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Clinical Guidelines (Nursing)

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Indwelling urinary catheter - insertion and ongoing care

  • Introduction

    Insertion of an indwelling urethral catheter is an invasive procedure that should only be carried out by a qualified competent health care professional using aseptic technique. Catheterization of the urinary tract should only be done when there is a specific and adequate clinical indication, as it carries a high risk of infection.

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    Aim

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

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    Definition of Terms

    IDC: Indwelling Urinary Catheter

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    Indications

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

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    Environment

    • Explained procedure to the child and the parents and obtain consent
    • The bed is screened to ensure privacy
    • Keep the child warm at all times
    • Ensure adequate light source

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    Equipment

    • Dressing trolley
    • Catheterization pack and drapes
    • Sterile gloves
    • Appropriate size catheter (see catheter size guideline below)
    • Xylocaine jelly syringe (plain sterile lubricant for infants)
    • Sterile water for balloon
    • 5ml Syringe
    • Specimen jar
    • Antiseptic solution. Aqueous Chlorhexidine 0.1% with Cetrimide (yellow solution) or Aqueous Chlorhexidine 0.1% (blue solution).
    • Tape to secure catheter to leg
    • Drainage bag
    • Urine bag holder

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    Catheter size guideline

    • Use the smallest bore that will allow good drainage to minimise bladder and urethral trauma
    • Consider silicone catheter if for long term use
     Age  Weight  Foley
    Neonate < 1200g

    3.5Fr umbilical catheter

    Neonate 1200-1500g

    5Fr umbilical catheter

    Neonate 1500-2500g

    5Fr umbilical catheter or size 6 Foley

     0-6 months  3.5-7kg  6
     1Y  10kg  6-8
     2Y  12kg  8
     3Y  14kg  8-10
     5Y  18kg  10
     6Y  21kg  10
     8Y  27kg  10-12
     12Y  Varies  12-14

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    Procedure for insertion of urinary catheter

    • The procedure should be carried out by a nurse or doctor competent in urinary catheterization only

    Female child

    1. Place child in supine position with knees bent and hips flexed
    2. If soiling evident, clean genital area with soap and water first
    3. Perform hand hygiene
    4. Open catheter pack
    5. Add equipment needed using aseptic technique
    6. Pour antiseptic onto tray
    7. Perform aseptic hand wash and don sterile gloves
    8. Apply drapes
    9. Separate labia with one hand and expose urethral meatus.
    10. Using swabs held in forceps in the other hand clean the labial folds and the urethral meatus. Move swab from above the urethral meatus down towards the rectum. Discard swab after each urethral stroke.
    11. Lubricate catheter
    12. Place sterile tray onto drape.
    13. Insert catheter into meatus, upward at approximately 30 degree angle until urine begins to flow.
    14. Inflate the balloon slowly (do not use balloon catheter in neonates) 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 further into the bladder. ALWAYS ensure urine is flowing before inflating the balloon.
    15. Withdraw the catheter slightly till resistance is felt and attach to drainage system.
    16. Secure the catheter to the thigh with tape
    17. Ensure the child is left dry and comfortable.
    18. Remove gloves and dispose of used articles into yellow biohazard bag.
    19. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine handwash

    Male child

    1. Place child in supine position
    2. If soiling evident, clean genital area with soap and water first
    3. Perform hand hygiene
    4. Open catheter pack
    5. Add equipment needed using aseptic technique
    6. Pour antiseptic onto tray
    7. Perform aseptic hand wash and don sterile gloves
    8. Apply the drapes
    9. Lift the penis and retract the foreskin if non circumcised. Do not force the foreskin back, especially in infants
    10. Using other hand, clean the meatus with swabs held in forceps. Use a circular motion from the meatus to the base of the penis.
    11. For older boys insert the Xylocaine gel into the urethra. Hold the distal urethra 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
    12. Place the sterile tray on the drapes.
    13. Hold the penis with slight upward tension and perpendicular to the child's body. Insert the catheter.
    14. When the first sphincter is reached (at level pelvic floor muscles) lower the penis 90 degrees  (facing child's toes), apply constant gentle pressure. If resistance is felt the following strategies should be considered:
      1. 2nd tube lubricant
      2. Increase traction on penis and apply gentle pressure on the catheter
      3. Ask the child to take a deep breath
      4. Ask the child to cough and bear down eg try to pass urine
      5. Gently rotate the catheter.
      6. If unable to pass the catheter seek assistance from treating medical team or Urology registrar
      7. DO NOT use force as you may damage the urethra
    15. Advance the catheter and gently insert it into the urethra until urine flows.
    16. Inflate the balloon slowly (do not use balloon catheter in neonates)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 further into the bladder. ALWAYS ensure urine is flowing before inflating the balloon.
    17. Withdraw the catheter slightly till resistance is felt and attach to drainage system.
    18. Secure the catheter to the thigh with tape
    19. Reposition the foreskin if applicable.
    20. Ensure the child is left dry and comfortable.
    21. Remove gloves and dispose of used articles into yellow biohazard bag.
    22. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine handwash

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    Specialprecautions

    • Rapid drainage of large volumes of urine from the bladder may result in hypotension and/or haemorrhage
      • Clamp catheter if the volume seems excessive. Release clamp after 20 minutes to allow more urine to drain
    • For post obstructive diuresis IV replacement of electrolytes may be required

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    Documentation

    The procedure is documented in the child's medical record. The documentation should be signed by the person inserting the catheter. Documentation should include:

    • Indication for catheterization
    • Time and date of procedure
    • Type of catheter.
    • Size of catheter
    • Expiry date of catheter
    • Amount of water in balloon
    • Any problems with insertion
    • Description of urine, colour and volume
    • Specimen collected
    • Review date

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    Ongoing nursing management

    • Measure urine output hourly and document
      • Normal urine output is 0.5-1ml/kg/hr. Report any variation from this
      • If oliguric ensure catheter is not blocked (see trouble shooting below)
        • No routine change of urinary catheter or drainage bag is necessary. Change for clinical indicators if infection, obstruction or if system disconnects or leaks. Replace system and/or catheter using aseptic technique and sterile equipment
      • Maintain unobstructed urine flow. Gravity is important for drainage and prevention of urine backflow. Ensure the drainage bag is below the level of the bladder, is not kinked and is secured
        • Urine for urinalysis or culture should be collected fresh from sampling port of catheter tubing (not drainage bag). Clean port with disinfectant first
    • 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
    • Hygiene
      • Daily warm soapy water is sufficient meatal care or PRN if build up of secretions is evident
      • Uncircumcised boys should have the foreskin gently eased down over the catheter after cleaning
    • Infection surveillance
      • Consider daily the need for the IDC to remain insitu. Remove as soon as no longer required to reduce risk of UTI
      • Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs further investigation
      • Full Ward Test (dipstick) should be done each day. This test can detect urinary protein, blood, nitrates (produced by bacterial reduction of urinary nitrate) and leucocyte esterase (an enzyme present in White Blood Cells)
      • Specimen collection
      • § Large volumes e.g. 24hr collection, can be collected from drainage bag
    • 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

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    Troubleshooting

    • Catheter not draining/ patient oliguric
      • Check catheter/tubing not kinked
      • Check catheter is still secured to patient leg and hasn't migrated out of bladder
      • Checking patency by irrigating catheter with 2-3ml of sterile 0.9% normal saline. Do not use force to instil fluid. This is an aseptic procedure
    • Catheter leaking
      • Remove catheter. If indication for IDC remains follow insertion procedure with new catheter

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    Removal of urinary catheter

    1. Explain procedure to child and family
    2. Perform hand hygiene & don gloves
    3. Deflate balloon completely
    4. Gently withdraw catheter
      • If resistance felt, and catheter cannot be removed easily do not force, leave catheter insitu and consult medical team
    5. Inspect catheter for intactness. Report if not intact
    6. Dispose of catheter and drainage system in appropriate waste
    7. Remove gloves & perform social hand wash
    8. Document catheter removal in patient notes
    9. Observe for urine output post catheter removal

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    Complications

    • Inability to catheterize
    • Urethral injury from trauma sustained during insertion or balloon inflation in incorrect position
      • Haemorrhage
      • False passage
      • Urethral strictures following damage to urethra. This may be a long term problem
    • Infection
    • Psychological trauma
    • Paraphimosis due to failure to return foreskin to normal position following catheter insertion

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    References

    • A guide for nurses- Management and care of catheters and collection systems (2001). USA: Bard
    • Gould, C; Umscheid,C; Agarwal,R; Kuntz,G; Pegues, D; and the Healthcare Infection Control Practices Advisory Committee (HICPAC).(2009). Guideline For Prevention Of Catheter-Associated Urinary Tract Infections. Centre for Disease Control. Downloaded from: http://www.cdc.gov/hicpac/cauti/001_cauti.html
    • Department of Health. (2001). Guidelines for preventing Infections associated with the Insertion and Maintenance of Short Term Catheters in Acute Care. Journal of Hospital Infection, 47(Suppl), S39 - S46
    • Laker, C (1995). Urological Nursing. Great Britain, Alden Press Ltd.
    • Royal Children's Hospital, Infection Control Dept. Antiseptic and Disinfectant Usage.
    • Association of Continence Advice, Notes on Good Practice (2006) Urethral Catheterisation NO.6
    • Robson, J (2001) Urethral Catheter Selection. Nursing Standard. 15 (25)
    • Royal College of Nursing Catheter Care RCN Guidance for Nurses ( 2007)
    • The Australian and New Zealand Urological Nurses Society INC. (ANZUNS) Talbot, Kay (2006)
    • Kids Health Info for Parents. The Royal Children's Hospital, Melbourne. Indwelling Urinary Catheter Fact Sheet. ( 2008)
    • Simpson, L (2001) Indwelling Urethral Catheters. Nursing Standard. 15 (46) : 47 - 54

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    Evidence Table

    Indwelling urinary catheter insertion and management evidence table

    Please remember to read the disclaimer.

    The development of this clinical guideline was coordinated by Maureen Scoble, Rosella - PICU. Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey, Executive Director Nursing Services. First published March 2012, revised February 2013.

     

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