Urinary (Urethral) Catheterization Procedure / Protocol - Page 1 of 10

Nursing Services Manual

URINARY (URETHRAL) CATHETERIZATION PROCEDURE / PROTOCOL

PURPOSE

/ To outline nursing responsibilities/management of Urinary Catheters.
  • Steps of Urethral Catheterization (male & female)...... Page 2
  • Use/insertion of COUDE catheter...... Page 3
  • Obtaining Urine Specimen……………………………………...Page 3
  • Intermittent Irrigation of Urinary Catheter……………………...Page 4
  • Catheter Care……………………………………………………..Page 4
  • Removal of Urinary (Urethral) Catheter………………………..Page 4
  • Continuous Bladder Irrigation (CBI) set up/initiation…...... Page 5
  • Catheter Leg Bag…………………………………………………Page 6

SUPPORTIVE

DATA

/ Criteria/Indications for insertion of Urinary Catheters are: use only when necessary- urinary retention, pre/intra/post-operative drainage of urine, epidural catheter, clinical need/trauma/unstable, medications, accurate/strict output, protect open sacral/perineal wound if incontinent, provide comfort care in the terminally ill. Catheter Associated Urinary Tract Infections (CAUTI) Risk Factors include prolonged catheterization, female gender, inserting the catheter outside the operating room, diabetes, malnutrition, renal insufficiency, abnormal creatinine level, older age, fecal incontinence, co-existing infection, absence of antibiotics, faulty aseptic management of catheter, bacterial colonization of collection bag. Non-Latex catheters are available.
Urinary catheters should be removed as soon as possible as longer indwelling time leads to higher risk of biofilm (bacteria adhere to and multiply on catheter surfaces, multiply quickly and advance in a retrograde fashion) formation leading to infection. Preconnected closed systems with Cleanser Prep of 10% Povidone Iodine or 1-2% Aqueous Chlorhexidine are recommended. No evidence exists to support routine catheter changes.
Catheter size: Use smallest diameter that will prevent trauma and provide good drainage (usually 14-18Fr) unless presence of blood clots or sediment that can occlude lumen. For those with obstructions, closed continuous 3-way irrigation larger catheter may be needed.
Balloon size: Typically 5ml balloon used (inflates with 10ml sterile water) for routine catheterizations; 30ml balloon may be used with prostate surgery to provide traction to surgical area or per physician preference.
A Coude-tipped catheter which has a firm, curved tip designed to negotiate the male prostatic curve may be needed for difficult male catheterizations (with physician order).
Urinary catheters should be removed as soon as possible; Post-op by day 1 or 2 recommended. Evidence Based Practice indicates to identify patients daily with indwelling urinary catheters, and check for removal. Daily documentation of day number of indwelling time to be done.

EXPECTED

OUTCOME: / Patient will have catheter removed as soon as possible. CAUTI preventive measures utilized. Patient will have no occurrance of CAUTI.
INSERTION OF URINARY (URETHRAL) CATHETER

Equipment

  • Anti-Infective preconnected closed system with infection control drainage bag and microbiocidal outlet tube/bacteriostatic urine catch system (2000ml) with antireflux chamber and uroprep tray inclusive in kit
  • Antiseptic wash (10% povidone iodine or 1%-2% aqueous chlorhexidine solution. (Povidone Iodine Solution in kit)
  • With physician order: UROJET (Lidocaine 2% Jel) for lubrication/discomfort.
  • Catheter Securement device

STEPS

/ KEY POINTS
1.Select catheter 14-18fr with 5ml balloon unless otherwise ordered
2.Wash hands, apply gloves
3.Wash external genital area thoroughly with soap and water-rinse well—FEMALE: Identify Urethra prior to beginning sterile procedure
4.Open kit-apply sterile gloves, use strict aseptic technique.
5.Drape and cleanse urethra/meatus and surrounding area utilizing sterile technique.
FEMALE: Open labia to cleanse-hold open
MALE:
  • If uncircumcised, retract foreskin and cleanse prepuce area.
  • Recommend use of 1-2% Lidocaine Jelly (UROJET) with physician order and no allergy-gently inject directly into urethra
6.Insert catheter gently:
FEMALE: Supine position-use
Lubricant
MALE: Gently insert catheter (with
penis upright pointing slightly towards umbilicus) into urethra- Advance catheter almost to inflation port (bifurcation or Y) before inflation of balloon.
7.Obtain urine flow.
8.Inflate (gently) balloon with 10ml sterile water (per manufacturer instructions), then pull catheter gently to seat balloon at bladder neck
9.MALE: If Uncircumcised-Reposition forward (or reduce) foreskin
10. Catheter Securement:
FEMALE: secure to inner thigh
MEN: secure to upper thigh or lower abdomen.
11. Position drainage bag lower than bladder
12. Do not allow drainage tubing to fall below the drainage bag / Wash hands before/after each patient
Decreases risk of CAUTI
Sterile procedure/strict Aseptic technique
Use Povidone Iodine or 1-2% Chlorhexadine for prep
Use good lighting and assistant as needed
Check for allergies. Provides lubrication for entire length of urethra and some anesthesia to prevent external sphincter spasm—wait 2-5 minutes before continuing with procedure.
If catheter inadvertently placed in vagina, leave in temporarily as a landmark-obtain new catheter.
Have patient take slow deep breaths to help in relaxation and allow easier catheter passage.
Prevents balloon from inflating into urethra.
Do not use normal saline (can cause crystal formation leading to problems with deflation at removal) or air for balloon inflation. Avoid under or overinflation-can cause asymmetrical balloon which can deflect catheter tip to one side
Prevents Paraphimosis (retraction and constriction of foreskin behind glans penis secondary to catheterization)
Use a catheter specific anchor that prevents slipping in and out. Allow for slack to prevent tension on catheter. (unsecured catheters can lead to bleeding, trauma, pressure sores around meatus, and bladder spasms from pressure and traction
Prevents retrograde flow of urine into drainage tubing and migration into bladder.

INSERTION OF COUDE CATHETER (for difficult male insertions-with physician order)

Equipment

  • Coude Catheter with balloon port (has firm curved tip) of appropriate size.
  • Urethral Catheterization tray
  • Closed System Urinary Drainage Bag-2000ml size
  • With physician order: UROJET-1-2% Lidocaine Jelly
  • Catheter Securement device

STEPS

/ KEY POINTS
1. Wash hands
2. Prep for urethral catheterization-use
sterile technique
3. Follow urethral catheterization
Procedure
4.Insert Coude-tipped catheter with tip pointed upward towards the patient’s umbilicus
5.Advance to bifurcation/port
6.Continue per catheterization procedure and secure. / Wash hands before and after
Coude-tipped catheter has a firm, curved tip designed to negotiate the male prostatic curve. “Tip up and to the Hub”
OBTAINING URINE SPECIMAN
Equipment
  • Sampling Port is on urinary catheter drainage tubing
  • Urine Speciman Container

STEPS

/ KEY POINTS
1.Kink Catheter approximately 3” below sampling port
2.Swab port with antiseptic
3.Apply gloves
4.Using Aseptic technique, position leurlock syringe in center of sampling port (hold perpendicular)-Lock into place onto port.
5.Aspirate urine sample into syringe.
6.Inject into Urine Speciman container
7.Unkink urinary catheter
8.Label, attach printed order, send Speciman to Lab in Biohazard Bag. / Use Aseptic technique
Using port maintains closed system
Urine for a C&S should be obtained from newly inserted catheter and drainage bag to avoid culturing the system rather than the urine

INTERMITTENT IRRIGATION OF URINARY (URETHRAL) CATHETER (To be done only if obstructed—clots or mucous anticipated)

Equipment

60cc Piston Syringe with Irrigation Tray (Toomey)-sterile

0.9 Normal Saline (sterile) irrigation solution (or solution per order)

STEPS

/ KEY POINTS
1.Wipe outside of catheter/tubing connection with antiseptic
2.Apply gloves
3.Disconnect catheter from tubing
4.Aspirate first to attempt clot/obstruction removal-if no return instill 30-60 ml irrigation solution into catheter, aspirate gently. Repeat as needed to clear catheter
5.Reattach catheter to system / Use Aseptic technique/sterile equipment
Breaking catheter drainage bag connection (closed system) is a major point of bacterial entry into system
Avoid vigorous irrigation-can be damaging to delicate bladder mucosa
CATHETER CARE

Equipment

STEPS

/ KEY POINTS
1.Routine Perineal care BID-avoid specific meatal cleansing or ointments to meatus (unless specifically ordered) / There is no evidence to support special meatal cleansing or use of ointments or creams to meatus. Avoid petroleum based products to catheters. Avoid catheter manipulation

REMOVAL OF URINARY (URETHRAL) CATHETER

Equipment

12 ml leurlock syringe

STEPS

/ KEY POINTS
1.Slide syringe plunger back and forth in barrel to loosen
2.Compress plunger all the way then pull back 0.5ml to prevent adherence
3.Gently attach syringe to balloon port, allow all of inflation fluid to return to syringe by gravity—do not aspirate.
4.Remove catheter-assure all is intact
5.Discard all in Biohazard Bag / Wait at least 30 seconds for deflation. If water does not return, reposition patient, ensure catheter not in traction verify urine flowing freely in tubing. If balloon still fails to deflate, apply gentle, slow aspiration.
Measure urine output. Assess for meatal drainage
INITIATION OF CONTINUOUS BLADDER IRRIGATION (CBI)

Equipment (available in Urology Cart from 7N or Sterile Processing)

3-Way Urinary Catheter-(size per physician order)

Urinary (Urethral) Catheterization Tray

Cystoscopy/Irrigation Set (Single Irrigation Tubing)

2000ml or 3000ml Irrigation Solution (Sterile Water or Saline)-per order/need

Closed System Urinary Drainage Bag-4000 ml size

With physician order: UROJET - 1-2% Lidocaine Jelly

Catheter Securement device

STEPS

/ KEY POINTS
1.Wash hands
2.Spike irrigation bag with Cystoscopy/Irrigation Set single irrigation tubing. Flush tubing, clearing of air. Maintain sterility of end of tubing.
3.Apply Gloves
4.Prep for urinary (urethral) catheterization-use sterile technique.
5.Follow urethral catheterization procedure
6.Insert foley catheter-advance to bifurcation/port
7.Continue per catheterization procedure and secure.
8.Attach Continuous Bladder Irrigation tubing to Irrigation Port of 3-Way Catheter. Infuse at rate to keep return solution and urine clear
9.MAINTAIN ACCURATE INTAKE AND OUTPUT
-With each new added bag of 2000-3000ml irrigation solution, empty urinary/solution drainage bag and measure / NOTE: if patient received Post-op with (Y) double infusion tubing/bag, recommend switching to single set-up for easier management. If rapid infusions anticipated, use 3000ml bag, available from storeroom
As each irrigation bag is infused, add new bag and empty (and measure) outflow drainage bag contents. Continue cycles to maintain clear return
Output EXAMPLE: CBI-2000ml, FOLEY (solution and urine)-2450ml, URINE-450ml

USE OF LEG BAG

Equipment – Leg Bag (Follow instructions on package)

STEPS:

Fits with fabric leg straps

Put flutter valve @ top, attaches to catheter

Size to fit/place below knee (male—use extension tubing)

NURSING PROTOCOL

URINARY (URETHRAL) CATHETERIZATION

ASSESSMENT/INTERVENTIONS

  • Assess readiness for catheter removal every day
  • Assess continued need for catheter
  • Assess for readiness for alternative method
  • Assess day of dwell time
  • Assess for S/S UTI: pain, urine color, abdominal/flank discomfort,

temperature >38 degrees C

  • Assess for clots or mucous in urine
  • Assess for adequate urinary volume-> 250ml/shift

URINARY CATHETER TUBING/DRAINAGE SYSTEM

  • Assess tubing/drainage bag intact, patent, and free of kinks-CLOSED SYSTEM maintained.
  • Assess tubing not kinked, not obstructed- urine flowing thru tubing
  • Suprapubic Catheters: Assess catheter securement and insertion site. Secure to avoid enlargement of stoma tract and leakage.
  • Assess for signs of blockage or encrustation
  • Leg Bag: assess for circulatory impairement of extremity
  • Empty drainage bag at least every shift-do I&O
  • Maintain patent system at all times
  • Irrigate only if necessary (clots, mucous, or obstruction). Avoid vigorous bladder irrigation to minimize mucosal irritation

CONTINUOUS BLADDER IRRIGATION (CBI)

  • Assess system patent and intact
  • Assess solution return color and clarity-clear or light pink, free from clots
  • Assess urine output/return
  • Assess for suprapubic pain and fullness (bladder spasms, clogged catheter)
  • Clogged catheter: turn off CBI, take apart and irrigate outflow tube manually to remove clots/obstruction-maintain sterility—use new kit with each occurrence, resume CBI.
  • Bladder spasms: per physician approval, try removing water from balloon to decrease irritation, treat with antispasmodics per order.

UNCIRCUMCISED MALE

  • Assess foreskin pulled forward over glans penis with no S&S of Phimosis

MEATAL AREA

  • Assess for drainage, bleeding, leaking, or redness around urinary meatus or catheter insertion site
  • Assess for leakage causes: bladder spasms, infection, fecal impaction or constipation, occlusion, encrustation.

SKIN

  • Assess skin condition under external devices in contact with skin or around urinary meatus or insertion site, S-P insertion site

FLUID BALANCE/I&O

  • Assess I&O q shift
  • Monitor fluid balance q shift and q 24 hours

S&S of CAUTI

  • Assess for new onset temperature, chills, flank or suprapubic pain
  • Assess for urinary “urgency”, changes in urine character
  • Assess Laboratory values, positive urine culture (colony count > 10 2-3cfu/ml)
  • Assess for altered mental status

BLADDER STATUS (use Ultrasound Bladder Scan as needed/approved)

  • If Bladder distention, reposition patient, check tubing for kinks or clots (especially if decrease in urine output)-Irrigate only if necessary
  • Check bladder status-if output low, check volume with Utrasound Bladder Scan
  • Use Ultrasound Bladder Scan to check for discomfort

FLUID BALANCE/I&0

  • Routine every shift or per order

CATHETER REMOVAL

  • Use alternatives when possible (S-P or intermittent catheterizations)
  • Remove all water from balloon to avoid trauma
  • Check for orders/actions after removal
  • Assess patient’s ability to void post removal or within specified time as ordered-use Ultrasound Bladder Scan to evaluate amount of urine in bladder as needed
  • Check for bladder distention and/or residual
  • Notify physician if unable to void

TROUBLESHOOTING-SELECTED SITUATIONS

  • Leakage Management- Identify cause, change catheter if lumen occluded-per order.
  • Bladder Distention/CO of pain: check for kinked catheter or drainage tubing, check if patient lying on tubing, tubing twisted, occlusion of catheter, pressure on catheter. Try changing positions, secure catheter, verify catheter positioned over thigh, check/remove fecal impaction.
  • Blockage/Lumen Occluded: Causes: blood clots, sediment or mucous; Solution/prevention: Aspirate/Irrigate only if necessary, consider 3-way CBI (per order), increase catheter size (not balloon) with order, increase fluids if tolerated, check/remove fecal impaction.
  • BLADDER SPASMS: Possible causes: involuntary bladder contraction, under/overinflated balloon, large balloon. Solution/prevention: secure catheter over thigh or lower abdomen (for men), hang drainage bag properly, empty when ½-2/3 full. Per physician approval, remove water from balloon to decrease frequency of spasms (ie: big balloon can cause spasms).

REPORTABLE CONDITIONS

Report to physician

  • Unable to insert/pass urinary catheter—Abort procedure if resistance, bleeding, severe pain.
  • Leaking around insertion site/new drainage from meatal area
  • Low or no urine output (verify with bladder scanner)
  • Color change of urine-cloudy, red
  • Obstruction/unable to irrigate
  • Call if unable to void after expected or ordered time frame
  • S&S of UTI: Fever > 38C or >100.4F, chills, new flank or S-P pain, changes in urine character, altered mental status, positive urine culture
  • S&S/appearance of Phimosis-tightened foreskin compromising blood flow to glans penis

EMERGENCY MEASURES

  • Paraphimisis in uncircumcised males with tight prepuce/foreskin-call physician (is a Urological emergency)-patient may need surgical repair
  • Unable to pass catheter, patient obstructed.
  • Notify Physician, anticipate/prepare Bedside Flexible Cystoscopy or to Surgery.

SAFETY

  • Avoid/prevent pulling or tugging on catheter
  • Secure carefully with securement device that prevents in and out movement of catheter-allow catheter slack
  • Use Coude with order for difficult male catheterizations
  • Avoid positioning drainage bag between legs or on abdomen-hang properly to facilitate forward flow (keep tubing in straight line)
  • Empty CBI outflow bag before filled to decrease pressure on bladder
  • Empty bag when ½ to 2/3 full to avoid traction on catheter
  • Avoid petroleum based creams/ointments (can degrade latex catheter)
  • Catheterization: ABORT procedure if resistance is met, bleeding is noted, patient complains of severe pain

INFECTION CONTROL

CAUTI Preventive Measures:

  • Remove urinary catheter ASAP-recommend on Post-op day 1 or 2
  • Use aseptic technique with sterile equipment with insertion (Category I)
  • Maintain closed system (Category 1)—do not irrigate unless absolutely necessary (prevents bacterial entry)-wipe end of tubing and catheter with antimicrobial solution prior to reconnecting system
  • Keep drainage bag below bladder (Category I)
  • Do not allow tubing to loop, dangle, fall below drainage bag, or kink—keep patent.
  • Wash hands before and after, wear gloves with each urinary catheter bag emptying
  • Do not allow outflow drain spigot to touch measuring container (can be a source of UTI from retrograde bacterial migration).
  • Do not place urinary drainage bag up between patient’s legs.
  • Do not let bag lay on floor
  • Anchor catheter with securement device to minimize in and out motion to urethra
  • Avoid catheter manipulation around meatal area-can contribute to bacterial migration into bladder
  • Prior to exercise/ambulation or transfer, drain all urine from tubing into drainage bag to prevent retrograde flow of urine into bladder

PATIENT/SO EDUCATION

  • Purpose of urinary catheter
  • Wash hands before and after working with catheter
  • CAUTI preventive measures (ie: maintain closed system, no looping, no bag below bladder, avoid outlet touching floor or collection container, no bag on floor)
  • Avoid pulling on catheter
  • Notify if new pain, abdominal distention, or no urine return (validated)
  • Application/removal of Leg Bag-if to be used at home (Teaching Protocol-Indwelling Urinary Catheter).

DOCUMENTATION (in Care Link)

  • Procedure with tolerance (include catheter size & inflation amount) in “Renal, Urinary intrv and intrv response, urine source, device type”
  • Urine return (characteristics: color, clarity, amount) in “Renal, urine source, & I&O”
  • Catheter anchored with Cath Secure & location in “Renal, urine source, urine Intrv”
  • Date inserted in “Renal, urine source”
  • Day Number # of indwelling catheter (ie: Catheter Day #2) in: “Renal, Catheter, Insertion Date” (document insertion date daily)
  • Assessment and need for ongoing catheterization every 24 hours/daily
  • MALE-Uncircumcised precautions –foreskin positioning in “Renal, Intervention, Envelope or Reproduction, Foreskin”
  • Maintenance/irrigations if necessary and results in “Renal, Intrv, Envelope”
  • Bladder Scan amount in “Renal, Bladder Scan amt”
  • Perineal Care “Reproduction, Intrv”
  • Catheter Removal in “Renal, Catheter, Intervention”
  • CBI Initiation in “Renal, Urine Source #1, Device Type, CBI Status”
  • CBI Intake & Output in “I&O”:
  • “Intake, Bladder Irrigtn” (enter cumulative amount instilled)
  • “Output, Bladder Irrigtn” (enter cumulative amount instilled-returned out)
  • “Output, Urine Cath, Amount of Urine” (subtracted amt from total emptied)
  • Intake & Output in “I&O”
  • Leg Bag-Home with Urinary Catheter Teaching in “Patient Education”
  • Patient/Family teaching in “Patient Education”

REFERENCES: