Download Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic

Urinary Catheterisation: Adults and Children
(Urethral, Supra Pubic and Intermittent)
Policy and Standard Operating Procedures (SOPs)
Authors
Rachel Baker-Green and Alison Berry
Clinical Nurse Specialists
Continence, Urology and Colorectal Service (CUCS)
Corporate Lead
Paul Morrin
Director of Nursing Interim
Document Version
2
Date ratified by
Quality Committee
20th April 2015
Date issued
18 May 2015
Review date
April 2016
Policy Number
PL337
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Executive summary
This policy and SOPs have had a comprehensive review following the outcomes of a
Serious Incident investigation for a Bacteraemia in June 2014.
This policy provides information on how to manage the care and treatment of patients
who require a urinary catheterisation procedure and maintaining standards and
improving care of the patient, irrespective of whether the catheterisation is
intermittent, short term or long term.
The policy includes:





best practice in urinary catheterisation
specific documents to be completed
competency framework
prescribing prophylaxis
recognising signs and symptoms of infection
The implementation plan of disseminating the policy into practice will be led by the
CUCS, highlighting the key changes in practice from the previous policy.
6 important messages to staff for the release of this policy:
1.
2.
3.
4.
5.
6.
Diagnosis of CAUTI using initial signs and symptoms and not dip testing
Appropriate CSU sampling process from old catheter, via port
CSU to be taken before commencement of antibiotics
When CAUTI identified change catheter at point of antibiotic
commencement
Documentation requirements. Catheter Risk assessment, management
Plan, change record and care plan
Competency requirements
A clinical audit will be undertaken with staff in July 2015 measuring clinical practice
compliance levels of care standards from within this policy.
Equality Analysis
Leeds Community Healthcare NHS Trust's vision is to provide the best possible care
to every community. In support of the vision, with due regard to the Equality Act 2010
General Duty aims, Equality Analysis has been undertaken on this policy and any
outcomes have been considered in the development of this policy.
Page 2 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Contents
Section
1
Introduction
Page
5
2
Aims and Objectives
5
3
Definitions
5
4
Responsibilities
6
5
Indications for urinary catheterisation
6
6
Resources and Equipment
7
7
Assessment and Risk Assessments
7
7.1
Catheter Risk Assessments
7
7.2
Catheter associated urinary tract infections (CA-UTI)
8
7.3
Antibiotic prophylaxis
8
8
Discharge from Hospital
8
9
Documentation
9
10
Catheter Materials
9
11
Catheter Care – refer to SOP
9
12
Education of patients/carers
10
13
Monitoring Compliance
and Effectiveness
11
14
Approval and Ratification process
12
15
Dissemination and implementation
12
16
Review arrangements
12
17
Associated documents
12
18
References
12
Page 3 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Section
Page
Appendices
1
Catheter Change Record
13
2
Urinary Catheter Management Plan
14
3
Catheterisation competency framework
15
4
Standard Operating Procedure for Obtaining a Catheter
Specimen of Urine (CSU)
25
5
27
6
Patient undergoing trial without catheter who requires
antibiotic prophylaxis
Urinary Catheter Handbook
7
Standard Operating Procedure for Female Catheterisation
38
8
Standard Operating Procedure for Male Catheterisation
39
9
Standard Operating Procedure for Supra - pubic
Catheterisation
Standard Operating Procedure for Intermittent
Catheterisation Using Single Use Catheters: Female
Patients
41
11
Standard Operating Procedure for Intermittent
Catheterisation Using Single Use Catheters: Male Patients
43
12
Standard Operating Procedure for Changing a Catheter Bag
(Adhere to manufacturer’s guidance)
44
13
Standard Operating Procedure for Connecting a Night
Catheter Bag
45
14
Standard Operating Procedure for Administering a Catheter
Maintenance Solution (CMS)
46
15
Standard Operating Procedure for Disconnecting a Night
Drainage Bag
47
16
Standard Operating Procedure for Emptying a Catheter Bag
48
17
Support Workers and catheterisation
49
18
Poster: Has your patient got signs and symptoms of a CAUTI?
50
10
Page 4 of 51
28
42
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
1
Introduction
This policy is for all health care professionals (HCP) caring for patients who require urinary
catheterisation care within Leeds Community Healthcare NHS Trust (LCH).
Catheterisation and catheter care is a key component of nursing care. Advice and support
is available from the Continence, Urology and Colorectal Service (CUCS).
Urinary catheterisation must be performed using the LCH Aseptic Non Touch Technique
policy (ANTT).
This policy is based on the most recent publications from National Institute for Health and
Clinical Excellence (2012 Royal College of Nursing (2012) and Epic 3.
The catheterisation procedure must only be performed after alternative methods of urinary
management have been considered. The patient's clinical need for catheterisation must be
reviewed regularly and the urinary catheter removed as soon as possible (NICE 2012).
Patients/carers must be given the appropriate level of information, written and verbal, to
allow them to continue to care for a urinary catheter safely, thus reducing risk of infection.
2
Aims and Objectives
The aim of this policy is to provide evidence based instruction on the safe management of
catheter systems. To identify the process of urinary catheterisation, maintain standards
and improve care of the patient, irrespective of whether the catheterisation is intermittent,
short term or long term.
Objectives are:
 To provide a uniform process for all patients who experience urinary catheterisation;
reducing adverse events
 To describe best practice in urinary catheterisation
 To provide an evidenced based framework
 To provide auditable practices.
3
Definitions
Urinary catheterisation is the insertion of a catheter into the bladder via the urethra or
abdomen (supra-pubic) using an aseptic non-touch technique (ANTT), for the purpose of
evacuating urine or instilling fluids.
Urethral catheterisation - a catheter is inserted into the bladder via the urethra.
Intermittent catheterisation - patient (self-catheterisation) or carer inserts and removes
catheter intermittently (clean procedure if done by patient) in order to drain bladder
Supra pubic catheterisation - catheter inserted through stoma in lower abdomen into
bladder.
Catheter Change Record – records each catheterisation see Appendix 1
Urinary Catheter Management Plan – captures a record of the most recent
catheterisations see Appendix 2
CA-UTI – Catheter Acquired Urinary Tract Infection
Page 5 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
4
Responsibilities
All staff employed by LCH must work in concordance with the Leeds Safeguarding Multiagency Policies and Procedures and local policies in relation to any safeguarding
concerns they have for service users and the public whom they are in contact with.
The patient must be fully informed and give verbal consent, where able (if unable to give
consent documentation must include rationale, for “Best Interest” decision made) prior to
the procedure (for further guidance refer to the Consent to Examination or Treatment,
Patient Information Leaflet Policy and Mental Capacity Act).
Chief Executive and Director of Nursing the Chief Executive and Trust Board have a
collective responsibility within LCH and a commitment to support and endorse measures to
prevent, minimise and manage urinary catheter related risks. As well as ensuring all staff
performing urinary catheterisation are appropriately trained.
Service Managers and Professional / Clinical Leads must ensure all staff are aware of
and adhere to this policy and related policies.
Registered staff must complete training every three years and be assessed as competent
to perform urinary catheterisation and catheter care using the catheter competency
framework. Registered staff members have a duty to work within the NMC code of conduct
in relation to catheter care.
Non-registered staff involved in catheter care/catheterisation must complete training
every three years and be assessed as competent to perform urinary catheterisation and
catheter care.
Training and Competency
All HCP’s performing catheterisations must provide evidence of their competencies – see
Appendix 3. The Urinary Catheterisation Competency Framework must be completed and
includes observing practice and theory related to catheterisations, catheter care and
management.
HCPs are required to complete training 3 yearly via e-learning or face to face.
CUCS deliver bespoke training to HCP’s and in partnership with Clinical Professional
Leads and a “train the trainer” approach is recommended for this work area.
Refer to the Statutory and Mandatory Training Policy including Training Needs Analysis.
Up to date information is available on the Intranet for course details.
5
Indications for urinary catheterisation
To:
 re-establish a flow of urine in acute/chronic urinary retention
 monitor urine output and fluid balance in the seriously ill patient
 empty contents of bladder before and after abdominal, pelvic, rectal surgery and
promote healing following surgery in the perineal region
 measure the volume of residual urine remaining in the bladder following micturition
 provide a channel for drainage of urine when micturition is impaired/obstructed
 remove residual urine when voiding does not completely empty the bladder
 facilitate bladder irrigation procedures
Page 6 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures







6







7
enable bladder function tests to be performed
obtain an uncontaminated specimen of urine
empty bladder during childbirth if necessary
avoid complications during intra cavity insertion of radioactive sources
maintain a dry environment and prevent skin maceration when a patient is suffering
from urinary incontinence and all other forms of nursing intervention have failed
instil pharmacological preparations for the therapeutic benefit in malignant and nonmalignant conditions
empty the bladder when there is an inability to toilet self due to disability, chronic
illness, terminal illness and alternative methods of urinary management have been
considered.
Resources and Equipment
Urinary catheters and accessories e.g. drainage bags, valves, straps;
Catheter packs ‘Cath-It’;
Cleansing fluid –normal saline;
Lubricating/anaesthetic gel;
Personal Protective Equipment (PPE) (aprons, sterile and non-sterile gloves);
Hand cleansing kit;
Catheter documentation.
Assessment and Risk Assessments
Prior to any catheter change, the patient should be assessed for ongoing need for
catheterisation and consideration for trial without catheter. If catheterisation is deemed
necessary, assess need for prophylaxis.
7.1 Catheter Risk Assessment must be completed on SystmOne for every patient with
an indwelling catheter (see example below).
Page 7 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Outcome of risk assessment score:
0 - 25 Low Risk
26-50 Medium Risk
Over 50 High Risk All high risk patients must be referred to CUCS.
7.2 Catheter associated Urinary Tract Infection (CA-UTI)
Wherever possible, patients with long term indwelling catheters should have the catheter
changed with appropriate antibiotic cover when treating for CA-UTI.
For Guidance on Urinary Tract Infections with a Catheter (CAUTI)
7.3 Antibiotic prophylaxis
Patients, who are found to be MRSA positive at hospital admission screening if not known
to be MRSA positive as below, should have a CSU collected from the existing catheter and
a meatal/suprapubic entrance site swab. See Appendix 4.
Patients who are MRSA positive in their urine and/or on meatal / supra pubic site swab
must be given antibiotic prophylaxis prior to changing catheter or removing for trial without
catheter. See Appendix 5.
Either Doxycycline 200mg 2 hours prior to catheter removal / insertion
Or
Gentamicin 1.5mg per Kg body weight 30 min pre manipulation.
Further advice can be obtained from LTHT Microbiology Department or LCH CUCS
Team.
Patients identified as MRSA positive will require assessment for topical skin
decolonisation.
For prophylaxis in other circumstances refer to the Guideline for Antimicrobial Prophylaxis
during Urinary Catheterisation in Adults.
For Guidance on Urinary Tract Infections with a Catheter (CAUTI)
8
Discharge from hospital:
The Hospitals are responsible for:



Referring the patient to the Neighbourhood Team Community Nursing
Providing a Home Catheter pack for patients on discharge
Faxing via Gateway, or sending with the patient, a copy of the Urinary Catheter
Management Plan detailing if the catheter can be changed in community and
infection status.
If a patient is discharged without a Urinary Catheter Management Plan – the discharging
ward/unit must be contacted by Gateway or the relevant Neighbourhood Team Community
Nursing to establish rational for ongoing use of catheter, if there are any reasons why the
catheter should not be changed in the community and the patients’ infection status.
Any Discharge Incidents must be reported via the Datix® system.
Page 8 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
9
Documentation
The Urinary Catheter Management Plan should accompany the patient discharged from
hospital with a new catheter. It must be placed in the patient held records, and clearly state
if the catheter can be changed in community.
The patient should also be supplied with a catheter passport on discharge. If this is not
provided this should be supplied in the community.
A Catheter Care Plan must be used to record the rationale for insertion; on-going
management; relevant equipment required; including any need for antibiotic prophylaxis.
All catheter changes must be recorded on the Catheter Change Record.
10
Catheter materials
PTFE catheter – Teflon coated latex (NOT latex free) – for use up to 28 days only.
Some patients are discharged home from hospital with PTFE catheters insitu and will need
a catheter change within 28 days of insertion which may be soon after discharge – check
all patients Catheter Management Record or discharge information and the catheter itself.
Hydrogel coated latex catheter – (NOT latex free) – for use up to 12 weeks only. These
catheters should be used first line unless patient has a latex allergy
100% Silicone – (Latex free) – for use up to 12 weeks ONLY for patients with latex
allergy/sensitivity.
Hydrogel coated silicone – (Latex free) - for use up to 12 weeks for patients with latex
allergy.
Catheter size
Male
Ch 12 -14
Female
Ch 12
Recommended catheter size
Supra pubic
Children under 12
Ch 14 – 16
Ch 6, 8, 10
URETHRAL catheterisation - Males must be catheterised with a STANDARD length
catheter.
Females and Supra pubics may be catheterised with a female or with a standard length
catheter.
In general, the balloon should be inflated with 10mls of sterile water in adults and 3-5mls in
children, according to manufacturers’ instructions. Some adult catheters need only 5mls always check manufacturers’ instructions.
11
Catheter Care - Refer to SOPs (Appendices)
Indwelling catheters must be connected to a sterile closed urinary drainage system or
catheter valve. A catheter valve may be used as an alternative to a bag by patients with
the necessary cognitive ability.
HCP’s and formal carers must decontaminate hands with alcohol gel or soap and water
and wear a new pair of clean, non-sterile gloves before handling a patient’s catheter and
decontaminate hands after removing gloves.
Page 9 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Urine drainage bags must be positioned below the level of the bladder and must not be in
contact with the floor.
A link system should be used to facilitate overnight drainage. A single use, drainable night
bag is the first line of choice.
The urinary drainage bag must be emptied regularly; no more than 2/3rds full. The closed
urinary drainage system must not be disconnected for emptying.
The bag or valve must be changed when clinically indicated and in line with manufacturers
recommendations (usually 5-7 days).
A strap/adhesive fixation device must be used to secure the catheter. If the patient
declines, this must be recorded in their notes.
Belly bags are available and must be used for 28 days.
12
Education of patients/carers
Patients and carers must be taught how to decontaminate their hands correctly, insert
catheters where applicable and manage their own catheter and equipment.
The Neighbourhood Nursing team must offer ongoing support and monitor standards of
catheter care being performed by patients.
Patients must be given a Catheter Passport Appendix 8 which includes written advice on
caring for their catheter.
All discussions must be recorded in the patient’s record – including compliance and non
compliance of advice given.
Page 10 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating
Procedures
13
Monitoring Compliance and Effectiveness
Minimum
Process for Lead for the
requirement to be
monitoring / monitoring/audit
monitored / audited audit
process
Incident reporting
Training –e-learning
Face to face
Training
Catheter Risk
Register
Infection Monitoring
including MRSA
Meatal damage
Via Datix®
Frequency
of
monitoring /
auditing
Lead for
reviewing
results
Lead for
developing /
reviewing
action plan
CUCS
Lead for
monitoring
action plan
CUCS
CUCS/Workforce
Workforce to
gain report
Workforce
Specialist Reviewer
for urinary catheter
related incidents
CUCS
Monthly
Specialist
Reviewer CUCS
CUCS
Workforce
Quarterly
CUCS/Workforce CUCS/Workforce CUCS/Workforce
SystmOne
CUCS
Quarterly
CUCS
CUCS
CUCS
ICNET
IPC/CUCS
Daily
IPC/CUCS
IPC/CUCS
HSEGG
Datix®
Ongoing
Specialist
Reviewer CUCS
CUCS
CUCS
HSEGG
CUCS
CUCS
CUCS
Clinical
Effectiveness
Governance
Group
CUCS
CUCS
CUCS
CUCS
Staff implementing
the policy into
practice
Audit
Specialist Reviewer
CUCS
CUCS
Competency
framework
Audit
CUCS
Documentation Audit Audit
including compliance
with Catheter
Passport
CUCS
Ongoing
Annual
Initially
annually and
then 3 yearly
Annual
Page 11 of 51
HSEGG
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
14
Approval and Ratification process
The policy has been approved by the Clinical and Corporate Policies Group and ratified by
the Quality Committee on behalf of the Board.
15
Dissemination and Implementation
Dissemination of this policy will be via the Clinical and Corporate Policy Group to services
and made available to staff via the intranet.
Implementation will require:
• Operational Directors/ Heads of Service/General Managers to ensure staff have
access to this policy and understand their responsibilities for adhering to it
• CUCS and Quality and Professional Development Department provide appropriate
support and advice to staff on the implementation of this policy
 Launch, raised in training sessions, clinical forums, meetings and highlighted in
CUCS and Adult Business Unit Newsletters which are shared with all clinical staff
16
Review arrangements
This policy will be reviewed in one year, following ratification, by the author or sooner if
there is a local or national requirement.
17
Associated documents
Consent to Examination or Treatment and Patient Information Leaflet Policy
LCH Aseptic Non Touch Technique (ANTT) Policy
Mental Capacity Act
Standard Operating Procedure – The Deprivation of Liberty Safeguards
Guideline for Antimicrobial Prophylaxis during Urinary Catheterisation in Adults
Standard Precautions Policy (Includes Hand Hygiene, Personal Protective Equipment and
Management of Spillages in the Community)
Diagnostic and Screening Procedures including Safe Sampling, Handling and
Transportation of Specimens Policy
Management of patients with MRSA in Community Health and Social Care Settings
18 References
Epic 3: National Evidence-Based Guidelines for Preventing Healthcare-Associated
Infections in NHS Hospitals in England. H.P. Lovedaya*, J.A. Wilsona, R.J. Pratta, M.
Golsorkhia, A. Tinglea, A. Baka, J. Brownea, J. Prietob, M. Wilcox.
National Institute for Health and Clinical Excellence (2012) CG139 Infection: prevention
and control of healthcare-associated infections in primary and community, NICE
Manchester
Royal College of Nursing (2012) Catheter Care Guidance for Nurses, RCN, London.
Page 12 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating
Procedures
Appendix 1 – Catheter Change Record
Catheter Change Record
Date/time
of
catheter
change
Reason
for
change
Weeks
catheter
in situ
Patient Name:
Encrustation/
mucus in lumen
or outside of
removed
catheter?
D.O.B:
New catheter
make, size, batch
number, expiry
date?
Lubricant
batch
number/expiry
date?
Affix label
here if
available
Affix label
here if
available
Affix label
here if
available
Affix label
here if
available
Affix label
here if
available
Affix label
here if
available
Page 13 of 51
Date of
next
planned
change?
Comments/
problems
Signature
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Appendix 2 – Urinary Catheter Management Plan
Page 14 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures
Appendix 3: Catheterisation Competency Framework
Competency Framework for Urinary Catheterisation
Introduction
This competency framework must be completed, as a minimum requirement, by all healthcare professionals who are involved with catheterising
patients. All staff must be familiar with the Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and
Standard Operating Procedures and carry with them the required procedures.
The document records the required competencies for staff undertaking urinary catheterisation. The document is completed by the healthcare
professional who is being assessed … and signed off as competent by the supervisor.
1
2
3
4
5
6
Core Competencies
Removal and insertion of female indwelling urethral catheter
Removal and insertion of male indwelling urethral catheter
Removal and insertion of supra pubic catheter
Intermittent female catheterisation
Intermittent male catheterisation
Performance Criteria
You must demonstrate that:
1.
2.
3.
4.
5.
Standard precautions for infection prevention and control are embedded into your clinical practice.
Patients consent is recorded and there is evidence of information provided.
Support and reassurance is given to the patient throughout the procedure
The Urinary Catheterisation: Adults and Children (Urethral, Supra pubic and Intermittent) Policy and Standard Operating
Procedures is used in your practice
Action is taken, where required, with any adverse effects.
Page 15 of 51
COMPETENCY FRAMEWORK DOCUMENT FOR
THE MANAGEMENT OF URINARY CATHETERISATION IN ADULTS
(1) Date
(1) Date
Reference to care plan and
documentation prior to procedure.
Deliver care and document appropriately
post procedure
Explain the procedure, address patient’s
concerns and obtain consent
Standard precautions Infection prevention and control and
patient and staff safety
Page 16 of 51
(2) Date
Observed
by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
1: Core Competencies
Date
competence
achieved
Signature of
supervisor
Comments
(1) Date
(1) Date
Attach drainage system fixation devices
Demonstrate knowledge of anatomy and
physiology of female and male genito –
urinary system
Process for CSU collection and swabs
Fluid intake
Urine output
Skin integrity at insertion site and
pressure areas
Observe, assess and review for adverse
effects taking appropriate action, i.e.
meatal tear, safeguarding
Page 17 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
Selection of equipment
Date
competence
achieved
Signature of
supervisor
Comments
Promotion of self care and health
education
Monitor stock control, equipment and
take appropriate action
Page 18 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures
(1) Date
(1) Date
Removal of female catheter safely,
implementing the Urinary Catheterisation:
Adults and Children (Urethral, Supra
pubic and Intermittent) Policy and
Standard Operating Procedures
Insertion of the female indwelling urethral
catheter safely, implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Page 19 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
2: Removal and insertion of female indwelling urethral catheter
Date competence
achieved
Signature of
supervisor
Comments
(1) Date
(1) Date
Removal of male catheter safely
including implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Insertion of the male indwelling urethral
catheter safely implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Page 20 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
3: Removal and insertion of male indwelling urethral catheter
Date competence
achieved
Signature of
supervisor
Comments
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures
(1) Date
(1) Date
Anatomy and physiology of supra pubic
catheterisation
Clean the suprapubic catheter site
before and after removal of catheter
Removal of catheter safely implementing
the Urinary Catheterisation: Adults and
Children (Urethral, Supra pubic and
Intermittent) Policy and Standard
Operating Procedures
Insertion of the suprapubic catheter
implementing the Urinary Catheterisation:
Adults and Children (Urethral, Supra
pubic and Intermittent) Policy and
Standard Operating Procedures
Page 21 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
4: Removal and insertion of suprapubic catheter
Date competence
achieved
Signature of
supervisor
Comments
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy and Standard Operating Procedures
(1) Date
(1) Date
Insertion of female intermittent urethral
catheter safely implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Removal of female intermittent urethral
catheter safely implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Page 22 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
5: Intermittent female catheterisation competency
Date competence
achieved
Signature of
supervisor
Comments
(1) Date
(1) Date
Insertion of male intermittent urethral
catheter safely implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Removal of male intermittent urethral
catheter safely implementing the Urinary
Catheterisation: Adults and Children
(Urethral, Supra pubic and Intermittent)
Policy and Standard Operating
Procedures
Page 23 of 51
(2) Date
Observed by
supervisor
(2) Date
Observe
procedure
(2) Date
Application of
knowledge to
practice
(1) Date
6: Intermittent male catheterisation competency
Date competence
achieved
Signature of
supervisor
Comments
EVIDENCE OF COMPLETION and TRAINING RECORD FOR
THE MANAGEMENT OF URINARY CATHETERISATION IN ADULTS
Healthcare Professional Name:
Name of Supervisor:
__________________________ Work address:
__________________________
Competency
________________________
Commencement date:
Date of completion
__________________________
Signature of Healthcare
Professional
1: Core competencies
2: Removal and insertion of female indwelling
urethral catheter
3: Removal and insertion of male indwelling
urethral catheter
4:
Removal and insertion of suprapubic catheter
5: Intermittent female catheterisation
6: Intermittent male catheterisation
Signature of Supervisor: ………………………………………
Date: ……………………………………
Page 24 of 51
Signature of Supervisor
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy
and Standard Operating Procedures
Appendix 4: Standard Operating Procedure for Obtaining a Catheter Specimen of Urine
(CSU) for CA-UTI
If CA-UTI is suspected (Symptoms: Generally unwell plus one or more of the following symptoms:
Pyrexia/Rigors pain (tenderness in flank, back, supra-pubic, bladder), nausea, vomiting, confusion,
lethargy, haematuria), collect CSU from sample port on catheter.
DO NOT USE URINE DIPSTICK TO DIAGNOSE CA-UTI
Collect urine sample via needle-free sample port from an existing catheter
using an aseptic non-touch technique (ANTT).
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13
Gain consent. Use interpreter if necessary.
Collect necessary equipment.
Label a red top universal urine container and laboratory form.
Write laboratory form with: MC & S, suspected CA-UTI, and also indicate
method of collection i.e. from sample port.
Decontaminate hands and open pack.
Put on sterile gloves and apron.
Place absorbent pad under sampling port. Clean the access port with a swab,
saturated with 70% isopropyl alcohol and allow to dry.
Needle- Free Sampling Port:
Insert the syringe firmly into the sampling port (following manufacturer’s instructions).
Withdraw the required amount of urine, and ideally collection container to be filled to
line indicated, and disconnect the syringe.
Re-clean sampling port with 70% isopropyl alcohol swab and allow to dry
Remove gloves and apron and decontaminate hands.
Ensure the specimen container and request form are correctly labelled and are
transported as per Trust transportation of specimens’ policy.
Complete relevant documentation.
Wherever possible patients with long term indwelling catheters should have the
catheter changed with appropriate antibiotic cover when treating for CA-UTI.
Standard Operating Procedure for Obtaining Catheter Specimen of Urine CSU for MRSA
Screen
1.
Collect urine sample via needle-free sample port from an existing catheter.
2.
Follow procedures outlined in section 1 – 12 above.
NB. A site swab / meatal or suprapubic is also required and
should be sent with the CSU.
Page 25 of 51
Appendix 5: Patient undergoing trial without catheter who requires antibiotic prophylaxis
1.
2.
3.
4.
Administer prescribed antibiotic:Doxycycline 200mg, 2 hours before removal of catheter
Gentamicin 1.5mg /kg body weight, 30 min before removal of catheter.
Remove catheter after appropriate interval
If patient requires re-catheterisation this to be undertaken within 24hrs for
Doxycycline and 8 hours for gentamicin. No further antibiotics are required.
If recatheterisation is needed outside of these parameters then a further dose of
doxycycline or gentamicin is required.
Page 26 of 51
Appendix 6: Urinary Catheter Handbook for LCH Staff
URINARY CATHETER HANDBOOK
Page 27 of 51
INDEX
Introduction
Page 3
Aims and Objectives
Page 3
Catheter Bypassing
Page 4
Catheter Blockage
Page 5
Unable to deflate balloon
Page 6
Difficulty removing catheter
Page 7
Haematuria
Page 8
Unable to insert catheter
Page 9
Expelling
Page 10
Autonomic Dysreflexia
Page 11
Page 28 of 51
INTRODUCTION
Indwelling urinary catheters often cause significant problems for community nurses. The indwelling
catheter is prone to complications which can lead to significant mortality.
It is important to choose catheter equipment and accessories which are appropriate for the
individual patient to reduce the likelihood of complications with the drainage system.
Urinary catheters are also prone to problems with blockage and bypassing which cause disruption
to the patient’s life and account for a significant amount of community nursing time.
AIMS AND OBJECTIVES
The catheter handbook has been developed to:



Assist staff caring for catheterised patients to make safe clinical decisions when dealing
with catheter problems.
To promote good practice in urinary catheterisation
Give guidance in line with relevant international, national and local clinical policies and
procedures, namely EAUN Good Practice in Healthcare: Urethral Catheterisation (2005),
RCN Catheter Care guidance (2008), Leeds Community Healthcare Guidelines for Urinary
Catheterisation Adults and Children (2012)
Page 29 of 51
TROUBLESHOOTING - CATHETER BYPASSING
Bypassing
Sudden Onset
? UTI
? Constipation
History, PR/Abdo
Exam
Symptoms: Generally unwell plus
one or more of the following
symptoms
Catheter bypassing
and debris evident –
See Blockage
Pyrexia/Rigors pain (tenderness in
flank, back, supra-pubic, bladder),
nausea, vomiting, confusion,
lethargy, haematuria
Bowel Clearance
Management
Collect CSU as per
Appendix 4
No
Yes
Commence
antibiotics
Monitor patient
condition
Change catheter
If frequent
bypassing refer to
CUCS
CSU result to be followed up by
appropriate practitioner
Treatment course to be modified by
appropriate practitioner if CSU
demonstrates resistant organisms
If frequent UTI’s,
refer to CUCS
Page 30 of 51
TROUBLESHOOTING – BLOCKAGE
(No mechanical obstruction evident)
Page 31 of 51
TROUBLESHOOTING – UNABLE TO DEFLATE BALLOON
If still unable to deflate balloon
ring the LCH CUCs or if
unavailable the Surgical
Assessment Unit at SJUH
Page 32 of 51
TROUBLESHOOTING – DIFFICULTY REMOVING CATHETER
Difficulty
Removing
Catheter
(encrustation or
cruffing)
Apply firm traction
Rotate catheter
Apply firm traction
Re-position patient
Using a syringe,
insert 1ml or
normal saline or
sterile water back
into the balloon
If urethral
catheter, leave
patient for one
hour to see if
catheter falls out
If supra-pubic
catheter, re-inflate
balloon to 10ml
If catheter remains
insitu
contact
If still
unable
to the LCH CUCS
team, if unavailable
contact
remove,
ring the Surgical
Assessment Unit at SJUH
CUCS
Page 33 of 51
TROUBLESHOOTING - HAEMATURIA
Haematuria
Sudden Onset/
Ongoing
Slight/Moderate
Haematuria
Frank Haematuria
Reassure patient
Admit to A&E
Attempt to
establish cause,
e.g. trauma, UTI
If UTI, follow UTI
flowchart
If trauma, check if
poorly supported,
over-full or
malpositioned
Increase fluid
intake
Contact or visit
after 4 hours and
then as necessary
If persists speak to
GP
and GP refer
may to
need
If persists,
refer
to urology
Urologist
Page 34 of 51
TROUBLESHOOTING – UNABLE TO INSERT CATHETER
If LCH CUCS are
unavailable and patient has
retention of urine ring the
Surgical Assessment Unit at
SJUH
Page 35 of 51
TROUBLESHOOTING – EXPELLING
If problem persists refer to
the LCH CUCS team
Page 36 of 51
TROUBLESHOOTING – AUTONOMIC DYSREFLEXIA
•
•
•
•
A sudden rise in blood pressure triggered by acute pain or stimulus.
Unique to spinal cord injured people at T6 –T10.
Autonomic nervous system attempts to lower blood pressure above T6 but not below this
level which continues to rise.
THIS IS A MEDICAL EMERGENCY – SEE MANAGEMENT BELOW
SYMPTOMS
• Pounding headache
• Flushed appearance
• Sweating
• Pallor below T6
• Nasal congestion
• No urine output
• Tight chest
• Bradycardia
•
CAUSES
• Catheter blockage
• Constipation/full rectum
• UTI/ bladder spasm
• Renal/ bladder stone
• DVT
• Pain or trauma
• Wound site, burn, in growing toenail
• Pregnancy
• Over stimulation during sexual activity
MANAGEMENT
• Identify and remove cause
• If catheter blocked – change –no bladder washout
• If bowels – encourage emptying – proceed with caution
• Check blood pressure
• Administer prescribed vasodilator if required
Page 37 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and Intermittent) Policy
and Standard Operating Procedures
Appendix 7: Standard Operating Procedure for Female Catheterisation
1.
2.
Decontaminate hands
Check care plan and/or prescription sheet. Collect and ensure correct equipment is available
and in date
3.
Gain consent - Use interpreter if necessary.
4.
Instruct/assist (put on PPE) the patient to empty bag, adjust their clothing as appropriate and to
lie on their back with legs extended or in foetal position.
Bed clothes or towel etc. should be used at this stage to cover the patient’s genital area.
5.
Decontaminate hands and open catheter packs Cath-It and add additional items i.e. catheter,
gel, drainage bag. Put on a disposable plastic apron
6.
Put on non/sterile gloves and having released any straps securing catheter or leg bag use a
syringe to deflate the balloon. Do not pull back on syringe, allow water pressure to push
plunger out.
7.
Ask patient to relax and gently remove catheter.
8.
Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/
crystals.
9.
Decontaminate hands and put on sterile gloves
10. Place sterile towel across the patients thighs
11. Use low-linting swabs, separate the labia minora so that the urethral meatus is seen. One hand
should be used to maintain labial separation until catheterisation is completed.
12. Clean around the urethral meatus with 0.9% sodium chloride soaked swabs, using single
downward strokes.
13. Apply the lubricating/anaesthetic gel around and into the urethra.
14. If gloves have become contaminated put on new pair sterile gloves.
15. Place the receiver containing the catheter between the patient’s legs or attach drainage bag or
valve.
16. Introduce the tip of the catheter into the urethral meatus in an upward and backward direction.
17. Advance the catheter until urine begins to flow and then advance a further 3-5cm.
18. Having ensured the catheter is draining gently inflate the balloon according to the
manufacturer’s instructions.
19. Withdraw the catheter gently until resistance is felt and attach it to the drainage system.
20. Support the catheter using a strap/adhesive fixation device. Ensure that the catheter does not
become taut, that it will not kink or become trapped when patient is mobilising. Ensure that the
catheter lumen is not occluded by the fixation device.
Support drainage system by attaching straps or sleeve The drainage system must not be in
contact with the floor.
21 Ensure the perineum is dry and advise the patient to redress.
22. Dispose of equipment.
23. Remove gloves and apron and decontaminate hands
24. Record information in relevant documents. Use of a Change Record is required. Information
should include date and time of catheterisation, reason, catheter type, amount of water instilled
in balloon, manufacturer, batch number and expiry date of catheter, any problems, date next
change due. Description of urine draining
Ensure patient has a copy of Catheter Passport and document change for patient
record.
Page 38 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Appendix 8: Standard Operating Procedure for Male Catheterisation
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
Decontaminate hands
Check care plan and/or prescription sheet. Collect and ensure correct equipment is available
and in date.
Gain consent. Use interpreter if necessary.
Instruct/assist (put on PPE) the patient to empty bag, adjust their clothing as appropriate and
to lie on their back with legs extended.
Bed clothes or towel etc. should be used at this stage to cover the patient’s genital area.
Decontaminate hands and open catheter packs Cath-It and add additional items ie catheter,
gel, drainage bag. Put on a disposable plastic apron
Put on non/sterile gloves and having released any straps securing catheter or leg bag use a
syringe to deflate the balloon. Do not pull back on syringe, allow water pressure to push
plunger out.
Hold the penis upright. Ask patient to breathe in and out; as patient exhales gently remove
catheter. Male patients should be warned of discomfort as the deflated balloon passes through
the prostate gland. Instruct to cough to ease passage at this point.
Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/
crystals.
Decontaminate hands and put on sterile gloves
Place sterile towel across the patients thighs
Wrap a sterile topical swab around the penis. Retract the foreskin if necessary and clean the
glans penis with 0.9% sodium chloride soaked gauze, using single strokes.
Holding the penis upright insert the nozzle of the lubricating/ anaesthetic gel into the urethra.
Squeeze the gel slowly into the urethra, remove the nozzle and discard the tube. Hold penis
upright if possible while anaesthetic gel takes effect- approximately 6 minutes
If gloves have become contaminated put on new pair sterile gloves
Grasp the penis, wrapped in sterile swab, firmly and hold in an upright position -60-90 degrees
to body, gently extended away from body. Maintain hold of penis until procedure is completed.
Place the receiver containing the catheter between the patient’s legs or connect catheter to
drainage system or valve. Insert the catheter and advance the catheter along the urethra to the
bifurcation of the catheter. 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 strain
gently as if passing urine.
Having ensured the catheter is draining gently inflate the balloon with sterile water according
to the manufacturer’s instructions.
Withdraw the catheter gently until resistance is felt and attach it to the drainage system.
If slight haematuria occurs this will usually settle down over a few hours.
Refer to handbook for advice.
SEEK MEDICAL ADVICE if unexpected frank haematuria is observed
Support the catheter using a strap/adhesive fixation device. Ensure that the catheter
does not become taut that it will not kink or become trapped when patient is mobilising.
Ensure that the catheter lumen is not occluded by the fixation device.
Support drainage bag with straps or sleeve. The drainage system should not be in
contact with the floor
Ensure that the glans penis is clean and dry and then reposition the foreskin. Instruct/assist
the patient to redress.
Page 39 of 51
19.
20.
Dispose of equipment according to Trust policy.
Remove gloves and apron and decontaminate hands.
Record information in relevant documents. Use of a Change Record is required. Information
should include date and time of catheterisation, reason, catheter type, amount of water instilled
in balloon, manufacturer, batch number and expiry date of catheter, any problems, date next
change due. Description of urine draining
Ensure patient has a copy of Catheter Passport and document change for patient
record.
Page 40 of 51
Appendix 9: Standard Operating Procedure for Supra - pubic Catheterisation
1.
2.
3.
4
Decontaminate hands
Check care plan and/or prescription sheet, collect and ensure correct equipment is available
and in date
Gain consent. Use interpreter if necessary.
10.
Instruct/assist (put on PPE) the patient to empty bag, lie on their back and expose catheter site.
Position a disposable waterproof sheet or towel under the patient’s buttocks and thighs if
possible.
Decontaminate hands and open catheter packs ‘Cath-It’ and add additional items i.e. catheter,
gel. Put on a disposable plastic apron
Put on non-sterile gloves. Remove dressing (if applicable) from catheter site
Release any straps securing catheter or bag to leg and use a syringe to deflate the balloon
(having first confirmed the volume of water that was inserted into the balloon).Do not pull back
on syringe, allow water pressure to push plunger out.
Remove catheter ensuring some gauze is ready as there may be a ‘gush’ of urine, by pulling
firmly.
Dispose of used catheter, bag and gloves having examined catheter tip for signs of blockage/
crystals, completeness.
Decontaminate hands and put on sterile gloves.
11.
Place a sterile towel across the patients’ abdomen.
12.
Clean the insertion site with 0.9% sodium chloride soaked gauze and dry with gauze.
13.
Place the receiver containing the catheter between the patient’s legs or attach drainage bag or
valve.
Apply a little lubricating/anaesthetic gel to outside of supra pubic site before insertion
As quickly as possible insert new catheter into the tract a little further than the one removed
Having ensured the catheter is draining gently inflate the balloon with sterile water according to
the manufacturer’s instructions.
Withdraw the catheter gently until resistance is felt and attach it to the drainage system if
required.
Support the catheter using a strap/adhesive fixation device. Ensure that the catheter
does not become taut and that it will not kink or become trapped when patient is
mobilising. Ensure that the catheter lumen is not occluded by the fixation device.
Support drainage system with straps or sleeve plus top strap. The drainage system must
not be in contact with the floor.
Ensure the area is dry and advise the patient to redress.
Dispose of equipment according to Trust policy.
Remove gloves and apron and decontaminate hands
Record information in relevant documents. Use of a Catheter Change Record is required.
Information should include date and time of catheterisation, reason, catheter type, amount of
water instilled in balloon, manufacturer, batch number and expiry date, any problems, date next
change due. Description of urine draining
Ensure patient has a copy of Catheter Passport and document change for patient record.
5.
6.
7.
8.
9.
14.
15.
16.
17.
18.
19.
20.
21.
22.
Page 41 of 51
Appendix 10: Standard Operating Procedure for Intermittent Catheterisation Using
Single Use Catheters: Female Patients
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Decontaminate hands
Gain consent. Use interpreter if necessary.
Check care plan. Collect necessary equipment ensuring in date
Ask the patient to pass urine normally if possible
Ask the patient to decontaminate their genital area
Instruct/assist the patient to get into a supine position with knees bent, hips flexed and
feet resting 60cm apart.
Bed clothes or a towel etc should be used at this stage to cover the patient’s genital
area.
Decontaminate hands and put on a disposable plastic apron.
Prepare the catheter equipment as per manufacturers instructions. If unsuitable to be
placed onto a sterile field, position so that can be used following no touch technique.
Open packs, placing on suitable surface within easy reach
Remove cover exposing the patient’s genital area.
Decontaminate hands and put on sterile gloves
Using low-linting swabs, separate the labia minora so that the urethral meatus is
visible. One hand should be used to maintain labial separation until catheterisation is
completed
Clean around the urethral orifice with 0.9% sodium chloride soaked gauze using single
downward strokes.
Introduce the tip of the catheter into the urethra in an upward and backward direction
Advance the catheter until urine starts to flow (usually 6-8cm in total) and then a further
2-3 cm
When urine stops flowing gently remove the catheter, twisting it slightly to free any
trapped mucosa & pausing if stream resumes to ensure bladder is completely emptied.
If slight haematuria is observed this will usually resolve within a few hours.
Refer to catheter handbook for advice
SEEK MEDICAL ADVICE if unexpected frank haematuria is observed
Dispose of urine down the toilet
Dispose of equipment according to Trust policy.
Instruct/assist patient to redress
Remove gloves and apron and decontaminate hands.
Record in patient notes date, time, catheter type , batch no., ch, expiry date, volume
drained, nature of urine drained and any problems.
Page 42 of 51
Appendix 11: Standard Operating Procedure for Intermittent Catheterisation
Using Single Use Catheters: Male Patients
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21.
Decontaminate hands.
Gain consent. Use interpreter if necessary.
Check care plan. Collect necessary equipment ensuring in date
Ask the patient to pass urine normally if possible.
Ask the patient to decontaminate his genital area.
Instruct/assist (put on PPE) the patient to adjust their clothing as appropriate and to lie on
their back with legs extended.
Bed clothes or towel etc. should be used at this stage to cover the patient’s genital area.
Decontaminate hands and put on a disposable plastic apron
Prepare the catheter equipment as per manufacturers instructions. If unsuitable to be
placed onto a sterile field, position so that can be used following no touch technique.
Open packs placing on suitable surface within easy reach
Remove cover exposing the patient’s genital area.
Decontaminate hands and put on sterile gloves
Wrap a sterile swab around penis. Retract the foreskin if necessary and clean glans with
0.9% sodium chloride soaked swabs
Grasp the penis, wrapped in sterile swab and hold in an upright position -60-90 degree to
body, gently extended away from body. Maintain hold of penis until procedure is
completed. Holding the penis upright insert the catheter until urine flows, then a further 23cm.
If resistance is felt at the external sphincter increase traction of the penis and apply
steady but gentle pressure on the catheter. Ask the patient to strain as if passing urine.
When urine stops flowing, gently remove the catheter, twisting it slightly to free any
trapped mucosa & pausing if stream resumes to ensure bladder is completely emptied
Reposition foreskin if necessary. Dry.
If slight haematuria is observed this will usually resolve within a few hours.
Refer to catheter handbook for advice
SEEK MEDICAL ADVICE if unexpected frank haematuria is observed
Dispose of urine into the toilet.
Dispose of equipment according to Trust policy
Instruct/assist patient to redress.
Remove gloves and apron and decontaminate hands.
Record in patient notes date, time, catheter type, ch, batch no. expiry date, volume
drained, nature of urine drained and any problems.
Page 43 of 51
Appendix 12: Standard Operating Procedure for Changing a Catheter Bag
(Adhere to manufacturer’s guidance)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
Decontaminate hands.
Gain consent Use interpreter if necessary
Collect necessary equipment
Decontaminate hands and put on a disposable plastic apron and non-sterile gloves.
Empty catheter bag
Release any straps securing catheter to patient
Hold catheter in one hand and the catheter bag in the other near where the two are connected
and use a pulling and twisting movement to disconnect the two. Ensure catheter is not pulled
taught while doing this.
Nip the end of the catheter together
Remove the protective cap from the end of the new catheter bag being careful not to touch the
exposed end
Push the bag connection firmly into the end of the catheter
Support the catheter and drainage system according to patients wishes e.g. G-strap, leg bag
holster etc. Ensure that the catheter does not become taught kink or become trapped when
patient is mobilizing. Ensure that the catheter lumen is not occluded by the fixation device.
The drainage system should not be in contact with the floor.
Dispose of equipment according to Trust policy.
Remove gloves and apron and decontaminate hands.
Record information in relevant documents.
Page 44 of 51
Appendix 13: Standard Operating Procedure for Connecting a Night Catheter Bag
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
Decontaminate hands.
Gain consent. Use interpreter if necessary.
Collect necessary equipment
Decontaminate hands and put on non sterile gloves and a disposable plastic apron
Empty catheter bag
Remove the protective cap from the end of the night catheter bag, being careful not to
touch the exposed end
Push the bag connection firmly into the outlet tube on the end of the leg bag
Check the outlet tap on the end of the night bag is in the closed position and then open
the outlet tap on the leg bag.
Support the night bag according to the patients wishes (e.g. night bag stand)
Ideally 30cms below bladder. The drainage system should not be in contact with the
floor.
Release any straps securing catheter leg bag to patient but ensure catheter bag remains
supported (e.g. on bed) and that tubing will not kink or become trapped.
Remove gloves. Remove apron and decontaminate hands
Record information in relevant documents.
Page 45 of 51
Appendix 14: Standard Operating Procedure for Administering a Catheter
Maintenance Solution (CMS)
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
13.
14.
15.
16.
See catheter handbook for guidance on use of CMS’s
Decontaminate hands.
Gain consent Use interpreter if necessary
Collect necessary equipment
Check care plan and/or prescription sheet and ensure correct maintenance solution is
used and is in date
Ensure the patient is in a comfortable position which allows access to the catheter
Decontaminate hands and put on plastic apron.
Open packs and place on suitable surface within easy reach
Using Aseptic technique as per Trust policy put on sterile gloves.
Place absorbent pad under catheter drainage bag junction, remove bag. Place in
disposal bag
Administer solution as per manufacturers guidelines
Ensure patient is not left exposed
When all the solution has drained back out of the bladder, disconnect the solution
container and connect a NEW sterile drainage bag.
The drainage system should not be in contact with the floor.
Dispose of used equipment according to trust policy.
Remove gloves and apron and decontaminate hands.
Record actions in relevant documents. Note any complication or problem encountered
with the procedure.
Page 46 of 51
Appendix 15: Standard Operating Procedure for Disconnecting a Night Drainage Bag
1.
2.
3.
4.
5.
6.
7.
8.
9.
Decontaminate hands.
Gain consent. Use interpreter if necessary.
Collect necessary equipment
Decontaminate hands and put on plastic apron and non sterile gloves.
Close outlet tap on leg bag and disconnect night bag from leg bag by gently pulling and
twisting connection. Allow any urine remaining in night bag tubing to drain into bag.
Empty bag into appropriate receptacle (e.g. toilet).
Disposable single use drainable night bags are now recommended ie apply a new bag each
night
Support the catheter and drainage system according to patients wishes e.g. G-strap, leg bag
holster etc. Ensure that the catheter does not become taught , kinked or become trapped
when patient is mobilising. Ensure that the catheter lumen is not occluded by the fixation
device.
Remove gloves and decontaminate hands.
Record information in relevant documents.
Page 47 of 51
Appendix 16: Standard Operating Procedure for Emptying a Catheter Bag
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Decontaminate hands.
Gain consent. Use interpreter if necessary
Collect necessary equipment
Decontaminate hands and put on non sterile gloves and aprons.
Ensure the outlet tube is clean and free of visible contamination. Clean if necessary with a
detergent wipe.
Open the tap and allow the urine to drain into an appropriate receptacle (e.g. toilet, jug)
Close the tap and ensure outlet tube is clean and dry.
Flush urine down the toilet noting any abnormalities Liaise with GP/registered nurse as
appropriate.
Remove gloves and apron and decontaminate hands.
Document actions in nursing records as appropriate.
Page 48 of 51
Appendix 17
Standard Operating Procedure for Support Workers Catheterising Patients
Registered practitioners are accountable for delegating the procedure of catheterising
patients to a Support Worker (SW). The SW must be assessed as competent and this
must be clearly recorded in their personal file.
The SW is assessed as competent by a registered practitioner who is competent in this
area of care. The assessor must also confirm that they have completed their own
competency for catheterisation.
Prior to the catheterisation procedure taking place, the following specific patient related
documents must be evident and clearly state that a SW is able to catheterise




Urinary Catheter Management plan
Catheter Change Record
Care Plan
Catheter Risk Assessment completed on Systm1
SW’s can catheterise patients:


With a catheter risk assessment score of less than 50
Where a planned change has been delegated by a registered nurse
Unplanned Catheter Changes


Patients who present with an acute need for re-catheterisation, e.g. blockage or
bypassing can be re-catheterised by a SW if previously deemed suitable for a SW
catheter change. – this must be recorded clearly on the patient records
Unplanned catheter changes must be allocated on an alternate visit basis with a
registered nurse.
SW’s must not catheterise patients who fall into the following categories:








Risk Assessment score 50+
New catheterisations
Advanced cancer of the prostate, bladder or vulva.
Requiring prophylactic antibiotics prior to change.
MRSA positive
Urethral erosion/trauma
Any unusual anatomy
Those where there are known difficulties or complications.
This list is not definitive and the registered nurse must exercise clinical judgement on
the suitability of patients, according to the needs of the patient and the competencies
of the SW.
Page 49 of 51
Urinary Catheterisation: Adults and Children (Urethral, Supra Pubic and
Intermittent) Policy and Standard Operating Procedures
Appendix 18:
Page 50 of 51
Policy Consultation Process
Title of Document
Authors
Urinary Catheterisation: Adults and Children
(Urethral, Supra Pubic and Intermittent) Policy
and Standard Operating Procedures
Alison Berry, and Rachel Baker-Green, Clinical
Nurse Specialists
CUCS
Document
Lists of persons involved
in developing the policy
List of persons involved
in the consultation
process
Revised
Gill Armstrong, Clinical Effectiveness Lead
Kirsty Jones, Clinical Lead (District Nursing)
Rebecca Aspinall, Clinical Lead (District Nursing)
Lucy Hall , Clinical Lead (District Nursing)
Neil Harris, LTHT Consultant urologist
Nicholas Foster, LTHT Consultant microbiologist
Jenny Featherstone, (IPC) Nurse Specialist
Liz Grogan, IPC Nurse Specialist
David Hall, Lead IPC Specialist
Linda Doidge , Effectiveness and Audit Manager
(Interim)
Gill Armstrong, Quality Lead Adults, Quality and
Professional Development
Angela Gregson, Clinical Pathway Lead
Chris Toothill, Medicines Management
Pharmacist (Governance and Risk)
Nicola Cox Clinical Nurse Specialist (CUCS)
Jen Lodge Clinical Nurse Specialist (CUCS)
Jeanette Wood Clinical Nurse Specialist (IPC)
Caroline McNamara, Clinical Lead Adult
Business Unit
Dr Charlie Stanley Medical Lead Adult Business
Unit
Page 51 of 51