Read Catheterization- Straight and Retention/Care and Managment/ Removal of Catheter -Adult(cat05) text version

SARASOTA MEMORIAL HOSPITAL NURSING PROCEDURE

TITLE: CATHETERIZATION--STRAIGHT AND RETENTION/ CARE AND MANAGEMENT/REMOVAL OF CATHETER ­ ADULT (cat05) Nursing DATE: REVIEWED: PAGES: 05/86 8/11 1 of 8

ISSUED FOR:

RESPONSIBILITY: RN, LPN , *(Patient Care Tech/Multiskilled Tech ­ foley care and removal only)

PURPOSE:

1. To remove urine from the bladder using sterile technique. 2. To provide continuous drainage of urine and treatment when necessary. 3. To prevent urinary infections.

INDICATIONS/CRITERIA:

Indications/Criteria for an indwelling urinary catheter:: 1. Acute urinary retention or obstruction. 2. Need for accurate measurement of urinary output in critically ill patients. 3. Perioperative use for selected surgical procedures. 4. To assist in the healing of open sacral or perineal wounds in incontinent patients. 5. Patient requires prolonged immobilization. 6. To Improve comfort for end-of-life care if needed NOTE: An indwelling foley catheter is NOT indicated for incontinence or patient request/convenience.

KNOWLEDGE BASE:

1. Insert indwelling catheters only when needed (see criteria above) and leave in place only as long as needed. 2. Nursing may generate a protocol in SCM (Foley Catheter Insertion and Removal Protocol) if the patient meets the criteria for insertion or removal of an indwelling urinary catheter.

EXCEPTION: SCIP core measures patients have their own guidelines. 3. Catheters are inserted using sterile technique and a new catheter must be used for each insertion. 4. In a surgical patient, the drainage bag and tubing should be kept on the non-operative side of the patient to minimize contamination of the surgical area. 5. When inserting a retention catheter, the balloon should not be inflated until urine flow is established assuring that the

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catheter is not in the urethra, but in the bladder. If urine flow is not obtained, determine if the bladder was empty at the time of insertion. Obtain a bladder scan to determine if bladder is empty. Then make sure the catheter is advanced far enough before inflating the balloon to avoid injuring the urethra.

NOTE: Manufacturers generally pre-inflate (pre-test) the catheter balloon so it is not necessary again at the time of insertion. Additional checks of the balloon may stretch it and cause more trauma upon insertion. 6. If a catheter was inserted for long-term use, contact the MD to get an order to replace it (recommend after 30 days).

7. If a foley catheter is no longer necessary, use the nursedriven foley catheter removal order set or contact the physician for orders. PATIENT EDUCATION: Explain the procedure to the patient. When removing a catheter, tell the patient to save all voided specimens and explain urinary symptoms that may occur after the removal.

EQUIPMENT:

1.

CATHETER INSERTION: Assemble the following: a. b. Sterile disposable catheter pack Sterile Foley catheter, size 16 unless otherwise specified (optional). Use the closed system package unless a special catheter is needed. Urinary drainage bag Catheter strap Light source Extra sterile gloves (optional) Extra catheter (optional) Extra drapes (optional) Urojet/Xylocaine Jell 2% (if ordered) ­ refer to Nursing Procedure (cat10), Use of Urojet/Xylocaine Jell 2% for procedure.

c. d. e. f. g. h. i.

2.

CATHETER REMOVAL: a. b. c. Towel or linen-saver pad 12-ml or 35-ml-syringe depending on catheter balloon size Non-sterile gloves

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CATHETERIZATION--STRAIGHT AND PAGE: RETENTION/CARE AND MANAGEMENT/ REMOVAL OF CATHETER-ADULT (cat05)

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PROCEDURES:

1.

CATHETER INSERTION: (RN, LPN) a. Patient identification done. b. Perform hand hygiene. c. Assist patient to lie flat if not contraindicated. d. Adjust light. d. Open the catheter pack. e. Place a drape beneath patient's hips. f. Perform hand hygiene. Put on sterile gloves. g. Drape the patient's lower abdomen with the sterile fenestrated drape so only the genital area remains exposed. h. Tear open the packet of povidone-iodine solution and saturate cotton balls with the povidone-iodine. NOTE: If the patient has an allergy to povidone-iodine, a product such as Johnson's Head-to-Toe Baby Wash (obtained from CS) may be used instead. The Baby Wash must be thoroughly rinsed off after cleansing. i. Lift catheter pack container onto sterile underpad. j. Squeeze water-soluble lubricant onto catheter pack.

FEMALE: 1) Place female patient in supine position with her knees flexed and separated and her feet flat on the bed. Separate labia as widely as possible with the thumb and middle and index fingers of non-dominant hand. With free hand, use plastic forceps to pick up cotton ball and wipe one side of urinary meatus with a simple downward motion. Discard the cotton ball. Repeat with remaining two cotton balls, one using downward single stroke for other side, and the last cotton ball for center of urinary meatus. NOTE: The hand separating labia is no longer sterile. Do not use contaminated hand to touch sterile field again until catheter is inserted and draining. With sterile hand, pick up the catheter with thumb and index finger about four inches from the tip and lubricate the tip. Carefully insert lubricated tip into urinary meatus and advance about two to three

2)

3)

4)

5)

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7)

8) 9) 10)

11) 12) 13) MALE: 1)

inches until urine begins to flow. When urine starts flowing from a straight catheter, stabilize the catheter and maintain placement until the urine stops flowing. Then remove the catheter and discard. When the urine starts flowing from a retention catheter, make sure it is advanced far enough into the bladder, then inflate the balloon with the water-filled syringe. After inflation, pull gently until resistance is met. Attach sterile drainage bag to bedrail, making sure it is below bladder level. Remove the cap from the tubing on the collection bag and connect the tubing to the catheter, using aseptic technique. Make sure the tubing does not get tangled in side rails. Use a catheter strap to secure the catheter to the thigh. Discard the used equipment.

Place male patients in supine position with his legs extended and flat on the bed. 2) Grasp penis with your non-dominant hand and, if uncircumcised, retract the foreskin to expose the meatus. 3) Cleanse thoroughly with povidone-iodine saturated cotton balls, using a circular motion starting at urinary meatus and working outward. Repeat this three times, discarding each cotton ball after a single application. If the patient has a povidone-iodine allergy, a product such as Johnson's Baby Head-to-Toe Baby Wash (obtained from CS) may be used instead. The Baby Wash must be thoroughly rinsed off after cleansing. NOTE: The dominant hand should remain sterile. If you touch the penis or anything else not sterile with the dominant hand, the sterile field will be contaminated. 4) Lubricate the catheter. 5) Raise the penis upright. Grasp the catheter about three to four inches from the tip and insert gently about six to seven inches until urine begins to flow. 6) The catheterization should be attempted by the staff nurse first. If unable to catheterize patient,

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contact the Intervention Nurse for assistance. If the Intervention Nurse is not available, contact the communicator on the Urology Unit (ext. 7690) to see if one of the nurse's from there could attempt the catheterization. If still unsuccessful, obtain the GU Cart and flexible cystoscope from CS and have it available on the nursing unit. Contact the physician for a consult with a Urologist. Once consult order obtained, contact the Urologist to come in to perform the catheterization (once the above steps have been taken). 7) When urine starts flowing from a straight catheter, stabilize the catheter and maintain placement until the urine stops flowing. Then remove the catheter and discard. 8) When urine starts flowing from a retention catheter, continue to insert to the Y hub. If you are unsure if the catheter is all the way into the bladder, let go of the catheter. If the catheter stays in place, you are most likely in. If the catheter pushes back out, you are not in. Once you are in the bladder, inflate the balloon to keep catheter in place within the bladder. 9) If the foreskin was retracted, replace it to prevent compromised circulation and painful swelling. 10) Use a catheter strap to secure the catheter to the thigh. 11) Attach collection bag and tubing as previously mentioned. 2. CATHETER CARE AND MANAGEMENT: (RN/LPN/Patient Care Tech/Multi-skilled Tech) a. b. c. d. Catheter care should be done daily and PRN. Perform hand hygiene. Apply gloves. Inspect the urinary drainage for mucous shreds, blood clots, or sediment. Inspect the outside of the catheter where it enters the urinary meatus for encrusted material or drainage. Inspect the tissue around the meatus for irritation. Using soap and water, cleanse around the meatus wiping away from the meatus. In male patients, retract the foreskin before cleansing. Remove any encrusted materials which can be irritating. Try to avoid pulling on the catheter while cleaning as that could expose a section of the catheter that was inside the urethra (so when the catheter is released, the newly contaminated section could reenter the

e.

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f. g. h.

i.

j.

k.

urethra introducing organisms). Once, cleansing done, replace the foreskin of the male patient. Check the area beneath the catheter strap for redness or blisters. Remove gloves and perform hand hygiene. The foley catheter should be emptied every shift using a separate collection container for each patient. Avoid allowing the catheter spigot to touch the collection container. Avoid raising the drainage bag above bladder level, but try to keep the drainage bag off of the floor. This prevents reflux of urine, which can contain bacteria. When the patient requires transport to another department/procedure, do not place the collection bag on top of the stretcher or bed--try to keep the bag lower than the bladder to avoid backflow of urine. Try to maintain unobstructed urine flow. Remind the patient to keep the knee down (this includes the knee gatch) that has the catheter strap attached as that may impede the urine flow into the collection bag.

3. CATHETER REMOVAL: (RN, LPN, Patient Care Tech, multi-skilled tech) a. Remove the indwelling catheter when patient does not meet criteria to maintain the catheter. For Urology patients, an MD order is needed for the removal of a foley catheter. If feasible, remove an indwelling catheter in the morning to avoid after hour issues with urinary retention. This procedure may be delegated to the Patient Care Tech or multi-skilled tech by the nurse. Explain the procedure to the patient. Have the patient lie down in supine position. Perform hand hygiene. Don gloves. Place towel or linen-saver pad in appropriate position to prevent urine spillage. Insert syringe into valve opening and withdraw the fluid. NOTE: Make sure all the fluid is withdrawn. There may be more fluid than the recommended amount. When the fluid is withdrawn, steadily pull the catheter out catching the catheter in the towel or linen-saver pad at the same time to prevent spillage. When done, measure and record the amount of urine. Record the results. Dispose of the urine and drainage bag according to Hospital policy.

b. c. d. e. f. h.

i.

j. k.

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l. m.

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Ensure the patients comfort and understanding of the voiding trial. Troubleshooting (RN/LPN only, the Patient Care Tech/multi-skilled tech is to notify the nurse of any difficulty): 1) Valve Malfunction: a) The balloon valve can be difficult to manipulate. Sometimes you have to press hard with the syringe to withdraw the fluid. Sometimes you have to do it gently. b) If the balloon will not deflate after attempting with the syringe, try using a needle to push open the valve. c) If still unable to withdraw the fluid, try inserting the needle just behind the valve and try to withdraw the fluid. d) The last step is to cut the valve off. NOTE: Cut the valve only. Do not cut the outlet port off.

If nothing has worked, call the patient's physician. 2) Balloon deflates, but are unable to pull catheter out: a) When the balloon is inflated, the balloon area stretches. This can cause a raised edge on the end of the catheter. It can catch on the inside of the urethra. You may need to pull a little harder. STOP IF THE PATIENT COMPLAINS OF PAIN. b) Have the patient lie in different positions, and then try to remove the catheter. c) If none of the above works, call the physician. n. Post indwelling catheter removal: Follow the steps per the Foley catheter Insertion and Removal Protocol order set. DOCUMENTATION: 1. Electronic Medical Record: a. Record date, time, size and type of indwelling/straight catheter. Describe the amount, color and other characteristics of the urine, such as consistency and odor, and how the patient tolerated the procedure. (RN, LPN only) When removing a catheter, chart the time

e)

b.

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removed, the color of the urine, and any problems encountered. (RN, LPN, Patient Care Tech) 2. SCM I&O Flowsheet: Record output of initial catheterization and/or for the shift as appropriate. Record the urine output in the catheter when removed.

REFERENCE(s):

Allen, D. et.al., (2009). Nursing Procedures-Fifth Edition. (pp. 714-720). Lippincott, Williams and Wilkins. Philadelphia: PA. Diagnosis, Prevention, and Treatment of Catheter Associated Urinary Tract Infection in Adults: 2009 International Clinical Practice Guidelines from the Infectious Diseases Society of America. (2010). Hooten et. Al. Gould et. al. Guideline for Prevention of Catheter Associated Urinary Tract Infections. 2009. Center for Disease Control (CDC). Owensboro Medical Health System. Foley Catheter Protocol. (2008). Institute Healthcare Improvement (IHI) - Improvement Map. (2009). Gray, Mikel; et. al. (2009). Preventing Catheter-Associated Urinary Tract Infections-Build an Evidence-Based Program to Improve Patient Outcomes. HCPro, Inc. Marblehead, MA.

REVIEWING AUTHOR(S): Karen Diffley, RN, BSN, Nursing Standards Sue Shkrab, RN, MSN, Director, Nursing Strategies

APPROVAL(S):

Clinical Practice Council 8/4/11

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