Male and Female Catheterisation Practical Skills Teaching Year 3 Medical Students MB BCh 2012-2013
Contents Introduction to workshop... 3 Overall Session Aim... 4 Intended Learning Outcomes... 4 Workshop Structure Guidance for Tutors... 5 Introduction:... 6 Male Catheterisation... 6 Female Catheterisation... 7 Assessment:... 8 Appendix A Questions and Answers... 9 Appendix B Male Catheterisation Procedure Checklist... 11 Appendix C Female Catheterisation Procedure Checklist... 12 Appendix D - Useful resources:... 13 SW & AM September 2012 Page 2
Introduction to workshop Welcome! Thank you for agreeing to participate in Year 3 Practical Skills Teaching. The workshop outcomes for the students are to learn the skills required to perform male and female catheterisation in the adult patient. We also hope to use the opportunity to ask the students to develop their communication skills as this is a particularly personal procedure which will be uncomfortable / embarrassing of the patient. At the end of the workshop we will be asking you to complete evaluation forms. Please give as much information as you can, as we will use this data to develop the workshop for 2013/14. Just as a reminder, more information about this skill is found at the Clinical Skills Resource site for tutors. The link to the module is: http://medic.cardiff.ac.uk/clinicalskills/ Please find the Male and Female Catheterisation modules within the list of e- modules. We are aiming for the students to be: Accurate Efficient Compassionate Thank you again for your participation. The Clinical Skills Team SW & AM September 2012 Page 3
Overall Session Aim For students to provide practical evidence of their competency in performing the clinical procedure of male and female catheterisation Intended Learning Outcomes By the end of this workshop the students should be able to: 1. Define the reasons why urethral catheterisation may be necessary. 2. State the common risk factors that may arise as a result of the procedure being carried out. 3. Discuss the reasons why insertion of the urinary catheter may be contraindicated. 4. Demonstrate, to a level expected of the students stage of training, a degree of competence in the procedural steps required to carry out male and female urinary catheterisation on a simulation model. 5. Describe the information required for the completion of patient care plan documentation. 6. Display a professional manner and good communication skills towards the patient (actor or student colleague) if present, and throughout the skills simulation session. 7. Evaluate own learning and recognise how improvements can be made. SW & AM September 2012 Page 4
Workshop Structure Guidance for Tutors Please Note: Students arrive 15 minutes prior to taught session for registration and housekeeping Taught Session Time: 90 minutes Session Progression Male and Female Catheterisation 15 minutes Introduction Discussion, Question and Answer Session (See Appendix A) 20 minutes Demonstration Full demonstration of male and female catheterisation by Tutor(s) 4 minutes Questions and Answers Students given the opportunity to ask any questions that may have arisen during demonstration 35 minutes Practice Students work in pairs and practice performing male and female catheterisation Tutor to support and lend guidance where necessary Additional Resources Questions and Answers detailed in Appendix A Model - Advanced Male Catheterisation Trainer Model - Advanced Female Catheterisation Trainer -- Model - Advanced Male Catheterisation Trainer Model - Advanced Female Catheterisation Trainer Tutors to encourage patient / student communication Student pair can act out student-patient relationship 10 minutes Documentation Students to recapulate the contents required for documentation within patients notes Re-address: Indications Contra-indications Risks 6 minutes Assessment and Final Question and Answer Tutors to complete student assessment sheets Address any questions raised -- Assessment sheets SW & AM September 2012 Page 5
Introduction: Male Catheterisation Male urethral catheterisation is a procedure that is carried out in a variety of circumstances. 1. A patient may develop urinary retention secondary to prostatism and need catheterisation to relieve the pressure of urine in the bladder. 2. It may be required following prostatectomy to allow for infiltration of the bladder with fluid and to prevent clot retention. 3. When the urine output is variable, such as in shock or incipient renal failure, measurement of hourly urine output may become routine. 4. If a patient is unconscious or unable to void urine in the normal manner, urethral catheterisation may be required. Male catheterisation is slightly more difficult (especially in patients with prostate problems) and more commonly required than female catheterisation. Indications Urinary Retention Infiltration of Bladder Measuring Urinary Output Patient Unable to Void Urine Contra-Indications Lack of Consent Urethral Stricture Urethral Trauma Risks Catheter Associated Urinary Tract Infections (CAUTI) Bleeding Loss of Bladder Tone Urethral Stricture SW & AM September 2012 Page 6
Female Catheterisation Female urethral catheterisation is a procedure that is carried out in a variety of circumstances and with it comes some inherent risks which must be explained to the patient. In some instances also urethral catheterisations may not be the appropriate course of action. Please see the diagram below. Indications: Indications: Contra-Indications Risks Short Term (Up to 14 Days) Drainage of Urine during and post operatively Monitoring output during an acute illness To obtain an uncontaminated specimen of urine To measure post micturition residual urine Various urological investigations i.e. urodynamics, x-ray Relief of acute/chronic retention of urine Pre and Post-partum or during labour Long Term (Over 14 Days) Post surgical drainage when 'stenting' of urethra is required Hypotonic / Neuroenic conditions Management of terminally ill patients when micturition may be difficult, painful, frequent or when skin integrity may be compromised Intractable incontinence - in dwelling catheters should only be used when all other avenues have been explored and failed and skin integrity may be compromised Lack of Consent Urethral Stricture Urethral Trauma Catheter Associated Urinary Tract Infections (CAUTI) Bleeding Loss of Bladder Tone Urethral Stricture SW & AM September 2012 Page 7
Assessment: For the purposes of this workshop, students will be assessed on a formative basis. This will take place in two parts: 1. A quiz at the start of the session based on prior self-directed learning (Appendix A). 2. The practical component is assessed through observation and feedback on the student performance with the aim of encouraging further practice and improvement. Throughout the session it is proposed that frequent questions should be posed to the students, encouraging each student as the session progresses. A formative assessment sheet is provided, on which the tutor has to indicate that the student has participated in the practical component. There is room for comments regarding student performance if required. SW & AM September 2012 Page 8
Appendix A Questions and Answers Question Answer 1 List four (there are at least seven) generic circumstances that you would carry out short term urethral catheterisation in an adult male or female? 1. Infiltration of the bladder 2. Measuring urinary output in acute illness 3. Relief of acute retention of urine 4. Drainage of urine during and post operatively 5. To obtain an uncontaminated specimen of urine 6. Various urological investigations i.e. urodynamics, x-ray 7. To measure post micturition residual urine 2 Name a short term indication specifically for urethral catheterisation in a female adult? 3 List 4 long term indications for urethral catheterisation in an adult? Pre and Post-partum or during labour 1. Post surgical drainage when 'stenting' of urethra is required 2. Hypotonic / Neurogenic conditions 3. Management of terminally ill patients when micturition may be difficult, painful, frequent or when skin integrity may be compromised 4. Intractable incontinence - in dwelling catheters should only be used when all other avenues have been explored and failed and skin integrity may be compromised 4 What are 3 (there are at least 4) risks associated with urethral catheterisation? 1. Catheter Associated Urinary Tract Infections (CAUTI) 2. Bleeding 3. Loss of Bladder Tone SW & AM September 2012 Page 9
4. Urethral Stricture 5 How might loss of bladder tone be countered in mobile patients? 6 In what 3 instances would you not perform urethral catheterisation? By fitting a Flip-Flow value to the catheter 1. Lack of Consent 2. Urethral Stricture 3. Urethral Trauma 7 Blood at the meatus may indicate urethral trauma. What would be your plan of action in this instance? 8 What 10 points of information would you record in the patients notes 1. Seek Senior Support immediately 2. Imaging of the UG Tract (a Supra Pubic Catheter may be required) 1. Date 2. Time 3. Why the procedure was carried out 4. That informed consent was obtained. 5. If a chaperone present (name them) 6. That aseptic technique was used for the procedure 7. The type and size of the catheter used 8. The residual volume of urine 9. Post procedural investigations or complications 10. Your management plan 9 How many millilitres of 2% Lidocaine gel should be instilled into a male urethra? 10 How many millilitres of 2% Lidocaine gel should be instilled in to a female urethra? 10 ml 6 ml SW & AM September 2012 Page 10
Appendix B Male Catheterisation Procedure Checklist Explain procedure to patient and obtain informed consent Follow Guidelines for aseptic technique Wash hands Apply first pair of sterile gloves Retract the foreskin, if necessary, and cleanse the glans penis and underneath the penis with saline solution Instil all 10 ml of 2% Lidocaine gel into the urethra to achieve surface anaesthesia Remove gloves. Wash hands Apply second pair of sterile gloves Place a fenestrated towel over the penis Place a collecting vessel fro urine between the patient s legs Grasp the shaft of the penis with the non-dominant hand Using the blue sterile sheath to hold the catheter, tear a small hole in the perforations near the tip, and gently pass it into the urethral meatus. Continue to pass the catheter, slowly and smoothly, through the urethra and into the bladder. If resistance is encountered, use gentle traction on the penis, and ask the patient to cough Once urine starts to flow, pass the catheter to the bifurcation, or at least a further 5cm to ensure that the balloon is well inside the bladder Quickly attach the catheter to the urine collecting bag Slowly inflate the balloon with 10ml of sterile water Ensure that the glans penis is clean, and then replace the foreskin Make the patient comfortable. Attach the urine collecting bag to either: the thigh of the patient with the straps supplied, or urine collecting bag stand Dispose of waste materials in a tiger clinical waste bag Wash hands Record procedure in patient s notes SW & AM September 2012 Page 11
Appendix C Female Catheterisation Procedure Checklist Explain procedure to patient and obtain informed consent Follow Guidelines for aseptic technique Position patient comfortably. Main privacy Wash hands Apply first pair of sterile gloves Hold the labia open, and with your dominant hand cleanse the urinary meatus, using saline soaked gauze balls. Use each gauze for a single downward movement only. Instil all 6 ml of 2% Lidocaine gel into the urethra to achieve surface anaesthesia Cover patient with sterile drape for privacy and dignity Remove gloves Wash hands Apply second pair of sterile gloves Place a fenestrated drape appropriately Place a collecting vessel fro urine between the patient s legs Using the blue sterile sheath to hold the catheter, tear a small hole in the perforations near the tip, and gently pass it into the urethral meatus. Advance the catheter about 5-6cm, until urine begins to flow then advance the catheter a further 1-2cm Attach appropriate urine collection product Inflate the pilot balloon with the required amount of water. The catheter label indicates the amount needed. Ensure the patient is dry and made comfortable Attach the urine collecting bag to either: the thigh of the patient with the straps supplied, or urine collecting bag stand Dispose of gloves and waste materials in a tiger clinical waste bag Wash hands Record procedure in patient s notes SW & AM September 2012 Page 12
Appendix D - Useful resources: Patel, N. and Knight, D. 2009. Clinical Practical Procedures for Junior Doctors. Churchill Livingstone: Elsevier Dornan, T. and O Neill, P. 2006. Core Clinical Skills for OSCEs in Medicine. Churchill Livingstone: Elsevier Stoneham, M. and Westbrook, J. 2007. Invasive Medical Skills: A Multimedia Approach. Blackwell Publishing Athreya, B.H. 2010 Handbook of Clinical Skills: A Practical Manual. World Scientific Thomas, J. Monaghan, T. 2007. Oxford Handbook of Clinical Examination and Practical Skills. Oxford Medicine Online SW & AM September 2012 Page 13