S4E38: All Things Urinary Catheters

This podcast is available on iTunes, iHeartRadio, Spotify, and Google Play

Who You’ll Hear

Kati Kleber, MSN RN CCRN-K – Nurse educator, former cardiac med-surg/stepdown and neurocritical care nurse, author, speaker

Elizabeth Mills, BSN RN CCRN – highly experienced neurocritical care nurse, current Stroke Navigator for a Primary Stroke Center

What You’ll Learn

• CAUTI
• Non-Invasive Urinary Output Methods
• Tips for catheters insertion
• CAUTI prevention

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.

CAUTI – Catheter 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
• A small minority of patients are at higher risk for CAUTI.
  • Be aware of the patient’s factors.
• Most CAUTI are preventable
• The best prevention is not to have them
• Changing the mentality of why/when patients need catheters
  • Not using as frequently
  • The more specific rationale for the 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 the bed for easier transfers for patients with limited mobility
• Speci-Hats – Placed in the toilet to capture urine, but sometimes difficult to put in the perfect spot to avoid misses
• Female Urinals – Shaped differently, with a 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 the 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 the 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.
• The 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 the skin can (or body excretions) can adhere to the catheter and find a route
    into the bladder, even if the insertion was perfectly sterile.
• Diarrhea is particularly concerning with catheters, especially in females, because the 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 in 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 the 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 in the urethra
• Enlarged prostate
  • Consider coude catheter.
    • Has curved tip and is more rigid, curves past enlarged prostate easier
    • May require specific MD order
• Hypospadias
  • Urethral opening may appear to be in normal position, but there is no open pathway.
  • The actual urethral opening is on the underside 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
• The treatment of CAUTI is expensive.
  • According to an article published in the American Journal of Infection Control in July of 2018, costs
    can range from $1,000 – $10,000.
• Can be fatal – think urosepsis, amongst other complications
• Risk of CAUTI increases each day the catheter remains in place
  • According to the CDC, the risk increases 3-7% each day
• 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 the proper position
  • Urine should not flow uphill before draining into the bag
    • Leads to retrograde flow
• No dependent loops, whether 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 the 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?

More Resources on Catheters:

• S5E42 – Back to Nursing Basics
• For the Overwhelmed New Graduate Nurse
• S3E32a – Intensive Care Devices: Part 1