Urinary Catheterization

Urinary Catheterization Click on highlighted underlined words to get to informative links ! Updated Spring 2010

Recommended video:“Assessing Urinary Care”Available on Blackboard:Professor Hidle’s skills video on Foley Catheter insertion

Intermittent/straight cathetervsIndwelling Foley catheter

Indications/Purpose To relieve discomfort due to bladder distention (decompression) To assess residual urine from incomplete bladder emptying (retention) To obtain a urine specimen To empty the bladder completely prior to surgery (Maintained up to 12 hours in C/S.) For accurate urine output (hourly) To provide for intermittent or continuous bladder drainage and irrigation To prevent urine from contacting an incision after perineal surgery To manage incontinence when other measures have failed (i.e. neurogenic bladder)

Contraindication: Signs of Urethral trauma If trauma, perform genital and rectal exam first Blood at meatus Scrotal hematoma Prostate problems

Diagnostic Tests Post-void residual Urine Culture Cystoscopy and Ureteroscopy Intravenous Pylogram

Interpretation of Post-Void Residual PVR < 50cc - Adequate bladder emptying PVR > 150cc - Avoid bladder relaxing drugs PVR > 200cc - Outlet obstruction likely PVR > 400cc - Overflow UTI likely

Types of Catheters The first catheter from the top is called a Foley catheter or retention or indwelling catheter (continuous). Foley catheters have an inflatable bulb at the end that can be filled with H2O (~5-10 ml) to retain the tip of the catheter within the bladder. Asuprapubic catheter is basically an indwelling catheter that is placed directly into the bladder through the abdomen. The bottom catheter is a intermittent or straight catheter, usually red rubber.

Suprapubic catheters Indwelling catheter that is placed directly into the bladder through the abdomen (above the pubic bone) Placed by a urologist Changed by qualified medical personnel May be recommended in people who require long term catheterization, after some gynecological surgeries, and in people with urethral injury or obstruction Possible complications are similar to catheters

Catheter care With initial catheterization of a distended bladder, never allow more than 750cc to drain at one time. Clamp for 20-30 minutes and continue drainage (prevents patient from going into simulated hypovolemic shock). Catheter tubing should be over the patient's leg, not under. Catheter must alwaysbe stabilized by taping or using company prepared velcro leg straps to attach to leg. In male may also be attached to abdomen FOR MALE, REMBEMBER TO CONSIDER POSSIBLE REFLEX ERECTION THAT MAY PULL ON CATHETER – LEAVE ADDITIONAL LENGTH BEFORE TAPING.

Change catheter according to hospital policy or specific MD/NP orders (i.e each week) The catheter may need immediate removal &/or replacement if it is obstructed/clogged, painful or infected (some facilities teach intermittent bladder irrigation which requires an MD order) or continuous bladder irrigation may be ordered.

Routine care of the indwelling catheter must include daily cleansing of the urethral area and the catheter itself with soap and water (some hospital policies may vary in agent used) The area should also be thoroughly cleansed after all bowel movements to prevent infection Antimicrobial ointments are no longer used

Catheter Materials Latex: Long-term catheterization Silastic or Teflon: Short-term catheterization or Latex Allergy Minocycline and Rifampin impregnated catheters may reduce bacteriuria for up to 2 weeks

Catheter size • Use the narrowest, softest Urinary catheters are sized using French (F) units. The French number divided by 3 is the outer diameter of the catheter in millimeters. • Ranges: • Infant: 8F • Child/adolescent: 10-12 • Adult and large adolescent: 14-18F (female/male) • Most common: 14F to 16F used in large, older adolescents and adults

In some cases a larger catheter may be required to control leakage of urine around the catheter of if the urine is thick and bloody or contains large amounts of sediment. Balloon size: 5 – 10 ml balloon usually with fluid to inflate (15-30cc balloons may be used in patients with prostate surgery)

The urethra is about 1.5 inches long in the female and 8 inches long in the male so the catheter must be placed beyond this point to ensure entry into the bladder. In female, gently insert lubricated catheter into urethra until urine begins to flow. Then another 2-3 inches. In the male patient, advance almost to the catheter’s bifurcation. Most recent literature suggests that advancing until the bifurcation should be done in both male and female to ensure entry into the bladder before balloon is inflated.

Indwelling catheters • Long term (indwelling, continuous) urethral catheters, is frequently left in place for a period of time. • The tube is attached to a gravity drainage bag to collect the urine. • The drainage bag may be either a leg bag, which is a smaller drainage device that attached by elastic bands to the leg. Intended for use in males, this is used during the day since it fits under clothes. • A larger gravity collection bag (down drain) may be used during the night or in females or bedridden patients and is hung at the bedside, below bladder but off floor.

Stabilizing catheter To abdomen in male To leg in female or male

Foley Catheter (indwelling)

Straight Catheter The rounded tip of this intermittent catheter reduces urethral trauma as the catheter is passed. Urine enters the lumen of the catheter through two "eye" holes. Courtesy of http://www.vetmed.wsu.edu/courses_samDX/urinary.htm

Other Catheters Coude is a intermittent catheter with a tapered curved tip that is designed to be easier to insert when enlargement of the prostate is suspected. Mushroom (Pezzer) The mushroom-shaped tip this continuous catheter secures it in the patient's bladder after percutaneous placement.It may be sutured to your patient's abdomen or flank, or you may need to tape it in place.

Other Urinary Equipment Three-way Foley for Continuous Bladder Irrigation Continuous Bladder Irrigation Catheter Clamp

Home Care • Clean technique is used by patient. • Drainage bags may be cleaned periodically (especially for “clean catheter”): • Use 2 parts of vinegar and 3 parts of water to cleanse the drainage bag. Chlorine bleach can be substituted for the vinegar and water mixture. • Let the solution soak for 20 minutes and hang to dry

Straight catheter care (“Clean technique”): • Catheter is transported in anti-bacterial solution, i.e. zephrine (clear) or betadine. • Heavy red rubber tubing (Robinson) should be boiled daily to disinfect, or soaked in vinegar and water or chlorine bleach as above.

Discontinuing an indwelling(will demonstrate) • First, place a chux under the tubing and tuck under patient hips. • Deflate the balloon on the end of the catheter (usually 5-10cc which can be determined from catheter connection tip). (Not doing so can injure the bladder and urethra.) To deflate balloon: • Attach a 10cc syringe without a needle to the unattached end of the tubing's Y-shaped portion (inflating port). • Push the syringe tip firmly into the outlet. • Gently pull back on the plunger. The water in the balloon will flow into the syringe, deflating the balloon. • DO NOT DEFLATE THE BALLOON BY CUTTING THE CATHETER TIP ABOVE THE INFLATION PORT UNLESS FLUID CANNOT BE REMOVED WITH SYRINGE! This may result in water left in balloon which when removed will cause injury to bladder or urethra.

Be sure that tubing is not adhering to patients pubic hair. Tell the patient to take deep breaths and steadily withdraw the catheter onto the chux (expect leaking). Wrap catheter in chux to discard, measure amount of urine in drainage bag and discard. Position client for comfort until you return to assist with pericare. Chart time of discontinuation of Foley, amount on I&O flow sheet and color and consistency (i.e. blood, mucus, etc.) along with time in nurses note.

External Urinary Device • Condom or Texas Catheteris an external urinary incontinence device worn collect urine and protect the skin from the constant leakage. • Female external Urinary Collection systemis an odor-barrier plastic pouch that funnels urine into a collection bag and utilizes a comfortable hydrocolloid skin barrier that protects the skin from irritation. (In infants/young children; referred to as urine collection bag)

Complications of long-term catheterization Last resort r/t possibility of complications: • UTI, septicemia, urethral injury, skin breakdown, bladder stones and hematuria • Bacteriuria • Chronic renal inflammation • Pyelonephritis • Nephrolithiasis • Cystolithiasis • Bladder cancer may also develop after many years of catheter use

Nursing Implications: Monitor for Complications Foul smelling urine Thick, cloudy urine with or without sediment Painful urination (dysuria) Fever, chills Urethral swelling around the catheter Bleeding into or around the catheter Catheter draining little or no urine despite adequate fluid intake Leakage of large amounts of urine around the catheter

Troubleshooting a leaking catheter May be caused by incorrect size of catheter (too small), improper balloon size, or bladder spasms If bladder spasms occur, check that the catheter is draining properly. If no urine is detected in the drainage bag, the catheter may be obstructed by blood or thick sediment, or kinking of the catheter or drainage tube. Irrigation or the catheter may be indicated Other caused of urine leakage around the catheter include constipation or impaction of stool, or UTI

THE END!

Urinary Catheterization