Download Urine catheter guidelines – Insertion and ongoing care

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Derby Hospitals NHS Foundation Trust
Guidelines for the Insertion, Ongoing Care and Removal of
Indwelling Urethral Catheters
Reference No: CG-T/2011/140
Aim
These evidence based guidelines seek to provide guidance on safe insertion
and ongoing care for indwelling urethral catheters. Three clear sections are
identified: Insertion, ongoing care and removal.
Purpose and Scope
These guidelines apply to all staff involved in insertion, ongoing care or
removal of urine catheters. Suprapubic and intermittent catheters are not
covered by these guidelines. If needed, further advice should be sought from
the Trust Continence Advisory Team on ext 89162.
1. Insertion
1.1 Indications for Catheterisation
-
Retention of urine (use bladder scanner to confirm first)
To empty contents of bladder prior to surgery
To allow irrigation of the bladder
To determine a residual urine
To introduce cytotoxic drugs into the bladder for the treatment of
bladder cancer
To enable urodynamic tests to be carried out
To measure urine output accurately e.g. if a patient is in shock or
critically ill
To relieve incontinence only in exceptional circumstances and after all
other approaches have failed.
Unnecessary catheterisation should be avoided as indwelling catheters can
cause complications. If a catheter is deemed to be clinically necessary, then it
should be left in-situ for the shortest amount of time possible in order to
prevent some of these potential complications.
1.2 Patient Involvement
The patient must be involved in the decision to catheterise where appropriate.
CG-T/2011/ 140
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1.3 Antibiotic Prophylaxis
Some patients may need prophylactic antibiotic cover on insertion of catheter.
Refer to the surgical prophylaxis antibiotic guidelines on the Trust intranet for
advice.
1.4 Who can Catheterise?
Male Patients: Trained nursing staff who have successfully completed the
Trust Male Catheterisation Self Directed Learning Pack and assessment of
competence and other clinical staff within the Trust who undertake the
procedure within their own Scope of Practice and professional accountability.
Female Patients: Trained nursing staff who have successfully completed the
Trust Female Catheterisation Self Directed Learning Pack and assessment of
competence and other clinical staff within the Trust who undertake the
procedure within their own Scope of Practice and professional accountability.
Any further advice should be sought from the Continence Advisory
Team on extension (7)89162
1.5 Catheter Selection:
This table outlines the range of catheter types available. For the most up to
date range, refer to the online formulary on the intranet ‘Continence
Prescribing Guidelines’.
Type
Length of use
Disadvantages
Advantages
Plastic or
PVC Latex
silicone
treated
Intermittently or
post-op up to 48
hours.
Cheap. Thin walled, so
provides a wider lumen.
Prelubricated
intermittent
catheter
Latex
Single use only.
Develops cracks and
encrustation.
Uncomfortable, high
incidence of pain and
bladder spasm.
Single use only.
Increases cost. Needs
good dexterity as it is
slippery.
Can be irritant.
Develops cracks and
encrustations. Absorbs
water so the inside of
the catheter narrows.
Prone to encrustation
(Do NOT
use, if ?
latex allergy)
Teflon
coated latex
Silicone
coated latex
CG-T/2011/ 140
Up to 2 weeks
Up to 3-4 weeks
Up to 6 weeks
Silicone coating can
come off. Smaller
internal diameter due
to coating.
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Less discomfort.
Less urethral trauma
Flexible, cheap
Minimise irritation and
trauma. Prevents water
absorption, smooth
surface.
Resistant to encrustation.
Minimise irritation.
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Hydrogel
coated
Up to 3 months
Coating makes the
internal diameter
smaller
100%
Silicone
catheters
Up to 3 months
Permits gas diffusion
so the balloon can
deflate
Hydrogel resembles living
tissue.
Lower incidence of
infection
Lower incidence of
encrustation
Decreased friction to the
urethra
Lower incidence of
urethritis.
Lower incidence of
crustation
Flexible, comfortable
Catheter terms:
Foley Catheter : The design of the catheter with a balloon.
Nelaton Catheter: A straight catheter for intermittent use with no balloon.
3 way Catheter : A catheter for continuous irrigation made from PVC or latex.
Supra Pubic Catheter: Catheter inserted through an abdominal incision into
the bladder
When selecting an appropriate catheter consideration must be given to:
•
•
•
•
•
The material type. Short term catheters are usually latex based and
designed to remain in situ from 2-6 weeks. Long term catheters may be
made from silicone or a coated latex material and are designed to
remain in situ for up to 12 weeks.
Whether the patient has a known latex sensitivity or allergy
The catheter size. This should be as small as possible to maintain
adequate drainage (McGill 1982). A larger size catheter could cause
pain, pressure ulcers, stricture formation or abscess formation.
If using a Foley (self retaining) catheter, a 5-10ml balloon capacity is
recommended for routine use in adult patients and a 3-5ml balloon
capacity is recommended for use in children. Large balloons can cause
pressure on the bladder neck and pelvic floor and are associated with
bladder spasm and leakage. (Robinson 2001) 30ml balloons are
usually used post prostatectomy to aid haemostasis.
The length of the catheter. A longer length catheter must always be
used when catheterising a male as a shorter length catheter will not be
of sufficient length to reach the bladder. A shorter length catheter is
usually used in females as it is more discreet and will have less
potential problems caused by exposed catheter material (getting
caught in clothing, trapped etc).
CG-T/2011/ 140
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1.6 Catheterisation Procedure:
This must be performed by an appropriately trained individual, following the
procedures outlined in Appendix 1 or 2. An Aseptic technique must be
followed. Sterile single use lubricating anaesthetic gel must be used to reduce
trauma to the urethral mucosa. If the catheterisation attempt is unsuccessful,
refer to a more experienced practitioner or Urology specialist.
See:
Male Catheterisation:
Appendix 1 Page 9
Female Catheterisation:
Appendix 2 Page 13
1.7 Potential Complications of Indwelling Urethral Catheters
Infections
60 % of healthcare associated urinary tract infections are related to urine
catheter insertion (Smyth 2007). Micro organisms capable of causing infection
enter the body either during insertion, intra luminally through the catheter, or
extra luminally down the side of the catheter between the catheter tube and
urethral mucosa.
Trauma
Urethral mucosal trauma may occur with an incorrect size of catheter,
incorrect catheterisation procedure and movement of the catheter post
procedure. Damage to the urethral mucosa will increase the risk of infection.
In males fistula formation may occur on the penoscrotal angle because of this
movement.
Paraphimosis
In males, a fixed retracted foreskin may occur if the foreskin (if present) is not
replaced following a catheterisation procedure.
Bladder Spasm and Leakage
This could occur if too large a catheter or balloon has been inserted, or if the
catheter is blocked or blocking. The condition can cause pain and distress to
the catheterised patient.
1.7 Documentation
The following must be clearly documented following catheter insertion:
•
•
•
•
•
•
Indication for catheterisation
Name and designation of person catheterising
Technique used
Amount of residual urine
Use of lubricants / anaesthetic gel (e.g. Instillagel)
Size / type / lot number of catheter used
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•
•
•
•
Maximum duration of use for the catheter inserted
Size of balloon / amount of sterile water used to inflate
Any problems undertaking the procedure
Review date / plan of action (include when to change or remove)
2. Ongoing Care.
2.1 Documentation:
•
•
•
•
•
The ongoing need for the catheter must be reviewed daily (this can be
extended on clinical instruction on established long term catheters) and
the review documented in the patient's health record.
There must be an appropriate care plan
There must be at least daily review of the type of urine drainage – in
relation to amount, colour, consistency, odour and clarity. More frequent
review may be necessary depending on the individual patient.
Any issue or problems must be reported and actioned appropriately.
When fluid balance is monitored, this must be recorded on an
appropriate chart.
2.2 Patient involvement
Where possible, patients should be taught to be self caring with catheters,
patient information is available and must be given as appropriate (see
appendix 3).
2.3 Routine Catheter Care
Maintaining a sterile closed system is central to the prevention of infection.
Every time the system is broken – e.g. emptying the bag, taking a sample,
provides an increased risk for infection.
For certain patients, use of a catheter valve may be appropriate – for further
information please refer to the ‘Guideline for use of Catheter Valve in Adult
patients’ available on the intranet.
2.4 Drainage Bags
Drainage bags may be body worn i.e. leg bags, or free standing. Where
appropriate, leg bags should be promoted for patients. They are more discreet
and allow for increased mobility. Promoting mobility helps to reduce the risk of
other complications such as chest infections and pressure sores.
•
A closed system must be maintained as much as possible. If frequent
monitoring of urine output is required, an appropriate catheter bag with a
measuring chamber must be used.
•
There must be effective fixation of the catheter / support of the bag to
prevent trauma.
CG-T/2011/ 140
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•
Drainage bags must be kept below the level of the bladder, and tubing
must be kink free to allow free drainage.
•
If leg bags are being used, a larger bag must be attached to the leg bag
for the night time, an ‘over night bag’. This must be connected and
removed using an aseptic technique. The overnight bag must be single
use and disposed of according to the Trust Waste Policy.
•
Catheter taps must not be allowed to touch the floor. Appropriate stands
must be used where needed.
•
Bags must not be allowed to overfill as this will not allow free drainage
and will result in reflux of ‘old urine’ back into the bladder.
•
As
general guidance, bags must be emptied when 2/3rds full.
Unnecessary emptying breaks the closed system and increases the risk
of infection. As a compromise, patients monitored for fluid balance
should have their bags emptied on each shift (sooner if reached 2/3rds
full). This can be extended to daily on those with a urometer, or where
accurate fluid balance monitoring is not necessary.
•
Emptying the catheter drainage bag must be undertaken by staff wearing
appropriate protective clothing (non sterile gloves and disposable apron).
Hands must be washed before and after. The tap of the bag must not
touch the drainage receptacle and should be dried after emptying with a
clean tissue. If soiled this may be cleaned with soap and water.
•
If not emptying directly into the toilet, a separate clean container must be
used for each patient. Ideally, these should be maceratable single use
containers. Reusable jugs may be used according to the Cleaning and
Disinfection Policy in the Infection Control Manual. These must be
labelled to patient, dated and disposed of after 1 week. They must be
cleaned properly after each use and stored dry.
•
The need to change the catheter bag should be based on the
manufacturer's guidelines. It is not recommended to wipe or clean the
catheter connections routinely during this process and a no touch
aseptic technique must be used. If the connections have been
compromised they may be cleaned with a 70% alcohol wipe. A twist and
pull technique should be used to disconnect the bag and catheter.
•
When attaching night bags to leg bags, a no touch aseptic technique
must be used. There are no recommendations to routinely clean the
connections prior to attachment, however, if the leg bag tap is visibly
soiled this should be cleaned with soap and water
Hygiene
Routine personal hygiene with soap and water is all that is usually needed to
maintain meatal cleanliness i.e. during daily bath or shower. It is important to
wash around the catheter tubing from the urethral meatus then away from the
CG-T/2011/ 140
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body – thus preventing pushing any accumulation of bacteria into the urethra.
In hospital, disposable wipes should be used for this purpose. Certain patients
may have additional hygiene requirements e.g. due to incontinence.
Fluids
Unless advised to have a restricted fluid intake, patients with catheters should
be encouraged to drink plenty of fluids. 2-3 litres daily is advised as this helps
to reduce the risk of infection. Cranberry juice may be useful to some patients
in further reducing the risk of infection, but should not be used routinely in
diabetic patients. Sugar free versions are available.
Cranberry juice should be avoided if the patient is taking warfarin due to
the potential interaction.
Catheter Specimens of Urine
Catheter specimens of urine should be taken on suspicion of urinary tract
infection, based on clinical symptoms, (e.g., pyrexia, pain, sudden onset of
confusion) and also as part of MRSA screening for those who have an
indwelling catheter.
Needle and needle free sampling ports are currently in use, needle free are
the preferred option. In either case, the procedure must be done following a
strict aseptic technique, and the access port cleaned with 70% isopropyl
alcohol before and after sampling.
The sample must be collected from the designated port, never from the
drainage bag.
Complications
See Appendix 4 for the treatment and management of potential complications
3. Removal
Catheters must be reviewed regularly and removed promptly when no longer
required. The longer an invasive device is in situ the greater the risk of
infection.
Documentation;
This must include:
• The removal date / time / person
• The volume of fluid removed from balloon
• Any problems encountered
Procedure
The removal of a catheter must be undertaken as an aseptic technique by an
appropriately trained person wearing appropriate personal protective
equipment (apron, non sterile gloves and face protection if there is a risk of
splashes to face.
The patient must be monitored following removal in order to identify any
complications.
CG-T/2011/ 140
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Advice to Patient
Providing there are no clinical reasons not to, the patient should be advised to
continue to drink plenty of fluids and to inform staff if they develop problems
post removal such as dysuria, frequency, haematuria, pelvic discomfort, flank
pain or fever. The risk of developing a urinary tract infection following catheter
removal is greater than the risk for patients who have not had a catheter.
References:
IDSA Guidelines: Diagnosis, prevention, and treatment of Catheter associated
urinary tract infection in adults: 2009 International Clinical Practice guidelines
from the Infectious Diseases Society of America. Clinical Infectious Dieases
2010 vol 50, p625-663
Department of Health (revised Oct 2007) Saving lives: reducing infection,
delivering clean safe care. High impact Intervention No 6.
Pratt et al (2007) Epic 2: National Evidence based guidelines for preventing
healthcare associated infections in NHS hospitals in England. Journal of
Hospital Infection (2007) 655, s1-s64.
Smyth ETM, (2007) The third prevalence survey of healthcare associated
infections in acute hospitals 2006. presented at 6th international Hospital
Infection society conference, Amsterdam. In Department of Health (revised
Oct 2007) Saving lives: reducing infection, delivering clean safe care. High
impact Intervention No 6.
Doherty, L. and Lister,S. (Eds) 2004. The Royal Marsden Hospital Manual of
Clinical Nursing Procedures, 6th Edition, Blackwell publishing online edition.
Accessed February 2011 http://dhft-web/Marsden/content/mars16.htm#top
Documentation Controls:
Development of Guidelines:
Consultation with:
Approved By:
Signature:
Name and Position:
Approval Date:
Review Date:
Key Contact:
CG-T/2011/ 140
Infection Control team, continence
Care Team
Clinical Guidelines Group
Dr. Nick Reynolds, Chair of Clinical
Guidelines Group
March 2011
April 2014
Specialist Nurse, Infection Control
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Appendix 1
Male Catheterisation
Procedure
Equipment
1. Procedure trolley
2. Sterile catheterisation pack containing gallipot, receiver, low linting swabs,
disposable towel.
3. 2 pairs of sterile gloves
4. 2 appropriate catheters
5. Sterile anaesthetic lubricating gel
6. Sachet sterile normal saline
7. Alcohol hand sanitiser
8. Sterile water, syringe and needle (if not packaged together with catheter)
9. Disposable plastic apron
10. Sterile drainage bag, leg straps or floor stand
11. Small clinical waste bag (if not in catheterisation pack)
Action
1. Explain and discuss the procedure
with the patient.
2. Take the patient to a procedure
room or screen the bed.
3. Assist the patient to get into the
supine position with the legs
extended. Do not expose the patient
at this stage of the procedure
4. Wash hands using soap and water.
5. Put on disposable plastic apron.
6. Clean and prepare the trolley,
placing all equipment required on the
bottom shelf.
7. Take the trolley to the patient’s
side. Disturbing any curtains as little
as possible.
8. Use alcohol hand sanitiser.
Open the outer cover of the
catheterisation pack and slide the
pack onto the top shelf of the trolley.
CG-T/2011/ 140
Rationale
To ensure that the patient
understands the procedure and gives
his valid consent.
To ensure patient’s privacy. To allow
dust and airborne organisms to settle
before the sterile field is exposed
To maintain patient dignity and
comfort.
To reduce the risk of infection
To reduce the risk of cross infection
from micro-organisms on the uniform.
The top shelf acts as a clean working
surface.
To minimise airborne contamination.
To prepare equipment.
To reduce risk of introducing infection
into the bladder.
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Using aseptic non touch technique
(ANTT) open the pack and gain
access to gallipot – without
compromising the sterile field or
contents. Open any supplementary
packs onto the opened sterile
field.(N.B only open one catheter at
this point – the other is a spare
should it be needed)
9. Pour sterile saline onto the cotton
wool swabs within the galley pot
10. Remove cover that is maintaining
the patient’s privacy.
11. Clean hands with an alcohol rub.
12. Put on a pair of sterile gloves.
13. Place sterile towel across the
patient’s thighs, ensuring the scrotal
area is covered.
14. Wrap a sterile topical gauze swab
around the penis. With the same
gauze and non touch technique,
retract the foreskin if present and
clean the urethral meatus with sterile
saline (one wipe per swab and
discard), ensure finger tips do not
touch the glans penis.
15. Position the penis at a 90 degree
angle to the patient’s thigh, extending
the penis forward.
16. Insert the tip of the syringe of the
lubricating gel into the urethra. Insert
all 11mls of the gel into the urethra,
remove the syringe and discard it
along with the gauze. Leave the gel
for 4-5 minutes before continuing with
the procedure. If appropriate
manually occlude the urethra to
ensure the gel remains in the urethra
17. Discard topical gauze swab.
Remove used gloves, use alcohol
hand rub and don second pair of
sterile gloves. Remove catheter from
inner sleeve and place directly into
the sterile receiver.
18. Ensure the syringe containing the
water for inflating the catheter balloon
is prepared.
19. Place the receiver containing the
CG-T/2011/ 140
Hands may have become
contaminated by handling the outer
packs.
To reduce risk of cross infection.
To create a sterile field.
To reduce the risk of introducing
infection into the urinary tract during
catheterisation.
To ensure that the penis is in the
correct position to allow adequate
lubrication, helping to prevent urethral
trauma.
Adequate lubrication helps to prevent
urethral trauma. Use of the local
anaesthetic minimises the discomfort
experienced by the patient. 0.25%
chlorhexidine component of Instillagel
reduces the risk of introducing
infection.
To reduce the risk of introducing
infection into the urinary tract during
catheterisation.
This straightens the penile urethra
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catheter between the patient’s legs.
Wrap a new topical gauze swab
around the penis and with a non
touch technique, position the penis at
a 90 degree angle to the patient’s
thigh, extending the penis forward.
20. Insert the catheter for 15-25 cm,
ensuring finger tips do not touch the
glans penis.
21. If resistance is felt at the external
sphincter, increase the traction on the
penis slightly and apply steady gentle
pressure on the catheter. Ask the
patient to cough or strain gently as if
passing urine.
22. When urine begins to flow,
advance the catheter to its
bifurcation.
23. Slowly inflate the balloon
according to manufacturer’s
guidelines, having ensured that the
catheter is draining properly
beforehand. If patient displays
discomfort during inflation, stop and
deflate the balloon.
24. Withdraw the catheter until
resistance is felt and attach it to the
drainage system, ensuring that the
exposed connector on the bag is not
touched.
25. Secure the catheter and leg bag
in position allowing room for
movement should spontaneous
erection of the penis occurs. Night
drainage bags should be supported
on an appropriate floor standing
catheter bag holder.
26. Ensure the glans penis is clean
and then replace the foreskin (if
present).
27. Make the patient comfortable.
Ensure the urethral meatus and skin
are dry.
28. Measure and record in clinical
and nursing note, the amount of urine
drained. Note the appearance of the
urine.
29. Take a urine specimen for
laboratory examination if required.
CG-T/2011/ 140
and facilitates catheterisation.
The male urethra is approximately
18cm long.
To prevent contamination of the
catheter.
To facilitate relaxation of the levator
ani muscle and sphincter.
Advancing the catheter ensures that it
is correctly positioned in the bladder.
Inadvertent inflation of the balloon in
the urethra causes pain and urethral
trauma.
This smoothes out the urethral curve
and ensures the catheter is in an
optimum drainage position.
Securing the catheter will minimise
the “piston effect” of movement.
Securing the drainage bag will ensure
an optimum drainage position.
Retraction and constriction of the
foreskin behind the glans penis
(paraphimosis) may occur if this is not
done.
If the skin is left wet or moist,
secondary infection and skin irritation
may occur.
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30. Dispose of equipment in a clinical
waste bag and seal the bag before
moving the trolley.
31. Draw back the curtains.
32. Document:
• Indication for
catheterisation
• Name and designation of
person catheterising
• Technique used
• Amount of residual urine
• Use of lubricants /
anaesthetic gel (eg
instillagel)
• Size / type / lot number of
catheter used, include
maximum duration of use
for the catheter
• Size of balloon / amount of
sterile water used to inflate
• Any problems undertaking
the procedure
• Review date / plan of action
To prevent environmental
contamination.
Essential information.
Legal requirement to accurately
record interventions undertaken.
Important for ongoing care
References
IDSA Guidelines: Diagnosis, prevention, and treatment of Catheter associated
urinary tract infection in adults: 2009 International Clinical Practice guidelines
from the Infectious Diseases Society of America. Clinical Infectious Dieases
2010 vol 50, p625-663
Department of Health (revised Oct 2007) Saving lives: reducing infection,
delivering clean safe care. High impact Intervention No 6.
Pratt et al (2007) Epic 2: National Evidence based guidelines for preventing
healthcare associated infections in NHS hospitals in England. Journal of
Hospital Infection (2007) 655, s1-s64.
Smyth ETM, (2007) The third prevalence survey of healthcare associated
infections in acute hospitals 2006. presented at 6th international Hospital
Infection society conference, Amsterdam. In Department of Health (revised
Oct 2007) Saving lives: reducing infection, delivering clean safe care. High
impact Intervention No 6.
Doherty, L. and Lister,S. (Eds) 2004. The Royal Marsden Hospital Manual of
Clinical Nursing Procedures, 6th Edition, Blackwell publishing online edition.
Accessed February 2011 http://dhft-web/Marsden/content/mars16.htm#top
CG-T/2011/ 140
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CG-T/2011/ 140
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Appendix 2
Female Catheterisation
Procedure
Equipment
1. Procedure trolley
2. Sterile catheterisation pack containing gallipot, receiver, low linting swabs,
disposable towel.
3. 2 pairs of sterile gloves
4. 2 appropriate catheters
5. Sterile anaesthetic lubricating gel
6. Sachet sterile normal saline
7. Alcohol hand sanitiser
8. Sterile water, syringe and needle (if not packaged together with catheter)
9. Disposable plastic apron
10. Sterile drainage bag, leg straps or floor stand
11. Small clinical waste bag (if not in catheterisation pack)
Action
1. Explain and discuss the procedure
with the patient.
2. Take patient to procedure room or
screen the bed.
3. Assist the patient to get into the
supine position with the legs
extended. Do not expose the patient
at this stage of the procedure.
4. Wash hands using soap and water.
5. Put on disposable plastic apron.
6. Clean and prepare the trolley,
placing all equipment required on the
bottom shelf.
7. Take the trolley to the patient’s
side. Disturbing any curtains as little
as possible.
8. Use alcohol hand sanitiser.
Open the outer cover of the
catheterisation pack and slide the
pack onto the top shelf of the trolley.
Using aseptic non touch technique
(ANTT) open the pack and gain
access to gallipot pot – without
CG-T/2011/ 140
Rationale
To ensure that the patient
understands the procedure and gives
her valid consent.
To ensure patient’s privacy. To allow
dust and airborne organisms to settle
before the sterile field is exposed.
To maintain patient’s dignity and
comfort.
To reduce the risk of infection.
To reduce the risk of cross infection
from micro-organisms on the uniform.
The top shelf acts as a clean working
surface.
To minimise airborne contamination.
To prepare equipment.
To reduce risk of introducing infection
into the bladder.
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compromising the sterile field or
contents. Open any supplementary
packs onto the opened sterile
field.(N.B only open one catheter at
this point – the other is a spare
should it be needed)
9. Remove cover that is maintaining
the patient’s privacy and ask the
patient to bend her legs at the knee
and relax her knees outwards.
10. Clean hands with alcohol hand
rub.
11. Put on a pair of sterile gloves.
12. Place sterile towel across the
patient’s thighs.
13. Using sterile gauze in the pack,
use one hand to separate the labia so
that the urethral meatus can be seen.
Clean urethral meatus with sterile
normal saline (one wipe per swab and
discard)
14. Insert the tip of the syringe of the
lubricating gel into the urethra. Insert
all 6mls of the gel into the urethra,
remove the syringe and discard it
along with the gauze. Leave the gel
for 4-5 minutes before continuing with
the procedure.
15. Discard topical gauze swab.
Remove used gloves, use alcohol
hand rub and don second pair of
sterile gloves. Remove catheter from
inner sleeve and place directly into
the sterile receiver.
16. Ensure the syringe containing the
water for inflating the catheter balloon
is prepared.
17. Place the receiver containing the
catheter between the patient’s legs.
Using a new sterile gauze swab, with
one hand, separate the labia to
expose the urethral meatus.
18. Introduce the tip of the catheter
into the urethral orifice in an upward
and backward direction. Advance the
catheter until 5-6cm has been
inserted.
19. When urine begins to flow,
advance the catheter to its
bifurcation.
CG-T/2011/ 140
Hands may have become
contaminated by handling the outer
packs.
To reduce risk of cross infection.
To create a sterile field.
To reduce the risk of introducing
infection into the urinary tract during
catheterisation.
Adequate lubrication helps to prevent
urethral trauma. Use of the local
anaesthetic minimises the discomfort
experienced by the patient. 0.25%
chlorhexidine component of Instillagel
reduces the risk of introducing
infection.
To reduce the risk of introducing
infection into the urinary tract during
catheterisation.
To facilitate catheterisation
The direction of insertion and the
length of the catheter inserted should
bear relation to the anatomical
structure of the area.
Advancing the catheter ensures that it
is correctly positioned in the bladder.
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20. Slowly inflate the balloon
according to manufacturer’s
guidelines, having ensured that the
catheter is draining properly
beforehand. If patient displays
discomfort during inflation, stop and
deflate the balloon.
21. Withdraw the catheter until
resistance is felt and attach it to the
drainage system, ensuring that the
exposed connector on the bag is not
touched.
22. Secure the catheter and leg bag
in position allowing room for
movement. Night drainage bags
should be supported on an
appropriate floor standing catheter
bag holder.
23. Make the patient comfortable.
Ensure the urethral meatus and skin
are dry.
24. Measure and record in clinical
and nursing note, the amount of urine
drained. Note the appearance of the
urine.
25. Take a urine specimen for
laboratory examination if required.
26. Dispose of equipment in a clinical
waste bag and seal the bag before
moving the trolley.
27. Draw back the curtains.
28. Document:
• Indication for
catheterisation
• Name and designation of
person catheterising
• Technique used
• Amount of residual urine
• Use of lubricants /
anaesthetic gel (eg
instillagel)
• Size / type / lot number of
catheter used. Include
maximum duration of use
for the catheter
• Size of balloon / amount of
sterile water used to inflate
• Any problems undertaking
the procedure
• Review date / plan of action
CG-T/2011/ 140
Inadvertent inflation of the balloon in
the urethra causes pain and urethral
trauma.
This ensures the catheter is in an
optimum drainage position.
Securing the catheter will minimise
the “piston effect” of movement.
Securing the drainage bag will ensure
an optimum drainage position.
If the skin is left wet or moist,
secondary infection and skin irritation
may occur.
To prevent environmental
contamination.
Essential information.
Legal requirement to accurately
record interventions undertaken.
Important for ongoing care.
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References
IDSA Guidelines: Diagnosis, prevention, and treatment of Catheter associated
urinary tract infection in adults: 2009 International Clinical Practice guidelines
from the Infectious Diseases Society of America. Clinical Infectious Dieases
2010 vol 50, p625-663
Department of Health (revised Oct 2007) Saving lives: reducing infection,
delivering clean safe care. High impact Intervention No 6.
Pratt et al (2007) Epic 2: National Evidence based guidelines for preventing
healthcare associated infections in NHS hospitals in England. Journal of
Hospital Infection (2007) 655, s1-s64.
Smyth ETM, (2007) The third prevalence survey of healthcare associated
infections in acute hospitals 2006. presented at 6th international Hospital
Infection society conference, Amsterdam. In Department of Health (revised
Oct 2007) Saving lives: reducing infection, delivering clean safe care. High
impact Intervention No 6.
Doherty, L. and Lister,S. (Eds) 2004. The Royal Marsden Hospital Manual of
Clinical Nursing Procedures, 6th Edition, Blackwell publishing online edition.
Accessed February 2011 http://dhft-web/Marsden/content/mars16.htm#top
CG-T/2011/ 140
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Appendix 3
Patient Information
Catheter Care In Hospital
What is a catheter?
A catheter is a small hollow tube which is inserted into the
bladder. It is held in place by a small balloon which is inflated
with water after it is inserted.
How long will I need a catheter?
A catheter is normally needed before or after an operation on
the bladder or prostate. Sometimes a catheter is inserted due
to a medical condition, injury, or after major surgery. Your
doctor will tell you how long you will need the catheter for.
Urine drainage bags
There are 2 types of bags:
1. Small bag (leg bag)
Where possible your catheter will be connected to this bag. It holds up to 500
mls of urine and is held in place by straps either on your thigh or calf. This bag
has a tap at the base to allow the urine to be emptied into the toilet. If this is
not possible the bag may be emptied into a disposable container kept for this
purpose only. This bag can remain connected for up to 1 week.
If more urine is passed at night than during the day, the leg bag can be
connected to a large/night bag. It is connected directly into the outlet tap of
the small leg bag, then the tap is put into the open position so that urine can
freely pass from the leg bag to the large/night bag.
In the morning, close the tap on the small leg bag and disconnect the
large/night bag. This can then be emptied down the toilet and discarded.
2. Large/night bag
It may not be medically possible or practical to have a small/leg bag - in which
case your catheter will be connected directly to a large/night bag.
This bag has a 2 litre capacity with a long tube connected to your catheter.
The bag remains connected for up to 1 week when a new bag is connected,
emptying the bag as necessary by the tap at the base. This bag must be kept
off the floor by placing it on a hanger or floor stand. If the bag becomes
disconnected it must be changed for a new one.
Disposal of bags
Bags may be disposed of in a clinical waste (yellow bag) bin after they have
been emptied.
Hygiene
It is advisable to bathe or shower every day and to ensure that the skin
around the catheter is washed once a day. This will help to reduce infection.
Here are a few simple steps to follow:
a. Wash your hands before handling your catheter or bag.
CG-T/2011/ 140
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b. Always use a clean disposable wipe to clean any discharge from
c.
d.
e.
f.
around the catheter.
Males must pull back the foreskin, clean behind it and then return it to
its normal position.
Females must wash from the front to the back to ensure that no germs
from the anus (back passage) touches the catheter.
Wash the catheter tubing from where it is inserted and away from the
body.
Yet again - wash your hands!
Pain
Sometimes you might feel pain in your lower abdomen (stomach), it may be
the muscles of your bladder tightening around the balloon of the catheter.
If you experience any pain, please discuss this with a member of the nursing
staff.
Diet and Fluids
A well balanced diet and a good fluid intake is important, it will help to
minimise the risk of infection and therefore prevent blockage of the catheter.
Try to drink 8 - 10 cups of fluid each day, if the urine looks dark in colour then
try to drink a little more.
Cranberry juice is helpful to some people with a catheter, as it may prevent
urine infections. You should drink 1 glassful in the morning and 1 in the
evening. Cranberry juice is not suitable for people with diabetes as it contains
a high level of sugar. Sugar free versions are available.
You should not have cranberry juice if you taking warfarin as this may
interact with this medicine.
Constipation must be avoided as this can cause extra pressure on your
bladder. It may cause urine to leak around the catheter, and therefore please
ensure that you eat plenty of fresh fruit and vegetables.
IMPORTANT
It is important that you inform a member of staff if:•
The pain does not go away
•
NO urine has drained after 4 hours
•
After drinking plenty of fluids there is blood in the urine
•
The urine smells, is cloudy or feels like it is burning, even after drinking
extra fluids
•
The urine leaks around the catheter
REFERENCE CODE: AC V1 JUNE 2010
© Copyright 2010 All rights reserved. No part of this publication may be reproduced in any form or by
any means without prior permission in writing from Urology Outpatients, Derby Hospitals NHS
Foundation Trust.
CG-T/2011/ 140
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Appendix 4
Potential Complications of an Indwelling Urethral Catheter –
Treatment and Management
Problem
Leaking / bypassing catheter caused
by catheter blockage
Leaking / bypassing catheter caused
by bladder spasm
Pain and inability to tolerate the
catheter
CG-T/2011/ 140
Suggested Action
Assess urinary output. If no urine output
or less than normal consider
• Checking the position of the
catheter to alleviate kinks and
pressure on the catheter or
drainage bag tubing
• Checking for and treating
constipation
• Using a bladder washout or
appropriate bladder instillation.
An assessment as to the likely
cause of the blockage would
need to take place. If the
blockage is caused by debris or
blood clots, it may be appropriate
for a competent practitioner to
use a sterile solution and a
bladder tip syringe to manage
this. Alternatively, commercial
sachet solutions are available –
usually normal saline. If
encrustation is thought to be the
cause of the blockage, it may be
appropriate to use a citric acid
based bladder instillation.
• Using continuous irrigation
• Re-catheterisation
Assess urinary output. If the catheter is
draining normally but the patient is
experiencing sporadic pain and cramps
associated with leakage of urine around
the catheter consider
• If possible using a smaller size
catheter and / or smaller capacity
balloon
• Assessing the patient for latex
sensitivity / allergy and if using a
latex based catheter, recatheterising with a latex free
alternative
• Using simple prescribed
analgesia
• If appropriate using prescribed
anticholinergic or smooth muscle
relaxant medication
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•
Review the need for the catheter
and if possible remove it
Catheter expulsion with an intact
• If possible, leave the patient
balloon
without a catheter for at least 48
hours post expulsion to allow for
an assessment of any trauma
caused by the expulsion. If there
is a suggestion of trauma
(prolonged haematuria, undue
pain) a urological opinion should
be sought prior to recatheterisation
• Consider the cause of the
expulsion. Check that the
catheter and drainage bag are
correctly and securely fixed at all
times.
• If the likely cause of the
expulsion is bladder spasm,
follow the suggested action for
management of this
• If the catheter has been self
removed by the patient, explain
the need for and the functioning
of the catheter. Consider that an
indwelling catheter may not be
appropriate for patients with
confusion or cognitive problems.
Unexpected or prolonged haematuria. Catheterisation and certain surgical
procedures can cause haematuria.
However if this bleeding is unusual or
unexpected consider
• Assessing and treating the
patient for a urinary tract
infection
• Checking that the bleeding has
not been caused by trauma
caused by a poorly secured
catheter or drainage system
• Seeking a urological opinion if
the bleeding is unexpectedly
prolonged or unexplained.
Unable to deflate the balloon prior to
This can be caused by valve failure in
removal
the inflation arm of the catheter, valve
expansion or inflation channel
obstruction. The use of guidewires and
puncturing of the balloon may be
necessary to alleviate this and should
ONLY be attempted by or under the
directions of a urologist.
CG-T/2011/ 140
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CG-T/2011/ 140
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