Catheterization

catheterization nursing procedure

1. catheterization Manisha kumari Igims con , patna

2. INTRODUCTION :- Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried out by a qualified competent health care professional using aseptic technique. Catheterization of the urinary tract should only be done when there is a specific and adequate clinical indication, as it carries a risk of infection

3. DEFINITION :- THE ACTION OR PROCESS OF INSERTING A CATHETER INTO A BODY CAVITY CALLED CATHETERIZATION .

4. PURPOSE :- Used to maintain urine output in patients who are undergoing surgery Patient who are confined to the bed and physically unable to use a bedpan . Critically ill patient who require strict monitoring of urinary output . Improve the quality of life to someone who is bed ridden . Relieve urinary retention , bladder distension. Obtain sterile urine specimen. Measure residual volume Empty bladder of patients.

5. Indications :- Prostatic hyperplasia (men) Acute or chronic retention Hypotonic bladder Pre & post pelvic surgery Measurement of urine output To empty the bladder during labour Investigations To obtain an uncontaminated urine specimen • In Urodynamic investigations • X-ray investigations Instillation • To irrigate the bladder • Chemotherapy Management of intractable incontinence To be used ONLY when all other methods have been tried

6. Principles of catheterization:- Meatal /Labia cleansing to remove exudates or smegma in men Aseptic technique – to avoid introducing infection Anaesthetic gel ( Instillagel ) • Should be used for men and women • Reduces pain and discomfort • Provides lubrication • Has antibacterial properties (contains chlorhexidine) • Needs time to work (5 minutes) • Documentation

7. Types of catheterization :- Indwelling catheters Intermittent catheterization

8. Types of catheters :- Folley’s catheter Robinson’s intermittent catheter Turp catheter Silicone catheter Coude catheter Condom c atheter /external catheter Suprapubic catheter

9. General instructions :- Catheter Selection It is important to choose the correct catheter for the individual patient Considerations include: Material, size, length and balloon infill volume The make, type, length, Ch/ Fg size and balloon size should be specified on the prescription The Foley catheter is an indwelling catheter that is retained by inflating an integral balloon Catheters without the inflating balloon are usually used for intermittent catheterization The material determines the length of time a catheter can remain in situ • However, the nurse must always refer to the manufacturer’s guidelines

10. Contd.. Catheter Selection – Material Short Term (7 to 28 days) Plastic/PVC should not be left in for more than 7 days Uncoated latex/silicone treated should not be left in situ for more than 7 days Polytetrafluroethylene (PTFE) bonded latex (Teflon) should not be left in situ for more than 28 days

11. Contd.. Catheter Selection - Material Long Term (up to 12 weeks) Silicone elastomer coated latex (combines advantages of silicone and latex) Hydrogel coated latex (combines advantages of hydrogel and silicone) – these are the only catheters suitable for patients with a latex allergy

12. Contd.. Catheter Selection – Size and length The internal diameter of a catheter is measured in Charriere (Ch) – one Ch equals 1/3 mm, therefore 12 Ch equals 4 mm Usual sizes for men are between 12Ch & 16Ch Usual sizes for women are between 8Ch & 12Ch The smallest size should be chosen to provide adequate drainage Male catheter length 43cms, female catheter 26cms

13. Contd.. Catheter Selection – Balloon Size The balloon should always be filled with sterile water Catheter balloons should be filled as specified by the manufacturer - routinely 10mls The heavier weight and larger balloon may cause bladder spasm and irritation of the Trigone Over or under filling may interfere with drainage

14. Contd.. Safety considerations:  Perform hand hygiene . Check room for  additional precautions . Introduce yourself to patient. Confirm patient ID using two patient identifiers (e.g., name and date of birth). Explain process to patient; offer analgesia, bathroom, etc. Listen and attend to patient cues. Ensure patient’s privacy and dignity. Assess  ABCCS /suction/oxygen/safety. Apply principles of  asepsis and safet y. Check  vital signs . Complete necessary  focused assessments .

15. Preparation of child and family :- As per our FICare policy, families/primary care givers should be given a thorough explanation of the procedure. Nursing staff should discuss and plan the procedure and use of pain relief with the family prior to commencing the procedure. Involve the parents where possible when providing non- pharmalogical pain relief, distraction and restraint. Consider the use of pharmacological pain relief such as sucrose as appropriate. Ensure the patient’s privacy is maintained throughout the procedure. Consider thermoregulation needs, particularly for preterm neonates

16. Preparation of environment & equipements - Ensure there is adequate light to perform the procedure Prepare the following equipment:  Clean Dressing Trolley  Dressing pack  Sterile gloves  Sterile Gown  Sterile Plastic Drape  Sterile Scissors  Sterile Kidney Dish  Appropriate sized catheters (see Table 1)  Sterile lubricating jelly  0.2% Chlorhexidine irrigation solution (Catheterisation preparation solution: Chlorhexidine gluconate 60mg/30mL).  IDC drainage bag and connector  Sleek tape and a safety pin (only if no safety clip on IDC bag drainage tubing).  Specimen container  Waste Bag  Small Hydrocolloid cut to size for fixation point to skin  Small Leukostrips / adhesive tape like fixomull /Tegaderm. Or large Leukostrips in the premature neonate

17. A ssessment :- Assess the pt’s medical record. Access the general status of pt’s . Check the time of last urination . Check the intake and output chart . Check the level of awareness , gender , age and allergy . Assess bladder for fullness . Assess the pt’s knowledge of catheterization .

18. Procedure :- 1. Verify physician order for catheter insertion. Assess for bladder fullness and pain by palpation or by using a bladder scanner. 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.

19. Contd.. 3. Remove gloves and  perform hand hygiene . 4. Gather supplies: Sterile gloves Catheterization kit Cleaning solution Lubricant (if not in kit) Prefilled syringe for balloon inflation as per catheter size Urinary bag Foley catheter

20. Contd.. 5. Check for size and type of catheter, and use smallest size of catheter possible. 6. Place waterproof pad under patient. 7. Positioning of patient depends on gender. 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.

21. Contd.. 8. Place a blanket or sheet to cover patient and expose only required anatomical areas. 9. Place a blanket or sheet to cover patient and expose only required anatomical areas. 10. Ensure adequate lighting. 11.  Perform hand hygiene . 12. Add supplies and cleaning solution to catheterization kit, and according to agency policy. 13. If using indwelling catheter and closed drainage system, attach urinary bag to the bed and ensure that the clamp is closed.

22. contd.. 14. Apply  sterile gloves  using sterile technique. 15. 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. 16. Lubricate tip of catheter using sterile lubricant included in tray, or add lubricant using sterile technique. 17. Check balloon inflation using a sterile syringe 18. Place sterile tray with catheter between patient’s legs.

23. Contd.. 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.

24. Contd. 20. Pick up catheter with sterile dominant hand 7.5 to 10 cm below the tip of the catheter. 21. Insert catheter as follows. Female patient : Ask patient to bear down gently (as if to void) to help expose urethral meatus. Advance catheter 5 to 7.5 cm until urine flows from catheter, then advance an additional 5 cm.

25. Contd.. Male patient : Hold penis perpendicular to body and pull up slightly on shaft. Ask patient to bear down gently (as if to void) and slowly insert catheter through urethral meatus. Advance catheter 17 to 22.5 cm or until urine flows from catheter. Note:  If urine does not appear in a female patient, the catheter may be in the patient’s vagina. You may leave catheter in vagina as a landmark, and insert another sterile catheter. Note:  If catheter does not advance in a male patient, do not use force. Ask patient to take deep breaths and try again. If catheter still does not advance, stop procedure and inform physician. Patient may have an enlarged prostate or urethral obstruction.

26. Contd. 22. Place catheter in sterile tray and collect urine specimen if required. 23. Slowly inflate balloon for indwelling catheters according to catheter size, using prefilled syringe. Note:  If patient experiences pain on balloon inflation, deflate balloon, allow urine to drain, advance catheter slightly, and reinflate balloon. 24. After balloon is inflated, pull gently on catheter until resistance is felt and then advance the catheter again. 25. Connect urinary bag to catheter using sterile technique.

27. Contd.. 26. Secure catheter to patient’s leg using securement device at tubing just above catheter bifurcation. 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. 27. Dispose of supplies following agency policy. 28. Remove gloves and  perform hand hygiene . 29. Document procedure according to agency policy, including patient tolerance of procedure, any unexpected outcomes, and urine output.

28. Removal of catheter:- Removal of urinary catheter  Explain procedure to child and family. Perform hand hygiene & don gloves. Deflate balloon completely. Gently withdraw catheter, with rotation movements if necessary. Bear in mind that once inflated, the balloon won’t deflate to its total initial flat state and the balloon portion of the catheter will remain larger than the catheter itself. If resistance felt and catheter cannot be easily removed do not force, leave catheter in situ and consult medical team.  Consider cutting the catheter at the balloon inflation point to ensure the balloon is deflated.  Once removed inspect catheter for intactness. Report if not intact

29. After care :- Drainage system Adherence to a sterile continuously closed method of urinary drainage has been shown to markedly reduce the risk of acquiring a catheter associated infection. Therefore breaches to the closed system should be avoided. Consider changing the catheter tube and/or bag based on clinical indicators including infection, contamination, obstruction or if system disconnects, if the equipment is damaged or leaks. Replace system and/or catheter using aseptic technique and sterile equipment. Hygiene Routine hygiene should be maintained with routine bathing/showering, including daily clean IDC insertion site with warm soapy water and more frequently if build-up of secretions is evident. Uncircumcised boys should have the foreskin gently eased down over the catheter after cleaning.

30. Contd.. Perform hand hygiene. Document catheter removal in the LDA activity. Observe for urine output post catheter removal. If the patient has not passed urine 6 – 8hours post catheter removal assess the patient’s hydration status and consider the need to perform a bladder scan. Discuss findings with the treating medical team. 

31. Catheter leakage:- Catheter leaking Ensure the catheter is still draining and that the urine is not overflowing around a blocked catheter. See above for tips regarding catheters not draining. Make sure the balloon is still inflated. Hold the catheter tubing securely in the same position and empty the balloon to make sure the amount that has been placed initially in the balloon is still present. If not, reinflate the balloon to its initial volume with water. Deflation of the balloon happens easily with a 6Fr catheter. Check catheter size is correct for age/size of the child. Use of a balloon catheter in neonates should only be with consultation with the treating medical team. Consider the need to remove and reinsert a new catheter in consultation with the treating medical team. 

32. Discharge information :- Some children will be discharged from the hospital with their IDC in situ. It is important to teach the families how to care for the catheter, how to perform hygiene, how to monitor the output and how to troubleshoot. Discuss the following with the child and family: Assess the catheter insertion site at least once per day. Clean the site of insertion once per day if accessible with warm soapy water when attending to their normal bath or shower. Regularly check the tubing is not kinked or leaking, if any concerns contact the treating team.  The family should have enough supplies to take home to last until they return for removal of the catheter or until their supplies organised with stomal therapy department have commenced. This includes leg bags, overnight bag and securement devices.

33. Contd.. In the home each catheter bag can last up to a week. If using leg bags and overnight bags when they are swapped over rinse the bag through with warm soapy water and allow to air dry. Troubleshooting at home:  No drainage: ensure the catheter has not fallen out, tubing is not kinked, and your child is adequately hydrated. Flush the catheter otherwise if taught how to do so and/or attend your nearest emergency department if necessary. Leaking: try to ascertain where the leak is coming from, if it is a connecting point ensure it is firmly connected, check the tap is closed. If it is the tubing or the bag that is damaged it will need to be replaced. Catheter by–passing: Attempt to flush the catheter if taught how to do so, if it continues speak with your child’s doctors. Catheter accidently removed: Ring the hospital to speak with your child’s doctors as you may need to be assessed in emergency.

34. Complication :- Inability to catheterize: ensure appropriate catheter size has been selected based on the age/size of the child. Ensure adequate procedural pain relief and distraction is in place during the procedure. Escalate to the treating medical team and consider the need for a referral to the urology team.  In young girls, the urethra can be difficult to localise and the catheter can go directly in the vagina. In this case, leave the first catheter in the vagina and use another one to place immediately above, which will be more likely to go in the urethra. Urethral injury may occur from trauma sustained during insertion or balloon inflation in incorrect position: it is very important to ensure the catheter is in the bladder before inflating the balloon, this can be confirmed by visualising the stream of urine prior to balloon inflation. Haemorrhage

35. Contd.. False passage (catheter pushed through urethral wall): The risk of false passage is actually higher when using a smaller catheters, ensure catheter size utilised is appropriate for child’s age and size. Infection To minimise risk of infection insertion of IDC’s must be performed using surgical aseptic technique with single use sterile gloves.  Regular hygiene should be maintained whilst IDC is in situ.  Psychological trauma Paraphimosis due to failure to return foreskin to normal position following catheter insertion: To minimise risk remember to replace the foreskin in non-circumcised patients and check at catheter care or nappy change that the foreskin is in place.

36. Specimen collection :- Urine for urinalysis or culture should be collected fresh from the needleless sampling port of catheter tubing (not drainage bag), this should be completed in line with the  Aseptic Technique Procedure. Clamp below the sampling point.  Scrub sampling point vigorously with 70% alcohol and chlorhexidine (0.5% or 2%) soaked gauze or swabs for at least 15 seconds and allow to air dry prior to accessing port with a 10ml syringe to collect sample. Large volumes e.g. 24hr collection, can be collected from drainage bag.

37. Some do’s of catheterization :- Do  perform peri-care using only soap and water Do  keep the catheter and tubing from kinking and becoming obstructed Do  keep catheter systems closed when using urine collection bags or leg bags Do  replace catheters and collection bags that become disconnected Do  ensure the resident's identifier/implementation date is on their urine collection containers Do  make sure to disinfect the sampling port before obtaining a sample

38. Some don’t :- Don't  change catheters or drainage bags at routine, fixed intervals Don't  administer routine antimicrobial prophylaxis Don't  use antiseptics to cleanse the periurethral area while a catheter is in place Don't  clean the periurethral area vigorously Don't  irrigate the bladder with antimicrobials Don't   instill antiseptic or antimicrobial solutions into drainage bags Don't  routinely screen for asymptomatic bacteriuria Don't  contaminate the catheter outlet valve during collection bag emptying

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