Download Urinary Catheterization Procedure Protocol

Nursing Services Manual
URINARY (URETHRAL) CATHETERIZATION PROCEDURE / PROTOCOL
PURPOSE
SUPPORTIVE
DATA
To outline nursing responsibilities/management of Urinary Catheters.
 Steps of Urethral Catheterization (male & female) ............... Page 2
 Use/insertion of COUDE catheter ........................................ Page 3
 Obtaining Urine Specimen……………………………………...Page 3
 Intermittent Irrigation of Urinary Catheter……………………...Page 4
 Catheter Care……………………………………………………..Page 4
 Removal of Urinary (Urethral) Catheter………………………..Page 4
 Continuous Bladder Irrigation (CBI) set up/initiation…............Page 5
 Catheter Leg Bag…………………………………………………Page 6
Criteria/Indications for insertion of Urinary Catheters are: use only when necessaryurinary retention, pre/intra/post-operative drainage of urine, epidural catheter, clinical
need/trauma/unstable, medications, accurate/strict output, protect open sacral/perineal
wound if incontinent, provide comfort care in the terminally ill. Catheter Associated
Urinary Tract Infections (CAUTI) Risk Factors include prolonged catheterization,
female gender, inserting the catheter outside the operating room, diabetes,
malnutrition, renal insufficiency, abnormal creatinine level, older age, fecal
incontinence, co-existing infection, absence of antibiotics, faulty aseptic management
of catheter, bacterial colonization of collection bag. Non-Latex catheters are available.
Urinary catheters should be removed as soon as possible as longer indwelling time
leads to higher risk of biofilm (bacteria adhere to and multiply on catheter surfaces,
multiply quickly and advance in a retrograde fashion) formation leading to infection.
Preconnected closed systems with Cleanser Prep of 10% Povidone Iodine or 1-2%
Aqueous Chlorhexidine are recommended. No evidence exists to support routine
catheter changes.
Catheter size: Use smallest diameter that will prevent trauma and provide good
drainage (usually 14-18Fr) unless presence of blood clots or sediment that can occlude
lumen. For those with obstructions, closed continuous 3-way irrigation larger catheter
may be needed.
Balloon size: Typically 5ml balloon used (inflates with 10ml sterile water) for routine
catheterizations; 30ml balloon may be used with prostate surgery to provide traction to
surgical area or per physician preference.
A Coude-tipped catheter which has a firm, curved tip designed to negotiate the male
prostatic curve may be needed for difficult male catheterizations (with physician order).
Urinary catheters should be removed as soon as possible; Post-op by day 1 or 2
recommended. Evidence Based Practice indicates to identify patients daily with
indwelling urinary catheters, and check for removal. Daily documentation of day
number of indwelling time to be done.
EXPECTED
OUTCOME:
Patient will have catheter removed as soon as possible. CAUTI preventive measures
utilized. Patient will have no occurrance of CAUTI.
Urinary (Urethral) Catheterization Procedure / Protocol - Page 2 of 10
INSERTION OF URINARY (URETHRAL) CATHETER
Equipment
 Anti-Infective preconnected closed system with infection control drainage bag and
microbiocidal outlet tube/bacteriostatic urine catch system (2000ml) with antireflux
chamber and uroprep tray inclusive in kit
 Antiseptic wash (10% povidone iodine or 1%-2% aqueous chlorhexidine solution.
(Povidone Iodine Solution in kit)
 With physician order: UROJET (Lidocaine 2% Jel) for lubrication/discomfort.
 Catheter Securement device
1.
2.
3.
4.
5.
STEPS
Select catheter 14-18fr with 5ml
balloon unless otherwise ordered
Wash hands, apply gloves
Wash external genital area thoroughly
with soap and water-rinse well—
FEMALE: Identify Urethra prior to
beginning sterile procedure
Open kit-apply sterile gloves, use strict
aseptic technique.
Drape and cleanse urethra/meatus
and surrounding area utilizing sterile
technique.
FEMALE: Open labia to cleanse-hold
open
MALE:
 If uncircumcised, retract foreskin
and cleanse prepuce area.
 Recommend use of 1-2%
Lidocaine Jelly (UROJET) with
physician order and no allergygently inject directly into urethra
KEY POINTS
Wash hands before/after each patient
Decreases risk of CAUTI
Sterile procedure/strict Aseptic technique
Use Povidone Iodine or 1-2%
Chlorhexadine for prep
Use good lighting and assistant as needed
Check for allergies. Provides lubrication
for entire length of urethra and some
anesthesia to prevent external sphincter
spasm—wait 2-5 minutes before
continuing with procedure.
If catheter inadvertently placed in vagina,
6. Insert catheter gently:
leave in temporarily as a landmark-obtain
FEMALE: Supine position-use
new catheter.
Lubricant
Have patient take slow deep breaths to
MALE: Gently insert catheter (with
help in relaxation and allow easier catheter
penis upright pointing slightly
passage.
towards umbilicus) into urethraPrevents balloon from inflating into
Advance catheter almost to inflation
port (bifurcation or Y) before inflation of urethra.
balloon.
7. Obtain urine flow.
8. Inflate (gently) balloon with 10ml sterile Do not use normal saline (can cause
crystal formation leading to problems with
water (per manufacturer instructions),
then pull catheter gently to seat balloon deflation at removal) or air for balloon
inflation. Avoid under or overinflation-can
at bladder neck
cause asymmetrical balloon which can
Urinary (Urethral) Catheterization Procedure / Protocol - Page 3 of 10
STEPS
9. MALE: If Uncircumcised-Reposition
forward (or reduce) foreskin
10. Catheter Securement:
FEMALE: secure to inner thigh
MEN: secure to upper thigh or lower
abdomen.
11. Position drainage bag lower than
bladder
12. Do not allow drainage tubing to fall
below the drainage bag
KEY POINTS
deflect catheter tip to one side
Prevents Paraphimosis (retraction and
constriction of foreskin behind glans penis
secondary to catheterization)
Use a catheter specific anchor that
prevents slipping in and out. Allow for
slack to prevent tension on catheter.
(unsecured catheters can lead to bleeding,
trauma, pressure sores around meatus,
and bladder spasms from pressure and
traction
Prevents retrograde flow of urine into
drainage tubing and migration into bladder.
INSERTION OF COUDE CATHETER (FOR DIFFICULT MALE INSERTIONS-WITH
PHYSICIAN ORDER)
Equipment
 Coude Catheter with balloon port (has firm curved tip) of appropriate size.
 Urethral Catheterization tray
 Closed System Urinary Drainage Bag-2000ml size
 With physician order: UROJET-1-2% Lidocaine Jelly
 Catheter Securement device
STEPS
1. Wash hands
2. Prep for urethral catheterization-use
sterile technique
3. Follow urethral catheterization
Procedure
4. Insert Coude-tipped catheter with
tip pointed upward towards the
patient’s umbilicus
5. Advance to bifurcation/port
6. Continue per catheterization
procedure and secure.
KEY POINTS
Wash hands before and after
Coude-tipped catheter has a firm, curved
tip designed to negotiate the male
prostatic curve. “Tip up and to the Hub”
OBTAINING URINE SPECIMAN
Equipment
 Sampling Port is on urinary catheter drainage tubing
 Urine Speciman Container
STEPS
1. Kink Catheter approximately 3”
below sampling port
2. Swab port with antiseptic
KEY POINTS
Use Aseptic technique
Using port maintains closed system
Urinary (Urethral) Catheterization Procedure / Protocol - Page 4 of 10
3. Apply gloves
4. Using Aseptic technique, position
leurlock syringe in center of
sampling port (hold perpendicular)Lock into place onto port.
5. Aspirate urine sample into syringe.
6. Inject into Urine Speciman
container
7. Unkink urinary catheter
8. Label, attach printed order, send
Speciman to Lab in Biohazard Bag.
Urine for a C&S should be obtained from
newly inserted catheter and drainage bag
to avoid culturing the system rather than
the urine
INTERMITTENT IRRIGATION OF URINARY (URETHRAL) CATHETER (To be done
only if obstructed—clots or mucous anticipated)
Equipment
60cc Piston Syringe with Irrigation Tray (Toomey)-sterile
0.9 Normal Saline (sterile) irrigation solution (or solution per order)
STEPS
1. Wipe outside of catheter/tubing
connection with antiseptic
2. Apply gloves
3. Disconnect catheter from tubing
4. Aspirate first to attempt
clot/obstruction removal-if no return
instill 30-60 ml irrigation solution into
catheter, aspirate gently. Repeat as
needed to clear catheter
5. Reattach catheter to system
KEY POINTS
Use Aseptic technique/sterile equipment
Breaking catheter drainage bag
connection (closed system) is a major
point of bacterial entry into system
Avoid vigorous irrigation-can be damaging
to delicate bladder mucosa
CATHETER CARE
Equipment
STEPS
1. Routine Perineal care BID-avoid
specific meatal cleansing or
ointments to meatus (unless
specifically ordered)
KEY POINTS
There is no evidence to support special
meatal cleansing or use of ointments or
creams to meatus. Avoid petroleum based
products to catheters. Avoid catheter
manipulation
REMOVAL OF URINARY (URETHRAL) CATHETER
Equipment
12 ml leurlock syringe
STEPS
1. Slide syringe plunger back and forth
in barrel to loosen
2. Compress plunger all the way then
pull back 0.5ml to prevent
KEY POINTS
Urinary (Urethral) Catheterization Procedure / Protocol - Page 5 of 10
adherence
3. Gently attach syringe to balloon
port, allow all of inflation fluid to
return to syringe by gravity—do not
aspirate.
Wait at least 30 seconds for deflation. If
water does not return, reposition patient,
ensure catheter not in traction verify urine
flowing freely in tubing. If balloon still fails
to deflate, apply gentle, slow aspiration.
4. Remove catheter-assure all is intact Measure urine output. Assess for meatal
5. Discard all in Biohazard Bag
drainage
INITIATION OF CONTINUOUS BLADDER IRRIGATION (CBI)
Equipment (available in Urology Cart from 7N or Sterile Processing)
3-Way Urinary Catheter-(size per physician order)
Urinary (Urethral) Catheterization Tray
Cystoscopy/Irrigation Set (Single Irrigation Tubing)
2000ml or 3000ml Irrigation Solution (Sterile Water or Saline)-per order/need
Closed System Urinary Drainage Bag-4000 ml size
With physician order: UROJET - 1-2% Lidocaine Jelly
Catheter Securement device
STEPS
1. Wash hands
2. Spike irrigation bag with
Cystoscopy/Irrigation Set single
irrigation tubing. Flush tubing,
clearing of air. Maintain sterility of
end of tubing.
3. Apply Gloves
4. Prep for urinary (urethral)
catheterization-use sterile
technique.
5. Follow urethral catheterization
procedure
6. Insert foley catheter-advance to
bifurcation/port
7. Continue per catheterization
procedure and secure.
8. Attach Continuous Bladder
Irrigation tubing to Irrigation Port of
3-Way Catheter. Infuse at rate to
keep return solution and urine clear
9. MAINTAIN ACCURATE INTAKE
AND OUTPUT
-With each new added bag of 20003000ml irrigation solution, empty
urinary/solution drainage bag and
measure
KEY POINTS
NOTE: if patient received Post-op with (Y)
double infusion tubing/bag, recommend
switching to single set-up for easier
management. If rapid infusions
anticipated, use 3000ml bag, available
from storeroom
As each irrigation bag is infused, add new
bag and empty (and measure) outflow
drainage bag contents. Continue cycles to
maintain clear return
Output EXAMPLE: CBI-2000ml, FOLEY
(solution and urine)-2450ml, URINE450ml
Urinary (Urethral) Catheterization Procedure / Protocol - Page 6 of 10
USE OF LEG BAG
Equipment – Leg Bag (Follow instructions on package)
STEPS:
Fits with fabric leg straps
Put flutter valve @ top, attaches to catheter
Size to fit/place below knee (male—use extension tubing)
NURSING PROTOCOL
URINARY (URETHRAL) CATHETERIZATION
ASSESSMENT/INTERVENTIONS
o Assess readiness for catheter removal every day
o Assess continued need for catheter
o Assess for readiness for alternative method
o Assess day of dwell time

Assess for S/S UTI: pain, urine color, abdominal/flank discomfort,
temperature >38 degrees C

Assess for clots or mucous in urine

Assess for adequate urinary volume-> 250ml/shift
URINARY CATHETER TUBING/DRAINAGE SYSTEM
 Assess tubing/drainage bag intact, patent, and free of kinks-CLOSED SYSTEM
maintained.
 Assess tubing not kinked, not obstructed- urine flowing thru tubing
 Suprapubic Catheters: Assess catheter securement and insertion site. Secure
to avoid enlargement of stoma tract and leakage.
 Assess for signs of blockage or encrustation
 Leg Bag: assess for circulatory impairement of extremity
 Empty drainage bag at least every shift-do I&O
 Maintain patent system at all times
 Irrigate only if necessary (clots, mucous, or obstruction). Avoid vigorous bladder
irrigation to minimize mucosal irritation
CONTINUOUS BLADDER IRRIGATION (CBI)
 Assess system patent and intact
 Assess solution return color and clarity-clear or light pink, free from clots
 Assess urine output/return
 Assess for suprapubic pain and fullness (bladder spasms, clogged catheter)
 Clogged catheter: turn off CBI, take apart and irrigate outflow tube manually to
remove clots/obstruction-maintain sterility—use new kit with each occurrence,
resume CBI.
Urinary (Urethral) Catheterization Procedure / Protocol - Page 7 of 10

Bladder spasms: per physician approval, try removing water from balloon to
decrease irritation, treat with antispasmodics per order.
UNCIRCUMCISED MALE
 Assess foreskin pulled forward over glans penis with no S&S of Phimosis
MEATAL AREA
 Assess for drainage, bleeding, leaking, or redness around urinary meatus or
catheter insertion site
 Assess for leakage causes: bladder spasms, infection, fecal impaction or
constipation, occlusion, encrustation.
SKIN
 Assess skin condition under external devices in contact with skin or around
urinary meatus or insertion site, S-P insertion site
FLUID BALANCE/I&O
 Assess I&O q shift
 Monitor fluid balance q shift and q 24 hours
S&S of CAUTI
 Assess for new onset temperature, chills, flank or suprapubic pain
 Assess for urinary “urgency”, changes in urine character
 Assess Laboratory values, positive urine culture (colony count > 10 2-3cfu/ml)
 Assess for altered mental status
BLADDER STATUS (use Ultrasound Bladder Scan as needed/approved)
 If Bladder distention, reposition patient, check tubing for kinks or clots (especially
if decrease in urine output)-Irrigate only if necessary
 Check bladder status-if output low, check volume with Utrasound Bladder Scan
 Use Ultrasound Bladder Scan to check for discomfort
FLUID BALANCE/I&0
 Routine every shift or per order
CATHETER REMOVAL
 Use alternatives when possible (S-P or intermittent catheterizations)
 Remove all water from balloon to avoid trauma
 Check for orders/actions after removal
 Assess patient’s ability to void post removal or within specified time as ordereduse Ultrasound Bladder Scan to evaluate amount of urine in bladder as needed
 Check for bladder distention and/or residual
 Notify physician if unable to void
TROUBLESHOOTING-SELECTED SITUATIONS
 Leakage Management- Identify cause, change catheter if lumen occluded-per
order.
 Bladder Distention/CO of pain: check for kinked catheter or drainage tubing,
check if patient lying on tubing, tubing twisted, occlusion of catheter, pressure on
Urinary (Urethral) Catheterization Procedure / Protocol - Page 8 of 10


catheter. Try changing positions, secure catheter, verify catheter positioned over
thigh, check/remove fecal impaction.
Blockage/Lumen Occluded: Causes: blood clots, sediment or mucous;
Solution/prevention: Aspirate/Irrigate only if necessary, consider 3-way CBI (per
order), increase catheter size (not balloon) with order, increase fluids if tolerated,
check/remove fecal impaction.
BLADDER SPASMS: Possible causes: involuntary bladder contraction,
under/overinflated balloon, large balloon. Solution/prevention: secure catheter
over thigh or lower abdomen (for men), hang drainage bag properly, empty when
½-2/3 full. Per physician approval, remove water from balloon to decrease
frequency of spasms (ie: big balloon can cause spasms).
REPORTABLE CONDITIONS
Report to physician
 Unable to insert/pass urinary catheter—Abort procedure if resistance, bleeding,
severe pain.
 Leaking around insertion site/new drainage from meatal area
 Low or no urine output (verify with bladder scanner)
 Color change of urine-cloudy, red
 Obstruction/unable to irrigate
 Call if unable to void after expected or ordered time frame
 S&S of UTI: Fever > 38C or >100.4F, chills, new flank or S-P pain, changes in urine
character, altered mental status, positive urine culture
 S&S/appearance of Phimosis-tightened foreskin compromising blood flow to glans
penis
EMERGENCY MEASURES
 Paraphimisis in uncircumcised males with tight prepuce/foreskin-call physician (is a
Urological emergency)-patient may need surgical repair
 Unable to pass catheter, patient obstructed.
 Notify Physician, anticipate/prepare Bedside Flexible Cystoscopy or to Surgery.
SAFETY
 Avoid/prevent pulling or tugging on catheter
 Secure carefully with securement device that prevents in and out movement of
catheter-allow catheter slack
 Use Coude with order for difficult male catheterizations
 Avoid positioning drainage bag between legs or on abdomen-hang properly to
facilitate forward flow (keep tubing in straight line)
 Empty CBI outflow bag before filled to decrease pressure on bladder
 Empty bag when ½ to 2/3 full to avoid traction on catheter
 Avoid petroleum based creams/ointments (can degrade latex catheter)
 Catheterization: ABORT procedure if resistance is met, bleeding is noted, patient
complains of severe pain
INFECTION CONTROL
CAUTI Preventive Measures:
 Remove urinary catheter ASAP-recommend on Post-op day 1 or 2
Urinary (Urethral) Catheterization Procedure / Protocol - Page 9 of 10
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Use aseptic technique with sterile equipment with insertion (Category I)
Maintain closed system (Category 1)—do not irrigate unless absolutely necessary
(prevents bacterial entry)-wipe end of tubing and catheter with antimicrobial solution
prior to reconnecting system
Keep drainage bag below bladder (Category I)
Do not allow tubing to loop, dangle, fall below drainage bag, or kink—keep patent.
Wash hands before and after, wear gloves with each urinary catheter bag emptying
Do not allow outflow drain spigot to touch measuring container (can be a source of
UTI from retrograde bacterial migration).
Do not place urinary drainage bag up between patient’s legs.
Do not let bag lay on floor
Anchor catheter with securement device to minimize in and out motion to urethra
Avoid catheter manipulation around meatal area-can contribute to bacterial migration
into bladder
Prior to exercise/ambulation or transfer, drain all urine from tubing into drainage bag
to prevent retrograde flow of urine into bladder
PATIENT/SO EDUCATION
 Purpose of urinary catheter
 Wash hands before and after working with catheter
 CAUTI preventive measures (ie: maintain closed system, no looping, no bag below
bladder, avoid outlet touching floor or collection container, no bag on floor)
 Avoid pulling on catheter
 Notify if new pain, abdominal distention, or no urine return (validated)
 Application/removal of Leg Bag-if to be used at home (Teaching Protocol-Indwelling
Urinary Catheter).
DOCUMENTATION (in Care Link)
 Procedure with tolerance (include catheter size & inflation amount) in “Renal, Urinary
intrv and intrv response, urine source, device type”
 Urine return (characteristics: color, clarity, amount) in “Renal, urine source, & I&O”
 Catheter anchored with Cath Secure & location in “Renal, urine source, urine Intrv”
 Date inserted in “Renal, urine source”
 Day Number # of indwelling catheter (ie: Catheter Day #2) in: “Renal, Catheter,
Insertion Date” (document insertion date daily)
 Assessment and need for ongoing catheterization every 24 hours/daily
 MALE-Uncircumcised precautions –foreskin positioning in “Renal, Intervention,
Envelope or Reproduction, Foreskin”
 Maintenance/irrigations if necessary and results in “Renal, Intrv, Envelope”
 Bladder Scan amount in “Renal, Bladder Scan amt”
 Perineal Care “Reproduction, Intrv”
 Catheter Removal in “Renal, Catheter, Intervention”
 CBI Initiation in “Renal, Urine Source #1, Device Type, CBI Status”
 CBI Intake & Output in “I&O”:
o “Intake, Bladder Irrigtn” (enter cumulative amount instilled)
o “Output, Bladder Irrigtn” (enter cumulative amount instilled-returned out)
o “Output, Urine Cath, Amount of Urine” (subtracted amt from total emptied)
 Intake & Output in “I&O”
Urinary (Urethral) Catheterization Procedure / Protocol - Page 10 of 10


Leg Bag-Home with Urinary Catheter Teaching in “Patient Education”
Patient/Family teaching in “Patient Education”
REFERENCES:
-Centers for Disease Control and Prevention and Association of Practitioners in
Infection control Guidelines.
-Chettle,C.,RN,MS,MPH,CIC,COHN-S, Nurses Critical as Reimbursement Dries Up
for Catheter Associated UTI’s, Nursing Spectrum, August, 2008, pp. 24-29.
-Perry & potter, Fundamentals of Nursing, 2005, pp.1412-31.
-Reilly, L., RN,BSN,CCRN, et al;Reducing Foley Catheter Device Days in an ICU, Using
the Evidence to Change Practice, AACN Advanced Critical care, Vol. 17, #3, AACN
2006, pp. 272-83.
-Sanjay,S. MD,MPH, et al, Preventing Hospital-Acquired Urinary Tract Infection in the
United States: A national Study, Nosocomial UTI Preventive Practices, Clinical
Infectious Diseases, 2008:46 (15 January), pp. 243-49.
-Smith, JoAnn Mercer, BSN,RN,CWOCN, Indwelling Catheter Management: From
Habit-Based to Evidence-Based Practice, Ostomy Wound Management, 2003,
49(12), 34-45.
-Society of Urological Nurses & Associates (SUNA), Clinical Practice Guidelines, 2005.
-Staff Educator (EBP), Urinary Tract Infections with Practical Measures, Infection
Control, Prevent, Vol.4, #3, 3/08.
-Society of Urologic Nurses and Associates (SUNA), Clinical Practice Guidelines, 2005
-Nursing Standard