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Season 4, Episode 6 All Things Urinary Catheters

All Things Urinary Catheters

In this episode we talk all things urinary catheters… CAUTIs, tips, tricks, internal and external devices, and nursing considerations.

Key Focus: Catheters can lead to infections, which can be fatal.

CAUTICatheter Associated Urinary Tract Infection

  • CAUTI is a type of HAI – Hospital Acquired Infection
    • NOT an infection the had at the time of admission
    • An infection we gave the patient because we placed a catheter
  • Impacts the hospital’s reimbursement (https://www.cms.gov/Medicare/Quality-Initiatives-Patient-
    Assessment-Instruments/Value-Based-Programs/HAC/Hospital-Acquired-Conditions.html)

    • Hospitals don’t get reimbursed for infections that they give infections
  • Small minority of patients are at higher risk for CAUTI.
    • Be aware of patient’s factors.
  • Most CAUTI are preventable
  • Best prevention is not to have them
  • Changing mentality of why/when patients need catheters
    • Not using as frequently
    • More specific rationale for use
    • Not to be used for nurse convenience

Non-Invasive Urinary Output Methods

Males

  • Urinal – Be aware of challenges
    • Enlarged prostate
    • Positioning – some men need to sit or stand
    • Anatomical – consider use of female urinal (larger opening)
  • Condom Catheter – A condom that is applied externally, connected to a catheter bag
    • Use proper size
    • Needs a good seal for best prevention against leaks
      • Consider use of skin prep or benzoin to help with placement
      • Easy to pull off unintentionally.
      • Urostomy bags or fecal bag may be an alternative for some male genitalia

Females

  • Bedpan – Can be difficult to avoid spills
  • Bedside commode – Place next to bed for easier transfers for patients with limited mobility
  • Speci-Hats – Placed in toilet to capture urine, but sometimes difficult to put in perfect spot to avoid
    misses
  • Female Urinals – Shaped differently, with larger opening, to fit against female genitalia
  • External Catheter for females – Purewick (https://youtu.be/xSOuvcShikw) catheter, lays against
    the perineum and is connected to continuous suction

    • Need to use proper suction to assure that urine is pulled away from perineum, but not high
      enough to cause tissue damage
    • Use for appropriate patients (not those who are constant wiggle worms)
    • Cannot be used during menses, nor for patients having frequent stools.

Universal Considerations

  • Diapers – Many facilities now avoid them
    • Can lead to skin breakdown, as moisture is captured against skin
  • Disposable Pads
    • Some weigh disposable pads (the pads patient’s lay on for repositioning) to calculate output
      (like diapers in NICU)
  • Does your patient need to have accurate I/O?
    • Some patients can simply be assisted to the bathroom with no need for measurement
  • Although non-invasive methods may create more work for the nurse/nursing assistant, we must weigh
    the risks associated with an indwelling catheter.
  • An indwelling urinary catheter, just by being there, is a risk of infection.
  • Urinary system is sterile. You are inserting a foreign device (which can easily be contaminated),
    inside the body and all the way up into the bladder.

    • This is a direct line from the outside world to a sterile part of the body.
    • Normal flora found on skin can (or body excretions) can adhere to the catheter and find a route
      into the bladder, even if insertion was perfectly sterile.
  • Diarrhea is particularly concerning with catheters, especially in females, because urethra is close to
    the rectum.
  • Excellent peri-care is essential, use your hospital policy for guidance

Tips for Catheter Insertion

Universal Tips

  • Explain the procedure, using simple, plain language, before starting the insertion process.
    • What is a catheter?
    • Why is it needed?
    • What is involved for insertion?
  • Especially important for:
    • Young
    • Disabled
    • Language Barriers
    • Hx of sexual trauma
  • Remember: What is routine for us, is NOT to other people.
  • Start with excellent Hand Hygiene
  • Good peri-care prior to insertion
    • Use hospital approved cleanser
    • Be thorough
    • No fecal matter should be present
  • New sterile catheter following each unsuccessful insertion
  • Be mindful of how much urine is drained at once. Too much can lead to bladder spasms or
    hemodynamic instability.
  • Know when it is appropriate to remove catheter. (MD order vs standing order)

Female Tips

  • Can be more difficult than males, because the urethral opening is so close to vaginal opening
  • Be sure that vaginal discharge, if present, is cleaned thoroughly prior to insertion
  • Use 2 person insertion technique
    • One person on each side, holding leg and helping to spread labia
  • Uretheral opening is not always clearly visible
    • Be generous with the betadine; a large quantity can “highlight” the urethral opening
    • Some women have the uretheral opening inside the vaginal opening; look closely
    • Women won’t know that about themselves
      • Explain to women that if you don’t get it on the first try, nothing is wrong with them.
  • Aim high
  • If you don’t get urine, leave the catheter in place
    • Marks the vaginal opening, and gives you a landmark on where to aim next time
  • Get a new sterile catheter for the next insertion attempt
  • Lay flat (maybe even a little trendelenburg), if not concerned about ICP issues.
  • Exam lights are helpful
  • Take your time in getting the patient and the catheter in ideal positions for insertion

Males

  • If meeting resistance during insertion, elevate the penis and point the tip toward the patient’s head
  • Do not be overly aggressive during insertion, as this may cause trauma
    • Leads to bleeding which can occlude urethra
  • Enlarged prostate
    • Consider coude catheter.
      • Has curved tip and is more rigid, curves past enlarged prostate easier
      • May require specific MD order
  • Hypospadias
    • Uretheral opening may appear to be in normal position, but there is no open pathway.
    • Actual uretheral opening is on the under side of the penis, and may appear as a slit.
  • Urology consult may be required, as they can use tools to dilate the urethral opening and assist with
    insertion

Care of the Non-Circumcised Male

  • Peri care is important, regardless if applying an external or an indwelling urinary catheter
    • Retract foreskin and clean thoroughly. There can be a collection of discharge under the foreskin.
  • If applying an external catheter, condom cath should be placed over the penis with the foreskin in the
    original position.
  • Return foreskin back into the original position after foley insertion.
  • If foreskin stays retracted, the penis will swell.
    • Can lead to the patient needing circumcision as an adult.
  • You may need to clarify with the patient (or family) if there is question whether patient has been
    circumcised

CAUTI prevention

  • Don’t have a catheter unless truly needed
  • Treatment of CAUTI is expensive.
  • Can be fatal – think urosepsis, amongst other complications
  • Risk of CAUTI increases each day the catheter remains in place
  • Excellent hand hygiene & peri care prior to insertion
  • Regular and thorough peri-care (follow your hospital policy).
    • Use your hospital approved cleanser
  • Clean Stool immediately and thoroughly
    • Clean all the way from the foley insertion site to the rectum
    • For women, be sure to inspect vaginal canal for feces
  • Consider fecal management device for patients with indwelling catheters.
    • Can be internal or external
    • Be aware that internal FMS can have their own complications
      • There are contra-indications for using internal FMS
  • Use a catheter securing device. Excessive movement can lead to bladder spasms, and also
    exposure to more skin tissue.

    • Secure devices should be placed in proper position
    • Urine should not flow uphill before draining into the bag
      • Leads to retrograde flow
  • No dependent loops, whether the close to the patient or closer to the bag.
  • Do not put foley bag into the bed with the patient
    • Foley should remain below bladder level at all times
  • Empty foley bag before traveling.
    • At a minimum of clamp foley during transport.
  • Remove catheter as soon as possible.

CBI – Continuous Bladder Irrigation

  • Uses 3 way foley
  • Larger catheter, to accommodate flow into and out of bladder, usually place by provider
  • Sterile fluid flows into the bladder and drains out catheter (mixed with urine).
    • Essential to track all fluid entering bladder
    • Subtract irrigant from total fluid output to calculate actual urine output.
  • Flow of irrigant can be adjusted based on how much blood (or blood clots) need to be cleared.
  • Can be needed following urinary trauma or surgery (anything that causes bleeding)
  • Usually requires an MD order to remove

In/Out Catheter (straight cath)

  • Catheter is inserted into bladder, urine is drained, and catheter is removed
  • Sterile procedure same as indwelling catheter
  • Be mindful of how much urine is drained at once.
  • Risk of infection is lower because catheter does not stay in place

Bladder Scan

  • Non-invasive ultrasound which calculates urine in the bladder
  • If a patient is not urinating bladder scan helps determine cause.
    • Does the patient need more fluids or are they retaining urine?
  • If a patient urinates frequently but in small amounts, the patient may not be fully emptying their
    bladder. They may be retaining a large amount of urine
  • Urinary retention can be caused by many reasons, such as:
    • Enlarged prostate
    • Spinal injury
    • Brain injury
    • Medications

In Summary, always ask yourself:

  • Do they have a catheter?
  • Why do they have hit?
  • Do they still need it?
  • When can it come out?

Preventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesPreventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesPreventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesThe 2019-2024 World Outlook for Urinary CathetersThe 2019-2024 World Outlook for Urinary CathetersThe 2019-2024 World Outlook for Urinary CathetersMinimize The Microbial Load On Urinary CathetersMinimize The Microbial Load On Urinary CathetersMinimize The Microbial Load On Urinary Catheters