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Urinary
Catheterisation
Copyright © 2004-2006
Tayside Health Board,
Fife Health Board &
University of Dundee
1
Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Collaborative Working
The Multi-Professional Clinical Skills Project is funded by the TUHT Endowment Fund
with the remit of establishing standardised training for procedural clinical skills for
medical, nursing and relevant allied health care professions.
NHS Tayside, NHS Fife and Dundee University, Faculty of Medicine, Dentistry and
Nursing are all collaborative partners in the venture. The packs are created by authors
who are experts from various professions involving primary and secondary care.
The packs have been designed to be adaptable to the local context, with agreement
between the collaborators to alter only sections 1, 4 and 5. All other sections are
standardised and cannot be altered out-with the agreed review process.
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Tayside Health Board,
Fife Health Board &
University of Dundee
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Urinary Catheterisation
Contents
Page No.
Section 1
Rationale for the Urinary Catheterisation Programme
How to Use this Programme
Learning Outcomes – Urinary Catheterisation
4
4–5
6–7
Section 2
Introduction
Indications for Urinary Catheterisation
Rationale for Urinary Catheterisation
Anatomy and Physiology
Patient Assessment
Urethral Catheterisation
Clean Intermittent Self-Catheterisation
Supra-Pubic Catheterisation
Risk Factors of Urinary Catheterisation
Infection Control
Discharge Information
8
8
8–9
10 – 13
14 – 16
17
17 – 18
19 – 20
21 – 22
23 – 24
25
Section 3
Paediatric/Neonatal Considerations
26 – 28
Section 4
Theoretical Assessment (adult)
29 – 32
Theoretical Assessment (paediatric)
33 – 36
Supervised Practice Assessment (Assessment of Skill Acquisition) 37 – 38
Section 5
Record of Completion of Programme
Practitioners’ Evaluation Questionnaire
References
Authors, Contributors & Reviewers
39
40 - 41
42 – 44
45 - 46
Appendices
A – Clinical Skills Framework for Practitioners
B – International Prostate Symptom Score
C – Urethral Catheterisation Procedural Checklist
D – Supra pubic Catheterisation Procedural Checklist
E – Child/Neonatal Urethral Catheterisation Procedural Checklist
F – Urinary Catheterisation Equipment List
47
48
49
50
51
52
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Section 1
Rationale for the Urinary Catheterisation Programme
This clinical skills programme has been developed by authors from different health care
professions to enable practitioners to develop their knowledge and skills in urinary
catheterisation. Adopting a multi-professional approach to clinical skills training will
promote standardised practice in the delivery of health care procedures, will encourage
effective working relationships and will provide patients with access to multi-skilled,
flexible health care practitioners.
The programme is suitable for any health care practitioner currently working in the
NHS, in the UK, who is involved as part of their work in the delivery of procedural
clinical skills and nominated as appropriate by their line manager.
How to Use this Programme
This clinical skills programme will support practitioners in their studying, enabling them
to work at their own pace, learning about urinary catheterisation in the context of their
own practice.
Each participant should negotiate a suitable time frame for completion of the
suggested activities contained within the programme with their assessor. Participants
should aim to complete the programme within a 6 weeks time frame.
Practitioners should begin working through the pack prior to attending a simulated
practice session. Practitioners should arrange supervised practice with an assessor in
their own clinical area. There are circumstances when practitioners will require
supervised practice out-with their own clinical area and this should be negotiated with
senior charge nurses/managers. Supervised practice should only occur following
attendance at a simulated practice session. Unsupervised practice should only occur
when the assessor deems the practitioner competent (successful completion of both
theoretical and practical assessments). An assessor will be a practitioner who is
competent in the skill of urinary catheterisation and familiar with this programme. A
flow diagram explaining the process of clinical skills training can be found at Appendix
A. Throughout the text, activities are provided which will encourage the use of
reflective, decision-making, observational and cognitive skills.
N.B The Professional Issues good practice study guide is a core pack designed to
prevent repetition of content in subsequent packs. All practitioners must complete the
Professional Issues pack prior to commencing any other skills pack. Some activities in
subsequent packs will require you to refer back to the Professional Issues good
practice study guide. The study guide is available for download from the NHS Tayside
intranet via Learning and Development > Clinical Skills > Good Practice Study Guides.
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University of Dundee
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Assessment includes:
• Answers to theoretical assessments must be checked by the assessor using the
marking guide provided. Assessors should guide practitioners to reference material
in the resource pack if the practitioner does not provide similar answers to the
marking guide.
•
Practitioners will be assessed using procedural checklists during simulated practice
sessions. Practitioners successfully completing this assessment are deemed safe to
undergo supervised practice in their clinical areas.
•
Assessors must use the ‘Assessment of Skill Acquisition’ tool provided to assess the
practitioners’ practical application of the skill during supervised practice. The
Assessment of Skill Acquisition form should be completed a minimum of 3 times.
The number of assessments required will depend on individual competency.
Completed assessment forms should be retained by the practitioner and not the
assessor. The practitioners who are deemed not yet competent must undergo a
further period of supervised practice.
Evaluation:
This is a new clinical skills training pack, therefore we would like to know what you
thought of the pack by taking a few minutes to fill in the evaluation form on
completion.
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Learning Outcomes - Urinary Catheterisation
Aim: On completion of the urinary catheterisation programme (completion of the
pack, attendance at simulated practice session, supervised practice and successful
completion of assessments) the practitioner will be competent in the clinical skill of
urinary catheterisation (supra pubic/urethral, depending on clinical area/exposure).
Competency Standard
Understands and debates
professional issues in relation
to urinary catheterisation
Performance Indicators
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•
•
•
•
•
Performs accurate
assessment of patient
requiring urinary
catheterisation
•
•
•
•
•
•
•
•
Demonstrates competence in
the procedure of urinary
catheterisation
•
•
•
•
•
•
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Applies ethical principles and guidelines to inform
decision making in practice
Actively involves the patient in the decision making
process
Demonstrates the ability to work in accordance with legal
and statutory guidelines
Exercises autonomy and initiative
Demonstrates responsibility and accountability for own,
and applicable others’ practice
Maintains accurate record keeping
Demonstrates knowledge of the anatomy and physiology
of male/female urinary system
Identifies and analyses the appropriateness of urinary
catheterisation
Provides patient education regarding suprapubic and
urethral catheterisation to aid decision-making
Recognises when assistance is required from specialists
Selects appropriate catheter (size and type) with
rationale for choice
Awareness of psychological impact of urinary
catheterisation for the patient
Discusses the indications of urinary catheterisation
Details contra-indications of urinary catheterisation
Obtains consent and prepares the patient for the
procedure
Assembles necessary equipment, in accordance with
devised checklist
Practises skill competently (see checklist)
Justifies the skill/procedural checklist of catheterisation
using evidence (published and other sources)
Critically analyses the clinical risks associated with
urinary catheterisation and takes appropriate action to
manage risks
Recognises fundamental differences of catheterisation in
children and the need for specialist assistance
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Date developed: December 2004
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Engages in evaluation and
critical analysis post
procedure
•
•
•
•
•
•
•
•
•
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Responds promptly and appropriately to complications
Takes action to prevent commonly known associated
complications of urinary catheterisation
Adequately prepares patient for discharge with a urinary
catheter in place
Recognises limitations and accesses assistance as
required
Reflects on attitude, behaviour (skill) and cognitions post
procedure
Appraises context in which skills were practised
Identifies learning which has occurred to influence future
practice
Identifies area/enquiries for further learning
Draws on a range of resources for further
learning/reading
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Section 2
Introduction
Urinary catheterisation involves the insertion of a catheter into the urinary bladder to
drain urine or instil fluids or drugs. The intervention can be performed by multiprofessionals in a variety of settings, as long as sufficient training and assessment has
occurred. This programme covers urethral (male and female), supra pubic,
intermittent as well as paediatric catheterisation. It is not envisaged that all
practitioners will become competent in all modes of urinary catheterisation on
completion of the programme. Rather, practitioners can select the catheterisation
procedure/s most applicable to their setting and focus their training specifically.
Procedural checklists are provided for all modes of catheterisation. Please ensure you
have circled the appropriate mode of urinary catheterisation on the completion
certificate before it is returned.
Some general principles cover all modes of catheterisation and all patient groups.
However, other more specific information will be covered under relevant sections.
Indications for Urinary Catheterisation
•
•
•
Prophylaxis: Access to bladder during surgery; minimise the risk of
damage during surgery; relieve blockage;
Diagnostic: To perform urodynamic studies and to monitor output in
critically ill patients;
Therapeutic: Management of the neuropathic bladder; to instil medication;
to relieve acute or chronic retention of urine; and to relieve intractable urinary
incontinence.
Rationale for Urinary Catheterisation
•
•
•
•
•
•
•
•
•
to re-establish a flow of urine in urinary retention;
to provide a channel for drainage when micturition is impaired;
to maintain a dry environment in urinary incontinence when all other forms of
nursing intervention have failed;
to empty bladder pre-operatively;
to allow monitoring of fluid balance in a seriously ill patient;
to facilitate bladder irrigation procedures;
recatheterisation of patients requiring regular change of indwelling catheter;
recatheterisation of patients when trial without catheter is unsuccessful;
to introduce drugs into the urinary bladder.
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Activity
Consider the common indications for urinary catheterisation in your clinical
area. Discuss your answer with your assessor in practice.
In order to become competent in the skill of catheterisation, practitioners must
understand and revisit the anatomy and physiology of the urology system.
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Version Number: 9
Date developed: December 2004
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Next review date: December 2007
Anatomy and Physiology
Figure 1. Anatomy of the male and female lower urinary tract
Marieb (1995) Human Anatomy and Physiology.
Anatomy and Physiology of the Lower Male Urinary Tract
The lower male urinary tract (figure one, left side) consists of the:
•
•
•
•
bladder
prostate gland
urethra
sphincters (external and internal)
• The Bladder
The urinary bladder receives urine from the kidneys, via the ureters, and retains it until
micturition (voiding) occurs. As urine is continuously formed by the kidneys, the
bladder must have sufficient storage capacity (approx. 400mls). This storage ability
enables urine to be retained for an acceptable interval, until the person reaches a
socially acceptable site for micturition. When empty, the bladder lies in the pelvic
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Version Number: 9
Date developed: December 2004
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cavity; as it fills it rises into the abdomen and changes shape depending on the
amount of urine in it.
The posterior wall of the bladder is related to the rectum in the male.
The trigone is a triangular area on the base of the bladder. The apex of the trigone
points forwards and contains the opening of the bladder into the urethra (the bladder
neck). The two ureteric orifices lie at the other two angles of the triangle.
The neck of the bladder is the exit. In the male the prostate gland, which contains the
urethra, is attached to the bladder base (Tortora 1996).
• The Prostate Gland lies below the neck of the bladder. It is about the size
of a walnut and completely encircles the urethra. It has no role in renal or bladder
function, but can affect passage of the catheter if enlarged.
• The Urethra is 15-20cms long and has a dual purpose as a route for urine
elimination and a passageway for semen from the reproductive organs.
The canal is in three sections.
Prostatic urethra: the first three cms is enclosed in the prostate and is the widest
section.
Membranous urethra: this short section connects the prostatic urethra with the
spongy portion of the penile urethra. A sheet of voluntary muscle surrounds this
section of the urethra and is the voluntary sphincter that prevents escape of urine.
Spongiose urethra: runs from the membranous urethra to the end of the penis,
opening onto the surface at the external urethral orifice, usually called the urethral
meatus.
Urethral Sphincters
The internal sphincter (bladder neck sphincter) is composed of smooth muscle. It has
a role in containing urine in men, but its main function is to close off the bladder neck
during ejaculation, preventing semen entering the bladder.
The external sphincter is a ring of specialised striated muscle encircling part of the
urethra just below the prostate (the membranous part of the urethra). It is partly
under voluntary control, but mostly remains closed “subconsciously” to provide the
main continence mechanism in men, and the only one in women. Spasm in this muscle
is the main cause of difficulty in passing a catheter in men. Because this sphincter lies
just below the prostate, this difficulty is often wrongly interpreted as being due to the
prostate.
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Version Number: 9
Date developed: December 2004
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Anatomy and Physiology of the Female Lower Urinary Tract
The female lower urinary tract (refer to figure one, right) consists of the:
•
bladder
•
urethra
•
sphincter
The main differences from the male lower tract are
• The urethra is shorter (about 5 cm compared to 15cm in males)
• The urethra is almost straight
• There is no equivalent to the prostate gland
Figure 2. Anatomy the female perineum
Springhouse Corporation (2001) Atlas of Human Anatomy
The first two points are the most important in the context of catheterisation.
In the male, the length and configuration of the urethra cause most of the difficulties.
In the female most difficulties are due to problems finding the urethral orifice. In
young healthy women, this is usually easily found (see Figure 2). Difficulties arise in
old age when the genitalia are atrophic; in obesity where large labia majora or even
overhanging suprapubic fat obscure the introitus; and where the person cannot widely
abduct the thighs because of arthritis or neurological disease such as MS.
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Activity
Describe medical conditions from your clinical practice that may alter the
anatomy of the male and female urinary system. Discuss with your
assessor how you would deal with this when considering urinary
catheterisation.
• The Bladder
As in the male, the urinary bladder receives urine from the kidneys, via the ureters and
retains it until micturition (voiding) occurs. As urine is continuously formed by the
kidneys, the bladder must have sufficient storage capacity (about 400mls) to hold urine
for an acceptable interval, and to retain it until the person reaches a socially acceptable
site for micturition. When empty, the bladder lies in the pelvic cavity; as it fills it rises
into the abdomen and changes shape depending on the amount of urine in it. The
trigone is a triangular area on the base of the bladder. Its apex points forwards and
contains the opening of the bladder into the urethra (the bladder neck). The two
ureteric orifices lie at the other two angles of the triangle. The trigone is related to the
upper vagina, and the posterior wall of the bladder is related to the body of the uterus.
• The Urethra
The female urethra is about 5 cms long and acts only as a route for urine elimination.
It is not part of the reproductive system. It is normally straight (Fig 1, right hand side).
•
Urethral Sphincters
The internal sphincter (bladder neck sphincter) is virtually absent in women.
The external sphincter is a ring of specialised striated muscle encircling the mid
part of the urethra. As in men, it is partly under voluntary control, but mostly
remains closed (subconsciously) to provide the continence mechanism in
women.
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Patient Assessment
The practitioner must be able to assess effectively the individual needs for
catheterisation (Pomfret 1996). The assessment process and subsequent decision
making should involve the multi-professional team and of course the patient.
Practitioners should consider if catheterisation is really required. Patients should not
be catheterised unless absolutely necessary, due to its association with significant
morbidity and mortality (Saint et al, 2005). Effective catheter care is an essential
component of the holistic care and management of patients (Winn, 1996). The ongoing
assessment, evaluation of procedures and selection of catheters and drainage
equipment demands up to date knowledge and skill on the part of practitioners.
• clinical examination
Assess the patient’s symptoms, such as dysuria, haematuria, difficulty and inability to
micturate, frequency and incontinence (catheterisation should be a last resort in
managing incontinence). There are various tools available to assess patients’ urinary
symptoms, such as the International Prostate Symptom Score (see appendix B) used in
Tayside NHS.
• physical examination
Bladder inspection – look at the abdomen for signs of distension. Gross bladder
distension may be seen as suprapubic swelling (Douglas et al, 2005)
Bladder palpation – the bladder should not be palpable post voiding
Bladder percussion – hypo-resonance indicates a full bladder (medical staff)
Bladder scanning - (if available) estimates volume of urine in the bladder
• psychological/social/sexual/cultural considerations
Has the patient been catheterised previously?
If so, what problems (if any) occurred?
• Consider the patient’s mental acuity and manual dexterity, for example would
the patient be able to open the catheter valve to empty their catheter?
• Consider the patient’s clothing preferences
• Sexually active patients may prefer supra pubic catheterisation.
• Libido may be affected by altered body image (Getliffe, 1993).
• Development and independence in continence is a recognised developmental
stage in children (Bee and Mitchell, 1984).
Activity
One of your patients is complaining of abdominal pain and an inability to
pass urine. The patient is 12 hours post operative. Make notes on how
you would assess the patient’s suitability for urinary catheterisation.
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Supra pubic or urethral?
Urethral catheterisation involves the insertion of a urinary catheter via the urethra into
the bladder and is the usual route of choice in an acute emergency situation. Supra
pubic catheterisation occurs usually when urethral is contraindicated. Supra-pubic
catheterisation is the insertion of a urinary catheter into the bladder via an incision in
the anterior abdominal wall. If the catheter is required long term then the decision
between supra pubic or urethral is a joint decision amongst the patient, relatives and
multi-disciplinary team.
Catheter Selection
Urinary catheters are available in varying lengths, gauges, balloon sizes and materials.
Choice of catheter material and gauge will depend on assessment of individual,
purpose and estimated duration. The catheter should meet the individual needs of the
patient, be easy to insert and remove, be comfortable and minimise secondary
complications of tissue inflammation, colonisation and encrustation (Cannon, 2001).
Lengths
Female – 20-26cm, some female patients require or prefer to have a male length
catheter.
Paediatric - purpose made paediatric catheters are 30cm
Male – 40cm standard length only
Gauge
Measured in French gauge or charriere. Range from 6fg to 28fg. Recommended size
in adults 12fg – 16fg, although 18fg can be used if debris or clots are present.
Balloon size
Each catheter states recommended inflation size in mls. This should be adhered to,
due to risk of rupture caused by over inflation.
Materials
Silver-coated catheters
Recent studies (Saint et al, 2000; EPIC Guidelines, 2001; Lai & Fontecchio, 2002,
Schaeffer, 2005) have endorsed the use of silver-coated urinary catheters. These
studies have shown that using silver coated catheters significantly lowers the incidence
of UTI and bacteraemia, when compared with the use of silicone or Teflon latex
catheters. Saint et al (2000) found that using silver coated catheters reduced
symptomatic UTIs by 47% and bacteraemia by 44%. Silver coated catheters (silver
alloy or silver oxide) are available in the UK. Although silver coated catheters are
initially more expensive to purchase, the long-term benefits may be cost-effective.
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Catheter Material
PVC –
Hydrophyllic or
with gel reservoir
Recommended Usage
Intermittent self
Catheterization
Teflon coated with
latex core
Short term up to
28 days
Silver Alloy coated
Hydrogel
Maximum of 28
days
Advantages
Single use only
Suitable for
intravesical
installations
More resistant
to encrustation
Smoother surface
therefore less
urethral trauma
Inhibit bacterial
adhesion to
catheter surface
reducing CAUTI
Wide lumen for
drainage
Suitable for
latex allergy
100% Silicone
Long term use
up to 12 weeks
Hydrogel coated
Latex
Long term use
up to 12 weeks
More compatible
with body tissue
More resistant
to bacterial
colonization
Silicone elastomer
coated latex
Long term use
up to 12 weeks
Hydrogel coated
Silicone
Long term use
up to 12 weeks
May help to
reduce potential
for encrustation
Suitable for
patients with
latex allergy
Disadvantages
Teflon coating can
wear thin if left longer
than recommended
time
Unsuitable in latex
allergy
More expensive
Unsuitable in latex
allergy
Cuffing of balloon on
Deflation known to
occur – potential
trauma on removal
can predispose to
encrustation
Unsuitable in latex
allergy
Unsuitable in latex
allergy
Rigid, may be
uncomfortable
Activity
You have a 30 year old patient suffering from Multiple Sclerosis requiring
long term urinary catheter use. Explain your decision for catheter selection,
providing a rationale for your choice.
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Urethral Catheterisation
Urethral catheterisation involves the insertion of a urinary catheter via the urethra into
the bladder. The urethra is the first route of choice in an acute emergency, probably
largely due to the fact that the procedure can be carried out anywhere so long as the
appropriate equipment is available and an aseptic technique is used (see appendix C). An
equipment list can also be found at appendix F.
Contraindications:• urethral stricture
• urethral trauma
• occlusive prostate
• unable to perform leg abduction in female patients
Clean Intermittent Self-Catheterisation
An alternative to an indwelling catheter is to teach the patient or their carer
intermittent self-catheterisation (CISC). CISC has developed over the last 30 years and
is an effective management strategy for people who have urinary retention or
incomplete emptying (Moore 1995). This technique has been demonstrated to reduce
infection hazards and greatly improve the lives of many patients with voiding disorders
(Lapides et al 1972) and can improve quality of life and promote independence (Cowan
1997).
The procedure of self-catheterisation involves the patient being taught to pass a prelubricated catheter up the urethra and into the bladder. The frequency of this will
depend on whether the patient has the ability to void at all.
Each episode of CISC empties the bladder of urine, resulting in less chance of bacterial
growth caused by retained urine (Addison 2001), as it is believed to
• mimic the regular filling and emptying of voiding
• prevents distension and ischaemia of the detrusor, thus maintaining adequate
circulation in a vascular muscle which allows the natural defence mechanisms
to fight infection (Lapides et al 1972).
The success of CISC depends on a number of factors which include:
Patients:• sufficient manual dexterity
• ability to understand procedure
• motivation to perform procedure
• ability to identify and access urethra (females)
(All of the above may be overcome by teaching a carer.)
Health Professionals:• knowledge and ability to teach the technique
• up to date knowledge of the products available
• ability to motivate the patient
• the giving of continuing support
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Advantages
• improves quality of life
• improves body image
• allows freedom during sexual activity
• reduces upper tract complications
• reduces risk of bladder malignancy
• less demands on health care resources
• can in some cases rehabilitate and restore normal bladder function
Risks:• urethral trauma
• recurrent or chronic urinary tract infection
• non-compliance
Individual patient assessment is required in all circumstances. If the patient is suitable
for teaching CISC, a referral should be made to the Urology team.
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Supra-Pubic Catheterisation
Supra-pubic catheterisation is the insertion of a urinary catheter into the bladder via an
incision in the anterior abdominal wall. Supra-pubic catheterisation is becoming an
increasingly common alternative to urethral catheterisation (Robinson, 2005). The
procedure can be performed under local or general anaesthetic and an aseptic
technique must be employed.
Indications
• When urethral catheterisation is not possible due to contraindication listed
above
•
Post operatively following:urethral/bladder/pelvic surgery
•
Long term management of continence problems:preferred patient choice
allows sexual intercourse
improved management for wheelchair bound patients
Contraindications
• known bladder tumours
• previous pelvic/bladder surgery
• small fibrotic bladders
• prosthetic devices or material in lower abdomen
• altered body image which the patient may not accept (Robinson, 2005)
Advantages:• reduced infection rates
• less trauma to urethra
• less pain
• easier voiding assessment (Shah and Shah, 1998 & Horgan et al, 1992)
• reduced urethral stricture
• Greater freedom of expression if sexually active.
Disadvantages/Complications:• increased risk of bowel perforation
• possible long term risk of squamous cell carcinoma (Shah & Shah, 1998 and
West el al, 1999). Young patients who may require long term use (20 years)
should be informed of this potential risk
• Urethral leakage
• Increased risk of lignocaine absorption
• Cystostomy complications.
Supra-pubic Catheter change
First changes will be undertaken by a Urology nurse, at eight weeks post procedure,
usually in the Urology clinic. Subsequent changes can be undertaken by practitioners
in many settings, providing suitable training has been given. Supra-pubic catheters are
usually changed every 8 – 10 weeks, although individual patients may require more
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frequent changes. See Appendix D for supra-pubic catheter change checklist and
Appendix F for equipment checklist.
NB: Ideally, supra-pubic catheters should be re-inserted after removal
within one hour, to prevent the tract from closing. Staff experiencing
problems with re-insertion should contact the urology team.
Only catheters licensed for supra-pubic use should be used for this purpose
(Medicines and Healthcare products Regulatory Agency, 2001). Always
check packaging before proceeding.
Activity
You are working in the community setting and are required to visit a patient
at home to change their supra-pubic catheter. What information would you
need to establish prior to carrying out the supra-pubic catheter change?
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Risk Factors of Urinary Catheterisation
The knowledge and skills of catheter care will ensure that patients receive safe and
effective management. Pre-planned and routine care should always supercede ‘crisis’
interventions and ongoing management is the approach of choice. Through
appropriate, evidence based care complications are minimized and resources will be
used effectively.
Risk Identified
Urethral Suprapubic
Prevention/Action
Informed catheter selection, thorough
handwashing, aseptic technique, patient
education, catheter care and antibiotic use
only when symptomatic. Evidence of reduced
infection with suprapubic catheter (Robinson,
2005).
Urinary tract infection
(Tew at al, 2005)
Establish patient’s allergies prior to inserting
catheter.
Allergy or reaction
(Association for Continence
Advisors, 2001)
Encrustation
(Shah & Shah, 1998)
Informed catheter choice, increased fluid intake
bladder washout indicated if catheter blocked,
catheter changed according to manufacturer’s
instructions
Trauma and tissue
Damage (Bardsley, 2005)
Appropriate training in technique, correct size of
catheter used, use of anaesthetic gel on
insertion, balloon inflated as per manufacturer’s
instructions.
Ensure foreskin is replaced following catheter
insertion, apply cold compress and return
foreskin to correct position, seek assistance if
swelling does not reduce.
Paraphimosis
Barua & Reynard (1999),
Choe (2000)
Secure catheter drainage bag,
empty drainage bag before more
than two thirds full, inflate balloon
to manufacturer's instructions.
Ensure patient is well informed, use of
anaesthetic gel, correct size of catheter, ensure
secure collection bag, consider anticholinergic
drug for bladder spasm.
Pressure necrosis
(Getliffe, 1993)
Pain
(Doherty, 1999)
Insert smaller catheter size (Ch), ensure correct
volume fluid in balloon, assess patient for
constipation and UTI, assist patient
to reposition, check the tubing is not kinked,
consider anticholinergic medication.
Catheter Bypassing
(Winn, 1998)
Use of anaesthetic gel, correct size
of catheter used and secure anchoring of the
catheter system.
Splitting of the meatus
Chapple (2000)
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Version Number: 9
Date developed: December 2004
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yBest Practice Statement
Patients should be encouraged to drink an adequate (2 litres) fluid volume in a day (if
not otherwise contraindicated).
Rationale: Normal fluid intake is adequate and research suggests that increased fluid
intake makes little difference in reducing the risk of catheter blockage.
Source of Evidence Descriptor: Stickler and Hughes (1999) Ability of Proteus
mirabilis to swarm over urethral catheters. European Journal of Clinical Microbiology
and Infectious Diseases.
yBest Practice Statement
Indwelling catheters are connected to a closed drainage system. The closed system
is maintained as much as possible (NHS QIS, 2004).
Rationale: By maintaining a closed drainage system the risk of catheter-related
infection is reduced.
Source of Evidence Descriptor: Kunin, C. (1997) Urinary Tract Infections:
Detection, Prevention and Management. Baltimore; London: Williams & Wilkins.
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Version Number: 9
Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
Infection Control
There is consistent evidence that a significant number of hospital acquired infections
are related to urinary catheterisation (Pratt et al, 2001).
Factors that drive the continued rise in healthcare associated infections are well
understood particularly in the use of medical devices such as urinary catheters to drain
the bladder (associated with 80% of urinary infections). The challenge to the NHS is
to keep sources of infection as low as possible and to minimise and manage the risks
of transmission to patients (NHS QIS, 2004).
Some common organisms responsible for urinary tract infections include:• Proteus
• Escherichia coli
• Coliforms
• Methicillin Resistant Staphylococcus Aureus
• Pseudomonas
Several different species of bacteria may occur together and can be resistant to
antibiotics. One reason for this resistance may be the mode of growth of microorganisms. These adhere to the catheter’s surface causing a living layer – biofilm – to
form. Secretions cement the biofilm to the catheter surface making it impossible to
remove and unable to be penetrated by antibiotics (Tew, 2005). Micro-organisms such
as enterococci are part of the normal bowel flora, but may cause disease if they are
transferred to a different part of the body e.g. Escherichia Coli from the intestine
causes UTI.
Antibiotics should only be used if the patient is symptomatic of urinary tract infection
(Simpson, 2001). Antibiotic solutions have not been shown to have any effect on
catheter associated infections (NHS QIS, 2004).
yBest Practice Statement
Catheter drainage bags should be changed every 5-7 days or if it becomes discoloured,
damaged, odorous, or there is a build up of sediment before this.
Rationale:
To reduce the risk of infection and encrustation.
Source of Evidence Descriptor:
National Institute for Clinical Excellence (2003) Prevention of healthcare associated
infection in primary and community care.
Infection Control Measures
•
•
•
•
Hand hygiene
Personal protective equipment
Aseptic technique
Closed drainage system to ensure that urine remains sterile until it reaches the
drainage bag
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•
•
•
Collection of specimens via aspiration port
An outlet tap which will facilitate emptying without removing the bag from the
catheter using a separate and clean container for each patient
Disconnections should be kept to a minimum as frequent changes can increase
the risk of infection.
yBest Practice Statement
Urine bags should be emptied frequently enough to maintain urine flow and prevent
reflux.
Rationale: To prevent backflow of urine.
Source of Evidence Descriptor: National Institute for Clinical Excellence (2003)
Prevention of healthcare associated infection in primary and community care.
Activity
Explain what actions you can take in your clinical area to reduce the risk of
urinary tract infections, due to indwelling catheters. Discuss your answer
with your assessor.
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Version Number: 9
Date developed: December 2004
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Discharge Information
Patients should be given written information on discharge for both themselves or their
carer and the Community Nurse/GP.
Health Care Professional information should include:
• reason for catheterisation
• size and type of catheter, amount of sterile water in the balloon and type of
drainage
• initial amount drained and any subsequent diuresis
• degree of difficulty of catheterisation
• whether short term or long term management
• follow-up
Patient information to include:
• day to day care of catheter
• when and how often drainage system to be changed
• how to connect , disconnect and dispose of night bag
• importance of closed drainage system
• how to contact Community nurse if any difficulties
• if this is a short or long term management plan
• any follow up planned
Patients will also require to be given the following take home supplies:
• 5 night bags
• 2 leg bags or drainage valves
Community Nurse should be contacted by phone to inform him/her of the patient’s
discharge into the community.
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Section 3
Child/Neonatal Considerations
Urethral catheterisation of children and babies requires special considerations and
should only be undertaken after specific supervised practice in a child or neonatal
setting. Subsequently there is a separate Child/Neonatal Procedural Checklist which
should be followed (see Appendix E). There is also a generic equipment list available at
Appendix F.
The use of a urethral catheter in boys is particularly controversial. There is a definite
risk of urethral stricture formation in boys who have had urethral catheterization for
any length of time, or whose catheterization has been ‘traumatic’. It should not be
used ‘as standard’ in boys to measure urine output unless other methods - such as
perineal urine bags and bladder expression - have been tried and found not to be
adequate.
Most children are frightened of the procedure and few young children are able to be
co-operative. It is therefore essential that a good explanation be given taking into
account the developmental age of the child and that an assistant is present to help and
reassure and distract the child (Hockenbury, 2004). It is preferable for the parent/
carer to be present but they should be given the opportunity to decide prior to
commencing the procedure.
Parents may become upset when the child is catheterised. Some parents, especially
those from a different culture, may fear that the procedure affects their daughter’s
virginity. A full explanation of the genitourinary tract should then be given to clarify
this misconception (Hockenbury, 2004).
Analgesia/Sedation
☺
Children over 1 year old should be assessed for sedation as per Paediatric
sedation guidelines (available on the Intranet on Paediatric & Child Health
Directorate site).
☺
Local anaesthetic lubricating disinfecting gel should be used to reduce or
eliminate the burning discomfort except when allergies are known
(Hockenberry, 2004). Instillagel is the local anaesthetic lubricating gel
recommended by Tayside University Hospital policy.
Recommended volumes for Instillagel are:–
Age
0 – 2 years
2 – 5 years
5 – 10 years
10 plus years
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2
4
4
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–
–
–
–
Dosage in mls
2 mls
4 mls
6 mls
6 mls
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Date developed: December 2004
Last review Date: December 2005
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Catheter selection and procedure
☺
The catheter should be selected based on the purpose of the procedure, the
age and gender of the child and any history of prior urologic surgery
(Hockenberry, 2004)
Where at all possible silicone catheters should be used rather than standard latex
‘Foley’.
The recommended size of catheters to be used for urethral catheterisation are
as follows:Age
Girls
Boys*
< 1 year
6Fg
6Fg
1 – 5 years
8Fg
6Fg
>5 years
8Fg
8Fg
The size of catheter in boys depends very much on the size of the urethral
meatus. However, a non-retractile foreskin should NOT be forced back in order
to see it - it is possible to pass the catheter without doing so.
VERY IMPORTANT: The catheter balloon should NEVER EVER be inflated before
urine is seen coming from the catheter - no matter how far in the catheter
appears. It is not uncommon in boys for the catheter to curl up in the posterior
urethra and a balloon inflated here will cause severe damage and this is
indefensible in court.
Any difficulty at all encountered when placing a catheter in a boy warrants
discussion with a paediatric surgeon.
Prophylactic use of antibiotics in children
Depending on the indications for the catheter, prophylactic antibiotics may be indicated
to cover the procedure and possibly until it is removed. This needs to be decided on a
case by case basis by the clinician involved.
Low-dose antibacterial prophylaxis should be commenced after a urine infection, to
continue until after all investigations have been completed (Poole 2002).
Supra-pubic Catheterisation In Children
This is very rarely performed outside an operating theatre setting unless by a
paediatric urologist/surgeon.
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Activity
A 12 year old, suffering from 20% scalds requires urinary catheterisation
for accurate fluid output measurement. Explain the legal and ethical issues
you would need to consider regarding obtaining informed consent. Discuss
what mode of urinary catheterisation and what equipment you would use.
Discuss your answer with your assessor.
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Date developed: December 2004
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Section 4
Theoretical Assessment
Adult Urinary Catheterisation
Guidance notes for the theoretical assessment are available to download from the NHS
Tayside intranet via Learning and Development > Clinical Skills > Clinical Skills
Programmes to enable your assessor to give you feedback on your work. Practitioners
should cover key points for each question. Practitioners who have not considered key
points in their answers should be guided by their assessor to further reading, before
attempting to answer the questions again.
Question One
All practitioners have a responsibility to keep up to date and prevent skill fade. Explain
what actions you can take to keep up to date with urinary catheterisation and prevent
skill fade.
Case Study
Mrs Niven, 45 years old, suffers from Multiple Sclerosis. She lives at home with her
husband and two teenage children. Mrs Niven is complaining of a feeling of being
unable to empty her bladder properly and she often cannot get to the toilet on time
due to her limited mobility. She feels these symptoms are having a negative impact on
her quality of life.
Question two
Discuss the factors you would consider when assessing Mrs Niven’s continence
difficulties.
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Question three
Following assessment and discussion between practitioner and patient, Mrs Niven
decides that she would like to try an indwelling urinary catheter to manage her
continence difficulties. Make notes on the information you would give Mrs Niven in
order for you to obtain informed consent.
Question four
Following urinary catheterisation, write what information you would document in Mrs
Niven’s medical/nursing notes.
Question five
Critically analyse the risks associated with the procedure of urinary catheterisation and
explain what actions you would take to minimise these risks.
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Question six
Following urinary catheterisation, Mrs Niven experiences bladder spasm. What actions
would you take to reduce this unpleasant side effect?
Question seven
If, when attempting to catheterise Mrs Niven, you are unable to pass the urinary
catheter, what action would you take?
Question eight
Your patient is being discharged home with an indwelling urethral catheter. Explain
what information your patient will require prior to discharge.
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Question nine
Reflect on what learning has occurred and discuss the changes this will make to your
clinical practice.
Question ten
Regarding urinary catheterisation, identify areas where you can further improve your
practice and learning.
Explain what possible sources you may obtain further
information from.
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Theoretical Assessment
Child Urinary Catheterisation
Guidance notes for the theoretical assessment are available to download from the NHS
Tayside intranet via Learning and Development > Clinical Skills > Clinical Skills
Programmes to enable your assessor to give you feedback on your work. Practitioners
should cover key points for each question. Practitioners who have not considered key
points in their answers should be guided by their assessor to further reading, before
attempting to answer the questions again.
Question One
All practitioners have a responsibility to keep up to date and prevent skill fade. Explain
what actions you can take to keep up to date with urinary catheterisation and prevent
skill fade.
Case Study
Luke, a 6 year old boy, is admitted for neurological observation after sustaining a head
injury from a 2 ft fall from a tree. Luke had loss of consciousness for approximately 2
minutes at the scene of the accident. His Glasgow Coma Scale is 12 on admission and
all x-rays show no abnormalities. However, he is now having frequent episodes of
urinary incontinence. Both parents are present on the ward. Luke is particularly upset
about his episodes of incontinence.
Question Two
Discuss the factors to be considered when assessing Luke for his continence problems.
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Question Three
A few hours after admission, Luke’s condition begins to deteriorate. With a lower GCS,
the decision is made to transfer him to the high dependency unit. Due to an altered
level of consciousness and a requirement to monitor accurate fluid balance, the team
discuss the possibility of urethral catheterisation. Following assessment and discussion
with Luke’s parents the decision is made to try an indwelling urinary catheter for short
term use. Make notes on the information you would give Luke and his parents in order
for you to obtain informed consent.
Question Four
Following the procedure of urinary catheterisation, what information needs to be
documented in the child’s notes?
Question five
Critically analyse the risks associated with the procedure of urinary catheterisation and
explain what actions you would take to minimise these risks.
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Question six
Following urinary catheterisation, the catheter appears to be bypassing. What actions
would you take to remedy this problem?
Question seven
If, when attempting to catheterise Luke, no urine appears when you pass the catheter,
what actions would you take?
Question eight
Children are not regularly sent home with indwelling urinary catheters. However, if
this situation arose, what information would Luke and his parents require prior to
discharge?
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Question nine
Reflect on what learning has occurred and discuss the changes this will make to your
clinical practice.
Question ten
Regarding urinary catheterisation, identify areas where you can further improve your
practice and learning.
Explain what possible sources you may obtain further
information from.
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Assessment of Skill Acquisition
Assessor: ____________________
Status: _____________________
Practitioner: _________________
Status: _____________________
Clinical Skill: ________________
Date: ______________________
Number of Supervised Evaluations: ______
Practitioners should be assessed until competence is achieved in all domains or if competence is achieved on first
attempt they must undergo a minimum of 3 observations. Competence is achievement when all criteria are met in all
domains. Assessors should indicate if competence has been achieved in each domain by circling ‘YES’ or ‘NOT YET.’
Feedback should be entered in each remarks box, identifying criteria to be achieved or demonstrated.
Competence Achieved YES/NOT YET
1. Professionalism Criteria
- applies ethical principles to inform decision making
- involves patient in decision making process
- practices in accordance with professional code
- demonstrates autonomy and initiative
- maintains accurate record keeping
Remarks:
Competence Achieved YES/NOT YET
2. Patient Assessment Criteria
- assesses patient suitability for the procedure
- selects equipment (providing rationale for choice)
- discusses the potential psychological impact with the
patient
- critically analyses potential risks
Remarks:
Competence Achieved YES/NOT YET
3. Knowledge and Application Criteria
- demonstrates knowledge of relevant A&P
- provides appropriate patient information
- discusses indication and contraindications with patient
- seeks information from appropriate sources when
necessary
Remarks:
Competence Achieved YES/NOT YET
4. Communication Criteria
- skill explained to patient/significant others to obtain
informed consent
- practitioner demonstrates accurate and legible
documentation of skill
5. Organisational Criteria
- correct equipment is prepared and checked
- skill is carried out in a timely, logical sequence
- responds appropriately to any complications
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Remarks:
Competence Achieved YES/NOT YET
Remarks:
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Competence Achieved YES/NOT YET
6. Technical Ability Criteria
- skill is performed accurately and efficiently
- recognises limitations of technical ability and seeks
assistance as required
- takes appropriate action to reduce risk of
complications i.e. aseptic technique as required
Remarks:
Competence Achieved YES/NOT YET
7. Overall Competence Criteria
- achievement of all of the above qualities
- practitioner’s ability to practice skill in accordance
with standardised procedure
- demonstrates aptitude to reflect on learning and
identifies areas for further learning.
Remarks:
Assessor’s Feedback (indicating areas for improvement as necessary):
Agreed Action Plan (Between assessor and practitioner):
Time to achieve action plan
I week
Practitioner Signature:______________________
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2 weeks
other please specify___________
Assessor Signature:_________________________
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Date developed: December 2004
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Section 5
Record of Completion of Programme (Urinary Catheterisation)
All staff must complete and return this slip to the appropriate person.
All Nursing and Midwifery Staff:
Return to Manager (i.e. Senior Charge Nurse).
Postgraduate Medicine:
Return to Training & Research Officer, Postgraduate Office, Level 7, Ninewells Hospital, Dundee.
Full Name: ________________________________
Profession (Please circle one): Nursing & Midwifery / Medicine / AHP
Job Title: __________________________
Clinical Area: _____________________________
Directorate (If applicable): ______________________________________________________
Hospital/Primary Care Facility: ___________________________________________________
Please circle which type of catheterisation the practitioner has achieved competence in:Male urethral
Female urethral
Supra-pubic
Signature
(Practitioner)
Signature
(Assessor/Facilitator)
Date
Attendance at simulated
practice session
Completion of theoretical
assessment/s
Completion of practical
assessment/s
Competent to carry out
Urinary Catheterisation
Practitioners will not be deemed competent until this information is entered into the Tayside
Training Database and appears in their personal training record. It is vital, therefore, that the
Manager/Training & Research Officer photocopies this form and returns it to:
Lorna Ferri,
Nursing & Patient Services,
Level 7,
Ninewells Hospital,
Dundee.
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Version Number: 9
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Practitioners’ Evaluation Questionnaire (Urinary Catheterisation)
This questionnaire has been devised to address potential deficits and improve the service of clinical skills programmes.
To enable practitioners to influence future developments please take a few minutes to complete this questionnaire.
Questionnaires should be completed following completion of each clinical skills pack. Responses will remain confidential
and will only be seen by those evaluating the multi-professional clinical skills project.
1. What is your profession? __________________________________________________________________________
2. Which ward/department do you work in? _____________________________________________________________
3. Which hospital/primary care facility do you work in? ____________________________________________________
Paper-based
Online (Virtual Learning Environment)
4. Which version of the clinical skills pack was chosen?
5. How was the clinical skills pack accessed? (i.e. paper-based from the intranet, paper-based from the Charge Nurse,
VLE from the ward computer, VLE from a home computer etc) ___________________________________________
Please rate the following statements
Agree
Undecided
Disagree
6. The best practice statements were useful.
7. The activities throughout the pack assisted learning.
8. The theoretical assessment was a useful method of testing knowledge.
9. The marking guide enabled you to measure your learning.
10. If you disagreed with statement 9, please explain why: ________________________________________________
11. Assessors in practice provided adequate support and feedback.
12. If you disagreed with statement 11, please explain why: _______________________________________________
13. Procedural checklists were valuable in practice.
14. The practical assessment was usable in practice.
15. The simulated practice session was useful.
16. If you disagreed with statement 15, please explain why: _______________________________________________
17. The trainer answered any questions/queries appropriately.
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18. The programme has enabled you to attain competency in the skill.
19. If you disagreed with statement 18, please explain why: ________________________________________________
20. The skill will benefit patients in your clinical area.
21. If you disagreed with statement 20, please explain why: ________________________________________________
Please choose an appropriate answer
Too much
Just right
Too little
22. The volume of the skills pack was:
Too difficult
Just right
Too easy
23. The level of theoretical content was:
24. Please add any additional comments that may assist in this evaluation:
Please return all completed questionnaires to:
Multi-Professional Clinical Skills Project Secretary,
Clinical Skills Centre,
Level 6,
Ninewells Hospital,
Dundee, DD1 9SY.
Many thanks for taking the time to complete this questionnaire
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References
Addison R (2001) Intermittent self catheterisation, Nursing Times Plus, 97(20): 67-69.
Association for Continence Advisors (2001) The Quarterly Journal of the ACA; 21, p28.
Bardsley, A. (2005) Use of lubricant gels in urinary catheterisation. Nursing Standard,
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Barua, J. M. and Reynard, J. M. (1999) Reduction of paraphimosis the simple way –
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Bee, H. L. and Mitchel, S. K. (1988) The Developing Person. A Lifespan Approach;
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Cannon C. (2001) With careful management of urinary catheters, a significant number
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Last review Date: December 2005
Next review date: December 2007
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Version Number: 9
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Authors, Contributors & Reviewers
The Multi Professional Clinical Skills project, based at the clinical skills centre in
Ninewells, has been funded by the TUHT Endowment Fund. The project team are as
follows: Project
Project
Project
Project
Director: Dr Jean Ker
Manager: Michelle Lorente
IT Facilitator: Chris Lawrie
Secretary: Michelle Harvey
Authors:
Keith Baxby – Consultant Urologist (Retired), Ninewells Hospital, Dundee.
Norma Craig – Continence Advisor, Primary Care, Tayside.
Lynn Doig – Urology Charge Nurse, Acute Care, Tayside.
Allison Robertson – Urology Specialist Nurse, Acute Care, Tayside.
Kate Dean – Senior Staff Nurse, Paediatric Out-patients, Ninewells Hospital, Dundee.
Margaret Peebles – Paediatric Associate Specialist, Ninewells Hospital, Dundee.
William Manson – Consultant Paediatric Surgeon, Ninewells Hospital, Dundee.
George Hogg – Senior Clinical Skills Tutor, University of Dundee, School of Medicine,
Clinical Skills Centre, Ninewells Hospital.
John Ramsay – Patient Bank Trainer, University of Dundee, School of Medicine, Clinical
Skills Centre, Ninewells Hospital.
Michelle Lorente – Multi-Professional Clinical Skills Project Manager, Clinical Skills
Centre, Ninewells Hospital.
Steve Kite – Infection Control Nurse, Acute Care, Tayside.
The pack was distributed to the following reviewers:
Internal Review:
Multi-Professional Clinical Skills Steering Committee:Jean Ker – Project Director, Undergraduate Medicine, University of Dundee
Michelle Lorente – Project Manager, Acute Care, NHS Tayside
Charles Sinclair – Head of Practice & Professional Development, Acute Care,
NHS Fife
Madge Balfour - Practice Development Nurse, Acute Care, NHS Fife
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Version Number: 9
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Next review date: December 2007
Julie Peacock – Clinical Practice Development Officer, Primary Care, NHS Fife
Jim Foulis – Lead Nurse, Acute Care, NHS Tayside
Iain Rennie – Clinical Educator, Acute Care, NHS Tayside
Kay Wilkie – Director of Learning & Teaching. University of Dundee
Phillip Roddam – Postgraduate Medicine, Acute Care, NHS Fife
Fiona Anderson – Training & Educational Development Manager, NES
George Hogg – Senior Clinical Skills Tutor, University of Dundee
Santosh Chima – Clinical Educator, Primary Care, NHS Tayside
Chris Goodman – Consultant Urological Surgeon, Acute Division, NHS Tayside.
External Review:
Professor Rowley - Director of Education, Royal College of Surgeons of Edinburgh.
Alistair Lawrie – Head of English, Cults Academy, Aberdeen.
Date developed: December 2004
Last review date: December 2005
Next review date: December 2007
Persons responsible for review:
The Multi-Professional Clinical Skills Project Team will be responsible for reviewing this
pack and liaising with appropriate authors and contributors.
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Appendix A
Clinical Skills Framework for Practitioners
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Appendix B
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Next review date: December 2007
Appendix C
Urethral Catheterisation Procedural Checklist
Task
Perform hand wash
Collect and prepare required equipment
Check identity of the patient
Explain procedure to the patient and obtain informed consent
Establish patient allergies (especially latex)
Ensure patient privacy
Assist the patient into a comfortable position and ensure not unduly exposed
Place protective sheet under the patient’s buttocks and adjust lighting as necessary
Put on apron
Perform hand wash
Open catheterisation pack and apply both pairs of gloves
Apply the sterile drapes appropriately over the patient.
a
r
An aseptic technique using sterile gloves is used during this procedure.
Retract the foreskin (if present) and cleanse the glans and urethral meatus with
saline solution, swabbing away from the urethral orifice.
Hold the penis gently and laterally behind the glans with a gauze swab.
Before applying anaesthetic gel, check with patient regarding any previous
allergies/reactions
Anaesthetise the urethra with 11ml of local anaesthetic lubricating disinfecting gel,
instilling slowly.
Gently squeeze the end of the penis (or apply a penile clamp) to prevent the anesthetic
from escaping the urethra.
Using saline cleanse the vulval area swabbing from above downwards
Identify the urethral meatus
Insert 6mls of local anaesthetic lubricating disinfecting gel into urethra
Allow 5 minutes to elapse
Remove outer gloves
Position receptacle for urine
Pick up catheter in dominant hand and remove packaging
Using the gauze swab, hold the penis at a 90 degree angle from the pelvis.
Introduce catheter into meatus and continue to insert until urine flows.
If resistance is felt, increase traction on the penis slightly and apply steady, gentle
pressure on the catheter
Insert into urethral orifice for about 6-8cm until urine flows
Once urine flows insert the catheter a further few centimetres
Inflate the balloon with sterile water as per manufacturer’s instructions
Withdraw the catheter slightly until resistance if felt
Attach catheter to drainage system
Ensure the foreskin (if present) is placed back over the glans
Collect urine sample if required
Make sure the patient is comfortable
Dispose of equipment as per local policy
Perform hand wash
Document procedure in patient’s notes/care plan/fluid chart, including reason for
procedure, catheter used (size, type, batch number, volume in balloon), anaesthetic
gel used, any problems and signature of practitioner
Key:
Male
Female
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N/A
Appendix D
Supra-Pubic Catheterisation Procedural Checklist
Task
REMOVAL
Perform hand wash
Collect and prepare equipment required
Establish patient allergies (especially latex)
Check identity of patient
Explain procedure to patient and obtain informed consent
Ensure patient privacy
Protect patient’s clothing/bedding with absorbent pad
Assist patient into supine position and expose cystostomy site
Put on apron
Perform hand wash
Apply one pair of non-sterile gloves
Remove any dressing from site and observe for discharge, granulation or
inflammation
Remove and dispose of non-sterile gloves and apron
Put on apron
Perform hand wash
Apply 2 pairs of sterile gloves
Clean around site with swab soaked in saline solution
Apply half syringe of local anaesthetic lubricating disinfecting gel around site
Connect syringe to balloon port and allow balloon to deflate
Inform patient that catheter is about to be removed
Hold catheter at entry site and remove (may require some traction)
Observe length and angle of catheter as this will guide reinsertion
Observe catheter tip for any encrustation
Dispose of equipment as per local policy
If any difficulties are experienced contact urology team
RE-INSERTION
Apply remaining half syringe of local anaesthetic lubricating disinfecting gel around
site
Remove outer pair of gloves
Estimate length of catheter for reinsertion and gently insert into site
Observe for urine flow and inflate balloon as per manufacturer’s recommendations
If any resistance is felt on balloon inflation, deflate and reposition catheter, re-inflate
balloon
Withdraw catheter slightly until resistance is felt
Attach catheter to drainage system
Observe cystostomy site for bleeding and apply keyhole dressing as required
Collect urine sample if required
Dispose of equipment as per local policy
Perform hand wash
Observe to check for free drainage
Document procedure in patient’s notes/care plan/fluid chart, including reason for
procedure, catheter used (size, type, batch number, volume in balloon), length of
catheter inserted, anaesthetic gel used, state of cystostomy site, colour of urine
drained, any problems encountered and signature of practitioner
If any difficulties are experienced contact urology team
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a
r
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Date developed: December 2004
Last review Date: December 2005
Next review date: December 2007
N/A
Appendix E
Child/Neonatal Urethral Catheterisation Procedural Checklist
Task
Perform hand wash
Collect and prepare equipment required
Check identity of the child
Explain procedure to the child, according to developmental level, and parent and
obtain informed consent
Establish any allergies (especially latex)
For child over 1 year assess whether or not sedation is required
Administer sedation as per paediatric sedation guidelines
Ensure child’s privacy
Assist the child into comfortable position and ensure not unduly exposed
Place protective sheet under child’s buttocks and adjust lighting as necessary
Put on apron
Perform hand wash
Open catheterisation pack and apply both pairs of gloves
Apply sterile drapes appropriately over the child.
a
r
An aseptic technique using sterile gloves is used during this procedure
Cleanse the entire glans penis with saline solution, in outward circular motion
swabbing away from the urethral meatus. If the foreskin cannot be easily retracted,
do not force, but ensure that the glans is thoroughly cleaned.
Hold the penis gently and laterally behind the glans with a gauze swab
Using saline cleanse the perineum, including the labia, vaginal introitus and urethral
meatus, swabbing in above downwards
Identify the urethral meatus (may appear as dimple above the hymen)
Anaesthetise the urethra with local anaesthetic lubricating disinfecting gel (volumes
dependent on age, see guidelines)
Allow 2-5mins to elapse
Remove outer gloves
Position receptacle for urine
Pick up catheter in dominant hand and remove packaging
Lubricate catheter tip with anaesthetic lubricating gel
Using the gauze swab, maintain gentle compression of the glans penis with one hand
Insert catheter into the meatus and continue to insert until urine flows
Once urine flows insert the catheter a further 1-2cm
Inflate the balloon with sterile water as per manufacturer’s instructions
Attach catheter to drainage system
Ensure the foreskin (if present) is replaced back over the glans
Collect urine sample if required
Make sure the child is comfortable
Dispose of equipment as per local policy
Perform hand wash
Document procedure in child’s notes/care plan/fluid chart, including reason for
procedure, catheter used (size, type, batch number, volume in balloon), amount of
anaesthetic gel used, any problems encountered and signature of practitioner
Key:Male
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N/A
Appendix F
Urinary Catheterisation Equipment List
•
•
•
•
•
•
•
•
•
•
•
•
•
Trolley
Alcowipe
Cover for patient
•
•
•
•
Universal specimen container
Disposable pad
Hand cleansing facilities
Plastic apron
Sterile catheterisation pack
Sterile gloves (2 pairs required, one pair should be in catheter pack)
Cleaning solution i.e. 0.9% Sodium Chloride
Sterile local anaesthetic lubricating gel
Appropriate size and type of catheter
10ml sterile water (if not in catheter pack)
10ml syringe (Two 10ml syringes will be required if catheter already in
situ)
Drainage system (bag or valve)
Catheter stand or leg fixation
Disposal bag
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Version Number: 9
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Next review date: December 2007