What are some key teaching points for the patient with an indwelling catheter?
*Disclaimer: A multidisciplinary team reviewed the literature, and while there is a general lack of research and evidence surrounding leg bag and bath basin care, this team was able to make general recommendations. Please remember to follow your facility's policy and direct any questions to your supervisor. Show
7. Centers for Medicare & Medicaid Services (CMS). Department of Health & Human Services (DHHS). State Operations Manual. Appendix PP –Guidance to Surveyors for Long Term Care Facilities. (Rev. 157, 06-10-16). Slide 7: The DO's of Indwelling Urinary Catheter Care2,3,6,7
2. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014 May;35(5):464-79. PMID: 25376068. Slide 8: The DON'Ts of Indwelling Urinary Catheter Care2,3,6,7
2. Lo E, Nicolle LE, Coffin SE, et al. Strategies to prevent catheter-associated urinary tract infections in acute care hospitals: 2014 Update. Infect Control Hosp Epidemiol. 2014 May;35(5):464-79. PMID: 25376068. Slide 9: Mutual Support in Teamwork11
11.TeamSTEPPS® Long-Term Care Version. Rockville, MD: Agency for Healthcare Research and Quality; content last reviewed September 2015. Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required:
Catheter-Associated Urinary Tract InfectionsCatheter-associated urinary tract infections (CAUTI) are a common complication of indwelling urinary catheters and have been associated with increased morbidity, mortality, hospital cost, and length of stay (Gould et al., 2009). Urinary drainage systems are often reservoirs for multidrug-resistant organisms (MDROs) and a source of the transmission of microorganisms to other patients (Gould et al., 2009). The most important risk factor for developing a CAUTI, a health care associated infection (HAI), is the prolonged use of a urinary catheter (Centers for Disease Control and Prevention [CDC], 2015). Urinary tract infections (UTIs) are the most commonly reported HAIs in acute care hospitals and account for more than 30% of all reported infections (Gould et al., 2009). Catheters in place for more than a few days place the patient at risk for a CAUTI. A health care provider must assess patients for signs and symptoms of CAUTIs and report immediately to the primary health care provider. Signs and symptoms of a CAUTI include:
The following are practices for preventing CAUTIs (Perry et al., 2014):
Urinary CatheterizationUrinary catheterization refers to the insertion of a catheter tube through the urethra and into the bladder to drain urine. Although not a particularly complex skill, urethral catheterization can be difficult to master. Both male and female catheterizations present unique challenges. Having adequate lighting and visualization is helpful, but does not ensure entrance of the catheter into the female urethra. It is not uncommon for the catheter to enter the vagina. Leaving the catheter in the vagina can assist in the correct insertion of a new catheter into the urethra, but you must remember to remove the one in the vagina. For some women, the supine lithotomy position can be very uncomfortable or even dangerous. For example, patients in the last trimester of pregnancy may faint with decreased blood supply to the fetus in this position. Patients with arthritis of the knees and hips may also find this position extremely uncomfortable. Catheterization may also be accomplished with the patient in the lateral to Sims position (three-quarters prone). The male urinary sphincter may also be difficult to pass, particularly for older men with prostatic hypertrophy. There are two types of urethral catheterization: intermittent and indwelling. Intermittent catheterization (single-lumen catheter) is used for:
Indwelling catheterization (double- or triple-lumen catheter) is used for:
The steps for inserting an intermittent or an indwelling catheter are the same, except that the indwelling catheter requires a closed drainage system and inflation of a balloon to keep the catheter in place. Indwelling catheters may have two or three lumens (double or triple lumens). Double-lumen catheters comprise one lumen for draining the urine and a second lumen for inflating a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation and for instilling medications into the bladder; the additional lumen delivers the irrigation fluid into the bladder. Indwelling urinary catheters are made of latex or silicone. Intermittent catheters may be made of rubber or polyvinyl chloride (PVC), making them softer and more flexible than indwelling catheters (Perry et al., 2014). The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the tube. Recommended catheter size is 12 to 16 Fr for females, and 14 to 16 Fr for males. Smaller sizes are used for infants and children. The balloon size also varies with catheters: smaller for children (3 ml) and larger for continuous bladder irrigation (30 ml). The size of the catheter is usually printed on the side of the catheter port. An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine. Make sure that the urinary bag hangs below the level of the patient’s bladder so that urine flows out of the bladder. The bag should not touch the floor, and the patient should carry the bag below the level of the bladder when ambulating. To review how to insert an indwelling catheter, see Checklist 80. Checklist 80: Insertion of an Intermittent or Indwelling Urinary CatheterDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Verify physician order for catheter insertion. Assess for bladder fullness and pain by palpation or by using a bladder scanner.Palpation of a full bladder will cause an urge to void and/or pain.2. Position patient prone to semi-upright with knees raised; apply gloves; and inspect perineal region for erythema, drainage, and odour. Also assess perineal anatomy.Assessment of perineal area allows for determination of perineal condition and position of anatomical landmarks to assist with insertion.Apply non-sterile gloves3. Remove gloves and perform hand hygiene.This prevents transmission of microorganisms.Remove non-sterile glovesPerform hand hygiene4. Gather supplies:
Female patient: On back with knees flexed and thighs relaxed so that hips rotate to expose perineal area. Alternatively, if patient cannot abduct leg at the hip, patient can be side-lying with upper leg flexed at knee and hip, supported by pillows. Male patient: Supine with legs extended and slightly apart. Patient should be comfortable, with perineum or penis exposed, for ease and safety in completing procedure.8. Place a blanket or sheet to cover patient and expose only required anatomical areas.This step helps protect patient dignity.9. Apply clean gloves and wash perineal area with warm water and soap or perineal cleanser according to agency policy.Cleaning removes any secretions, urine, and feces, and reduces risk of CAUTI.10. Ensure adequate lighting.Adequate lighting helps with accuracy and speed of catheter insertion.11. Perform hand hygiene.This reduces the transmission of microorganisms.Perform hand hygiene12. Add supplies and cleaning solution to catheterization kit, and according to agency policy.This step ensures preparation and organization for procedure.Add supplies as necessary13. If using indwelling catheter and closed drainage system, attach urinary bag to the bed and ensure that the clamp is closed.Urinary bag should be closed to prevent urine drainage leaving bag.Urinary bag14. Apply sterile gloves using sterile technique.This reduces the transmission of microorganisms.Apply sterile gloves15. Drape patient with drape found in catheterization kit, either using sterile gloves or using ungloved hands and only touching the outer edges of the drape. Ensure that any sterile supplies touch only the middle of the sterile drape (not the edges), and that sterile gloves do not touch non-sterile surfaces. Drape patient to expose perineum or penis.The outer 2.5 cm is considered non-sterile on a sterile drape.Cover patient with sterile drape16. Lubricate tip of catheter using sterile lubricant included in tray, or add lubricant using sterile technique.Lubrication minimizes urethral trauma and discomfort during procedure.Lubricate tip of catheter17. Check balloon inflation using a sterile syringe.This maintains sterility of catheter.Check balloon inflation using a sterile syringe18. Place sterile tray with catheter between patient’s legs.Sterile tray will collect urine once catheter tip is inserted into bladder.19. Clean perineal area as follows.Female patient: Separate labia with fingers of non-dominant hand (now contaminated and no longer sterile). Using sterile technique and dominant hand, clean labia and urethral meatus from clitoris to anus, and from outside labia to inner labial folds and urethral meatus. Use sterile forceps and a new cotton swab with each cleansing stroke. Male patient: Gently grasp penis at shaft and hold it at right angle to the body throughout procedure with non-dominant hand (now contaminated and no longer sterile). Using sterile technique and dominant hand, clean urethral meatus in a circular motion working outward from meatus. Use sterile forceps and a new cotton swab with each cleansing stroke. This reduces the transmission of microorganisms.Cleanse perineal area20. Pick up catheter with sterile dominant hand 7.5 to 10 cm below the tip of the catheter.Holding catheter closer to the tip will help to control and manipulate catheter during insertion.21. Insert catheter as follows.Female patient:
Male patient:
Female patient: Secure catheter to inner thigh, allowing enough slack to prevent tension. Male patient: Secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension. Ensure foreskin is not retracted. Securing catheter reduces risk of CAUTI, urethral erosion, and accidental catheter removal.Secure catheter to patient’s legFor male patients, leaving the foreskin retracted can cause pain and edema. Video 10.2Video 10.3Removing a Urinary CatheterPatients require an order to have an indwelling catheter removed. Although an order is required, it remains the responsibility of the health care provider to evaluate if the indwelling catheter is necessary for the patient’s recovery. A urinary catheter should be removed as soon as possible when it is no longer needed. For post-operative patients who require an indwelling catheter, the catheter should be removed preferably within 24 hours. The following are appropriate uses of an indwelling catheter (Gould et al., 2009):
When a urinary catheter is removed, the health care provider must assess if normal bladder function has returned. The health care provider should report any hematuria, inability or difficulty voiding, or any new incontinence after catheter removal. Prior to removing a urinary catheter, the patient requires education on the process of removal, and on expected and unexpected outcomes (e.g., a mild burning sensation with the first void) (VCH Professional Practice, 2014). The health care provider should instruct patients to
Review the steps in Checklist 81 on how to remove an indwelling catheter. Checklist 81: Removing an Indwelling CatheterDisclaimer: Always review and follow your hospital policy regarding this specific skill.Safety considerations:
StepsAdditional Information1. Verify physician orders, perform hand hygiene, and gather supplies.Supplies include non-sterile gloves, sterile syringe (verify size of balloon on Foley catheter), waterproof pad, garbage bag, and cleaning supplies for perineal care.2. Identify patient using two identifiers. Create privacy and explain procedure for catheter removal.This ensures you have the correct patient and follows agency policy on proper patient identification.3. Educate patient on catheter removal and post-urinary catheter care.Patient must be informed of what to expect after catheter is removed and how to measure urine output, etc.4. Perform hand hygiene and set up supplies.Perform hand hygieneRaise bed to working height. Organize supplies. Position patient supine for easy access. 5. Apply non-sterile gloves.This reduces the transfer of microorganisms.Apply non-sterile gloves6. Measure, empty, and record contents of catheter bag. Remove gloves, perform hand hygiene, and apply new non-sterile gloves.Remove catheter securement/anchor device. Record drainage amount, colour, and consistency according to agency policy.Always change gloves after handling a urinary catheter bag. Removing catheter securement device provides easy access to catheter for cleaning and removing. Remove catheter securement device7. Perform catheter care with warm water and soap or according to agency protocol.This reduces the transfer of microorganisms into the urethra.8. Insert syringe in balloon port and drain fluid from balloon. Verify balloon size on catheter to ensure all fluid is removed from balloon.A partially deflated balloon will cause trauma to the urethra wall and pain.Insert syringe in balloon port and drain fluid from balloon9. Pull catheter out slowly and smoothly. Catheter should slide out slowly and smoothly.If resistance is felt, stop removal and reattempt to remove the fluid from the balloon. Attempt removal again. If unable to remove the catheter, stop and notify physician.Pull catheter out slowly and smoothly10. Wrap used catheter in waterproof pad or gloves. Unhook catheter tube from urinary bag. Discard equipment and supplies according to agency policy.This prevents accidental spilling of urine from the catheter.Wrap used catheter in waterproof pad or gloves11. Provide perineal care as required and reposition patient to a comfortable position.This promotes patient comfort.12. Review post-catheter care, fluid intake, and expected and unexpected outcomes with patient.Ensure patient has access to toilet, commode, bedpan, or urinal. Place call bell within reach. Ensure first void (urine output) is measured as per agency policy.Encourage patient to maintain or increase fluid intake to maintain normal urine output (unless contraindicated).13. Lower bed to safe position, remove gloves, and perform hand hygiene.Lowering the bed helps prevent falls. Hand hygiene prevents the transmission of microorganisms from patient to health care provider.Hand hygiene with ABHR14. Document procedure according to agency policy.Document time of catheter removal, condition of urethra, and any teaching related to post-catheter care and fluid intake. Document time, amount, and characteristics of first void after catheter removal. Data source: ATI, 2015d; BCIT, 2015b; Perry et al., 2014; VCH Professional Practice, 2014If a patient is unable to void after six to eight hours of removing a urinary catheter, or has the sensation of not emptying the bladder, or is experiencing small voiding amounts with increased frequency, a bladder scan may be performed. A bladder scan can assess if excessive urine is being retained. Notify the health care provider if patient is unable to void within six to eight hours of removal of a urinary catheter. If a patient is found to have retained urine in the bladder and is unable to void, an intermittent/straight catheterization should be performed (Perry et al., 2014). What education should you give a patient with an indwelling catheter?When you have an indwelling catheter, you or someone caring for you needs to: Make sure urine is flowing into the catheter. Check for signs of skin irritation or infection. Make sure that the urine collection bag is always below the level of the bladder.
What are the important home instructions you can provide for those patients with indwelling catheter?Preventing Infections. Keep the drainage bag below the level of your bladder.. Keep your drainage bag off the floor at all times.. Keep the catheter secured to your thigh to keep it from moving.. Don't lie on your catheter or block the flow of urine in the tubing.. Shower daily to keep the catheter clean.. What instructions you will give to a catheterized patient?Making Sure Your Catheter is Working. Always keep your bag below your waist.. Try not to disconnect the catheter more than you need to. Keeping it connected to the bag will make it work better.. Check for kinks, and move the tubing around if it is not draining.. Drink plenty of water during the day to keep urine flowing.. When caring for a client with an indwelling catheter You would?Insert the catheter using clean technique.. Keep the drainage bag on the bed with the client.. Remove obvious encrustations from the external catheter surface by washing it gently with soap and water.. |