/ CHHS16/008

Canberra Hospital and Health Services

ClinicalProcedure

Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (TURP)

Contents

Contents

Purpose

Alerts

Scope

Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients)

Section 2 – Insertion of Female Indwelling Catheter (IDC)

Section 3 – Insertion of Male Indwelling Catheter (IDC)

Section 4 – Suprapubic Catheter (SPC) Procedures for Inpatients and Community Based Patients

4.1Insertion of Suprapubic Catheter

4.2Changing Suprapubic Catheter: Inpatient

4.3Removal Suprapubic Catheter

4.4 Management of Supra Pubic Catheter: Community Based Patient

Section 5 – Catheterisation Intermittent in the adult Inpatient

Section 6 – Catheter Intermittent: Patient Education

Section 6 – Catheter Flushing for Adult Community based patient

Section 7 – Trial of Void: Community based patient

Section 8 – Indwelling Urinary Catheter Management: Inpatient and Community

8.1Emptying a Urinary Drainage Bag: Inpatient specific

8.2Urinary Drainage Bag Management: Community Specific

8.3Removal of Indwelling Urinary Catheter

Section 9 – Trans Urethral Prostatectomy (TURP)

Section 10 – Bladder Irrigation

10.1Continuous Bladder Irrigation

10.2Manual Bladder Irrigation

Section 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy

Section 12 – Management of patients undergoing a Percutaneous Nephrolithotomy

Section 13 – Management of patients admitted with Pre-Existing Continent Urinary Reservoirs/Neobladder during routine hospital admissions

Implementation

Related Policies, Procedures, Guidelines and Legislation

Search Terms

References

Attachments

Attachment A: Stat Lock – Foley Stabilisation Device

Attachment B: Insertion of Urinary Catheter Sticker

Attachment C: How to care for your Urinary Catheter

Attachment D: Troubleshooting guide for urinary catheters

Attachment E: Source of information and/or suppliers for urinary catheter equipment

Attachment F: Catheter selection

Purpose

The Urology Assessment and Management Procedures describe practice which will be performed by registered nurses,medical staff and allied health. New nursing or medical staff, or students (within their defined scope of practice) will be required to perform these skills under the direct supervision of a competent practitioner.

Clinicians providing assessment, education and clinical procedures must have current theoretical and clinical knowledge in continence management.

To provide best practice in managing, educating and supporting patients requiring short/long term management of urinary catheters.

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Alerts

Strict hand hygiene should be adhered to at all times when performing all clinical procedures as per Healthcare Associated Infections Procedure-Section 2 Infection Prevention & Control Strategies

Consent must be gained for all interactions with patients and care provided consistent withIntimate Body Care and Examinations by Health Care workers Standard Operating Procedure

All staff to adhere to Patient Identification and Procedure Matching Clinical Policy

Scope

This document applies to:

  • Medical Officers (MO)
  • Nurses and Midwives who are working within their scope of practice
  • Students under direct supervision of a registered nurse.

Note: A medical officer/ nurse/ midwife is assessed as competent when they have:

  • Observed the procedure
  • Performed the procedure at least once under the supervision of a competent medical officer/ registered nurse/ midwife
  • Been assessed as competent by another competent registered nurse/midwife, medical officer nominated by the Clinical Nurse Consultant (CNC) or CDN.

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Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients)

General Information:

  • It is recommended thatnursing staff who are inserting urinary catheters and/or caring forand/or removing urinary catheters from patients complete the eLearning course Indwelling Urinary Catheter and the competency assessment form, accessible via Capabiliti.
  • To introduce a urinary catheter to drain urine from the bladder. If a latex catheter is to be inserted determine the patient’s latex allergy status.
  • Patient assessment prior to catheterisation should include the exploration of possible patient’s cultural values and beliefs that may influence healthcare practices and consistent with ‘Intimate Body Care and Examinations by Health Care Worker SOP’. Verbal consent should be obtained especially where catheterisation of males by a female nurse or female catheterisation by a male nurse is required.
  • For patients with large capacity bladders, indwelling catheters and slow bladder decompression are recommended. No more than 600mls is to be withdrawn from the bladder at any one time unless otherwise indicated by the medical officer as this may induce a syncopic episode.

Community Based Patients:

Contraindications for Catheterisation in the Community

  • Acute prostatitis.
  • Suspicion of urethral trauma.
  1. ‘Medical Officer’s Orders for Urinary Catheter Management’ clinical record form (form no. 40950)must be completed for all urinary management in the community setting. Medical Officers orders for Catheters should be reviewed every three(3) years.
  2. Catheters should be appropriate, comfortable, easy to insert and remove and must minimize secondary complications such as tissue inflammation, encrustation and colonisation by micro- organisms (See Attachment F)
  3. The smallest gauge catheter suitable for the patient needs should be used and balloons should generally be 5 to 10ml in size. Patients with a lesion above T6 should use a size 18 to 20Frg to avoid blockage and complications of autonomic dysreflexia.
  4. Community Nurses will identify patients with spinal lesions at or above T6 and monitor for autonomic dysreflexia during catheterisation. Where applicable first line emergency management should be provided to those patients. Care provided should be consistent with‘Autonomic Dysreflexia SOP’
  5. All catheters become colonised with bacteria after a few days. If a catheter specimen of urine (CSU) is required this should only be obtained on change of the catheter not the bag.
  6. Community nurses will document the management of a patients ‘Urinary Catheter Management Chart’clinical record form (form no.60535)
  7. Patients and/ or carers should be educated on how to care for their catheters and also be provided with the pamphlet ‘How to care for your urinary catheter’, which can be found on the Policy Register (see sample at Attachment C)
  8. Catheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter
  9. Manual bladder irrigation or washout involves instilling large amounts of fluid into the bladder withdrawing fluids for the purpose of removing debris and mucus from the bladder. This procedure should be done under medical supervision and is not suitable to be done in the community.
  10. Patients with long - term catheter requirements are responsible for the provision of ongoing equipment (catheters, leg bags, overnight bags, catheter straps, catheter valves. Consider funding sources such as:
  11. Continence Aids Scheme (CAPS)
  12. ACT Equipment Subsidy Scheme (ACTES)
  13. Rehabilitation Appliances Program (RAP) of Department of Veterans Affairs (DVA)
  14. If the patient is not eligible for any of these schemes, they may source equipment from supplies either locally or interstate (see Attachment E)
  15. Where possible, liaison should occur with the medical practitioner or management team who inserted the catheter if there are any concerns regarding catheter management in the community
  16. Where possible patients should be encouraged to access one of theCommunity Health Centres ambulatory clinics for their routine catheter change.
  17. Where difficulties are experienced or anticipated, contact the continence CNC or GP; if the matter is urgent call an ambulance.
  18. If a catheter requires permanent removal, medical orders should be obtained from the treating doctor and documented in client’s file (refer to Removal of Catheter) attached.

Alerts:
  • Seek expert advice for patients with artificial heart values who grow Enterococcusspecies in the urine prior to the procedure
  • Patients with spinal lesions at or above T6 require monitoring for Autonomic Dysreflexia: refer to ‘Autonomic Dysreflexia SOP’for managementpathway
  • Do notclamp catheter prior to change
  • The following conditions do not preclude catheterisation but extra care should be taken when:
  • The Patient is taking high dose anticoagulants increasing the risk of haemorrhage.
  • If there is a history of recent surgery, cancer or radiotherapy to the lower urinary tract, as there is increased risk of damage
  • Consult with Medical officer or CNC if in doubt

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Section 2 – Insertion of Female Indwelling Catheter (IDC)

Equipment:

  • Disposable catheter pack (includes extra gloves)
  • 0.9% Sodium Chloride 60ml
  • Lubricant sachet Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16F
  • Sterile urinary drainage bag to meet patients needs
  • One x 10ml syringe
  • One x 10ml Sterile Water for Injection
  • Securement device

Inpatient specific:Foleys Statlock device pack including skin prep

Community specific: Urinary Retaining Strap

  • Measuring jug if required
  • Procedural under pad
  • Clean gown
  • Sterile gloves
  • Community specific: Sterile gloves x two
  • Community specific: non sterile gloves
  • Safety glasses or goggles
  • Sterile specimen jar, if required

Procedure:

  1. The medical officer must document the order for catheter insertion and removal in clinical record
  2. Community Specific: Medical Officers Catheter Management
  3. Explain procedure to patient and ensure privacy
  4. Patient identification and allergy band are checked against clinical notes and stickers.
  5. Prepare equipment
  6. Don safety goggles
  7. Inpatient specific: Raise bed to the appropriate height
  8. Position the patientsupine with knees flexed drawn up soles of feet together, or knees wide apart
  9. Place procedural under pad beneath the buttocks
  10. Don clean gown
  11. Don sterile gloves (separate) then gloves from catheter pack
  12. Remove the protective cover from the tip of the catheter ONLY. Lubricate, leaving the catheter cover in place
  13. Place the catheter in the dish
  14. Using a clean swab each time, cleanse the labia majora with 0.9% Sodium Chloride using downward strokes
  15. Separate the labia with free hand, using gloved hand
  16. Cleanse the labia minora and urethral meatus
  17. Discard forceps and first pair of gloves. Drape patient with fenestrated sheet to establish sterile area
  18. Separate the labia with free hand
  19. Maintain the separation until the catheterisation is complete
  20. Place the dish containing the catheter between the patient's thighs
  21. Identify the urethra
  22. Ask the patient to take a deep breath to relax the sphincter
  23. Gently insert the catheter until urine flows, then advance 2.5cm further into the orifice using the sterile catheter sleeve.

Note: Do not use force

  1. Remove the sterile catheter sleeve and drain urine into the dish
  2. Collect sterile urine specimen if required
  3. Inflate the balloon with the required amount of sterile water (see balloon hub)
  4. Remove the protective cap from the urinary drainage bag, seal outlet tube and attach to the catheter
  5. Inpatient specific:Attach statlock (dated) to the leg to anchor urinary catheter bag (Attachment A)

Community specific: Catheter Retention Strap

  1. Drain 600ml only then clamp for one (1) hour
  2. Leave the patient comfortable
  3. Lower the patient’s bed
  4. Discard equipment
  5. Inpatient specific: Record the procedure in the patient's clinical record (Attachment B):
  6. Date and time of procedure
  7. Type and catheter size
  8. Amount of water in the balloon
  9. Indication and scheduled date for removal or change
  10. Community specific: Record the procedure using the ‘Urinary Catheter Management Chart’ clinical record form (form no.60535)
  11. Record output, clarity, colour and odour on the patient's FBC and clinical record
  12. Perform urinalysis and document on General Observation Chart and clinical record
  13. Record if a specimen is sent to pathology
  14. Watch for haematuria and diuresis inpatients with chronic urinary retention
  15. Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated perineal toilets required for hygiene needs

Alert: Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weekly.

Stabilisation of Urinary Catheters:

  • Prepare skin with protectant and allow to dry
  • Align anchor pad over securement site (arrow towards body)
  • Press catheter into anchor and close lid
  • Position on anterior thigh or abdomen
  • Peel away paper backing and place on skin (See Attachment A)

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Section 3 – Insertion of Male Indwelling Catheter (IDC)

Equipment:

  • Disposable catheter pack (contains extra gloves)

Community specific: sterile gloves x two

Inpatient specific:Betadine (check for Iodine allergy)

  • 0.9% Sodium Chloride 60ml
  • 10ml Lignocaine gel syringe
  • Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16FSterile urinary drainage bag
  • 1 x 10ml syringe
  • Community specific: two x 10ml syringe
  • 1 x 10mls Sterile Water for Injection
  • Securement devices

Inpatient specific:Foleys Statlock device

Community specific: Catheter Retention Strap

  • Inpatient specific: Measuring jug
  • Procedural under pads (one large & one small)
  • Clean gown

Community specific: non sterile gloves

  • Sterile gloves

Community specific: two x sterile gloves

  • Safety glasses or goggles
  • Sterile specimen jar, if required
  • Sterile catheter introducer, if required (to be used by Medical Officer only).

Alert:A catheter introducer for the introduction of a catheter for male catheterisation is only to be used by a medical officer

Procedure:

  1. Inpatient specific:The medical officer must document the order for catheter insertion and removal in clinical record

Community specific: Medical Officers Catheter Management

  1. Explain procedure to patient and ensure privacy
  2. Remove the protective cover from the tip of the catheter only. Lubricate, leaving the catheter cover in place
  3. Place the catheter in the dish
  4. Drape the genital area around the penis
  5. Don safety eyewear and gown
  6. Inpatient specific: Raise bed to appropriate height
  7. Wash hands and don sterile gloves x two
  8. Position fenestrated drape to provide sterile field
  9. Use non dominant hand to hold the penis. Where present retract the foreskin and swabhead of the penis paying particular attention to the urethral meatus and glans
  10. Hold penis at a right angle (90 degree)to the body and gently instil Xylocaine lubricant into the urethra: Gentle pressure underneath the head of the penis will minimise lubricant leaking out. Allow sufficient time for anaesthetic to work (three to five minutes).

Note: Do not proceed if patient has an erection, wait until this subsides

After this time you may:

  1. Remove outer pair of sterile gloves if contaminated during the procedure
  2. Holding penis at 90 degree angle, gently insert and advance catheterto the Y hub.
  3. If resistance is felt at the bladder neck, lower the penis slightly and suggest that the patient breathe slowly whilst pretending to pass urine. The catheter should never be forced
  4. If resistance continues, withdraw catheter and insert more anaesthetic gel. Re-insert sterile catheter after a further three to five minutes. If further resistance is encountered, seek advice from CNC, Continence CNC or Medical Officer
  5. When urine begins to flow,(at least 15-20mls )re-check the position of the catheter to ensure it is still in the bladder, then inflate balloon with required volume of sterile water (according to manufacturer’s instructions)

Alert:If resistance is felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask the patient to attempt to void in order to relax sphincter

  1. Attach sterile drainage bag
  2. Where present, replace foreskin to natural position
  3. Secure bag to patients requirements

Inpatient specific:Attach statlock to the leg to anchor urinary catheter bag (See Attachment A)

Community specific: Attach Catheter Retaining Strap

  1. Drain 600ml only then clamp for one hour
  2. Leave the patient comfortable
  3. Documentation:

Inpatient specific:Record the procedure in the patient's clinical record using the Urinary Catheter Label:(See Attachment B):

  1. Date and time of procedure
  2. Type and catheter size
  3. Amount of water in the balloon
  4. Indication and scheduled date for removal or change
  1. Community specific: Record the procedure using the ‘Urinary Catheter Management Chart’clinical record form (form no.60535)
  1. Record output, clarity, colour and odour on the patient's FBC and clinical notes
  2. Perform urinalysis and document on General Observation Chart and clinical notes
  3. Inpatient specific:Record if a specimen is sent to pathology

Community specific: Contact GP if signs of infection present

  1. Observe for haematuria and diuresis in patients with chronic urinary retention.

Inpatient specific: Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated penile toilets required for hygiene needs

  1. Perform hand hygiene when leaving the patients environment as per the 5 moments of hand hygiene

Alert:Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weekly

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Section 4 – Suprapubic Catheter(SPC) Procedures for Inpatientsand Community Based Patients

Background:

An SPC may be used for:

  • The management of long-term urinary incontinence or retention of urine
  • The drainage of urine post operatively in urological or gynaecological patients
  • Patients with urethral and/or pelvic trauma where the utilisation of a urethral catheter is not possible
  • Patients with ongoing problems associated with urethral catheters such as irritation or continued blockage

The purpose of this is to provide guidelines for the management of a Suprapubic Catheter (SPC) including:

  • Insertion
  • Catheter Change
  • Inpatient
  • Community based patient
  • Dressing Changes
  • Removal
  • Management in the Community

This document pertains to adult patients requiring management of a SPC at the Canberra Hospital and Community based patients

4.1Insertion of Suprapubic Catheter

Initial insertion of a SPC may only be performed by a Medical Officer. Further catheter changes may be attended in the community by nursing staff.