Download Urinary Catheterisation Policy

URINARY CATHETERISATION MANAGEMENT POLICY
Guideline Reference: 1705
Type:
Guideline applies to (Staff
Group)
Version: 3.0
Status: Adopted
Clinical Policy
All West Suffolk Hospital Employed SCH staff
As part of transition to the new service contract this Suffolk Community Healthcare (Serco) procedural
document has been adopted by West Suffolk NHS Foundation Trust with the following amendments:
•
Removal of Serco Equality and Diversity Impact Statement
•
The above is the only change to this clinical policy therefore we have not altered the version
control.
Where the procedural documents refer to Suffolk Community Healthcare (SCH) this is referring to those staff
employed by West Suffolk NHS Foundation Trust as part of the Suffolk Community Healthcare Consortia, with
The Ipswich Hospital NHS Trust and Norfolk Community Health and Care Trust.
Following a 30 day settling in period, a programme of review for all SCH procedural documents aligned with
West Suffolk NHS Foundation Trust will be reviewed in consultation with subject matter experts and Suffolk
Community Healthcare staff.
Date Adopted:
30 September 2015
Review Date:
No later than 30 August 2016
S/Internal/CatheterisationUrinaryPolicy/June15/V3.0
Urinary Catheterisation Management Policy
Guideline Reference: SCH Serco CP40
Version: 3.0
Status: Approved
Type: Clinical Guideline applies to : All Adult services within SCH
Guideline applies to (Staff Groups): All appropriate clinical staff within adult services
Required compliance: This policy must be complied with fully at all times by the appropriate staff. Where it is
found that this policy cannot be complied with fully, this must be notified immediately to the owner through
the waiver process
Guideline owner:
Guideline author:
Other contact:
Director of Nursing Therapies and Governance
Clinical Effectiveness Manager
Head of Nursing and Professional Practice
Date this version adopted
Last review date
Reviewer
Next review date
Location of electronic master
September 2015
June 2015
CIS Consultant Nurse/ CE Manager
September 2018
SCH Intranet
AGREED POLICY/GUIDELINE REVIEW / RATIFICATION / ADOPTION PATH:
Level 1:
Agreed by: Consultant Nurse SCH
Date: July 2015
Level 2:
Agreed by: Clinical Policy, Audit Steering &
Documentation Group
Date: August 2015 (virtual)
Level 4:
Noted by: SLT
Level 3:
Agreed by: Clinical Quality & Safety Assurance
Group
Date: August 2015 (virtual)
Date: September 2015
Name and Title of people who carried out the Name of Director who signed EQIA:
EQIA:
Pamela Chappell
Sarah Miller, Clinical Effectiveness Manager
Date EQIA completed:
Signature of Director:
30/6/15
Date EQIA signed: 2/9/15
S/Internal/CatheterisationUrinaryPolicy/June15/V3.0
Contents
1.
Introduction
4
2.
Definitions
4
3.
Indications For Urinary Catheterisation
4
4.
Assessing The Need For Urinary Catheterisation
5
5.
Complications Resulting From Urinary Catheterisation
5
6.
Choosing A Catheter
6
7.
Drainage System
7
8.
Catheter Insertion
8
9.
Antibiotic Prophylaxis
8
10.
Suprapubic Catheterisation
10
11.
Contra Indications for Catheterisation by Nursing Staff
10
12.
Hygiene
10
13.
Risk of Infection Following Catheter Insertion
11
14.
Information And After Care
11
15.
Long-Term Catheterisation
11
16.
Urinary Ph
12
17.
Catheter Maintenance Solutions
12
18.
Catheter Specimen of Urine
12
19.
Trial without Catheter
12
20.
Catheter Care Audit
12
21.
References
12
Appendix 1: Urethral Catheterisation Procedure
14
Appendix 2: Supra Pubic Catheterisation Procedure
18
Appendix 3: Catheter Diary
20
Appendix 4: Trouble Shooting
21
Appendix 5: Out of Hours Flowchart
22
S/Internal/CatheterisationUrinaryPolicy/June15/V3.0
URINARY CATHETERISATION MANAGEMENT POLICY
1.
Introduction
1.1.
Policy Objectives:
a)
Every member of Suffolk Community Healthcare staff dealing with urinary catheters will be able to
appropriately manage them to minimise the risk of infection.
b)
The use and management of equipment used in urinary catheterisation will be regularly reviewed
by Tissue Integrity and Appliance Group (TIAG)
1.2.
Standard Statement: All staff dealing with urinary catheters must do so in a manner which minimises
the risk of infection and prevents cross infection.
1.3.
Training Requirements: All staff dealing with urinary catheters should ensure that they attend relevant
training and assessed for competence.
(See http://nww.suffolkch.nhs.uk/Home/QualityGovernance/PracticeDevel.aspx)
2.
Definitions
2.1.
Urethral catheter is a hollow tube inserted into the urinary bladder for the purpose of draining urine or
instilling fluids as part of medical treatment. It is always done using an aseptic technique ensuring that
the patient’s privacy and dignity are maintained throughout the procedure.
2.2.
Supra-pubic catheter is a hollow tube inserted into an artificial tract in the abdominal wall, just above
the pubic bone and into the dome of the urinary bladder for the purpose of draining urine or instilling
fluids as part of medical treatment. It is often chosen for increased patient comfort and reduced
infection risk. It is best practice that a urethral catheter is not used for catheterisation via this route
but it is recognised that this may sometimes be unavoidable.
3.
Indications For Urinary Catheterisation
3.1.
Catheters should only be used:
3.2.
•
If the patient is in acute urinary retention
•
Pre / post operatively to drain the bladder contents
•
Decompression of chronic urinary retention
•
Where serious illness needs very accurate fluid balance to be recorded
•
To irrigate the bladder
•
To administer intra-vesical chemotherapy or medication
•
Intractable incontinence where all other types of management have failed or are inappropriate.
•
Intractable skin breakdown exacerbation by incontinence
•
The terminally ill or very frail where repeated bedding and clothing change would be distressing
•
Patient preference must be considered
Supra-pubic catheters are commonly used for the following reasons:
•
Urethral trauma; existing or preventative
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•
Congenital defects
•
Long-term catheterisation is required but patient is still sexually active
•
Post gynaecological procedure
•
Spinal cord patients who are unable or unwilling to use intermittent catheterisation and cannot
otherwise void
•
Patients with detrusor sphincter dysynergia
•
Clinicians should be aware of the disadvantages of supra-pubic catheters which include cellulitis,
leakage and prolapse through the urethra
4.
Assessing The Need For Urinary Catheterisation
4.1.
An indwelling catheter should only be inserted following consideration of other management
alternatives.
4.2.
The patient’s need for a urinary catheter should be regularly reviewed and the catheter should be
removed when it is no longer needed.
4.3.
Once the decision has been taken to catheterise the patient, and their informed consent obtained,
then the following points need to be considered:
5.
•
Type of catheter
•
Drainage system
•
Catheter insertion
•
Antibiotic cover
•
Hygiene
•
Information and after care for the patient/ carer
Complications Resulting From Urinary Catheterisation
•
Infective complications
 Asymptomatic Bacteruria
 Cystitis
 Urethritis
 Prostatitis
 Epididymitis & epididymo-orchitis
 Vesicoureteric reflux
 Pyelonephritis
 Abdominal wall infections
 Bacteraemia, septicaemia and septic shock
•
Urethral trauma possibly resulting in bleeding, infection and possible septicaemia
•
Traumatic removal of the catheter with the balloon inflated
•
Urinary tract infection
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•
Bypassing of urine around the catheter
•
Stricture formation
•
Encrustation and bladder calculi
•
Urethral perforation
•
Pain, bladder spasms and / or bleeding
•
Catheter blockage
•
Creation of false passages/ fistulae
6.
Choosing A Catheter
6.1.
Types of catheter material:
a)
For routine catheterisation: Always check for known latex allergy and if this is positive then a
100% silicone catheter should be used.
• Short term catheters (up to 2 weeks) – latex or PVC
• Medium term (up to 28 days) – PTFE/ silicone coated
• Long term (up to 3 months) -100% silicone or hydrogel coated
• For supra-pubic catheterisation, always check the catheter is licensed for this use.
b)
For specific situations:
• Open ended catheters may be useful in cases of persistent blockage
• Silver alloy coated catheters are available and are licensed for 28 day use (Bardex IC) and 3
month use (Dover silver catheter - although the silver is only active for 28 days). These may be
considered for patients who develop recurrent urinary infections.
• Antibiotic impregnated catheters (Release NF which is impregnated with nitrofurantoin) may
be considered for patients who develop recurrent urinary infections and are licensed for 3
month use.
NB Epic2 guidelines state that there is no conclusive evidence currently to support the use of the
silver alloy or antibiotic impregnated catheter across the board.
6.2.
6.3.
Length of catheter: Consideration must include patient’s lifestyle, gender & mobility
•
Standard (male)
40-45cm
•
Female
20-26cm
•
Paediatric
30-31cm
Recommended catheter length:
•
Standard length for most catheterisations 40-45cms
NB NEVER use female length catheters to catheterise male patients as the inflated balloon will be
within the urethra, rather than the bladder and can cause severe trauma.
6.4.
Charriere and balloon size:
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a)
The diameter of the catheter is measured in Charriere (Ch) units (1Ch=1/3mm). Select the smallest
size that will allow good drainage. With urethral catheters, the smaller the external diameter of
the catheter, the less irritation is caused to the urethral mucosa and the less discomfort is caused
to the patient. Larger sizes may cause pain, trauma and by-passing. They may also be associated
with abscess formation and an increased risk of infection.
b)
General recommended sizes:
• Paediatric
c)
6.5.
6-10 Charriere with 3-5 ml balloon
• Female
12-14 Charriere with 10ml balloon
• Male
14-16 Charriere with 10ml balloon
The balloon should be inflated to the size stated by the manufacturer using sterile water only.
Under inflation may result in the catheter falling out. There is danger of irritation of the bladder
mucosa, spasm of the bladder wall and the risk of necrosis of the trigone if over inflation occurs.
Select the type and gauge of an indwelling urinary catheter based on an assessment of the patient's
individual characteristics, including:
•
Age
•
Any allergy or sensitivity to catheter materials
•
Gender
•
History of symptomatic urinary tract infection
•
Patient preference and comfort
•
Previous catheter history
•
Reason for catheterisation.
6.6.
Intermittent self-catheterisation should be considered if clinically appropriate and the patient is
competent and motivated to undertake this procedure. There are many catheters available for
intermittent catheterisation, and should be selected to suit the patient’s ability and lifestyle.
7.
Drainage System
7.1.
This will depend on the reason for catheterisation and patient preference and lifestyle.
7.2.
Patients should be offered a choice of either single-use hydrophilic or gel reservoir catheters for
intermittent self-catheterisation. (NICE 2012)
7.3.
Leg-bags are connected directly to the catheter and are supported by leg-bag straps or a support sleeve
to the patient’s leg to prevent traction on the catheter.
7.4.
At night, a 2 litre drainage bag is connected into the outlet from the leg-bag to allow for extra capacity.
This maintains a closed system to minimise infection risk. It is recommended that the night bag should
be non-drainable and therefore single use only to further reduce the risk of infection.
7.5.
Night-bags should be hung on a catheter bag stand beside the bed, lower than the level of the bladder.
If the night bag has a drainage tap, ensure the tap does not touch the floor.
7.6.
A catheter valve may be used instead of leg-bags if a patient prefers and if clinically indicated. This
must be released regularly to prevent over distension of the bladder and is generally only suitable for
people who are mentally aware, have good manual dexterity, can feel the sensation of a full bladder
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and who have adequate bladder capacity. A night bag may be connected to the valve if the patient
wishes to have continuous drainage overnight.
7.7.
Leg-bags and valves should not be disconnected from the catheter except for bag change every 5-7
days, or to administer catheter maintenance solution or medication. If they are deliberately or
accidentally disconnected, a new bag or valve should be connected. Writing the date of change on the
bag may help with continuity of care.
7.8.
Emptying the drainage bag – all staff should perform hand hygiene and put on new non-sterile gloves
and disposable aprons before manipulating the catheter or drainage system, and perform hand
hygiene again afterwards. A single use container should be used to empty the drainage bag contents
and care should be taken not to touch the drainage tap onto the container.
8.
Catheter Insertion
8.1.
Catheterisation by an appropriately trained health professional:
8.2.
•
Must be performed using an aseptic technique. (Appendix 1)
•
Must be performed by personnel trained and assessed to be competent in the procedure.
•
Sterile, single-use lubricant should be used for both male and female catheterisation.
•
Meatal cleaning prior to catheterisation should follow procedure (see Appendix 1).
•
Documentation of the procedure must be entered into the patient’s notes and a care plan
formulated, specifying the type, size, expiry date and batch number of the catheter used, the
volume of sterile water used to inflate the balloon, any untoward events, the residual volume, the
reason for catheterisation, and the name of the person deeming the catheterisation necessary.
This should then be dated and signed.
Self-catheterisation
•
This does not need to be an aseptic procedure. However, patients managing their own catheters,
and their carers, must be educated about the need for hand decontamination before and after
manipulation of the catheter (NICE 2012)
9.
Antibiotic Prophylaxis
9.1.
The immediate clinical and economic impact of UTI is so great that patients at risk of infections are
sometimes offered the option to receive prophylactic antibiotics.
9.2.
Asymptomatic bacteria (ASB) is more common in people over 65 but is not associated with increased
morbidity. Diagnosis of UTI is therefore difficult so urine culture ceases to be a reliable diagnostic test.
Older people often receive unnecessary antibiotic treatment for ASB despite clear evidence of adverse
effects with no compensating clinical benefit (NICE 2015)
9.3.
The widespread use of antibiotics, including their prophylactic use, has been identified as a major
factor in the increasing levels of antibiotic resistance. There is currently an absence of evidence about
the short term and long term effects of prophylactic antibiotic use during catheter changes. (NICE
Quality Standards 2014)
9.4.
Prudent antibiotic prescribing is a key component of the UK’s action plans for reducing antimicrobial
resistance (NICE 2015) and unnecessary treatment of ASB is associated with a significantly increased
risk of clinical adverse events.
9.5.
Antibiotic cover is recommended by NICE guidelines 2003, 2012 in the following circumstances:
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9.6.
a)
Patients with a history of catheter associated urinary tract infections following catheter change.
b)
Patients who have a heart valve lesion, septal defect, patent ductus or a prosthetic valve.
c)
Patients who have had joint replacements or a pacemaker inserted in the last 3 months and/or are
at risk of endocarditis
d)
There is currently no evidence base to support the routine use of antibiotic prophylaxis prior to
catheterisation of MRSA positive patients.
NICE Clinical Guidelines139 (NICE Evidence update 2014) made the following recommendations for
preventing infection in patients with long term indwelling catheters. These are:
a)
Community and primary healthcare workers must be trained in catheter insertion, including suprapubic catheter replacement, and in catheter maintenance. Healthcare workers must
decontaminate their hands and wear a new pair of clean, non-sterile gloves before manipulating a
patient’s catheter and must decontaminate their hands after removing gloves.
b)
To minimise the risk of catheter-associated infections in patients with a long term indwelling
catheter, health care professionals should:
c)
9.7.
•
Develop a patient-specific care regime
•
Consider approaches such as reviewing the frequency of planned catheter changes and
increasing fluid intake
•
Document catheter blockages.
•
Clinical need for catheterisation should be reviewed regularly and the urinary catheter
removed as soon as possible.
•
Catheters should be changed only when clinically necessary or according to the manufacturer’s
current recommendations.
•
Catheter insertion, changes and care should be documented.
In addition NICE Quality Standard 90 (2015) advises that
•
Service Providers, Health Care Professional and Commissioners should ensure that all adults
age 65 and over receive a full clinical assessment before a diagnosis of a urinary tract infection
is made.
•
All men who have symptoms of an upper UTI are referred for urological examination.
•
Adults with a UTI who are not responding to antibiotic treatment should have a urine culture
•
Healthcare professionals do not prescribe antibiotics to treat ASB in adults with catheters or
prophylactic antibiotics for adults with long-term catheters.
Research supporting the use of oral cranberry juice in preventing urinary tract infection is limited.
Some studies have demonstrated that by preventing the adherence of bacteria to the bladder mucosa,
infection may be prevented. Others indicate that it may provide safe, symptomatic relief to those with
urinary tract infection (Getliffe 2002). It is important to note that there is a risk of kidney stone
formation if large amounts of cranberry juice are taken (University of Lancashire 1998). Cranberry juice
should not be given to clients with Multiple Sclerosis (NICE 2003) or clients on oral anticoagulant
therapy (CSM 2006) or Oral vitamins.
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10.
Suprapubic Catheterisation
10.1. This involves insertion of a catheter into the bladder through the lower abdominal wall, above the
symphysis pubis. A medical officer always undertakes the initial catheterisation, either under general or
local anaesthetic, and also usually performs the first catheter change. Subsequent catheter changes
may be undertaken by a nurse who has been trained in the technique. (Appendix 2)
10.2. The suprapubic route is especially useful after pelvic or urological surgery where the patient might have
difficulty in resuming voiding. A catheter valve can be used for a trial of urethral voiding and if this is
unsuccessful the valve can be released again, so avoiding repeated urethral catheterisations. Likewise,
a suprapubic catheter is useful in acute retention, as voiding can be attempted without catheter
removal.
10.3. Suprapubic catheterisation can be used for long term drainage and is preferential for paraplegic female
patients or those with neurological deficit affecting the vulval area in order to avoid the possibility of
the formation of urethra-vaginal fistula. It is also a system suitable for sexually active patients and
those who experience problems with urethral catheters.
10.4. The Charriere size is often larger for this method of catheterisation in order to maintain the viability of
the tract, and whilst it is best practice not to use the same types of catheters as are used for urethral
catheterisation this may be unavoidable in certain circumstances. The entry site should be gently
cleansed daily with mild soap and water and inspected regularly for any abnormal discharge, bleeding,
inflammation or over-formation of granulation tissue. A light, dry dressing may be used to cover a
newly formed suprapubic site, but once the tract is established, it may be left uncovered. Otherwise,
management is the same as for a urethral catheter, the same types of bags can be used and the same
information given on care.
10.5. When the suprapubic catheter is no longer required, it can simply be removed and a dry dressing
applied over the site until it has healed. The opening in the bladder and abdominal walls will close
spontaneously.
11.
Contra Indications for Catheterisation by Nursing Staff
•
Less than 6 weeks post prostate surgery.
•
Patients with known complications/difficulty in catheterising.
•
No consent from the patient.
•
If antibiotic cover has previously been indicated but has not been administered on this occasion.
Please note:
• If a patient experiences pain or bleeding during the procedure, this should be ceased immediately
and medical advice sought.
12.
•
Catheterisation should be used only after considering alternative methods of management.
•
The clinical need for catheterisation should be reviewed regularly and the urinary catheter
removed as soon as possible.
•
Patients must not be catheterised to ease the workload of nursing personnel
Hygiene
12.1. The patient or their carer should be taught to wash daily around the meatal/catheter junction using
soap and water. This may be done when bathing or showering.
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12.2. Initially, supra-pubic catheter sites should be treated as a wound and will need a dressing until the tract
has formed and any bleeding, exudate or discharge has stopped. A dressing is then no longer required.
12.3. Talcum powder and creams should be avoided as they can cause irritation, infection and may affect the
catheter material.
13.
Risk of Infection Following Catheter Insertion
13.1. Urinary catheterisation is an invasive procedure and should not be undertaken unless clinically
indicated. Urinary catheters rate second only to central venous catheters as a source of hospital
acquired infection.
13.2. The urinary tract is normally sterile but by introducing a catheter into the bladder the body’s natural
defences are bypassed. Micro-organisms may be introduced at the time of catheterisation, and once
the catheter is in situ, micro-organisms may travel intra- or extra-luminally via that catheter into the
bladder.
13.3. It is estimated that approximately 12.6% of hospital patients will be catheterised during their stay in
hospital, and in the community catheter care is estimated to account for approximately 4% of the
Community Nurses’ caseload. The Health Protection Agency estimates that deaths from bacteraemia
related to catheter associated urinary tract infections are between 13-30%. Therefore minimising the
risks of catheter associated infection is an important part of nursing and medical care.
13.4. Individual needs of the patient should be considered in all aspects of catheter care.
14.
Information And After Care
14.1. Wherever possible, patients and / or their carers should be independent in the ongoing management
of the catheter. Information and advice should be given on catheter hygiene, hand hygiene, fluid
intake, the prevention of constipation and correct use of the drainage system.
14.2. All patients should have written information via the SCH Catheter Care Leaflet
http://nww.suffolkch.nhs.uk/Home/Operations/CommunityHTs/Leaflets.aspx on the continuing care of
their catheter, how and where to obtain ongoing supplies and a contact number for a healthcare
professional in case of emergency.
14.3. It is advisable to keep a spare catheter and equipment for re-catheterisation in the patient’s home in
case of emergency. To minimise the risk of blockages, encrustations and catheter-associated infections
for patients with a long-term indwelling urinary catheter:
•
Develop a patient-specific care regimen
•
Consider approaches such as reviewing the frequency of planned catheter changes and increasing
fluid intake
•
Document catheter blockages.
(NICE 2012, 2014, 2015)
14.4. For trouble shooting see Appendix 4.
15.
Long-Term Catheterisation
15.1. Catheters should only be changed when clinically necessary (i.e. when blocked with debris that cannot
be cleared with the appropriate catheter maintenance solution – see section 16) or according to the
licensed usage time for that catheter.
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15.2. A catheter diary (Appendix 3) should be kept to monitor catheter changes and any problems arising.
This allows for planned catheter changes to take place, pre-empting any discomfort to the patient
caused by catheter blockage, and provides continuity of care.
15.3. When changing catheters in patients with a long-term indwelling urinary catheter:
16.
•
do not offer antibiotic prophylaxis routinely
•
consider antibiotic prophylaxis for patients who:

have a history of symptomatic urinary tract infection after catheter change or

experience trauma during catheterisation.
Urinary Ph
16.1. This can range from 4.5 to 8.5. Patients with high pH will have alkaline urine, which may result in
encrustation. Regular pH testing should be undertaken for patients whose catheters may be prone to
blocking in order to permit planned catheter changes before they block. (Getliffe 2002)
17.
Catheter Maintenance Solutions
17.1. These should only be used as part of the treatment of the catheter and must not be used routinely.
17.2. They may be used to help prolong the catheter life in patients whose catheters block excessively or
when frequent catheter change is not clinically desirable.
17.3. Monitoring of urinary pH should continue in order to monitor the effectiveness of interventions.
17.4. An aseptic technique should be used in their application and a new drainage bag / valve attached
afterwards.
18.
Catheter Specimen of Urine
18.1. An aseptic technique MUST be used to obtain the specimen of urine from the sample port found on the
drainage bag tubing and not from the catheter bag drainage tap.
19.
Trial without Catheter
19.1. When staff have been requested to remove a catheter for a patient’s trial without catheter (TWOC), a
subsequent contact should be made to ensure that the patient has voided satisfactorily. If possible, this
should be checked by a bladder scan to check whether any residual urine remains in situ and the
volume of that residual.
20.
Catheter Care Audit
20.1. All staff must ensure that best practice is maintained at all times and complete the catheter care audit
tool.
20.2. To ensure you are using the latest version of this tool, please ensure you access the audit toll via the
SCH intranet at:
http://nww.suffolkch.nhs.uk/Home/QualityGovernance/ClinicalAudit/AuditToolsRCA.aspx
21.
References
•
ACA (2007) Notes on Good Practice for Continence Advice: www.notesongoodpractice.co.uk
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•
DOH (2003) “Winning ways: Working together to reduce healthcare associated infection in
England”, London
•
DOH (2007) ”Essential steps to safe, clean care” Urinary Catheter Care, London
•
DOH (2007) “High Impact Intervention No 6” Urinary catheter care bundle. London
•
Getliffe K (2002) “Managing recurrent urinary catheter encrustration”. Journal of Community
Nursing 7(11):574- 80
•
NICE (2014) “Evidence Update 64; NICE CG139” National Institute for Clinical Excellence, London
•
NICE (2003, 2012) “Care of patients with long-term urinary catheters. Guidelines on the
prevention of healthcare associated infections in primary and community care (clinical guideline
no 139).” National Institute for Clinical Excellence, London
•
NPSA (2009) – Rapid Response Report Female urinary catheters causing trauma to adult males.
National Patient Safety Agency
•
Pratt RJ, Pellowe C. Loveday HP et al (2001) “The EPIC project: developing national evidencebased guidelines for preventing healthcare associated infections. Phase 1: guidelines for guidelines
for preventing hospital acquired infections”. Journal of Hospital Infection 47, S3-82
•
Pratt RJ et al (2007) “Epic 2: National evidence-based guidelines for preventing healthcare
associated infections in NHS hospitals in England”. Journal of Hospital Infection 65S: S1-64
•
Booth F and Clarkson M (2012): “Principles of Urinary Catheterisation” Journal of Community
Nursing; 26/3; May/ June 2012
•
Royal College of Nursing (2012): “Catheter Care: RCN Guidance for Nurse”
•
NICE (2015) “Urinary Tract Infections in Adults” Quality Standard 90
https://www.nice.org.uk/guidance/qs90
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Appendix 1: Urethral Catheterisation Procedure
Equipment Required
Protection for bed
Sterile catheter pack (or equivalent sterile supplies)
Catheter
2 pairs sterile gloves
0.9% sterile saline or water
Anaesthetic lubricant gel
10mls water for injection, syringe and needle
Syringe to deflate balloon
Drainage bag, leg straps/catheter valves
Bactericidal alcohol hand rub/soap and water
Disposable plastic apron
Stand for drainage bag
Notes
Male/Female as appropriate
Warmed to room temperature
Sterile sealed unit
Not required for pre filled balloons
If removing previous catheter
If required
Female Catheterisation
Action
1. Explain and discuss the procedure and
obtain consent
2. Consider the need for antibiotic cover (do
not give routinely; see section 9 above)
3. Assist the patient to get into the supine
position with knees bent, hips flexed and
feet resting about 60cms apart
4. Ensure that a good light source is available
5. Wash hands using bactericidal soap or
bactericidal alcohol handrub
6. Put on a disposable apron
7.
8.
9.
10.
Rationale
To ensure that the patient understands the
procedure and gives valid consent
To reduce the risk of infection
To enable genital area to be seen
To enable the genital area to be seen clearly
To reduce the risk of cross infection
To reduce the risk of cross infection from microorganisms on uniform
Position a disposable pad under the To protect bedding and mattress
patient’s buttocks
Prepare
equipment
using
aseptic To reduce the risk of introducing infection into the
technique.
urinary tract
Clean hands with a bactericidal alcohol Hands may have become contaminated by
handrub
handling outer packs etc
Put on sterile gloves
To reduce the risk of cross infection
11. Place sterile towel across the patient’s
thighs
12. Using low-linting swabs, separate the labia
minora so that the urethral meatus is seen.
One hand should be used to maintain labial
separation
until
catheterization
is
completed
13. Cleanse labia and urethral meatus with
0.9% sodium chloride or antiseptic solution
using single downward strokes
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
To create a sterile field
This manoeuvre provides better access to the
urethral orifice and helps to prevent labial
contamination of the catheter.
Inadequate preparation of the urethral orifice is a
major cause of infection following catheterization.
To reduce the risk of cross-infection
14
14. Apply 6ml anaesthetic gel to urethral
meatus. Wait 3-5 minutes for anaesthetic
effect.
15. Insert catheter gently into urethra in an
upward and backward direction for 5-6cm.
Stop if patient experiences pain/bleeding
occurs.
16. For indwelling catheters, advance the
catheter further 6-8 cm and inflate balloon
according to manufacturer’s instructions.
Adequate lubrication helps to prevent urethral
trauma. Use of a local anaesthetic minimizes the
patient's discomfort
The direction of insertion and the length of
catheter inserted should relate to the anatomical
structure of the area.
This prevents the balloon from becoming trapped
in the urethra. Inadvertent inflation of the balloon
within the urethra is painful and causes urethral
trauma
17. Withdraw the catheter slightly then To ensure that the balloon is inflated and the
connect catheter to compatible drainage catheter is secure.
system or valve.
18. Secure with leg straps or sleeve. Bag To maintain patient comfort and to reduce the risk
should be below bladder level to promote of urethral and bladder neck trauma. Care must be
drainage
taken in using adhesive tapes as they may interact
with the catheter material
19. Ensure urine has drained.
To ensure patency of catheter
20. Measure the amount of urine and take a To be aware of bladder capacity for patients who
specimen for laboratory inspection if have presented with urinary retention. To monitor
required.
renal function and fluid balance. It is not necessary
to measure the amount of urine if the patient is
having the urinary catheter routinely changed
21. Dispose of equipment by appropriate To prevent environmental contamination
method
22. Document procedure fully on completion. To provide a point of reference or comparison in
Record should include:
the event of later queries
a. Reasons for catheterisation
b. Date and time of catheterisation
Check that all these prompts are in care plan on
c. Catheter type, length and size
LHCT documentation
d. Amount of water instilled into the
balloon
e. Batch number and manufacturer
f. Any problems negotiated during
the procedure
g. A review date to assess the need
for continued catheterisation or
date for change of catheter
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
15
Male Catheterisation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Action
Explain and discuss the procedure and
obtain consent
Consider the need for antibiotic cover (do
not give routinely; see section 9 above)
Assist the patient to get into the supine
position with knees bent, hips flexed and
feet resting about 60cms apart
Ensure that a good light source is available
Wash hands using bactericidal soap or
bactericidal alcohol handrub
Put on a disposable apron
Rationale
To ensure that the patient understands the
procedure and gives valid consent
To reduce the risk of infection
To enable genital area to be seen
To enable the genital area to be seen clearly
To reduce the risk of cross infection
To reduce the risk of cross infection from microorganisms on uniform
Position a disposable pad under the To protect bedding and mattress
patient’s buttocks
Prepare
equipment
using
aseptic To reduce the risk of introducing infection into the
technique.
urinary tract
Clean hands with a bactericidal alcohol Hands may have become contaminated by
handrub
handling outer packs etc
Put on sterile gloves
To reduce the risk of cross infection
11. Place sterile towel across the patient’s
thighs
12. Wrap a sterile topical swab around the
penis. Retract the foreskin, if necessary,
and clean the glans penis with 0.9% sodium
chloride or sterile water.
13. Insert the nozzle of the lubricating jelly into
the urethra. Squeeze 11ml of the gel into
the urethra, remove the nozzle and discard
the tube. Massage the gel along the
urethra.
14. Hold the penis and wipe underside of shaft
in downward direction with dry swab to
encourage gel towards the prostatic
urethra
15. Grasp the penis behind the glans, raising it
until it is almost totally extended. Maintain
grasp of penis until the procedure is
finished
16. Place the receiver containing the catheter
between the patient's legs. With penis
extended at an angle of approximately
65%, insert the catheter into the urethra
smoothly for 15–25 cm until urine flows.
17. If resistance is felt at the external
sphincter, increase the traction on the
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
To create a sterile field
To reduce the risk of introducing infection to the
urinary tract during catheterization.
Adequate lubrication helps to prevent urethral
trauma. Use of a local anaesthetic minimizes the
patient's discomfort
To prevent loss of gel and ensure maximum
efficacy
This manoeuvre straightens the penile urethra and
facilitates catheterization. Maintaining a grasp of
the penis prevents contamination and retraction of
the penis.
The direction of insertion and the length of
catheter inserted should relate to the anatomical
structure of the area.
The male urethra is approximately 18 cm long and
this ensures that the catheter is in the bladder
Some resistance may be due to spasm of the
external sphincter. Straining gently helps to relax
16
18.
19.
20.
21.
22.
23.
penis slightly and apply steady, gentle
pressure on the catheter. Ask the patient
to strain gently as if passing urine
Stop and withdraw catheter if patient
complains of pain and/ or bleeding occurs
When urine begins to flow, advance the
catheter almost to its bifurcation.
Gently inflate the balloon according to the
manufacturer's direction, having ensured
that the catheter is draining properly
beforehand.
Withdraw the catheter slightly and attach
it to the drainage system.
Support the catheter, if the patient desires,
either by using a specially designed
support, for example Simpla G-Strap, or by
taping the catheter to the patient's leg.
Ensure that the catheter does not become
taut when patient is mobilizing or when
the penis becomes erect. Ensure that the
catheter lumen is not occluded by the
fixation device or tape.
Ensure that the glans penis is clean and
then reduce or reposition the foreskin.
24. Make the patient comfortable. Ensure that
the area is dry.
25. Measure the amount of urine and take a
specimen for laboratory inspection if
required.
the external sphincter.
To reduce the risk of trauma and prevent patient
discomfort
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
To ensure that the balloon is inflated and the
catheter is secure.
To maintain patient comfort and to reduce the risk
of urethral and bladder neck trauma. Care must be
taken in using adhesive tapes as they may interact
with the catheter material
Retraction and constriction of the foreskin behind
the glans penis (paraphimosis) may occur if this is
not done
If the area is left wet or moist, secondary infection
and skin irritation may occur.
To be aware of bladder capacity for patients who
have presented with urinary retention. To monitor
renal function and fluid balance. It is not necessary
to measure the amount of urine if the patient is
having the urinary catheter routinely changed
To prevent environmental contamination
26. Dispose of equipment by appropriate
method
27. Document procedure fully on completion. To provide a point of reference or comparison in
Record should include:
the event of later queries
• Reasons for catheterisation
• Date and time of catheterisation
• Catheter type, length and size
• Amount of water instilled into the
balloon
• Batch number and manufacturer
• Any problems negotiated during the
procedure
• A review date to assess the need for
continued catheterisation or date
for change of catheter
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
17
Appendix 2: Supra Pubic Catheterisation Procedure
4.
Action
Explain and discuss the procedure and
obtain consent
Antibiotic cover not usually required for
this procedure.
Wash hands using bactericidal soap or
bactericidal alcohol handrub
Put on a disposable apron
5.
Put on sterile gloves
6.
Place a sterile towel around the
insertion site
Prior to procedure, clamp drainage bag
Position a disposable pad under the
patient’s buttocks
Prepare equipment using aseptic
technique.
Measure new catheter against existing
one
Clean around existing catheter using
saline and lint free gauze.
Apply anaesthetic/ lubricating gel to
the supra-pubic site if required
1.
2.
3.
7.
8.
9.
10.
11.
12.
13.
Deflate balloon of existing catheter.
14.
Gently press down with fingers on the
skin surface, rotate the catheter and in
an upward motion pull the catheter
out; this may require a little force if
required.
Insert new catheter of the same size
within 10 minutes for the first change
and 30 mins thereafter. Advance into
the tract a little further than one
removed
Once urine starts to flow, proceed
another 2cms
Stop procedure if patient complains of
pain or bleeding or there is prolonged
resistance
Inflate
balloon
according
to
manufacturer’s instructions.
15.
16.
17.
18.
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
Rationale
To ensure that the patient understands the
procedure and gives valid consent
The risk of infection is lower for this procedure
providing asepsis is maintained
To reduce the risk of cross infection
To reduce the risk of cross infection from microorganisms on uniform
To reduce the risk of cross infection
To create a sterile field
To ensure bladder partially filled with urine.
To protect bedding and mattress
To reduce the risk of introducing infection into
the urinary tract
To provide guide of length needed to insert new
catheter
To reduce the risk of cross infection
To allow smooth and pain-free passage of the
catheter and reduce trauma and stricture
formation
To allow removal of existing catheter
To facilitate easy and rapid removal
To prevent closure of the insertion site
To ensure that the catheter is correctly
positioned in the bladder
To ensure patient comfort and reduce the risk of
trauma
To ensure retention of the catheter within the
bladder
18
19.
20.
21.
22.
Connect catheter to compatible
drainage system or valve and secure
drainage bag to patient’s leg using an
appropriate retaining strap
Measure the amount of urine and take
a specimen for laboratory inspection if
required.
To reduce trauma to bladder neck and promote
good drainage
To be aware of bladder capacity for patients
who have presented with urinary retention.
To monitor renal function and fluid balance.
It is not necessary to measure the amount of
urine if the patient is having the urinary catheter
routinely changed
Dispose of equipment by appropriate To prevent environmental contamination
method
Document procedure fully on
To provide a point of reference or comparison in
completion. Record should include:
the event of later queries
• Reasons for catheterisation
• Date and time of catheterisation
• Catheter type, length and size
• Amount of water instilled into the
balloon
• Batch number and manufacturer
• Any problems negotiated during
the procedure
• A review date to assess the need
for continued catheterisation or
date for change of catheter
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
19
Appendix 3: Catheter Diary
CATHETER DIARY
CONTINENCE ADVISORY SERVICE
Patient’s Name:
Date of Initial Catheterisation:
Address:
Reason for Initial Catheterisation/ Name of person agreeing rationale
GP Practice Address:
Type of Catheter:
Date
Urethral
or
Supra Pubic
Catheter Type
Rationale for Change
Comments
Size
Routine
Bypassing
Blocked
Weeks since
last change
………..
Routine
Bypassing
Blocked
Weeks since
last change
………..
Routine
Bypassing
Blocked
Weeks since
last change
………..
PH of urine
Debris
Crystallisation
Inside of catheter checked?
Results
Other
PH of urine
Debris
Crystallisation
Inside of catheter checked?
Results
Other
PH of urine
Debris
Crystallisation
Inside of catheter checked?
Results
Other
mls water
Lot Number
Expiry Date
Size
mls water
Lot Number
Expiry Date
Size
mls water
Lot Number
Expiry Date
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
Signature
20
Appendix 4: Trouble Shooting
Problem
No drainage
Bypassing
Infection
(symptomatic)
Bleeding
Pain/
discomfort
Unable
to
deflate balloon
No
urinary
return following
insertion
of
suprapubic
catheter
Possible Cause
Anuria
Evidence
Consensus
good
practice
Tubing kinked
Straighten tubing. Drainage bag below Robinson J. 2004
bladder.
Faecal impaction
Rectal examination and appropriate Stewart 2001
treatment. Dietary advice.
Encrustation/ blockage
Test pH or urine. If high (alkaline) Rew 2005
consider ways of reducing this. Replace
catheter. Instillations should be used NICE 2006
with
caution
(see
installation
guidelines).
Catheter too large
Try smaller gauge.
Robinson J. 2004
Tubing kinked
Straighten.
Robinson J. 2004
Bladder Irritation
Increase fluid intake. Antibiotics only if Robinson J. 2004
indicated.
Detrusor overactivity (bladder Try
smaller
gauge
catheter. Robinson J. 2004
spasm)
Anticholinergic therapy.
Constipation
Assess and advise as required.
Robinson J. 2004
Poor catheter care
CSU for microbiology.
NICE 2006
Contamination
Teach correct catheter care and NICE 2006
promote personal hygiene. Ensure
adequate/increased
fluid
intake Robinson J. 2004
including cranberry juice (see section
9.5 above)
Infection
See above.
Robinson J. 2004
Trauma
Check history and catheter position.
Robinson J. 2004
Heavy/ persistent bleeding
Seek medical advice.
Robinson J. 2004
Cramps
Should settle after 24hours.
Unstable bladder
Consider anticholinergic drugs.
Robinson J. 2004
Urethral discomfort
Smaller catheter.
Robinson J. 2004
Check for constipation
Manage as appropriate.
Robinson J. 2004
Check non return valve on Aspirate using needle and syringe.
inflation channel.
If 10ml balloon try using a 20ml syringe
DO NOT CUT CATHETER OR SEEK ADVICE FROM UROLOGIST.
Bristol
Urological
INFLATION CHANNEL
Institute Guidelines
2005
Catheter encrusted
Consider Suby G instillation.
Empty bladder
If no urinary drainage occurs 5-10 Robinson J. 2004
minutes after insertion, 10-15mls
sterile 0.9% sodium chloride may be
instilled gently into bladder and
returned to confirm correct position of
catheter if urine stained
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
Action
Medical advice.
Appendix 5: Out of Hours Flowchart
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
Any identified a potential discriminatory impact must be identified with a mitigating action plan to address
avoidance/reduction of this impact. This tool must be completed and attached to any SCH approved document
when submitted to the appropriate committee for consideration and approval.
Name of Policy: Urinary Catheterisation Policy
Equality Impact Assessment Tool
1.
Yes/No
Does the policy affect one group less or more
favourably than another on the basis of:
No
Race
No
Ethnic origins (including gypsies and travellers)
No
Nationality
No
Gender
No
Culture
No
Religion or belief
No
Sexual orientation including lesbian, gay and
bisexual people
No
Age
No
Disability - learning disabilities, physical
disability, sensory impairment and mental
health problems
No
2.
Is there any evidence that some groups are
affected differently?
No
3.
If you have identified potential discrimination,
are any exceptions valid, legal and/or
justifiable?
N/A
4.
Is the impact of the policy/guidance likely to
be negative?
No
5.
If so can the impact be avoided?
N/A
6.
What alternatives are there to achieving the
policy/guidance without the impact?
N/A
7.
Can we reduce the impact by taking different
action?
N/A
S/Internal/CatheterisationUrinaryPolicy/July15/V3.0
Comments