Skills III Urinary Catheterization.pptx

URINARY CATHETERIZATI ON Nursing Skills III NCSI- 1191B Instructor – Taylor Blackmore  OBJECTIVES/ COMPETENCIES  01 Principles, 02 Types and mate...

URINARY CATHETERIZATI ON Nursing Skills III NCSI- 1191B Instructor – Taylor Blackmore  OBJECTIVES/ COMPETENCIES  01 Principles, 02 Types and materials procedures, and of catheters rationales of (Indwelling, Straight, catheterization Coude) Latex & Silicone Documentation & 03 04of Care 05 Reporting Sterile insertion clients/patients unexpected technique, with suprapubic findings / perform securing catheter catheters required interventions & complications  Urinary catheterization is the placement of a tube through the urethra into the bladder to remove urine. This is an invasive procedure that requires a health care provider prescription/order and sterile technique This may be short-term (usually 2 weeks or less, but sources vary in terms of the exact time frame) or long-term (more than 30 days) Short-term catheterization is often used in patients who have acute urinary retention or have had urological and contiguous surgery and in critically ill patients requiring accurate measurement of urinary output. Urine output is 30 ml or greater per hour Conditions that require use of urinary catheters include the need to monitor urine output, relief of urinary obstruction, postoperative care, or a bladder that empties inadequately because of a neurological condition  Excessive accumulation of urine in the bladder increases the risk for UTI and can cause backward flow of urine up the ureters to the kidneys, causing kidney infection, damage, or both Urinary incontinence, an involuntary leakage of urine, may require in-dwelling catheterization if the leaking of urine interferes with wound healing Intermittent catheterization (In & Out) is used to measure postvoid residual (PVR) (Used to manage chronic urinary retention) The steps/sterile principles for inserting an in-dwelling and a singe-use straight catheter are the same. The difference lies in the inflation of a balloon to the in-dwelling catheter in place and the presence of a closed drainage system  A health care provider chooses a catheter based on factors such as latex allergy, history of complications, and susceptibility to infection. (In-dwelling catheters are made of latex or silicone) Straight or intermittent catheters are made of rubber (softer and more flexible) or polyvinyl chloride The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the catheter. Most adults with an in-dwelling catheter should have a size of 14 to 16 Fr to minimize trauma and risk for infection. Older persons or males with an enlarged prostate may need a smaller size (12 to 14 Fr). A Coude catheter is also available for men with an enlarged prostate with a urinary obstruction; it has a slightly bent tip designed to navigate past the obstruction. Larger catheter diameter increases the risk for trauma to the bladder neck and urethra.  In-dwelling catheters come in a variety of balloon sizes, from 3 ml for a child to 30 ml for continuous bladder irrigation (CBI). The size of the balloon and catheter is printed on the catheter port (Most commonly 10 mls) An in-dwelling catheter is attached to a urinary drainage bag to collect the continuous flow of urine The bag should always hang below the level of the bladder on the bedframe or chair, so urine drains down, out of the bladder (Think of gravitational flow) When a patient ambulates, the bag is carried below the level of the patient’s bladder as well  TYPES OF CATHETERS Intermittent or Indwelling “Foley” “Straight” catheter (In Catheter and Out)  TYPES OF CATHETERS 3-Way Catheter Coude Catheter INDICATIONS & CONTRAINDICATIONS Indications Contraindications -Relieve urinary -Current Urinary retention or tract infection incontinence (UTI) -Obtain a sterile -Urethral strictures collection of urine (narrowing) -Irrigate the bladder -Prostate and/or (CBI) bladder surgery -Pre/Post-Operative -Urethral trauma Care -Severe pelvic -Monitoring Input & fractures Outputs  EQUIPMENT Catheter Tray/Kit (Straight): single-lumen catheter, drapes (one has an opening in the center), sterile gloves, lubricant, cleaning solution (iodine), cotton balls and specimen container Catheter Tray/Kit (In-dwelling): drapes (one has an opening in the center), sterile gloves, lubricant, cleaning solution (iodine), cotton balls, specimen container and a prefilled syringe with sterile water (to inflate balloon) Sterile drainage tubing and bag (Small “leg bag”, large “night bag”, Urometer bag: to measure hourly urine output) Device to secure catheter (Statlock) Basin with warm water, washcloth, towel, and soap for perineal care Flashlight or other additional light source Additional catheter and sterile gloves (in case you contaminate your catheter and/or gloves) EQUIPMENT  Procedure/Steps Confirm MD’s order and verify your facility’s policy regarding urinary catheters Review your patient’s chart to see if they have any allergies, especially to Latex and/or Iodine, and review their medical record for any pathological condition(s) that may impair passage of catheter (enlarged prostate in men, urethral strictures) Assess your patient’s knowledge of and prior experience with urinary catheterization and feelings about the procedure Determine your patient’s positioning for catheterization: females should be in dorsal recumbent position (on back with knees flexed “birthing position”) and males in supine with legs extended and thighs slightly abducted. Extra hands might be needed to achieve this in either situation Also determine if the patient will be able to cooperate during the procedure or if extra help will be necessary (Patient who cannot follow commands and/or confused and/or is combative)  Procedure/Steps Provide privacy by closing room door and bedside curtain Perform hand hygiene Apply clean gloves and inspect perineal region, observing for perineal anatomical landmarks, erythema, drainage or discharge, and odour. Assessment of the female perineal landmarks improves accuracy and speed of catheter insertion. Remove gloves and perform hand hygiene again Raise bed to appropriate working height (Remember sterility principles-waist height) If side rails are in use, raise side rail opposite side of bed and lower rail on working side. Place waterproof pad/ bluepad under patient and provide peri-care Drape patient with bed linens (Females: In diamond fashion over the perineum. Males: Drape upper body and lower body so only perineum is exposed)  Procedure/Steps Position light or have an assistant available to hold light source to visualize urinary meatus Open outer wrapping of catheterization kit. Place inner wrapped catheter kit tray on clean, accessible surface such as a bedside table. Patient size and positioning will dictate exact placement Open inner sterile wrap covering tray containing catheterization supplies (Just as you would open a dressing tray), using sterile technique. Fold back each flap of sterile covering one at a time, with last flap opened toward you In-dwelling: Open separate package containing drainage bag and place in easily accessible location. Open outer package of sterile catheter, maintaining sterility of inner wrapper and place in sterile field (If you have someone assisting you, they can open catheter and you can grab sterile catheter wrapper after applying sterile gloves as well) Straight: All needed supplies are in sterile tray that contains supplies and can be used for urine collection  Procedure/Steps Apply sterile gloves. Option: Apply sterile drape with ungloved hands when drape is packed as first item. Touch only edges of drape. Then apply sterile gloves Drape perineum x2 keeping gloves and working surface of drape sterile Arrange remaining supplies on sterile field, maintaining sterility of gloves. Place sterile tray with cleaning solution (premoistened swab sticks or cotton balls, forceps, and solution) lubricant, sterile catheter, and prefilled syringe for inflating balloon (in-dwelling catheterization only) on sterile drape between the patient’s legs If kit contains sterile cotton balls, open package of sterile antiseptic solution and pour over cotton balls. If it contains premoistened swabs sticks, open end of package for easy access  Procedure/Steps For in-dwelling catheterization, open sterile wrapper of catheter and leave catheter on sterile field Attach prefilled sterile water syringe into the balloon port on the catheter Pretesting/prefilling a balloon for patency is no longer recommended. Testing the balloon may distort and stretch it and lead to damage, causing increased trauma on insertion Open lubricant and prepare on sterile field. Lubricate catheter tip by dipping it into water-soluble gel (2.5 to 5 cm for women and 5 to 7 cm for men)  Procedure/Steps Clean urethral meatus: For females, separate labia with fingers of nondominant hand (now contaminated) to fully expose urethral meatus. Maintain position of nondominant hand throughout procedure (Do not move or use this handv from now on as now it is contaminated and keeping it in position ensures your cleaned areas also remain sterile) Holding forceps in dominant hand, pick up one moistened cotton ball or pick up one swab/stick at a time. Clean labia and urinary meatus from clitoris toward anus. Use new cotton ball or swab for each area that you clean/each swipe. Clean by wiping far labial fold, near labial fold, and directly over center of urethral meatus (Distal, proximal, center) For male patients, with nondominant hand (now contaminated) retract foreskin (if uncircumcised) and gently grasp penis shaft just below glans. Hold shaft of penis at right angle/ 90 degrees to body. This hand remains in this position for remainder of procedure Using sterile dominant hand, clean meatus with cotton balls or swab sticks, using circular strokes, cleaning from meatus toward glans in a spiral motion  Procedure/Steps Repeat cleaning three times using clean cotton ball or swab stick each time Pick up and hold catheter 7.5 to 10 cm from catheter tip with catheter loosely coiled in palm of hand. Make sure to position urine tray so end of catheter can be placed there once insertion begins Insert catheter. Explain to patient that a feeling of burning, pinching, or pressure may be experienced as catheter is inserted into urethra. This sensation is normal and will go away quickly Ask to bear down gently, and slowly insert catheter through urethral meatus. Advance catheter a total of 5 to 7.5 cm or until urine flows out of catheter. When urine appears, advance another 2.5 to 5 cm. Do not use force to insert catheter. Release labia and hold catheter securely with nondominant  Procedure/Steps For male patient, lift penis to position perpendicular (90 degrees) to patient’s body and apply gentle upward traction Ask patient to bear down and slowly insert catheter through urethral meatus Advance catheter 17 to 22.5 cm or until urine flows out of end of catheter Stop advancing with straight catheter. When urine appears in in-dwelling catheter, advance it to bifurcation (inflation and deflation ports exposed, AKA the “Y”) At this time you can collect urine specimen Continue to hold catheter with nondominant hand and with free dominant hand, pick up the prefilled syringe that is connected to balloon port and slowly inject total amount of solution into balloon  Procedure/Steps If the patient indicates sudden pain during inflation of catheter balloon or when resistance is felt when inflating balloon, stop inflation, allow the fluid from the balloon to flow back into the syringe, advance the catheter farther, and reinflate the balloon. The balloon may have been inflating in the urethra. If pain continues, remove the catheter completely and notify the health care provider Allow bladder to empty fully unless facility policy restricts maximum volume of urine drained. There is no definitive evidence regarding whether there is benefit in limiting maximal volume drained; however, draining too much volume at once can cause a large fluid shift in the patient (fluid volumes >1L), resulting in dizziness and hypotension After inflating catheter balloon, release catheter from nondominant hand. Gently pull catheter until resistance is felt. Then advance catheter slightly (Back to where it was before  Procedure/Steps Connect drainage tubing/bag to catheter port Secure catheter tubing to inner thigh using a Statlock device allowing enough slack to prevent tension For uncircumcised men, make sure to replace foreskin back, no dot leave it retracted. If kept retracted, it will cause discomfort and edema Clip drainage bag tubing to edge of mattress. Position drainage bag lower than the bladder by attaching to bedframe. Do not attach to side of rails of bed Dispose of supplies in appropriate receptacles Remove gloves and perform hand hygiene Document  DOCUMENTATION Document and report the reason for catheterization Type and size of catheter Amount of fluid used to inflate balloon Specimen collection (if applicable) Characteristics and amount of urine Patient’s response to procedure Document amount of urine on intake and output (I&O) flow sheet and/or chart  UNEXPECTED FINDINGS & OUTCOMES Report: Persistent catheter-related pain, inadequate urine output, and discomfort to health care provider Catheter inserted into vagina: Leave catheter in vagina as a landmark, cleanse urinary meatus again. Reinsert another sterile catheter into meatus (check employer policy) NOTE: If gloves become contaminated, start procedure again. Remove catheter from vagina after successful insertion of second catheter Sterility is broken during catheterization by nurse or patient: Replace gloves if contaminated and start over. If patient touches sterile field but equipment and supplies remain sterile, avoid touching that part of the sterile field. If equipment or supplies become contaminated, replace with sterile items or start over with a new sterile kit  UNEXPECTED FINDINGS & OUTCOMES Patient indicates bladder discomfort, and catheter is patent as evidenced by adequate urine flow: Check catheter to ensure that there is no traction on it. Notify health care provider. Patient may be experiencing bladder spasms or symptoms of UTI. Monitor catheter output for colour, clarity, odour, and amount The urethral meatus of an older female may be difficult to identify because of urogenital atrophy Symptoms of a UTI in an older person may be difficult to recognize and may be indicated by cognitive changes, lethargy, anorexia, weakness, tachycardia, hypotension, and increased respiratory rate The presence of a urinary catheter and its drainage tubing and bag can interfere with the already compromised mobility of the older person  COMPLICATIONS Catheters do not come without risk, and typically long-term catheterization is not recommended and that they should be removed as soon as the patient can void Infection is another common complication with catheters, observe patient’s urine for both concentration, color, and odour Urethral trauma is another complication that can happen from improper care or insertion technique which can lead to bleeding or infection Obstruction can occur because of infection, or other conditions and should be reported to the doctor or another health care provider immediately, as it can lead to extremely painful bladder distension.  OTHER RISKS & SIDE- EFFECTS Bladder spasms, which feel like stomach cramps, are quite common when having a catheter in the bladder. Report to health care provider if it persists Leakage around the catheter is another problem associated with indwelling catheters. This can happen because of bladder spasms or when defecating. Leakage can also be a sign that the catheter is blocked, so it's essential to check that it's draining properly Blood or debris in the catheter tube is also common with an indwelling catheter. This could become a problem if the catheter drainage system becomes blocked Report as soon as possible if you think the catheter may be blocked, or if the patient is passing large pieces of debris or blood clots  OTHER RISKS & SIDE- EFFECTS Other (less common) issues may include: Injury to the urethra when the catheter is inserted Narrowing of the urethra because of scar tissue caused by repeated catheter use Injury to the bladder caused by incorrectly inserting the catheter  SUPRAPUBIC CATHETER CARE A suprapubic catheter is a urinary drainage tube inserted surgically into the bladder through the abdominal wall above the symphysis pubis. The catheter may be sutured to the skin, secured with an adhesive material, or retained in the bladder with a fluid-filled balloon like an in-dwelling catheter Suprapubic catheters are placed when there is blockage of the urethra (enlarged prostate, urethral strictures, after urological surgery) and when a long-term urethral catheter causes irritation or discomfort or interferes with sexual functioning Assessment: Urine in drainage bag for amount, clarity, colour, odour and sediment. Assess catheter insertion site (may be deferred until you clean site) for signs of inflammation (pain, erythema, edema and drainage) and for growth of granulation tissue. Ask patient if there is any pain at the site; if so, assess for pain using PQRST. Remove gloves and perform hand hygiene. Assess for elevated temperature and chills and patient’s knowledge of purpose of catheter and its care  SUPRAPUBIC CATHETER CARE Perform hand hygiene Prepare supplies and open gauze packets (Drain Sponge) in the same manner as for applying dry dressing Apply clean gloves. Loosen tape and remove existing dressing. Note type and presence of drainage. Remove gloves and perform hand hygiene Clean insertion site using sterile aseptic technique for newly established catheter  SUPRAPUBIC CATHETER CARE Review employer policy or consider patient need. In some facilities, clean gloves are appropriate Apply sterile gloves. Without creating tension, hold catheter up with nondominant hand while cleaning. Use sterile gauze moistened in saline and clean skin around insertion site in a circular motion, starting near the insertion site and continuing in outward widening circles for approximately 5 cm With new, moistened gauze, gently clean base of catheter, moving up and away from the site of insertion (proximal to distal). Once insertion site is dry, use a sterile gloved hand to apply drain dressing around the catheter. Tape in place to secure Observe catheter insertion site for erythema, edema, discharge, and tenderness. Check dressing at a minimum of every 8 hours  SUPRAPUBIC CATHETER CARE To clean a long term / established catheter: Apply clean gloves Without creating tension, hold catheter erect with nondominant hand while cleaning. Clean with soap and water in a circular motion, starting near catheter insertion site and continuing in outward widening circles for approximately 5 cm With a fresh washcloth or gauze, gently clean base of the catheter, moving up and away from site of insertion (proximal to distal). Option: Apply drain dressing around catheter and tape in place Secure catheter to lateral abdomen with tape or Velcro multipurpose tube holder. Coil excess tubing on bed. Always keep drainage bag below level of bladder Dispose of supplies in an appropriate receptacle Remove gloves and perform hand hygiene SUPRAPUBIC CATHETER CARE  UNEXPECTED OUTCOMES - SUPRAPUBIC Patient develops symptoms of UTI or catheter site infection: Monitor vitals signs, I&O, observe amount, colour, consistency of urine; assess site. Notify health care provider Suprapubic catheter becomes dislodged: Cover site with sterile dressing and notify health care provider. If this is a newly established catheter, it will need to be reinserted immediately Skin surrounding catheter exit site becomes red or irritated or develops open area: Notify health care provider, change dressing (if used) more frequently to keep site dry. Consult with wound care nurse  DOCUMENTATION - SUPRAPUBIC Document and report character of urine and type of dressing change, including assessment of insertion site and patient’s comfort level with the catheter and dressing change Urine output on the I&O flow sheet. When there is both a suprapubic and urethral catheter, document outputs from each separately Evaluation of your patient and caregiver learning QUESTIO NS?  REFERENCES Perry, A. G., Potter, P. A., Ostendorf, W. R., & Cobbett, S. L. (2020). Canadian Clinical Nursing Skills + Techniques (First). Elsevier. Luc Bourgeois, LPN, NBCC