
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
Melissa Stafford, BSN RN CCRN SCRN – Highly experienced and currently practicing nationally certified neurocritical care nurse
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.
- Need to use proper suction to assure that urine is pulled away from the perineum, but not high
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)
- Some weigh disposable pads (the pads patient’s lay on for repositioning) to calculate the output
- 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
- Consider coude catheter.
- 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.
- According to an article published in the American Journal of Infection Control in July of 2018, costs
- 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?
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