In addition to the indications stated above catheterisation may be carried out in female patients for two further reasons:

Transcription

1 Urinary Catheterisation This is the process of inserting a specially designed tube into the urinary bladder using an aseptic technique, for the purpose of draining urine, removing clots and/or debris and the instillation of medication. The process involves introducing a urinary catheter into the urethra and advancing the catheter into the bladder. This is an invasive procedure and is carried out using an aseptic field. Once the catheter is placed in the bladder it helps provide a continuous flow of urine. Indications for catheterisation In a male patient 1. Relieve acute urinary retention 2. For precise monitoring of urine output e.g. patients in shock, patients undergoing renal transplant surgery, post-operative care following major surgical procedures, seriously ill patient and the unconscious patient 3. To empty the contents of the bladder, e.g. before or after abdominal, pelvic or rectal surgery and before certain investigations, e.g. urodynamic studies 4. To determine residual urine (wherever possible, a bladder scanner is the preferred option to measure residual urine volumes) 5. To allow irrigation of the bladder 6. To allow for bladder function tests to be carried out 7. To relieve incontinence when no other means is practicable In a female patient In addition to the indications stated above catheterisation may be carried out in female patients for two further reasons: 1. To empty the urinary bladder before childbirth, if necessary 2. To avoid complications during the insertion of radioactive material e.g. caesium placement in the uterus/cervix 1

2 Catheter selection Careful selection of the size, balloon capacity and appropriate material of the catheter ensures that the catheter selected will be effective and that complications are minimised. Types of Catheters Balloon Foley two-way catheter two channels, one for urine drainage and a second smaller channel for balloon inflation. Materials Latex, PTFE (Polytetrafluorethylene) silicone elastomer coated, 100% silicone, hydrogel coated etc. Uses Most commonly used catheter in patients who need bladder drainage (short, medium or long term) Balloon Foley three-way irrigation catheter Three channels, one for urine, one for irrigation fluid and third for inflation of the catheter balloon Materials Latex, PTFE coated latex, silicone, plastic Uses To provide continuous irrigation e.g. following prostatectomy Non-balloon (Nelaton) or Scott, or intermittent catheter (single channel) Materials PVC or other plastics Uses To intermittently empty the bladder or continent urinary reservoir, to instill solutions into the bladder 2

3 Figure 1: Different types of catheters Foley two- way catheters, Female (top) and male catheters (2 nd from top). A Foley three-way irrigation catheter (3 rd from top) and a silicone catheter (bottom of the picture). Please note: You are unlikely to see a female catheter on most of the wards at STH. These are only available on a named patient basis when ordered from the stores. Balloon size: Recommendations for the filling volumes of the balloon are 10ml for adult sized catheters and 5ml for child sized catheters The correct volume of water should be used to fill the balloon as too much or too little can cause distortion of the tip of the catheter, resulting in irritation and trauma to the bladder wall causing pain, haematuria and urine to bypass the catheter Under inflation of the balloon may result in the catheter being unable to drain properly as the drainage eyes may become occluded or the catheter becomes dislodged Over inflation of the balloon can cause the balloon to burst, leaving remnants of the balloon in the bladder. It is highly recommended that 3

4 you only inflate the balloon with the stated volume of water. Most catheters come with their own pre filled syringe Large balloons were originally designed to p r e v e n t haemorrhage following prostatectomy and may cause damage to the bladder neck Catheter size Catheter size is measured in charrieres (ch). A charriere is the outer circumference of the catheter in millimetres and is equivalent to three times the diameter. (12ch = 4mm diameter). The higher the number, the larger the diameter of the catheter is. Choosing the right sized catheter also depends upon the following: The size of the patient s urethral canal. The expected duration of catheterisation Note: it is important to choose the smallest size of catheter necessary to maintain adequate drainage. (12ch - clear urine / larger ch for urine with debris or blood clots). Potential side-effects of large-gauge catheters: Pain and discomfort Pressure ulcers, which may lead to stricture formation Blockage of Para urethral ducts Abscess formation Note: it is important to choose the smallest size of catheter necessary to maintain adequate drainage. (12ch - clear urine / larger ch for urine with debris or clots) Spinal injuries patients use size 16ch (unless otherwise indicated) due to sediment in the bladder as the patients are sedentary 4

5 Length of catheter Available in two lengths: (Figure 2) Standard length (40 45cm) should always be used in males but can also be used in females. This is because the inflation valve in a shorter female catheter may cause soreness by rubbing against the inside of the thigh and is more likely to pull on the bladder neck. Shorter type (20-26cm) is for female catheterisation only.. Figure 2: Female catheter (top) is shorter as compared with the male catheter. Please note: you are unlikely to see a female catheter on most of the wards at STH. These are only available on a named patient basis when ordered from the stores. Length of time catheter can remain insitu This depends upon the material the catheter is made from. When selecting a catheter both the size and the material the catheter is made from are taken into consideration. The timescales are: Latex catheters up to 28 days (short term). But should be reviewed weekly Silicone or Hydrogel coated catheters up to 3 months (long term). But may need to be changed sooner depending on the condition of the patient. The information regarding how long a catheter can remain in situ is printed on the catheter packaging. 5

6 Equipment required for urinary catheterisation Figures 3 to 7 show the standard equipment required for urinary catheterisation. Figure 3: Equipment required for urinary catheterisation, all equipment is in sterile packaging. Bottom row: from left to right: Sterile gloves, drainage bag and catheter pack Middle row: Instillagel (local anaesthetic gel) and normal saline solution (top) for cleaning. Top row: A two- way Foley catheter in sterile packaging with prefilled syringe of sterile water for inflating catheter balloon. 6

7 Figure 4: Instillagel - local anaesthetic gel (top) and sterile water (bottom) for injecting catheter balloon Figure 5: A Two-way Foley catheter (bottom) in sterile plastic after removal of the outer packaging 7

8 Figure 6: After opening of catheter pack: Sterile tray with container for cleaning solution, sterile gauze, sterile swabs and the sterile drape Figure 7: Urinary drainage bag. 8

9 MALE URINARY CATHETERISATION PROCEDURE Initiating the procedure Wash hands according to recommended guidelines. This will help reduce the risk of cross infection. Usually with soap & water at this stage. Clean the trolley according to the local hospital policy. Collect the required equipment, check that all packaging is intact and within expiry date. Place all the equipment on the bottom shelf of the trolley. Introduce yourself by full name and post. Identify the patient by asking them to state their name, date of birth and first line of address and check all information against patient identification wrist band. This is done to ensure that the right patient will be catheterised. Explain the procedure to the patient and gain the patient s verbal consent. Check for any known drug allergies or adverse drug reactions in the past. Ensure that the patient does not have any allergies to latex, instillagel etc. ** Ask the patient to retract their foreskin (if necessary) and wash their genitalia. The aim of this step is to try and reduce the number of organisms. Please note that not all patients will be able to do this. Performance of task Draw the curtains around the patient s bed or take the patient to a separate room. It is important to ensure patient s privacy and dignity at all times. Help the patient to get into a supine position with legs extended. Do not expose the patient at this stage. Raise the patient s bed to an appropriate height and raise the safety rails. Don a disposable apron and wash hands with bactericidal soap and water. 9

10 Open the catheterisation/dressing pack on the top shelf of the trolley to form a sterile field. Do not touch the inside surface of the pack. Using an aseptic technique open all the supplementary packs including the catheter, instillagel and catheter bag, carefully placing them into the centre of sterile field. Keep the catheter information sticker for later use. Pour the cleaning solution (0.9% sodium chloride) in to the container making sure that you do not touch any other equipment on the sterile field. Ask the patient to expose themselves. If they are unable to do this on their own then help them ensuring that the appropriate area is exposed and is accessible. Wash your hands using a bactericidal alcohol hand gel and don a pair of suitable sized sterile gloves. Form a sterile field by arranging a sterile drape across the patient s thighs - using a non-touch technique. Using the sterile gauze provided in the pack, wrap one around the penis which will form a sling. Hold the sling with one hand and with your other hand clean around the urethral orifice using the swabs and the 0.9% sodium c h l o r i d e s o l u t i o n. This s h o u l d be done by u s i n g a single downward movement and carried out three times (but more if necessary) using a separate swab for each time you clean the external genitalia. By using single downward movements the risk of introducing organisms into the urinary tract is reduced. Inform the patient that you are going to insert the anaesthetic gel. The patient may feel a cold sensation as the gel is being inserted into the urethra. The penis will need to be held upright whilst the gel is being inserted. Insert the nozzle of the anaesthetic lubricating gel into the urethral opening of the penis and squeeze gel into the urethra. Hold glans at the tip for a couple of seconds after insertion of gel to prevent gel coming back out. Allow 3 to 5 minutes for the anaesthetic gel to take effect. Lubrication of the urethra helps prevent trauma and minimises discomfort to the patient. Remove your gloves following the cleaning and the use of Instillagel. Wash your hands with hand gel and don a new pair of sterile gloves. Inform the patient that you are now about to insert the catheter. Insert the tip of the catheter into the urethra and introduce, avoiding contact with the genitalia from the clean hand i.e. the hand holding the catheter. 10

11 Resistance may be experienced due to either spasm of the external sphincter or as the advancing catheter encounters the prostate. When urine appears out of the end of the catheter, continue to insert the catheter up to the bifurcation. It is important to advance the catheter, so that the catheter is correctly positioned in the bladder before the balloon is inflated. Inflate the balloon with the appropriate amount of sterile water. There may be initial resistance when pushing saline into balloon channel but then inflation should be easy. Urine should continue to drain and the balloon will prevent the catheter from being displaced. Gently withdraw the catheter until the balloon stops any further progress and if not already connected, connect the catheter to the sterile catheter bag using an aseptic technique. Fix the catheter to the patient s thigh and ensure that the catheter drainage bag is either placed on a stand or suspended from the side of the bed. This helps to maintain patient comfort and reduces the risk of trauma to the urethra or bladder neck. Ensure patient is comfortable and dry (if foreskin is present return it to the normal position). If foreskin is not reduced or repositioned, the patient may develop a paraphimosis. Dispose of waste in an appropriate clinical waste bag. Remove gloves and apron and wash your hands. Record amount of residual urine on the fluid balance chart and document the procedure in the medical notes including the catheter information sticker. State the indications for catheterisation. Also indicate the time and date, the catheter type, size and length used, use of Instillagel, catheter manufacturer batch number, volume of water injected in the balloon and review date. Document any problems encountered during the procedure. Reposition the bed as appropriate. Check patient s welfare. Request patient to inform ward staff if they experience any pain or discomfort. 11

12 FEMALE URINARY CATHETERISATION PROCEDURE Initiating the procedure Wash hands according to recommended guidelines. This will help reduce the risk of cross infection. Usually with soap & water at this stage. Clean the trolley according to the local hospital policy. Collect the required equipment, check that all packaging is intact and within expiry date. Place all the equipment on the bottom of the trolley. Introduce yourself by full name and post. Identify the patient by asking them to state their name, date of birth and first line of address and check all information against patient identification wrist band. This is done to ensure that the right patient will be catheterised. Explain the procedure to the patient and gain the patient s verbal consent. Check for any known drug allergies or adverse drug reactions in the past. Ensure that the patient does not have any allergies to latex, instillagel etc. ** Ask the patient to wash their genitalia. The aim of this step is to try and reduce the number of organisms. Please note that not all patients will be able to do this. Performance of task Draw curtains around the patient s bed or take the patient to a separate room. It is important to ensure patient s privacy and dignity at all times. Help the patient to get into a supine position with knees bent, hips flexed and feet apart. Do not expose the patient at this stage. Raise the patient s bed to an appropriate height and raise the safety rails. Don a disposable apron and wash hands with bactericidal soap and water. Open the catheterisation/dressing pack on the top shelf of the trolley to form a sterile field. Do not touch the inside surface of pack. 12

13 Using an aseptic technique open all the supplementary packs including the catheter, instillagel and catheter bag, carefully placing them into the centre of sterile field. Keep the catheter information sticker for later use. Pour the cleaning solution (0.9% sodium chloride) in to the container making sure that you do not touch any other equipment on the sterile field. Ask the patient to expose themselves. If they are unable to do this on their own then help them ensuring that the appropriate area is exposed and is accessible. Wash your hands using a bactericidal alcohol hand gel and don a pair of suitable sized sterile gloves. Form a sterile field by arranging the sterile drape under the patient s thighs using a non-touch technique. Use the low-linting gauze to separate the labia minora with one hand. With your other hand clean around the urethral orifice using the swabs and the 0.9% sodium chloride solution. This should be done by using a single d o w n w a r d movement and carried out three t i m e s ( b u t m o r e i f n e c e s s a r y ) using a separate swab for each time you clean the external genitalia. By using single downward movements the risk of introducing organisms into the urinary tract is reduced. Inform the patient that you are going to insert the anaesthetic gel. Insert the nozzle of the anaesthetic gel into the urethral opening and squeeze gel into the urethra. Allow 3 to 5 minutes for the anaesthetic gel to take effect. Lubrication of the urethra helps prevent trauma and minimises discomfort to the patient. Remove your gloves following the cleaning and the use of Instillagel. Wash your hands with hand gel and don a new pair of sterile gloves. Inform the patient that you are now about to insert the catheter. Insert the tip of the catheter into the urethra and introduce, avoiding contact with the genitalia from the clean hand i.e. the hand holding the catheter. When urine appears out of the end of the catheter, continue to insert the catheter up to another 3 5 cms. It is important to advance the catheter, making sure the catheter is correctly positioned in the bladder before the balloon is inflated. Inflate the balloon with the appropriate amount of sterile water. There may be initial resistance but then inflation should be easy. Urine should continue to drain and the balloon will prevent the catheter from being displaced. 13

14 Gently withdraw the catheter until the balloon stops any further progress and if not already connected, connect the catheter to the sterile catheter bag using an aseptic technique. Fix the catheter to the patient s thigh and ensure that the catheter drainage bag is either placed on a stand or suspended from the side of the bed. This helps to maintain patient comfort and reduces the risk of trauma to the urethra or bladder neck. Ensure the patient is comfortable and dry. Dispose of waste in an appropriate clinical waste bag. Remove gloves and apron and wash your hands. Record amount of residual urine on the fluid balance chart and document the procedure in the medical notes including the catheter information sticker. State the indications for catheterisation. Also indicate the time and date, the catheter type, size and length used, use of Instillagel, catheter manufacturer batch number, volume of water injected in the balloon and review date. Document any problems encountered during the procedure. Reposition the bed as appropriate. Check patient s welfare. Request patient to inform ward staff if they experience any pain or discomfort. 14

15 Catheter associated Infections Catheter-associated infections are the most common healthcare associated infections, up to 35 40%. To reduce the risk of infection, it is essential that manipulations of the closed drainage system are kept to a minimum. The most common sites where bacteria may enter the system and cause infection are: 1. Drainage bag poor technique when emptying. 2. Obtaining specimens poor technique. 3. Catheter being detached from the drainage bag. 4. Space between urethra and catheter. Common sites of cross-infection are: 1. On the tip of the catheter during insertion. 2. Migration on the inside of the catheter via the biofilm. 3. Connection points of the linked systems, e.g. catheter and drainage bag. To reduce the risk of cross infection hands should be washed and clean non-sterile gloves worn make sure that before handling the drainage system. All urine samples should only be obtained via the specially designed sampling ports, using an aseptic technique. Drainage bags should be kept below the level of the bladder to prevent reflux, which is associated with infection. Drainage bags should be attached to stands to avoid contact with the floor. Note: A video demonstrating male and female urinary catheterisation has been uploaded on the Clinical skills home page. You are requested to view the video prior to attending the teaching session at the clinical skills centre. 15

16 References British Association of Urological Nurses (2000/2001). Guidelines for Male Urethral Catheterisation using 2% Lignocaine Gel. Colley W (2000). Male Catheterisation.Practical Procedures for Nurses (13.1).Nursing Times. map Dougherty, L. & Lister S. (7 th Ed.) (2008) The Royal Marsden Hospital Manual of Clinical Nursing Procedures. Oxford: Wiley-Blackwell pp Sheffield Teaching Hospitals Local policy and guidelines