Note: This guideline is currently under review.

Introduction

Aim 

Definition of Terms

Indications

Preparation 

Catheter size

Procedure for insertion of urinary catheter 

Special precautions

Documentation

Ongoing nursing management

Troubleshooting

Removal of urinary catheter 

Complications

Discharge information

Companion documents

References

Introduction

Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried out using aseptic technique, Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried using aseptic technique, either by a nurse, or doctor if complications or difficulties with insertion are anticipated. Catheterisation of the urinary tract should only be done when there is a specific and adequate clinical indication, as it carries a risk of infection.


Aim

To ensure the insertion and care of the urinary catheter is carried out in a safe manner that minimises trauma and infection risks.
 

Definition of terms

• Indwelling Urinary Catheter (IDC): A catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine.  
  
• Oliguric: a reduction in urine output.
  
• Paraphimosis: occurs when the foreskin is left in a retracted position. The pain and swelling may make it difficult to return the foreskin to the non-retracted position, this may reduce blood flow to the tip of the penis which if left untreated could lead to necrosis of the glans penis. 
  

Indications

• To drain the bladder prior to, during, or after surgery
  
• For investigations
• To accurately measure the urine output 
  
• To relieve retention of urine
  
• To relieve urinary incontinence when no other means is practical
  

Preparation

Preparation of the child and family

• Gain patient/primary care givers consent for procedure
• Families/primary care givers should be given a thorough explanation of the procedure. Involve the parents where possible when providing an age appropriate explanation of the procedure to the patient.
• Consider the need for a referral to play therapy to assist in explaining and preparing the patient for the procedure. Play therapists are also able to empower the child to identify distraction techniques, as well as provide support and distraction throughout the procedure.
• Nursing staff should discuss and plan procedural pain management with the child and family prior to the procedure. This may include non pharmalogical (including distraction techniques) and pharmalogical considerations including Nitrous Oxide or sedation if necessary. For more information regarding this please see the Procedural Pain Management guideline.
  

Preparation of Environment and Equipment

Ensure the patient’s privacy is maintained throughout the procedure and that they are kept warm. Ensure there is adequate light to perform the procedure.

Prepare the following equipment:

• Dressing trolley
  
• Catheterization pack and drapes
  
• Sterile gloves
  
• Appropriate size catheter (see catheter size guideline below)
  
• Sterile Lubricant and/or Xylocaine jelly syringe (plain sterile lubricant for infants)
  
• Sterile water to inflate balloon (normal saline can crystallise and render the balloon porous, causing its deflation and the risk of catheter loss)
  
• 5ml/10ml Syringe – as stated on catheter packaging
  
• Specimen jar
  
• Sterile normal saline
  
• Straps/tape to secure catheter to leg
  
• Drainage bag
• Waterproof sheet

Catheter size

Use an appropriate size catheter depending on the age of the child. Catheters that are too big or small are at risk of urethral trauma or leakage. The rational for IDC insertion should also be considered when selecting catheter, for example a patient requiring an IDC post kidney trauma may require a larger size to provide adequate drainage of potential blood clots. Consider silicone catheter if for long term use. 

Procedure for insertion of urinary catheter 

The need for an IDC should be discussed with the patients’ medical team prior to insertion. Medical approval for IDC insertion should be ordered and/or documented.

The following should be completed in line with the RCH Aseptic Technique Procedure. 

Female child

• Perform hand hygiene
• Place child in supine position with knees bent and hips flexed
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open dressing pack (aseptic field) and prepare equipment needed using aseptic technique
• Pour sterile normal saline onto tray
• Perform aseptic hand wash and don sterile gloves
• Apply sterile drapes/towel
• Separate labia with one hand and expose urethral opening. In neonates, the urethral meatus is immediately above the hymeneal fringes.
• Using swabs held in forceps in the other hand clean the labial folds and the urethral opening. Move swab from above the urethral opening down towards the rectum. Discard swab after each urethral stroke into waste bag or designated waste area.
• Remove catheter wire if a 6Fr catheter is used
• Lubricate catheter
• Insert catheter into the urethral opening, upward at approximately 30 degree angle until urine begins to flow.
• Inflate the balloon slowly using sterile water to the volume recommended on the catheter. Check that child feels no pain. If there is pain, it could indicate the catheter is not in the bladder. Deflate the balloon and insert the catheter further into the bladder. ALWAYS ensure urine is flowing before inflating the balloon. Note that in a child under 6 months a balloon is not typically used. In this case be especially mindful that strapping is secure.
• Withdraw the catheter slightly until resistance is felt and attach to drainage system
• Remove gloves and perform hand hygiene
• Secure the catheter to the thigh with either a catheter securement device or tape
• Clean trolley and dispose of used articles into yellow biohazard bag
• Perform hand hygiene 
  

Male child

• Perform hand hygiene
• Place child in supine position
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open catheter pack (aseptic field) and prepare equipment needed using aseptic technique
• Pour sterile saline onto tray
• Perform aseptic hand wash and don sterile gloves
• Lift the penis and retract the foreskin if non-circumcised. Do not force the foreskin back, especially in infants. A sterile gauze swab can be used to hold the penis. 
• Using other hand, clean the urethral opening with swabs held in forceps. Use a circular motion from the urethral opening to the base of the penis.  Discard swab into waste bag or designated waste area. 
• For boys older than 3 years insert the Xylocaine gel into the urethra. Gently hold the urethra opening closed and wait 2 - 3 minutes to give the gel time to work. For infants apply sterile lubricant to catheter before insertion. Post urology surgery consider using two syringes of xylocaine gel to increase lubrication of the urethra and decrease risk of trauma.
• Remove the wire if using a 6Fr catheter
• Hold the penis with slight upward tension and perpendicular to the child's body. Insert the catheter.
• When the first sphincter is reached (at level of pelvic floor muscles) gently bring the penis down to face the child's toes, apply constant gentle pressure. If resistance is felt the following strategies should be considered:
  • Remove the catheter and utilise a 2nd tube of lubricant
  • Increase traction on penis and apply gentle pressure on the catheter
  • Ask the child to take a deep breath
  • Ask the child to cough and bear down e.g. try to pass urine
  • Gently rotate the catheter.
    

If unable to pass the catheter seek assistance from treating medical team or Urology registrar. DO NOT use force as you may damage the urethra.

• Advance the catheter and gently insert it completely into the urethra until the connection portion.
• ALWAYS ensure urine is flowing before inflating the balloon.
• Inflate the balloon slowly using sterile water to the volume recommended on the catheter. Check that child feels no pain. If there is pain, it could indicate the catheter is not in the bladder. Deflate the balloon and insert the catheter further into the bladder. Note that in a child under 6 months a balloon is not typically used. In this case be especially mindful that strapping is secure.
• Withdraw the catheter slightly till resistance is felt and attach to drainage system
• Reposition the foreskin if applicable
• Remove gloves and perform hand hygiene
• Secure the catheter to the thigh with either catheter securement device or tape
• Clean trolley and dispose of used articles into yellow biohazard bag
• Perform hand hygiene 
  

Special precautions

Rapid drainage of large volumes of urine from the bladder may result in hypotension and/or haemorrhage. If concerned clamp catheter if the volume seems excessive. Release clamp after 20 minutes to allow more urine to drain. A medical review of the child should be requested.

For post obstructive diuresis IV replacement of fluid and electrolytes may be required. This should be discussed with the treating medical team.

Documentation

Insertion of the IDC should be documented in the LDA activity. 

• Including catheter type, length and size 
  
• Amount of water instilled into balloon 
  
• Document all procedures and cares involving IDC cares
  

Ongoing nursing management

• Measure urine output as indicated 1 – 4 hourly, assessing the colour and concentration of urine output.        
  
• Unless otherwise specified by the treating team, normal paediatric urine output is 1-2ml/kg/hr. Report any variation from this to the treating medical team.  
  
  • Certain drugs will increase diuresis, such as diuretics and ACE inhibitors.
    
  • If oliguric ensure catheter is not blocked (see trouble shooting below).
    
  • Record fluid balance. A fluid balance which keeps the urine dilute will lessen the risk of infection. This may not be possible due to the clinical condition of the child.
    
• The IDC insertion site and securement should be assessed at least once a shift, to ensure the IDC is not pulling on the genitals and not twisted. 
  
• IDC drainage bags should be emptied once a shift at a minimum. 
  
• Position drainage bag to prevent backflow of urine or contact with the floor. Gravity is important for drainage and prevention of urine backflow. Ensure the drainage bag is below the level of the bladder, is not kinked or twisted and is secured.

Drainage system

Adherence to a sterile continuously closed method of urinary drainage has been shown to markedly reduce the risk of acquiring a catheter associated infection. Therefore breaches to the closed system should be avoided.

Consider changing the catheter tube and/or bag based on clinical indicators including infection, contamination, obstruction or if system disconnects. If the equipment is damaged or leaks, replace system and/or catheter using aseptic technique and sterile equipment.

Hygiene

• Routine hygiene should be maintained with routine bathing/showering, including daily clean IDC insertion site with warm soapy water and more frequently if build-up of secretions is evident
• Uncircumcised boys should have the foreskin gently eased down over the catheter after cleaning.
• Always check the strapping of the catheter is secure after hygiene is performed.
  

Infection surveillance

• Consider daily the need for the IDC to remain in situ. Remove as soon as no longer required to reduce risk of Urinary Tract Infection (UTI).
• Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs further investigation.
  

Specimen collection

• Urine for for urinalysis or culture should be collected fresh from the needleless sampling port of catheter tubing (not drainage bag), this should be completed in line with the Aseptic Technique Procedure.
  • Clamp below the sampling point. 
    
  • Scrub sampling point vigorously with 70% alcohol and chlorhexidine (0.5% or 2%) soaked gauze or swabs for at least 15 seconds and allow to air dry 
    
  • Access port with a 10ml syringe to collect sample
    
  • Unclamp catheter
• Large volumes e.g. 24hr collection, can be collected from drainage bag.
  

Troubleshooting

• Catheter not draining/ blocked/patient oliguric
  
• Check catheter/tubing not kinked
  
• Check catheter is still secured to patient leg and that it  hasn't migrated out of bladder
  
• Assess patient’s hydration status to ensure they are not dehydrated. Consider the need to perform a bladder scan to assess bladder volume. Escalate to medical team if concerned.
  
• The patency of a catheter can be checked via the sampling port or catheter tubing. A blocked catheter should be flushed via the catheter tubing, this is of particular importance in case of blood clots or mucus (for example after a bladder augment). 
  

The following techniques to check for patency and/or flush a catheter should be completed following the Aseptic Technique Procedure. 

Catheter leaking

• Ensure the catheter is still draining and that the urine is not overflowing around a blocked catheter. See above for tips regarding catheters not draining.
  
• If the catheter is a balloon catheter, make sure the balloon is still inflated. Hold the catheter tubing securely in the same position and empty the balloon to make sure the amount that has been placed initially in the balloon is still present. If not, reinflate the balloon to its initial volume with water. Deflation of the balloon happens easily with a 6Fr catheter.
  
• Check catheter size is correct for age/size of the child. Use of a balloon catheter in neonates should only be with consultation with the treating medical team.
  
• Consider the need to remove and reinsert a new catheter in consultation with the treating medical team. 
  

Removal of urinary catheter 

Equipment required for removal:

• Standard precaution PPE
  
• 5ml/10ml Syringe – as stated on catheter packaging
  
• Waterproof sheet
  
• Kidney dish / receiving container
  

Procedure:

• Explain procedure to child and family and gain consent.
  
• Check amount of water used to inflate IDC balloon.
  
• Gather equipment required for removal
  
• Ensure patient privacy and have patient in supine position. 
  
• Place waterproof sheet and/or kidney dish between patient legs.
  
• Perform hand hygiene & don gloves.
  
• Deflate balloon completely and remove any straps/tapes
  
• Gently withdraw catheter on exhale if possible, with rotation movements if necessary.
  • Bear in mind that once inflated, the balloon won’t deflate to its total initial flat state and the balloon portion of the catheter will remain larger than the catheter itself.
    • If resistance felt and catheter cannot be easily removed do not force, leave catheter in situ and consult medical team. 
      
    • Consider cutting the catheter at the balloon inflation point to ensure the balloon is deflated. 
      
    • Once removed inspect catheter for intactness. Report if not intact.
• Perform hand hygiene.
• Document catheter removal in the LDA activity.
• Observe for urine output post catheter removal.
• If the patient has not passed urine 6 – 8hours post catheter removal assess the patient’s hydration status and consider the need to perform a bladder scan. Discuss findings with the treating medical team. 

Complications 

• Inability to catheterise: ensure appropriate catheter size has been selected based on the age/size of the child. Ensure adequate procedural pain relief and distraction is in place during the procedure.
  
  • Escalate to the treating medical team and consider the need for a referral to the urology team. 
    
  • In young girls, the urethra can be difficult to localise and the catheter can go directly in the vagina. In this case, leave the first catheter in the vagina and use another one to place immediately above, which will be more likely to go in the urethra.
    
• Urethral injury may occur from trauma sustained during insertion or balloon inflation in incorrect position: it is very important to ensure the catheter is in the bladder before inflating the balloon, this can be confirmed by visualising the stream of urine prior to balloon inflation.
  
• Haemorrhage
  
• False passage (catheter pushed through urethral wall): The risk of false passage is actually higher when using a smaller catheters, ensure catheter size utilised is appropriate for child’s age and size.
  
• Urethral strictures following damage to urethra. This may be a long term problem
  
• Infection
  • To minimise risk of infection insertion of IDC’s must be performed using surgical aseptic technique with single use sterile gloves. 
    
  • Regular hygiene should be maintained whilst IDC is in situ. 
    
  • Where possible avoid disconnecting the IDC circuit to minimise risk of contamination
    
  • Monitor for and report signs of infection including fever, offensive smelling urine, unexplained blood or cloudy urine.
• Psychological trauma
  
• Paraphimosis due to failure to return foreskin to normal position following catheter insertion:
  
  • To minimise risk, remember to replace the foreskin to normal position in non-circumcised patients and check at catheter care or nappy change that the foreskin is in place.
    

Discharge information

• Some children will be discharged from the hospital with their IDC insitu. It is important to teach the families how to care for the catheter, how to perform hygiene, how to monitor the output and how to troubleshoot. Refer to  Kids Health Info Fact Sheet: Indwelling urinary catheter


Companion documents

Other RCH IDC resources available:

• Kids Health Info Fact Sheet: Indwelling urinary catheter

• RCH Teaching and supporting clean intermittent catheterisation for parents and children

References

• Anderson, C., & Herring, R. (2019). Pediatric Nursing Interventions and Skills. In M. Hockenberry, D. Wilson, & C. Rodgers (Eds.), Wong’s Nursing Care of Infants and Children (pp. 701-704) St. Louis, Missouri: Elsevier.
  
• Australia and New Zealand Urological Nurses Society, (2014). Catheterisation Clinical Guidelines
• Australian Guidelines for the Prevention and Control of Infection in Healthcare (2019) pages 137-140 https://www.nhmrc.gov.au/guidelines-publications/cd33
• Fasugba, O., Koerner, J., Mitchell, B. G., & Gardner, A. (2017). Systematic review and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections. Journal of Hospital Infection, 95(3), 233-242.
  
• Galiczewski, J. M. (2017). An intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: direct observation of catheter insertion procedure. Intensive Critical Care Nursing. 40:26–34. Intensive & Critical Care Nursing, 41, 2. https://doi.org/10.1016/j.iccn.2017.04.002
• Gould, C., Umscheid,C., Agarwal,R., Kuntz,G., Pegues, D., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009) Guideline for prevention of catheter associated urinary tract infections (2009) Updated: June 6, 2019. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
  
• Government of Western Australia Department of Health (2015). Indwelling Catheter: Blockage. Clinical Guideline, Women’s and Newborn Health Service, King Edward Memorial Hospital.
  
• Government of Western Australia Department of Health. Urethral Catheterisation Neonatal Guideline. (2019).
• Holroyd, S. (2019). Indwelling catheterisation: evidence-based practice. Journal of Community Nursing, 33(5), 40-46.
  
• NHS Southern Health, Urinary Catheter Care Guidelines (2020)
  
• Pradhan, S. K., & Das, K. (2017). Urinary Bladder Catheterization. Practical Procedures in Pediatric Nephrology, 4.
  
• Royal College of Nursing Catheter Care RCN Guidance for Healthcare Professionals (2019)
  
• Rowe, J. (2020). Urinary catheter management. Starship Hospital New Zealand.
  

Evidence table

Indwelling urinary catheter insertion and management evidence table

Please remember to read the disclaimer.

The development of this nursing guideline was coordinated by Liam Cunningham, RN, Day Medical Unit, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2020.