then first disinfect the port by wiping with a 70% isopropyl alcohol wipe and allow to dry and then aspirate the urine sample using a sterile small bore needle and syringe and transferred into a sterile urine container. Send the urine specimen to the Microbiology Lab for culture and sensitivity. Please record on the microbiology form that this is a CSU specimen and record any antibiotics which the patient is receiving. Sampling port on leg bag Q 15: Do I have to treat asymptomatic bacteriuria to prevent CAUTI? No. The treatment of asymptomatic bacteriuria (i.e. significant bacteriuria in the absence of clinical symptoms) in patients who require continued catheterisation is not indicated. Antibiotics are only indicated if there is evidence of infection and the patient is symptomatic 01 st October 2014 Guidance on the management of indwelling urinary catheters 8

9 Q 16: Should I send CSU on a regular basis even when the patient has no symptoms? No. Routine bacteriological testing of urine is not indicated. Urine sample for culture and sensitivity should only send if you suspect CAUTI. Use of dipstick in diagnosing CAUTI is not reliable and should not be used. Q 17: How do I diagnose CAUTI? This can be difficult as you cannot always rely on a positive culture result or dipstick which is invariably positive in most patients with a urinary catheter after few days of insertion. Diagnosing CAUTI is therefore based on your clinical assessment as most patients are elderly and may not able to communicate properly so a thorough examination of the patient is required and ruling out other sources of infection is essential before diagnosis of CAUTI is made. As a guide, most patients with CAUTI may have bladder spasm, suprapubic tenderness, usually have fever (> C), and/or renal angle tenderness. Renal angle tenderness in the absence of any other underlying pathology usually indicates pyelonephritis. Q 18: How do I treat CAUTI? Once the diagnosis of CAUTI is established, antibiotic treatment should be initiated on an empirical basis with broad-spectrum antibiotics based on local susceptibility patterns and later adjusted according to the urine culture results. Route of antibiotic therapy (IV or oral) depends on patient s clinical condition; septic patient should be referred to the hospital for IV therapy. If the culture result is not available use gentamicin (3-5 mg/kg of body weight); teicoplanin or vancomycin can be added if patient is known to be colonised with MRSA. Don t give additional dose of gentamicin until blood levels are available (refer to the Trust intranet for further guidance on monitoring of antibiotics). It is essential that CSU must be sent prior to administration of antibiotic therapy. The catheter should then be replaced after starting antimicrobial therapy to prevent bloodstream infections. Treating infection with an antibiotic in the presence of a catheter is not recommended as bacteria are embedded in the biofilm and encrustation on the surface of the catheter and may be protected from the action of antibiotics. However, if the indwelling catheter has been in place for less than a week, treatment with antibiotics without removal of the catheter may be successful. There are no adequate clinical studies to guide the length of therapy for CAUTI and therefore the duration of treatment depends on the severity of clinical symptoms; advice from the clinical microbiologist should be sought if necessary. Q 19: How do I manage Candiduria in presence of urinary catheter? While it is clear that symptomatic candiduria requires treatment, it is controversial whether asymptomatic candiduria requires treatment. Frequently, candiduria resolves without treatment if the catheter is removed. In the case of candiduria associated with urinary symptoms or if candiduria is secondary to systemic infection, parenteral therapy with an antifungal is indicated. However, the presence of candida in a urine sample may reflect local infection elsewhere, e.g. vaginal thrush in a female and balinitis in a male. Diabetes predisposes to the development of candiduria as glycosuria enhances urinary growth of Candida spp. In addition, diabetes also impairs host defenses, particularly phagocytosis and the development of a neurogenic bladder allows for urinary stasis and increases the likelihood that the urinary tract will be instrumented. 01 st October 2014 Guidance on the management of indwelling urinary catheters 9

10 REFERENCES APIC Implementation Guide Guide to Preventing Catheter-Associated Urinary Tract Infections. Washington: APIC, 2014 Cochrane Review: Cranberries for preventing urinary tract infections. Cochrane Library, epic3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 2014: 86 (Supplement 1): S1 S70. European and Asian guidelines on management and prevention of catheter-associated urinary tract infections. International Journal of Antimicrobial Agents 2008: 31S; S68-S78. European Association of Urology. Guideline on urological infections. European Association of Urology, HICPAC. Guideline for prevention of catheter-associated urinary tract infections Atlanta: CDC, International Clinical Practice Guidelines from the Infectious Diseases Society of America. Diagnosis, Prevention, and Treatment of Catheter Associated Urinary Tract Infection in Adults: Clinical Infectious Diseases 2010; 50: Royal College of Nursing Catheter care. RCN guidance for nurses. London: RCN, Royal Marsden Manual of Clinical Nursing Procedures. London: Wiley-Blackwell, SHEA/IDSA Practice Recommendation: Strategies to Prevent Catheter-Associated Urinary Tract Infections in Acute Care Hospitals: 2014 update. Infection Control and Hospital Epidemiology 2014; 35(5): SIGN 88. Management of suspected bacterial urinary tract infection in adults - A national clinical guideline. Edinburgh: Scottish Intercollegiate Guidelines Network, Tenke P et al. An update on prevention and treatment of catheter-associated urinary tract infections. Current Opinion in Infectious Diseases 2014; 27: st October 2014 Guidance on the management of indwelling urinary catheters 10

11 Appendix 1: PROCEDURE OF URETHRAL CATHETERISATION NOTE: Urethral catheterisation is considered as a minor surgical procedure therefore the catheter must be inserted using sterile equipment and Aseptic Non-Touch Technique (ANTT) which must be maintained throughout procedure. Equipment required Sterile catheterisation pack containing a gallipot, receiver, swabs, sterile drapes Single use sterile lubricating gel Appropriate catheter 0.9% sodium chloride or antiseptic solution Sterile water and needle & syringe for inflating balloon Sterile gloves x 2 pairs Disposable plastic apron Alcohol hand rub Disposable pad Appropriate drainage system Leg bag straps/stand or holder Explain the procedure to the patient, obtain a verbal consent and provide privacy to patient. Ensure all equipment is available. Check expiry dates, integrity of containers/packages. Decontaminate hands with alcohol hand rub or soap and water then assist patient into supine position with legs bent, hips flexed (female) and supine with legs extended (male). Ensure good light source is available. Place bed protection on the bed and cover the patient. Wash hands with an antiseptic solution for 1 minute or disinfect physically clean hands with alcohol hand rub. Clean trolley with a detergent wipe then disinfect with a 70% alcohol wipe and allow to air dry. Place all equipment required on the bottom shelf. Take trolley to bedside. Decontaminate hands with alcohol hand rub, apply a disposable plastic apron, open out sterile dressing pack & supplementary packs e.g. sterile gloves, catheter onto top of trolley using ANTT. Remove cover from patient, decontaminate hands with alcohol hand rub and apply sterile gloves. Pour sterile single use cleansing solution into gallipot & apply sterile drapes to patient.. Hold the penis with a sterile swab, retract the foreskin if present and clean the shaft, glans and urethral meatus using cleansing solution. Separate the labia so that the urethral meatus is visible. Cleanse the vulval area using a front-to-back technique, using cleansing solution. Instill a single use sterile lubricant or 2% lignocaine gel slowly into the urethral meatus (if 2% lignocaine used wait for 3-5 minutes. Remove and dispose of gloves, decontaminate hands with alcohol hand rub and apply sterile gloves. Open the inner sleeve of the catheter and expose the distal 10cm of catheter only. Advance catheter into the urethra orifice (touching only the inner sleeve and never the catheter directly) until urine flows, avoiding contact with non-sterile surface while observing for any signs of discomfort. NB if difficulty encountered seek advice/help. Inflate the balloon with sterile water as per manufacturer s recommendations. If the patient feels any pain or discomfort during balloon inflation, the catheter may not be inside the bladder remove any instilled water from inflation channel, advance the catheter a little further and try to inflate the balloon again. If this is still unsuccessful seek help. Otherwise withdraw catheter until resistance is felt and attach the drainage bag using ANTT. Hang the drainage bag below the level of the bladder to stop reflux or apply the leg bag with the support. The bag must be supported in the drainage stand to allow free flow of urine and to prevent the bag from touching the floor. Remove gloves then apron, dispose of used equipment in a clinical waste bag, then decontaminate hands. Clean trolley with detergent wipe and decontaminate hands. After 30 minutes measure the amount of residual urine drained. Document the procedure on the Urinary Catheter Insertion and Monitoring Form/Community catheterisation form, using the label supplied with the urinary catheter. 01 st October 2014 Guidance on the management of indwelling urinary catheters 11

12 APPENDIX 2 TYPES OF URINARY CATHETERS LENGTH OF STAY TYPE OF MATERIAL & SIZE BALLON SIZE CATHETER LENGTH Urethral Catheter Short-term: up to 28 days P.T.F.E. (Polytretrafluroethylene) Male: Female: Paediatric: 14-16ch 12-14ch 8-10ch Male 10ml Female 10ml Paediatric 5ml Inflate with sterile water according to manufacturer s instructions. Male/standard : Approx. 43 cm Female Approx. 25 cm Paediatric Approx. 30 cm Urethral Catheter Long-term: up to 12 week Hydrogel coated latex Hydrogel coated silicone 100% silicone Sizes as above Male/standard Female Paediatric 10ml 10ml 5ml Male/standard Female: Paediatric: Approx. 43 cm Approx. 25 cm Approx. 30 cm Supra-pubic catheter Long term: up to 12 weeks Bardex I C Short-term: up to 28 days Must not be used routinely but may be considered in selected patients only for recurrent CAUTI's Release NF Short-term: up to 28 days Must not be used routinely but may be considered in selected patients only for recurrent CAUTI's P.T.F.E (Polytretrafluroethylene) Hydrogel coated latex Hydrogel coated silicone 100% silicone (check is catheter is licensed for supra pubic use) Sizes: 16-18ch Foley catheter with silver alloy coating and hydrogel Male: 14-16ch Female: 12-14ch All-silicone Foley catheter that contains the antimicrobial agent nitrofurazone. Male/standard Female Paediatric 10ml 10ml 5ml Male/standard Female: Approx. 43 cm Approx. 25 cm Male/standard 10ml Female 10ml Male/standard Approx. 43 cm Female: Approx. 25 cm Male/standard: 10mls Male/standard Approx. 43 cm 01 st October 2014 Guidance on the management of indwelling urinary catheters 12

13 APPENDIX 3 URINARY CATHETER MONITORING FORM Urinary Catheter Insertion and Monitoring Form NOTE: Keep this form at the patient s bed and file in the medical notes when appropriate. If catheter needs reinserted please use new form and file the old form in patient s notes. PATIENT DETAILS (use Addressograph label) Addresaddressograph) Name Healthcare No. Date of birth Address Consultant Hospital Ward General Practitioner Health Care facility/home INDICATION FOR CATHETERISATION CATHETERIZATION Urinary Retention Result of Bladder scan ( if available) Painful Painless Failed TROC To maintain skin integrity Urinary Input/output monitoring Other CATHETER INSERTION Patient consent obtained Yes / No Date Time Operator name Grade/designation INSERTION BUNDLE 1. Disinfect hands before insertion 2. Sterile Catheter pack used Yes / No 3. Sterile gloves used 4. Sterile items used 5. Single use sterile water/saline/antiseptic 6. Aseptic non-touch technique maintained 7. Disinfect hands after insertion Easy insertion? Yes/No. If No, why (indicate no. of attempts) Description of urine Residual volume after 30 minutes CSU collected? Yes / No. If Yes, why Closed Drainage system PPE appropriately used Yes / No. Yes / No. CATHETER INFORMATION (use label from catheter) Catheter type Standard Female Short-term Long-term ATTACH TRACER LABEL Make Lot number Size Expiry date Amount of water used to inflate balloon 01 st October 2014 Guidance on the management of indwelling urinary catheters 13 Type of Gel used Lignocaine Sterile lubricant Gel

14 Daily Review of Catheterisation DAY/DATE NAME, DESIGNATION INDICATION TO REMAIN PLAN (REMOVE, FURTHER REVIEW) Date catheter removed If failed trial removal of catheter (TROC) use new form documenting clearly it is a repeat insertion of catheter. If the patient is going home with a new catheter inform the following: Date Signature General Practitioner District nurse if housebound Continence team if not housebound This information is documented on the patient s e-discharge letter? Yes / No Patient given a urinary catheter patient information leaflet? Yes / No NOTE: Please send a photocopy of this form to the GP/District nurse/continence Team/ Nursing home 01 st October 2014 Guidance on the management of indwelling urinary catheters 14

15 APPENDIX 4 PATIENT INFORMATION LEAFLET WHAT IS A CATHETER? A Catheter is a small, flexible tube which is passed through the water pipe (urethra) into the bladder for the purpose of draining urine. The urine flows through the catheter and passes into a bag which should be strapped to your leg. When the bag is 2/3 full of urine, you will need to empty it. This is done by opening the tap at the bottom of the bag, either over the toilet or into a suitable receptacle. The most widely-used types of catheter contains latex. If you have any history of latex allergy, please inform the staff before a catheter is inserted. If you do have latex allergy, an all-silicone catheter can be used which carries a reduced risk of an allergic reaction. The catheter will be inserted by either a doctor or a nurse. They will explain the reason for the catheter and whether it needs to be permanent or temporary. The catheter will feel strange at first and you will certainly feel conscious of it. To start with, you may have a constant feeling that you want to pass urine; this is quite normal and soon settles. HOW DO I LOOK AFTER THE CATHETER? Whilst at home, you will need to care for the catheter and its drainage system. The different component parts of this are: THE CATHETER: The catheter must be treated as a part of your own body and will need to be kept clean in the same way. It is important for men to remember to retract the foreskin to enable thorough cleaning of the area to occur and ensure that the foreskin is replaced after cleansing. You can wash the catheter each day with warm, soapy water, when you take a bath or shower. You are advised to wash the catheter away from the urethra to discourage germs from entering the body and causing infection. Ensure that you dry gently and thoroughly to prevent soreness. Whilst you have a catheter in place, you will need to increase your fluid intake in order to prevent urinary infections and constipation. It is advisable that you drink more dilute fluids water/dilute juices etc. and reduce your caffeine intake eg: tea, coffee, alcohol, fizzy drinks and high energy drinks, as these types of fluids can cause your catheter to bypass. You should take care not to kink the catheter or to raise the drainage bag above the level of your bladder. You may be provided with a G-Strap which will help to keep the catheter in 01 st October 2014 Guidance on the management of indwelling urinary catheters 15

16 place. This prevents the catheter from being pulled. It has a Velcro strap around the catheter and your leg to hold the catheter firmly in position. Once your catheter has been inserted, the nurse looking after you will give you any additional information that you require. They will also supply you with leg bags and night time bags to bring home with you and will refer you to a nurse within the community setting; this may be a District Nurse or a Continence Nurse. The District Nurse or Continence Nurse will liaise with your GP to order the further supplies you will need whilst you have a catheter in place. These may be obtained by prescription from your local chemist. THE DRAINAGE SYSTEM The leg-bag for daytime use: This is attached directly to the catheter and collects all the urine produced during the day. It will, of course, become heavier as it fills. Do not allow it to become too full, as this carries the risk of pulling out the catheter. Always wash your hands before and after emptying urine into the toilet.the leg-bag may be supported by leg straps or a net sleeve which is rather like a footless sock and these supports are used to keep your leg-bag securely attached to your leg. You should also alternate the position of the leg bag each day as this will help reduce any discomfort associated with catheter tension. The night drainage bag To connect the night drainage bag:remove the leg-bag support; wash your hands thoroughly empty the leg-bag and, with the tap still open, push the end of the night bag into the small piece of tubing at the end of the tap. This should form a direct route for urine to collect in the night bag; attach the night bag to its stand; this stays on the floor by the side of your bed; wash your hands thoroughly in the morning, wash your hands thoroughly, turn off the tap at the bottom of the leg-bag; and disconnect the night bag, empty the urine into the toilet and dispose of the night bag by placing it in a plastic bag and disposing of it with your normal household waste. reattach your leg bag support You will then need to wash your hands thoroughly again You will return home with a small supply of leg and night bags. Leg-bags should be changed according to the manufacturer s instructions (usually every 5-7 days) however you may need to consider changing the leg- bag earlier if it becomes discoloured, contains sediment, smells offensive or is damaged. It is important that all equipment is stored according to 01 st October 2014 Guidance on the management of indwelling urinary catheters 16

17 manufacturer s instructions, usually in a cool dry place, away from direct sunlight and heat and in the original packaging to maintain quality. WHAT IF I EXPERIENCE PROBLEMS? The following problems can occur when you have a catheter in place. To help reduce the likelihood of these problems occuring, please follow the advice contained within this booklet as well as any specific advice you have been given by your doctor / nurse. On discharge from the hospital you will be referred to a District Nurse or Continence Nurse who will supply you with contact numbers if a problem should occur a. Bladder spasms / Leakage around the catheter / Blood or debris in the urine Bladder spasms feel like abdominal cramp and are common when you have a catheter in your bladder. The pain is caused by the bladder trying to squeeze out the balloon. It is not usually a reason to change the catheter and if it becomes troublesome, your GP can prescribe a drug which stops the cramps. Leakage around the catheter is called by-passing. It is sometimes the result of bladder spasms (see above) or can happen when you open your bowels. If it does, check that your urine is still draining. If it is not, please contact your district nurse /Continence Service as soon as possible. Blood or debris in the urine can be common with a catheter and will usually resolve by increasing your fluid intake which helps to flush out the catheter. It is only of concern if you see large clots or solid pieces of debris passing down the catheter as this may cause a blockage see below. b. Blockage / Catheter falling out Catheter blockage can become an emergency if not dealt with promptly. Check that the drainage bag is below the level of your bladder, that the catheter has no kinks in it, that there are no clots or debris in the catheter, that you are drinking enough and that you are not constipated. If the catheter is not draining urine or if your catheter falls out contact your district nurse /continence service immediately as you may need to have a new catheter inserted. British Association of Urological Surgeons (BAUS) Limited This booklet has been adapted with modifications for use within the Southern health and Social Care Trust with kind permission from the British Association of Urological Surgeons. 01 st October 2014 Guidance on the management of indwelling urinary catheters 17

18 Hand Washing Technique 01 st October 2014 Guidance on the management of indwelling urinary catheters 18