URINARY CATHETERIZATION

Garre R. Garcia, RN

involves the introduction of a rubber or plastic tube through the urethra into the bladder.

URINARY CATHETERIZATION

Kinds1. Intermittent catheters - also known as straight catheters, are

placed into the bladder for short periods of time (5 -10 minutes).

2. Indwelling/Retention or Foley catheter - are those placed into the bladder for

extended periods of times. - these catheters have a balloon at the distal

end that is inflated after insertion.

Purposes• To relieve acute or chronic urinary retention.• To empty bladder before, during and after

surgery and before certain diagnostic procedure.

• To determine amount of residual urine after voiding

• To measure accurately the hourly urine output of critically ill patients.

Purposes

• To instill medications into the bladder• To irrigate the bladder• To obtain urine specimen for diagnostic

purposes.

CATHETERIZING THE FEMALE URINARY

BLADDER

Equipment

• sterile catheter kit that contains: - sterile gloves - sterile drapes (one of which is fenestrated) - sterile catheter - antiseptic solution - lubricant

Equipment

- cotton balls or gauze squares - forceps - pre-filled syringe - basin - specimen container

Equipment

• flashlight or lamp• waterproof disposable pad• disposable urine collection bag and drainage

tubings• disposable gloves

Assessment

• Assess bladder fullness before performing procedure, and question patient about any allergies, especially to latex and iodine.

• Ask patient if she has been catheterized. If she had an indwelling catheter previously, ask why and for how long it was used. The patient may have urethral strictures that may make insertion more difficult.

Implementation with Rationale

Nursing Action

1. Assemble all equipment. Perform hand hygiene. Explain the skill and its purpose to patient. Discuss any allergies with patient, especially to iodine and latex.

Rationale

Organization facilitates performance of the task. Hand hygiene defers spread of microorganisms. Explanation encourages patient cooperation and reduces apprehension. Most catheters and gloves in kits are made of latex. Some antiseptic solution contains iodine.

Nursing Action

2. Provide for good light. Artificial light is recommended.

Rationale

Good lighting is necessary to see meatus clearly.

Nursing Action

3. Provide for privacy by closing the curtain or door.

Rationale

Catheter insertion may be embarrassing for the patient.

Nursing Action

4. Assist patient to dorsal recumbent position with knees flexed and feet about 2 ft. apart. Drape patient or if preferable, place patient in side-lying position. Slide water proof drape under the patient.

Rationale

Good visualization of the meatus is important. Embarrassment and tension can interfere with catheter insertion; patient comfort will promote relaxation. The drape serve to protect bed from moisture

Nursing Action

5. Done gloves. Spread labia well with fingers, and clean area at vaginal orifice with washcloth and warm water, using a different corner of the washcloth with each stroke. Wipe from above orifice downward toward sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene again.

Rationale

Gloves reduce the risk of exposure to blood and body fluids. Clean technique decreases the possibility of introducing microorganism.

Nursing Action

6. Prepare urine drainage set up if indwelling catheter is to be inserted and if a separate urine collection system is to be used.

Rationale

This facilitates connection of the catheter to the drainage system and provides for easy access.

Nursing Action

7. Open sterile catheterization tray on a clean over-bed table using sterile technique.

Rationale

Placement of equipment near worksite increases efficiency. Sterile technique protects patient and prevents spread of microorganisms.

Nursing Action

8. Put on sterile gloves. Grasp upper corners of drape and unfold drape without touching unsterile areas. Fold back a corner on each side to make a cuff over gloved hands. Ask patient to lift her buttocks and slide sterile drape under her with gloves protected by cuff.

Rationale

The drapes provides a sterile field close to the meatus. Covering the gloved hands will keep the gloves sterile while placing the drape.

Nursing Action

9. A fenestrated sterile drape maybe placed over the perineal area, exposing the labia.

Rationale

The drape extends the sterile field and protects against contamination. Use of a fenestrated drape may limit visualization and is considered optional by some practitioners.

Nursing Action

10. Place sterile tray on drape between patient's thighs.

Rationale

This provides easy access to supplies.

Open all supplies:

Nursing Action

- If catheter is to be indwelling, test catheter balloon. Remove protective cap on tip of syringe and attached syringe pre-filled with sterile water to injection port. Inject appropriate amount of fluid. If balloon inflates properly, withdraw fluid.

Rationale

A balloon that does not inflate or that leaks needs to be replaced before insertion.

Nursing Action

- Fluff cotton balls in tray before pouring antiseptic solution over them. Open specimen container if specimen is to be obtained.

Rationale

It is necessary to open all supplies and prepare for the procedure while both hands are sterile.

Nursing Action

- Lubricate 1” to 2” of catheter tip.

Rationale

Lubrication facilitates catheter insertion and reduces tissue trauma.

Nursing Action

11. With thumb and one finger of non-dominant hand, spread labia and identify meatus. Be prepared to maintain separation of labia with one hand until catheter is inserted and urine is flowing well and continuously.

Rationale

Smoothing the area immediately surrounding the meatus helps to make it visible. Allowing the labia to drop back into position may contaminate the area around the meatus as well as the catheter. Your non-dominant hand is now contaminated.

Nursing Action

12. Using cotton balls held with forceps, move cotton ball from above meatus down toward rectum discarding each cotton ball after one downward stroke. Clean both labial folds and then directly over the meatus, discarding each cotton ball after one downward stroke.

Rationale

Moving from one area where there is likely to be less contamination helps prevent the spread of microorganisms. Cleaning the meatus last helps reduce the possibility of introducing microorganisms into the bladder.

Nursing Action

13.With uncontaminated gloved hand, place drainage end of catheter in receptacle. For insertion of an indwelling catheter that is pre-attached to sterile tubing and drainage container, position catheter and setup within easy reach on sterile field. Ensure that clamp on drainage bag is closed.

Rationale

This facilitates drainage of urine and minimizes risk of contaminating sterile equipment.

Nursing Action

14. Insert catheter tip into meatus 5 to 7.5cm (2” to 3”) or until urine flows. Do not force catheter through urethra into bladder.

Rationale

The female catheter is about 3.7 to 6.2 cm (1.5” to 2.5”) long. Applying force on the catheter is likely to injure mucous membranes.

Ask patient breathe deeply, and rotate catheter gently if slight resistance is met as catheter reaches external sphincter. For an indwelling catheter , once urine drains, advance catheter another 2.5 to 5.0 cm (1” to 2”).

The sphincter release and the catheter can enter the bladder easily when the patient relaxes. Advancing an indwelling catheter an additional 1.3 to 2.5 (1/2” to 1”) ensures placement in the bladder and facilitates inflation of the balloon without damaging the urethra.

Nursing Action15. Hold catheter

securely with non-dominant hand while bladder empties. Collect a specimen if required; specimen should be caught in middle of flow. After 50 to 100 ml of urine has drained, place specimen collection device under opening of catheter and allow urine to drain into container.

Rationale Withdrawing and

reinserting the catheter increases the chances of contaminating it. In general, no more than 750 ml of urine should be removed at one time.

When enough urine has been caught, remove specimen container. Continue drainage according to agency policy.

Pelvic floor blood vessels may become engorged from the sudden release of pressure, leading to possible hypotensive episode. This may also cause painful bladder spasms.

Nursing Action

16. Remove catheter smoothly and slowly if a straight catheterization was ordered.

Rationale

This causes less discomfort to patient.

If catheter is to be indwelling:

Nursing Action

- Inflate balloon according to manufacturer's recommendations.

Rationale

The balloon anchors the catheter in place in the bladder. Sterile water is used to inflate the balloon as a precaution in case the balloon ruptures.

Nursing Action

- Tug gently on catheter after balloon is inflated to feel resistance.

Rationale

Improper inflation can cause patient discomfort and malpositioning of catheter

Nursing Action

- Attach catheter to drainage system if necessary.

Rationale

Closed drainage system minimizes the risk for microorganisms being introduced into the bladder.

Nursing Action

- secure to upper thigh with tape. Leave some slack in catheter for leg movement.

Rationale

Proper attachment prevents trauma to the urethra and meatus from tension on the tubing. Whether to take the drainage tubing over or under the leg depends on gravity flow, patient's mobility and comfort of the patient.

.

Nursing Action

Check the drainage tubing is not kinked and that movement of side rail does not interfere with catheter or drainage bag.

Rationale

This facilitates drainage of urine and prevents the backflow of urine.

Nursing Action

- Remove catheter smoothly and slowly if a straight catheterization was ordered.

Rationale

This causes less discomfort to patient.

If catheter is to be indwelling:

Nursing Action

- Inflate balloon according to manufacturer's recommendations.

Rationale

The balloon anchors the catheter in place in the bladder. Sterile water is used to inflate the balloon as a precaution in case the balloon ruptures.

Nursing Action

- Tug gently on catheter after balloon is inflated to feel resistance.

Rationale

Improper inflation can cause patient discomfort and malpositioning of catheter.

Nursing Action

- Attach catheter to drainage system if necessary.

Rationale

Closed drainage system minimizes the risk for microorganisms being introduced into the bladder.

Nursing Action

- Secure to upper thigh with tape. Leave some slack in catheter for leg movement.

Rationale

Proper attachment prevents trauma to the urethra and meatus from tension on the tubing. Whether to take the drainage tubing over or under the leg depends on gravity flow, patient's mobility, and comfort of the patient.

Nursing Action

- Check that drainage tubing is not kinked and that movement of side rails does not interfere with catheter or drainage bag.

Rationale

This facilitates drainage of urine and prevents the backflow of urine.

Nursing Action

17.Remove equipment and make patient comfortable in bed. Send urine specimen to laboratory promptly.

Rationale

Nursing Action

18. Perform perineal care.

Rationale

Perineal care is done to remove antiseptic solution, which may cause skin irritation.

Nursing Action

19.Remove gloves from inside out. Perform hand hygiene.

Rationale

Contaminated area does not come in contact with hands or wrist. Hand hygiene defers spread of microorganisms.

Nursing Action

20.Record time of catheterization, size of catheter and balloon, amount of urine removed urine appearance, whether a specimen was sent, and the patient's reaction in the medical record; also document urine amount on intake/output flow sheet.

Rationale

A careful record is important for planning the patient's care.

Unexpected Situations and Associated Interventions

> Urine flow initially contains a large amount of sediment, and then suddenly stops; bladder remains palpable: Urinary catheter may be plugged with sediment. After obtaining a physician's order, gently irrigate the catheter.

Unexpected Situations and Associated Interventions

> After balloon is inflated, patient voids large amount. Check to make sure that required amount of solution has been injected into the balloon. Do not over inflate balloon. Leaking around a catheter is a common occurrence when initially inserting catheter owing to a large amount of urine pressure. If this continues to happen, a larger catheter may need to be inserted.

Unexpected Situations and Associated Interventions

> Patient complains of extreme pain when nurse is inflating balloon: Stop inflation of balloon. Balloon is most likely still in urethra. Allow solution in a balloon to withdraw. Insert catheter an additional 1.3 to 2.5 cm and slowly attempt to inflate balloon again.

Special Considerations

> If there is no immediate flow of urine after the catheter has been inserted, several measures may prove helpful:

- Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles.

- Rotate the catheter slightly, because a drainage hole may be resting against the bladder wall.

- Raise the head of the patients bed to increase pressure in the bladder area.

- Some catheter kits do not contain the catheter. This allows you to select a catheter and balloon size separately.

CATHETERIZING THE MALE URINARY BLADDER

Catheter insertion for a male patient is performed for the same reason as for a female. Although the skill is similar, it is important to keep in mind the anatomic difference in the male and female urethra.

Equipment

> sterile catheter kit that contains: - sterile gloves - sterile drapes (one of which is fenestrated)

- sterile catheter - antiseptic solution - lubricant

Equipment

- cotton balls or gauze squares - forceps - pre-filled syringe - basin - specimen container

Equipment

> flash light or lamp > waterproof disposable pad > disposable urine collection bag and

drainage tubings > disposable gloves

Assessment

> Assess bladder fullness before procedure

> Ask patient about allergies, especially to latex and iodine.

Assessment

> Ask patient if he has ever been catheterized. If he had indwelling catheter previously, ask why and how long it was used. The patient may have urethral strictures, which may take catheter insertion more difficult. If the patient is 50 or older, ask if he has had any prostate problems. Prostate enlargement typically is noted around the age of 50 years.

Implementation with Rationale

Nursing Action

Follow actions 1 through 3 for female catheterization.

Rationale

Nursing Action

4. Position patient on his back with his thighs slightly apart. Drape patient so that only the area around the penis is exposed.

Rationale

This prevents unnecessary exposure.

Nursing Action

Clean the penile area. Follow action 5 to 7 for female catheterization.

Rationale

Nursing Action

8. Put on sterile gloves. Open sterile drape and place on patient's thighs. Place fenestrated drape with opening over penis.

Rationale

This maintains a sterile working area.

Nursing Action

9. Place catheter set on or next to patient's leg on sterile drape.

Rationale

Sterile set up be arranged so that nurse's back is not turned to it, nor should it be out of nurse's range of vision.

Open all supplies.

Nursing Action - If catheter is to be

indwelling, test catheter balloon. Remove protective cap on tip of syringe and attach syringe, pre-filled with sterile water to injection port. Inject appropriate amount of fluid. If balloon inflates properly, withdraw fluid and leave syringe attached to port.

Rationale A balloon that does not

inflate or that leaks must be replaced before insertion.

Nursing Action

- Fluff cotton balls before pouring antiseptic solution over the cotton balls or gauze. Open specimen container if specimen is to be obtained.

Rationale

It is necessary to open all supplies and prepares for the procedure while both hands are sterile.

Nursing Action

- Remove cap from syringe pre-filled with lubricant

Nursing Action

10. Lift penis with non-dominant hand, which is considered contaminated. Retract foreskin in uncircumcised patient. cleansings.

Rationale

The hand touching the penis becomes contaminated. Cleaning the area around the meatus and under the foreskin in the uncircumcised patient helps prevent infection.

Nursing Action

11. Hold penis with slight upward tension and perpendicular to the patient's body. Gently insert tip of syringe with lubricant into the urethra and instill 10 ml of lubricant. If kit does not have pre-filled syringe, lubricate catheter tip.

Rationale

The lubricant causes the urethra to distend slightly and facilitates passages of the catheter without traumatizing the lining of the urethra.

Nursing Action

12. With dominant hand, place drainage end of catheter in receptacle. For insertion of an indwelling catheter that is pre-attached to sterile tubing and a drainage container, position catheter and set up with easy reach on sterile field. Ensure that clamp on drainage bag is closed.

Rationale

This facilitates drainage of urine and minimizes risk of contamination of sterile equipment.

Nursing Action

13. Ask patient to bear down as if voiding. Insert tip into meatus. Advance catheter 5 to 20 cm ( 6” to 8”) or until urine flows. Do not use force to introduce catheter. If catheter resists entry, ask patient to breathe deeply and rotate catheter slightly.

Rationale

Bearing down eases the passage of the catheter through the urethra. The male urethra is about 20 cm. Long. Having the patient take deep breaths or twisting the catheter slightly may ease the catheter past resistance at the sphincters.

Nursing Action

15. For an indwelling catheter , once urine drains, advance catheter to bifurcation of catheter. Once balloon is inflated, catheter may be gently pulled back into place. Replace foreskin over catheter. Lower penis.

Rationale

Advancing an indwelling catheter to the bifurcation ensures its placement in the bladder and facilitates inflation of the balloon without damaging the urethra.

Nursing Action

Follow actions 16 to 20 for female catheterization, except that the catheter may be secured to the upper thigh or lower abdomen with the penis directed toward patient's chest. Leave enough slack in the catheter to prevent tension.

Rationale

This done to prevent irritation at the angle of the penis and scrotum. Slack left in the catheter allows for penile erection, which can occur naturally during sleep.

Nursing Action

21. Remove gloves from inside out. Perform hand hygiene.

Rationale

Contaminated area does not come in contact with hands or wrists. Hand hygiene deters the spread of microorganisms.

Nursing Action

22. Record time of catheterization, catheter and balloon size, amount of urine removed, urine appearance, whether a specimen was sent, and patient's reaction to the procedure in the medical record. Also document urine amount on the intake/output flow sheet.

Rationale

A careful record is important for planning the patient's care.

Unexpected Situations and Associated Interventions

> Patient complaints of intense pain when nurse begins to inflate balloon. Stop inflation. Be sure to insert catheter all the way into the bifurcation. The balloon is probably still in the urethra. Damage to the urethra can result if balloon is inflated in the urethra.

Unexpected Situations and Associated Interventions

> Nurse cannot insert catheter past 3” to 4”; rotating the catheter and having patient breath deeply are of no help. If still unable to place catheter, notify physician. Repeated catheter placement attempts can traumatize the urethra.

Special Considerations

> If resistance is met while inserting catheter and rotating does not help, do not use force. Enlargement of the prostate gland is commonly seen in men over age 50. A special crooked tipped catheter called a COUDE catheter may be required to maneuver past the prostate.

Unexpected Situations and Associated Interventions

> Patient is obese and had retracted penis. Have assistant available to hold patient's penis up and back. The catheter still needs to be inserted to the bifurcation; the length of the urethra has not changed.

Thank you and study well!!!