What is a urinary catheter. How to insert a urinary catheter in female patients. What are the indications for catheter use. What equipment is needed for catheter insertion. How to maintain proper hygiene during catheterization. What are potential complications of catheter insertion. How to secure and care for an indwelling catheter.

Understanding Urinary Catheters: Purpose and Types

A urinary catheter is a vital medical device used in various healthcare settings to manage urinary issues. But what exactly is a urinary catheter? It’s a hollow, flexible tube inserted through the urethra into the bladder, designed to drain urine into an external collection bag. Once inserted, a small balloon on the internal end is inflated with sterile water to keep it securely in place.

Urinary catheters serve multiple purposes in patient care. They are commonly used to address:

• Urinary incontinence
• Urinary retention
• Assistance for patients unable to use the toilet independently

Healthcare professionals should be familiar with different types of catheters, including indwelling (also known as long-term) catheters, which are the focus of this guide.

Preparing for Catheter Insertion: Essential Steps

Proper preparation is crucial for successful catheter insertion. How should healthcare providers prepare for this procedure?

1. Gather all necessary equipment
2. Discuss the procedure with the patient, using educational resources or interpreters if needed
3. Obtain informed consent from the patient
4. Review the patient’s current medications and known allergies
5. Ensure adequate lighting and patient privacy
6. Position the patient correctly (supine position with flexed hips and bent knees)
7. Place a waterproof sheet under the patient’s buttocks

Attention to detail during preparation can significantly improve patient comfort and procedure outcomes.

Equipment and Supplies for Female Catheter Insertion

What equipment is necessary for female catheter insertion? A well-prepared catheterization tray should include:

• Sterile catheterization pack
• Appropriate catheter (consider size and material)
• Sterile gloves
• Antiseptic cleaning solution
• Lubricating gel
• Anaesthetic gel
• Sterile water for balloon inflation
• Syringe for balloon inflation
• Fenestrated drape
• Drainage bag or valve
• Catheter securing device (tape or strap)

For patients with latex allergies, it’s crucial to use a 100% silicone catheter. Always check your organization’s policies for specific equipment requirements.

Maintaining Aseptic Technique During Catheterization

Aseptic technique is paramount in catheter insertion to prevent urinary tract infections. How can healthcare providers ensure proper asepsis?

1. Perform thorough hand hygiene before and after the procedure
2. Use sterile equipment and maintain a sterile field
3. Don non-sterile gloves for initial cleaning, then switch to sterile gloves for insertion
4. Clean the urethral area with antiseptic solution using downward strokes
5. Avoid touching non-sterile surfaces once sterile gloves are on
6. Use a no-touch technique when handling the catheter

Strict adherence to aseptic technique significantly reduces the risk of introducing bacteria into the urinary tract.

Step-by-Step Guide to Female Catheter Insertion

Catheter insertion requires precision and care. Here’s a detailed breakdown of the procedure:

1. Position the patient and ensure privacy
2. Perform hand hygiene and don non-sterile gloves
3. Part the labia minora to view the urethral meatus
4. Cleanse the area surrounding the urethral opening
5. Remove non-sterile gloves, perform hand hygiene, and don sterile gloves
6. Place the fenestrated drape on the patient
7. Apply lubricating gel to the lower third of the catheter
8. Apply anaesthetic gel to the external urethral opening and into the urethra
9. Insert the catheter until urine flow is visible, then advance 2-4 cm further
10. Inflate the balloon with sterile water according to manufacturer instructions
11. Gently pull the catheter until resistance is felt
12. Connect the catheter to a drainage system or valve
13. Secure the catheter in place

If resistance is encountered during insertion, gently rotate the catheter or ask the patient to take a deep breath. Never force the catheter if significant resistance is felt.

Troubleshooting Catheter Insertion

Sometimes, catheter insertion may not go as smoothly as planned. What should you do if you encounter difficulties?

• If the catheter is accidentally inserted into the vagina, leave it in place temporarily as a guide for the correct insertion
• If the patient complains of pain during balloon inflation, or if urine is not flowing freely, do not inflate the balloon as this could indicate incorrect placement or bladder spasm
• In cases of difficult insertion due to vaginal atrophy or retracted urethral opening, repositioning the patient to a left lateral position with raised buttocks may help

Always prioritize patient comfort and safety. If difficulties persist, consult with a more experienced colleague or consider alternative catheterization methods.

Post-Insertion Care and Maintenance

Proper care after catheter insertion is crucial for patient comfort and infection prevention. What steps should be taken post-insertion?

1. Ensure the genital area is clean and dry to prevent skin irritation and infection
2. Secure the catheter with enough slack to prevent tension during patient movement
3. Regularly check the drainage system for proper functioning
4. Monitor urine output and characteristics
5. Educate the patient on catheter care and signs of potential complications
6. Schedule regular catheter changes according to institutional policy or manufacturer recommendations

Continuous assessment and care of the catheterized patient are essential for preventing complications and ensuring optimal outcomes.

Potential Complications and Their Management

While catheterization is a common procedure, it’s not without risks. What are some potential complications, and how can they be managed?

• Urinary tract infections (UTIs): Monitor for signs of infection and maintain strict hygiene
• Catheter-associated trauma: Use appropriate catheter size and insertion technique to minimize risk
• Bladder spasms: May require medication or catheter adjustment
• Catheter blockage: Ensure adequate fluid intake and consider catheter irrigation if necessary
• Catheter dislodgement: Properly secure the catheter and educate the patient on movement precautions

Early recognition and prompt management of complications are crucial for patient safety and comfort.

Documentation and Follow-up Care

Proper documentation is a critical aspect of catheter care. What information should be recorded after catheter insertion?

• Date and time of insertion
• Reason for catheterization
• Type and size of catheter used
• Amount of water used to inflate the balloon
• Any difficulties encountered during insertion
• Patient’s response to the procedure
• Urine characteristics (color, clarity, amount)
• Planned date for catheter change or removal

Accurate documentation ensures continuity of care and facilitates proper follow-up. Regular assessments should be scheduled to evaluate the ongoing need for catheterization and to monitor for any complications.

Patient Education for Long-term Catheter Care

For patients requiring long-term catheterization, education is crucial. What key points should be covered in patient education?

• Proper hand hygiene before and after handling the catheter
• Techniques for keeping the catheter and surrounding area clean
• Signs and symptoms of urinary tract infections or other complications
• How to manage the drainage bag, including emptying and changing
• Activity restrictions and precautions to prevent catheter dislodgement
• When and how to seek medical attention if problems arise

Comprehensive patient education empowers individuals to participate in their care and can significantly reduce the risk of complications.

Ethical Considerations in Catheterization

Healthcare providers must navigate various ethical considerations when performing catheterization. What are some key ethical issues to consider?

• Respecting patient autonomy and obtaining informed consent
• Balancing the need for catheterization with potential risks and complications
• Ensuring patient dignity and privacy during the procedure
• Addressing cultural or religious concerns related to catheterization
• Considering alternative methods of urinary management when appropriate

Ethical decision-making should always prioritize patient well-being and respect for individual preferences.

Cultural Sensitivity in Catheter Care

Cultural considerations play a significant role in providing comprehensive catheter care. How can healthcare providers ensure cultural sensitivity?

• Be aware of cultural beliefs and practices related to bodily functions and medical procedures
• Use professional interpreters when language barriers exist
• Respect patient preferences for same-gender caregivers when possible
• Adapt education materials to be culturally appropriate and accessible
• Be open to discussing and accommodating cultural practices that do not compromise care quality

Cultural competence enhances patient trust and improves overall care outcomes.

Advances in Catheter Technology and Future Directions

The field of urinary catheterization continues to evolve. What are some recent advances and potential future developments?

• Antimicrobial-coated catheters to reduce infection risk
• Novel materials that improve comfort and reduce irritation
• Smart catheters with sensors for early detection of complications
• Improved drainage systems for better hygiene and ease of use
• Alternative catheterization methods, such as suprapubic catheters

Staying informed about technological advancements can help healthcare providers offer the most up-to-date and effective catheter care to their patients.

Research and Evidence-Based Practice in Catheterization

Continuous research is essential for improving catheterization practices. How can healthcare providers stay current with evidence-based guidelines?

• Regularly review updated clinical guidelines from reputable organizations
• Participate in continuing education programs focused on urinary catheterization
• Engage in or support research initiatives related to catheter care
• Implement quality improvement projects to enhance catheterization practices
• Collaborate with specialists in urology and infection control for best practices

Evidence-based practice ensures that patients receive the highest quality care based on the most current research and clinical expertise.

Interdisciplinary Approach to Catheter Management

Effective catheter management often requires a team approach. Which healthcare professionals typically contribute to catheter care?

• Nurses: Primary caregivers responsible for insertion, maintenance, and patient education
• Physicians: Determine need for catheterization and manage complications
• Urologists: Provide specialized care for complex catheterization cases
• Infection control specialists: Develop and implement strategies to prevent catheter-associated infections
• Physical therapists: Assist with mobility and positioning for catheterized patients
• Occupational therapists: Help patients adapt to daily activities with a catheter

Collaboration among these professionals ensures comprehensive, patient-centered catheter care.

Communication Strategies in Catheter Care Teams

Effective communication is crucial for optimal catheter management. What strategies can improve team communication?

• Implement structured handoff protocols for shift changes
• Use standardized documentation tools for catheter care
• Conduct regular team meetings to discuss patient progress and care plans
• Encourage open dialogue between different specialties involved in catheter care
• Utilize electronic health records for real-time updates and care coordination

Clear and consistent communication helps prevent errors, improves patient outcomes, and enhances overall care quality.

Legal Aspects of Catheterization

Healthcare providers must be aware of the legal implications of catheterization. What are some key legal considerations?

• Obtaining and documenting informed consent
• Adhering to professional standards of care
• Maintaining accurate and complete medical records
• Reporting adverse events or complications as required by law
• Respecting patient privacy and confidentiality
• Following institutional policies and procedures for catheterization

Understanding and complying with legal requirements protects both patients and healthcare providers.

Risk Management in Catheterization Practice

Implementing effective risk management strategies is essential in catheterization. How can healthcare providers minimize risks?

• Conduct regular staff training on proper catheterization techniques
• Develop and enforce clear protocols for catheter insertion and care
• Implement a system for tracking catheter days and prompting timely removal
• Use checklists to ensure all steps of the procedure are followed consistently
• Encourage reporting of near-misses and adverse events for continuous improvement

Proactive risk management helps create a safer environment for both patients and healthcare providers.

Urinary Catheter Insertion for Females

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Transcript

Hi there! Let’s take a look at urinary catheters and catheter insertion for female patients.

A urinary catheter (also known as an ‘indwelling’ or ‘long-term’ catheter) is a hollow, flexible tube inserted through the urethra into the bladder to drain urine into an external collection bag.

Once the catheter has been inserted, a small balloon on the internal end is inflated with sterile water to keep it in situ.

Catheters are used often in healthcare settings to assist with a variety of conditions, such as both urinary incontinence and urinary retention, or by patients who may be unable to go to the toilet without assistance.

Procedure

The following demonstration is based on the Catheterisation Clinical Guidelines by the Australia and New Zealand Urological Nurses Society.

Remember to always refer first to your organisation’s internal policies and procedures when performing any procedure like this one.

• To start, gather all equipment required for the procedure.
• Discuss the procedure with the client. Consider using other educational resources such as brochures or interpreters if needed.
• Obtain the client’s consent.
• Check current medications and any known allergies.
• If the client has a latex allergy, a 100% silicone catheter is needed for this procedure.
• Ensure adequate lighting.
• Maintain the client’s privacy by using means such as hospital screens or bed curtains. Ensure the client is warm and not exposed.
• Have the client lie in their bed on their back.
• Ask the client to flex their hips, bend their knees and pull them apart, with their feet together.
• Place a waterproof sheet under the client’s buttocks.
• Perform hand hygiene.
• Prepare and sanitise the trolley or a clean surface.
• Using an aseptic technique, open the catheterisation pack, and add sterile equipment such as the catheter.
• Pour cleansing solution onto tray.
• If a specimen is needed, open the specimen container at this time.
• Empty sterile water (which may be included in the package) into tray in preparation for balloon inflation.
• Take covering off the client.
• Perform hand hygiene, and don non-sterile gloves.
• Part the labia minora to view urethral meatus.
• If the urethral opening is not easily identifiable due to vaginal atrophy and retraction of the urethral opening, you may need to reposition the client by turning the client to the left lateral position and raising the buttocks.
• Cleanse the labia and the area surrounding the urethral opening with cleansing solution using one downward stroke each time.
• Remove non-sterile gloves, perform hand hygiene and don sterile gloves.
• Put the fenestrated drape on the client.
• Apply gel to the lower third of the catheter.
• Prepare a syringe to inflate the balloon with by drawing up sterile water into the syringe.
• Apply gel on the external urinary opening.
• Apply anaesthetic gel into the urethra and discard the gel container.
• Insert the catheter until urine flow is visualised, then advance the catheter a further 2-4 centimeters to ensure the balloon has passed the urethra.
• If resistance is felt, slightly rotate the catheter or advise the client to take a deep breath.
• If the catheter is accidentally inserted into the vagina, it may be momentarily left in to be used as a guide to help insert a new, sterile catheter into the urethra.
• Once inserted successfully, discard the first attempt’s catheter.
• Slowly inflate the balloon per manufacturer instructions.
• Do not inflate if the client complains of pain or urine is not flowing freely, as this could indicate incorrect catheter placement or bladder spasm.
• One correctly inflated, pull on the catheter slightly until resistance is felt.
• Connect the catheter to a drainage system or compatible valve.
• Secure the catheter in place using tape or a catheter strap.
• Leave some slack to ensure that the catheter does not become taut when the client moves to reduce the risk of injury.
• Ensure genital area is kept clean and dry to avoid skin irritations or infections.
• Remove gloves and perform hand hygiene.
• Check in regularly to ensure the client is comfortable.
• Dispose of used equipment and gloves in a biohazard bag, and clinical waste bag in an appropriate waste system.
• Remember to maintain hand hygiene and complete any relevant documentation.

Clinical Guidelines (Nursing) : Indwelling urinary catheter

Introduction

Aim 

Definition of Terms

Indications

Preparation 

Catheter size

Procedure for insertion of urinary catheter 

Special precautions

Documentation

Ongoing nursing management

Troubleshooting

Removal of urinary catheter 

Complications

Discharge information

Companion documents

References

Introduction

Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried out using aseptic technique, Insertion of an indwelling urethral catheter (IDC) is an invasive procedure that should only be carried using aseptic technique, either by a nurse, or doctor if complications or difficulties with insertion are anticipated. Catheterisation of the urinary tract should only be done when there is a specific and adequate clinical indication, as it carries a risk of infection.


Aim

To ensure the insertion and care of the urinary catheter is carried out in a safe manner that minimises trauma and infection risks.
 

Definition of terms

• Indwelling Urinary Catheter (IDC): A catheter which is inserted into the bladder, via the urethra and remains in situ to drain urine.  
  
• Oliguric: a reduction in urine output.
  
• Paraphimosis: occurs when the foreskin is left in a retracted position. The pain and swelling may make it difficult to return the foreskin to the non-retracted position, this may reduce blood flow to the tip of the penis which if left untreated could lead to necrosis of the glans penis. 

Indications

• To drain the bladder prior to, during, or after surgery
  
• For investigations
• To accurately measure the urine output 
• To relieve retention of urine
  
• To relieve urinary incontinence when no other means is practical
  

Preparation

Preparation of the child and family

• Gain patient/primary care givers consent for procedure
• Families/primary care givers should be given a thorough explanation of
  the procedure. Involve the parents where possible when providing an age
  appropriate explanation of the procedure to the patient.
• Consider the need for a referral to play therapy to assist in explaining
  and preparing the patient for the procedure. Play therapists are also able to
  empower the child to identify distraction techniques, as well as provide
  support and distraction throughout the procedure.
• Nursing staff should discuss and plan procedural pain management with
  the child and family prior to the procedure. This may include non pharmalogical
  (including distraction techniques) and pharmalogical considerations including
  Nitrous Oxide or sedation if necessary. For more information regarding this
  please see the Procedural Pain Management guideline.

Preparation of Environment and Equipment

Ensure the patient’s privacy is maintained throughout the procedure and that they are kept warm. Ensure there is adequate light to perform the procedure.

Prepare the following equipment:

• Dressing trolley
  
• Catheterization pack and drapes
  
• Sterile gloves
  
• Appropriate size catheter (see
  catheter size guideline below)
  
• Sterile Lubricant and/or Xylocaine jelly syringe (plain sterile lubricant for infants)
  
• Sterile water to inflate balloon (normal saline can crystallise and render the balloon porous, causing its deflation and the risk of catheter loss)
  
• 5ml/10ml Syringe
  – as stated on catheter packaging
• Specimen jar
  
• Sterile normal saline
  
• Straps/tape to secure catheter to leg
  
• Drainage bag
• Waterproof sheet

Catheter size

Use an appropriate size catheter depending on the age of the child. Catheters that are too big or small are at risk of urethral trauma or leakage. The rational for IDC insertion should also be considered when selecting catheter, for example a patient requiring an IDC post kidney trauma may require a larger size to provide adequate drainage of potential blood clots. Consider silicone catheter if for long term use. 

Procedure for insertion of urinary catheter 

The need for an IDC should be discussed with the patients’ medical team
prior to insertion. Medical approval for IDC insertion should be ordered and/or
documented.

The following should be completed in line with the RCH Aseptic Technique Procedure. 

Female child

• Perform hand hygiene
  
• Place child in supine position with knees bent and hips flexed
  
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open dressing pack (aseptic field) and prepare equipment needed using
  aseptic technique
• Pour sterile normal saline onto tray
• Perform aseptic hand wash and don sterile gloves
• Apply sterile drapes/towel
• Separate labia with one hand and expose urethral opening. In neonates,
  the urethral meatus is immediately above the hymeneal fringes.
• Using swabs held in forceps in the other hand clean the labial folds and
  the urethral opening. Move swab from above the urethral opening down towards
  the rectum. Discard swab after each urethral stroke into waste bag or
  designated waste area.
• Remove catheter wire if a 6Fr catheter is used
• Lubricate catheter
• Insert catheter into the urethral opening, upward at approximately 30
  degree angle until urine begins to flow.
• 
  Inflate the balloon slowly using sterile water to the volume recommended
  on the catheter. Check that child feels no pain. If there is pain, it could
  indicate the catheter is not in the bladder. Deflate the balloon and insert the
  catheter further into the bladder. ALWAYS ensure urine is
  flowing before inflating the balloon. Note that in a child under 6 months a
  balloon is not typically used. In this case be especially mindful that
  strapping is secure.
• Withdraw the catheter slightly until resistance is felt and attach to
  drainage system
• Remove gloves and perform hand hygiene
• Secure the catheter to the thigh with either a catheter securement
  device or tape
• Clean trolley and dispose of used articles into yellow biohazard bag
• Perform hand hygiene 

Male child

• Perform hand hygiene
  
• Place child in supine position
• If soiling evident, clean genital area with soap and water first
• Perform hand hygiene
• Open catheter pack (aseptic field) and prepare equipment needed using
  aseptic technique
• Pour sterile saline onto tray
• Perform aseptic hand wash and don sterile gloves
• Lift the penis and retract the foreskin if non-circumcised. Do not force
  the foreskin back, especially in infants. A sterile gauze swab can be used to
  hold the penis. 
• Using other hand, clean the urethral opening with swabs held in forceps.
  Use a circular motion from the urethral opening to the base of the penis.
   Discard swab into waste bag or designated waste area. 
• For boys older than 3 years insert the Xylocaine gel into the urethra.
  Gently hold the urethra opening closed and wait 2 – 3 minutes to give the gel
  time to work. For infants apply sterile lubricant to catheter before insertion.
  Post urology surgery consider using two syringes of xylocaine gel to increase
  lubrication of the urethra and decrease risk of trauma.
• Remove the wire if using a 6Fr catheter
• Hold the penis with slight upward tension and perpendicular to the
  child’s body. Insert the catheter.
• When the first sphincter is reached (at level of pelvic floor muscles)
  gently bring the penis down to face the child’s toes, apply constant gentle
  pressure. If resistance is felt the following strategies should be considered:
  • Remove the catheter and utilise a 2nd tube of lubricant
  • Increase traction on penis and apply gentle pressure on the catheter
  • Ask the child to take a deep breath
  • Ask the child to cough and bear down e.g. try to pass urine
  • Gently rotate the catheter.

If unable to pass the catheter seek assistance from treating medical team or Urology registrar. DO NOT use force as you may damage the urethra.

• Advance the catheter and gently insert it completely into the urethra
  until the connection portion.
  
• ALWAYS ensure urine is flowing before
  inflating the balloon.
  
• Inflate the balloon slowly using sterile water to the volume recommended
  on the catheter. Check that child feels no pain. If there is pain, it could
  indicate the catheter is not in the bladder. Deflate the balloon and insert the
  catheter further into the bladder. Note that in a child under 6 months a
  balloon is not typically used. In this case be especially mindful that strapping
  is secure.
• Withdraw the catheter slightly till resistance is felt and attach to
  drainage system
• Reposition the foreskin if applicable
• Remove gloves and perform hand hygiene
• Secure the catheter to the thigh with either catheter securement device
  or tape
• Clean trolley and dispose of used articles into yellow biohazard bag
• Perform hand hygiene 

Special precautions

Rapid drainage of large volumes of urine from the bladder may result in hypotension and/or haemorrhage. If concerned clamp catheter if the volume seems excessive. Release clamp after 20 minutes to allow more urine to drain. A medical review of the child should be requested.

For post obstructive diuresis IV replacement of fluid and electrolytes may be required. This should be discussed with the treating medical team.

Documentation

Insertion of the IDC should be documented in the LDA activity. 

• Including catheter type, length and size 
• Amount of water instilled into balloon 
• Document all procedures and cares involving IDC cares

Ongoing nursing management

• Measure urine output as indicated 1 – 4 hourly, assessing the colour and concentration of urine output.        
• Unless otherwise specified by the treating team, normal paediatric urine output is 1-2ml/kg/hr. Report any variation from this to the treating medical team.  
  • Certain drugs will increase diuresis, such as diuretics and ACE inhibitors.
    
  • If oliguric ensure catheter is not blocked (see
    trouble shooting below).
    
  • Record fluid balance. A fluid balance which keeps the urine dilute will lessen the risk of infection. This may not be possible due to the clinical condition of the child.
    
• The IDC insertion site and securement should be assessed at least once a shift, to ensure the IDC is not pulling on the genitals and not twisted. 
  
• IDC drainage bags should be emptied once a shift at a minimum. 
  
• Position drainage bag to prevent backflow of urine or contact with the floor. Gravity is important for drainage and prevention of urine backflow. Ensure the drainage bag is below the level of the bladder, is not kinked or twisted and is secured.

Drainage system

Adherence to a sterile continuously closed method of urinary drainage has been shown to markedly reduce the risk of acquiring a catheter associated infection. Therefore breaches to the closed system should be avoided.

Consider changing the catheter tube and/or bag based on clinical indicators including infection, contamination, obstruction or if system disconnects. If the equipment is damaged or leaks, replace system and/or catheter using aseptic technique and sterile equipment.

Hygiene

• Routine hygiene should be maintained with routine bathing/showering, including daily clean IDC insertion site with warm soapy water and more frequently if build-up of secretions is evident
• Uncircumcised boys should have the foreskin gently eased down over the catheter after cleaning.
• Always check the strapping of the catheter is secure after hygiene is performed.

Infection surveillance

• Consider daily the need for the IDC to remain in situ. Remove as soon as no longer required to reduce risk of Urinary Tract Infection (UTI).
• Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs further investigation.

Specimen collection

• Urine for for urinalysis or culture should be collected fresh from the needleless
  sampling port of catheter tubing (not drainage bag), this should be completed
  in line with the Aseptic Technique Procedure.
  • Clamp below the sampling point.  
  • Scrub sampling point vigorously with 70% alcohol and chlorhexidine (0.5% or 2%) soaked gauze or swabs for at least 15 seconds and allow to air dry 
  • Access port with a 10ml syringe to collect sample
  • Unclamp catheter
• Large volumes e.g. 24hr collection, can be collected from drainage bag.

Troubleshooting

• Catheter not draining/ blocked/patient oliguric
  
• Check catheter/tubing not kinked
  
• Check catheter is still secured to patient leg and that it  hasn’t migrated out of bladder
  
• Assess patient’s hydration status to ensure they are not dehydrated. Consider the need to perform a bladder scan to assess bladder volume. Escalate to medical team if concerned.
  
• The patency of a catheter can be checked via the sampling port or catheter tubing. A blocked catheter should be flushed via the catheter tubing, this is of particular importance in case of blood clots or mucus (for example after a bladder augment).  
  

The following techniques to check for patency and/or flush a catheter should be completed following the Aseptic Technique Procedure. 

Catheter leaking

• Ensure the catheter is still draining and that the urine is not overflowing around a blocked catheter. See above for tips regarding catheters not draining.
• If the catheter is a balloon catheter, make sure the balloon is still inflated. Hold the catheter tubing securely in the same position and empty the balloon to make sure the amount that has been placed initially in the balloon is still present. If not, reinflate the balloon to its initial volume with water. Deflation of the balloon happens easily with a 6Fr catheter.
• Check catheter size is correct for age/size of the child. Use of a balloon catheter in neonates should only be with consultation with the treating medical team.
• Consider the need to remove and reinsert a new catheter in consultation with the treating medical team.  

Removal of urinary catheter 

Equipment required for removal:

• Standard precaution PPE
• 5ml/10ml Syringe – as stated on catheter packaging
• Waterproof sheet
• Kidney dish / receiving container

Procedure:

• Explain procedure to child and family and gain consent.
• Check amount of water used to inflate IDC balloon.
• Gather equipment required for removal
• Ensure patient privacy and have patient in supine position. 
• Place waterproof sheet and/or kidney dish between patient legs.
• Perform hand hygiene & don gloves.
• Deflate balloon completely and remove any straps/tapes
• Gently withdraw catheter on exhale if possible, with rotation movements if necessary.
  • Bear in mind that once inflated, the balloon won’t deflate to its total initial flat state and the balloon portion of the catheter will remain larger than the catheter itself.
    • If resistance felt and catheter cannot be easily removed do not force, leave catheter in situ and consult medical team. 
    • Consider cutting the catheter at the balloon inflation point to ensure the balloon is deflated. 
    • Once removed inspect catheter for intactness. Report if not intact.
• Perform hand hygiene.
• Document catheter removal in the LDA activity.
• Observe for urine output post catheter removal.
• If the patient has not passed urine 6 – 8hours post catheter removal
  assess the patient’s hydration status and consider the need to perform a
  bladder scan. Discuss findings with the treating medical team. 

Complications 

• Inability to catheterise: ensure appropriate catheter size has been
  selected based on the age/size of the child. Ensure adequate procedural pain relief
  and distraction is in place during the procedure.
  • Escalate to the treating medical team and consider the need for a
    referral to the urology team.  
  • In young girls, the urethra can be difficult to localise and the
    catheter can go directly in the vagina. In this case, leave the first catheter
    in the vagina and use another one to place immediately above, which will be
    more likely to go in the urethra.
• Urethral injury may occur from trauma sustained during insertion or
  balloon inflation in incorrect position: it is very important to ensure the
  catheter is in the bladder before inflating the balloon, this can be confirmed
  by visualising the stream of urine prior to balloon inflation.
• Haemorrhage
• False passage (catheter pushed through urethral wall): The risk of false
  passage is actually higher when using a smaller catheters, ensure catheter size
  utilised is appropriate for child’s age and size.
• Urethral strictures following damage to urethra. This may be a long term
  problem
• Infection
  • To minimise risk of infection insertion of IDC’s must be performed using surgical aseptic technique with single use sterile gloves.  
  • Regular hygiene should be maintained whilst IDC is in situ. 
  • Where possible avoid disconnecting the IDC circuit to minimise risk of contamination
  • Monitor for and report signs of infection including fever, offensive smelling urine, unexplained blood or cloudy urine.
• Psychological trauma
• Paraphimosis due to failure to return foreskin to normal position following catheter insertion:
  • To minimise risk, remember to replace the foreskin to normal position in non-circumcised patients and check at catheter care or nappy change that the foreskin is in place.

Discharge information

• Some children will be discharged from the hospital with their IDC
  insitu. It is important to teach the families how to care for the catheter, how to
  perform hygiene, how to monitor the output and how to troubleshoot. Refer to  Kids Health
  Info Fact Sheet: Indwelling urinary catheter


Companion documents

Other RCH IDC resources available:

• Kids Health Info Fact Sheet: Indwelling urinary catheter

• RCH Teaching and supporting clean
  intermittent catheterisation for parents and children

References

• Anderson, C. , & Herring, R. (2019). Pediatric Nursing Interventions and Skills. In M. Hockenberry, D. Wilson, & C. Rodgers (Eds.), Wong’s Nursing Care of Infants and Children (pp. 701-704) St. Louis, Missouri: Elsevier.
• Australia and New Zealand Urological Nurses Society, (2014). Catheterisation Clinical Guidelines
• Australian Guidelines for the Prevention and
  Control of Infection in Healthcare (2019) pages 137-140
  https://www.nhmrc.gov.au/guidelines-publications/cd33
• Fasugba, O., Koerner, J., Mitchell, B. G., & Gardner, A. (2017). Systematic review and meta-analysis of the effectiveness of antiseptic agents for meatal cleaning in the prevention of catheter-associated urinary tract infections. Journal of Hospital Infection, 95(3), 233-242.
• Galiczewski, J. M. (2017). An intervention to improve the catheter associated urinary tract infection rate in a medical intensive care unit: direct observation of catheter insertion procedure. Intensive Critical Care Nursing. 40:26–34. Intensive & Critical Care Nursing, 41, 2. https://doi.org/10.1016/j.iccn.2017.04.002
• Gould, C., Umscheid,C., Agarwal,R., Kuntz,G., Pegues, D., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2009) Guideline for prevention of catheter associated urinary tract infections (2009) Updated: June 6, 2019. https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf
• Government of Western Australia Department of Health (2015). Indwelling Catheter: Blockage. Clinical Guideline, Women’s and Newborn Health Service, King Edward Memorial Hospital.
• Government of Western Australia Department of Health. Urethral Catheterisation Neonatal Guideline. (2019).
• Holroyd, S. (2019). Indwelling catheterisation: evidence-based practice. Journal of Community Nursing, 33(5), 40-46.
• NHS Southern Health, Urinary Catheter Care Guidelines (2020)
• Pradhan, S. K., & Das, K. (2017). Urinary Bladder Catheterization. Practical Procedures in Pediatric Nephrology, 4.
• Royal College of Nursing Catheter Care RCN Guidance for Healthcare Professionals (2019)
• Rowe, J. (2020). Urinary catheter management. Starship Hospital New Zealand.

Evidence table

Indwelling urinary catheter insertion and management evidence table

Please remember to
read the disclaimer.

The
development of this nursing guideline was coordinated by Liam Cunningham, RN, Day Medical Unit, and approved by the Nursing Clinical Effectiveness Committee. Updated September 2020.  

Bladder catheterization: necessary preparation, course of the surgeon’s appointment and contraindications

Normally, the urinary tract is sterile, and in order to avoid infectious complications, sterility must be observed. Only sterile catheters are inserted. The doctor or nurse puts on sterile gloves. The head of the penis and the foreskin of men, the vulva with the external opening of the urethra in women are treated with furatsilin or other antiseptic solution, also sterile.

The patient (or patient) lies on his back, bending and spreading his legs. The nurse or doctor stands on the right, with his left hand exposes the head of the penis or pushes the labia apart. Sterile tweezers are taken in the right hand. These tweezers capture the catheter closer to the rounded end. In order for the catheter to move smoothly along the urethra and not injure it, the end of the catheter is moistened with a solution of petroleum jelly, which must also be sterile.

Then insert the end of the catheter into the opening of the urethra. Slowly continue insertion, intercepting the catheter with forceps until it is in bladder . Evidence of this will be the release of urine from the outer end of the catheter.

If catheterization is simultaneous, remove the catheter immediately after passing urine. Before extraction, a solution of furacilin is often injected into the lumen of the bladder with a syringe. With prolonged drainage of the bladder, the catheter is fixed with adhesive plaster to the inner surface of the thigh, lengthened by means of tubes and adapters, and connected to a container for collecting urine. In this case, special attention should be paid to asepsis. The catheter is essentially a foreign body, and its prolonged presence can provoke an infectious inflammation.

Since the urinary system of men and women has significant differences, the technique of bladder catheterization in both sexes will also be different. The urethra of women is short, so in order to release urine, it is enough to advance the catheter to a depth of about 5-10 cm. But at the same time, you need to make sure that the end of the catheter enters the opening of the urethra and does not slip into the vagina. In general, the catheterization technique for women is easier than for men.

In men, the urethra is much longer, and therefore the depth of catheter advancement is greater, and is about 20-25 cm. There are physiological constrictions and bends here, which make it somewhat difficult to advance the catheter. Significant difficulties can also be with strictures that develop as a result of inflammatory cicatricial changes in the urethra. An enlarged prostate interferes with the catheter’s progress.

Relatively long urethra with physiological and pathological obstacles creates preconditions for injuries. Therefore, in the event of obstacles, in no case should force be used. In these cases, re-catheterization is resorted to with more rigid or thin products of a different modification. In special cases, the urologist uses metal catheters. If catheterization is fundamentally impossible, they decide on the imposition of an epicystostomy, an opening communicating with the bladder on the anterior abdominal wall.

Despite the apparent ease of the procedure, it is by no means trusted to be performed by the patient on his own, nor are untrained persons involved in the installation of the catheter. Firstly, only a specialist knows about all the stages of installing a catheter, follows the rules of antisepsis, uses petroleum jelly or a special gel for gentle administration, and checks the tightness of the device with a syringe. Also, a nurse or urologist knows how to properly advance the catheter, follows the rules of asepsis. In men, the penis is held in a position perpendicular to the body during insertion and advancement of the catheter. The room itself, in which the catheter is installed, must meet the standards of sterility, so the introduction at home is carried out only in case of emergency.

If a catheter is to be inserted for a long time, then the general condition of the patient also needs to be monitored. The catheter should be emptied of accumulated urine every 8 hours.

If a patient tries to introduce a catheter on his own without proper knowledge and skills, then there is a high probability of damage to the urethra, which will lead to an inflammatory process and the need for treatment. Another likely option is the introduction of an infection, which can also lead to the development of an inflammatory process with the need for therapy under medical supervision.

Once the urine collection bag is in place, the patient or medical staff monitors the progress of the outflow. If the catheter fills with urine earlier than 8 hours, it is emptied. Getting rid of the accumulated urine is carried out before the complete filling of the catheter, as this can disrupt the flow of urine and lead to undesirable consequences. If the progress of the accumulation of urine in the catheter is monitored and full filling is not allowed, the insertion of the catheter is still a safe procedure without any negative consequences.

The specialist also ensures that the place of collection of urine is below the location of the bladder in a person. As a rule, for this it is attached at the hip, fixed and monitored for fullness. The recommended time to empty the device of accumulated urine is when the level is about half full. The patient can empty himself, having received prior instructions from the medical staff on how to do it correctly, and in no case removes the catheter on his own during the emptying procedure.

It is believed that it is easier for patients to insert a catheter than for patients. The reason is not only the greater length of the urethra in men, but also narrowing and expansion, which require sufficient sensitivity and skill from medical personnel when inserting a catheter. In addition, catheters are not only single-channel, but also multi-channel, up to 3. This allows you to enter any drugs directly into the bladder without disturbing the process of urine outflow through another channel.

Catheterization can be used for various diseases, operations and procedures. For example, this is required by an operation to increase the penis in men, therapy during inflammatory processes in the urogenital area. Catheterization is used in all cases of obstructed outflow of urine.

A properly placed catheter does not increase the risk of inflammatory processes and is not a cause of infectious diseases of the urogenital area. Catheterization can be carried out for women, men and children at any age if necessary and at the discretion of the doctor. If performed correctly, catheterization is a painless and safe option for diverting urine in an emergency.

Bladder catheterization in women

Intermittent bladder catheterization in women (also called intermittent)

It is considered a fairly simple operation to perform and one of the most common medical procedures, which, nevertheless, is of no small importance in medicine – both for diagnosis and as an independent therapeutic measure.

This procedure can be used in case of diagnosed inability to urinate independently, in the course of surgical interventions under general anesthesia, for a number of diagnostic medical actions, for example, if it is necessary to administer radiopaque preparations, and for some other purposes.

Bladder catheterization, in modern medicine, refers to the introduction of special tubes of varying degrees of rigidity into it, for the purpose of emptying, washing or filling with medicines. The technique and methodology of this process is quite simple compared to male catheterization, and the likelihood of injury and subsequent complications is significantly less. But this medical action should be carried out exclusively in strict accordance with the basic principles of asepsis, disinfection and antisepsis – both during the placement of the catheter and during its care. This will avoid the potential development of an infectious process that may occur if sterility is not observed.

Types of catheters

The main differences between female and male catheters are the length (female – shorter) and diameter (female – wider) of the product. In addition, male catheters are curved, unlike straight female ones. This is due to the anatomical and physiological features of the structure of the female and male genitourinary systems.

Modern catheters are most often made of silicone. This chemically inert material has high biocompatibility, low surface tension, thermal stability and good hydrophobic properties. This material allows easy insertion and removal of the catheter, does not cause allergic reactions and prevents the deposition of salts in the catheter. The main disadvantage of this material is the rather high production cost.

Another common catheter material is synthetic or natural latex. It is also a highly elastic and durable material, but it contains a variety of organic compounds that can cause an allergic reaction. Therefore, modern latex catheters are coated with silicone, which as a result provides an optimal combination of manufacturing cost, physical properties of the material and its anti-allergic properties.

Catheters are also made from PVC. This material has high strength, good elasticity and flexibility. In addition, its production is inexpensive. The main disadvantage of this material, due to which it is practically not used in modern catheters, is the possibility of allergic reactions to it from the body.

There are also metal rigid brass catheters that are used for one-time emptying during childbirth or surgery, but today they are practically not used.

By the time of establishment, permanent and temporary catheters are distinguished, and by the number of channels in the body – one-, two- or three-channel. Catheters also differ depending on the organ being catheterized – they can be for the bladder, urethral, ​​ureteral and renal pelvis catheters.

Nelaton and Tiemann catheters are the most common types of catheters for intermittent catheterization. Nelaton’s catheter is a straight catheter with a rounded end and two draining side holes. It is used for intermittent catheterization of the bladder, including for self-catheterization, when it is impossible to urinate naturally. The Tiemann catheter has similar characteristics but has a curved end and is most commonly used by men.

There are other types of catheters (Foley, Pezzera, Maleko, etc.), but they are mainly used for long-term and permanent catheterization. Therefore, their use is allowed only under the supervision of doctors and they will not be discussed in this article.

Indications for catheterization in women

They have a fairly wide range and include:

– collection of urine for analysis

– urine sampling at specified, based on the tasks, time intervals for diagnosis

– chronic or acute urinary retention, and as a result, the inability to urinate spontaneously

– bladder emptying in patients under general anesthesia

– diversion of urine in patients with spinal injury

– flushing of the bladder to remove stones or their remnants, purulent or blood clots

– administration of medicinal and radiopaque preparations

Contraindications for catheterization

Catheterization is not performed for:

– anuria

– cystitis

– urethritis

– bleeding from the urethra

– obstruction of the urethra

– severe spasms of the urethra

– acute damage to the organs of the genitourinary system

That is, catheterization is categorically not indicated for patients with injuries and injuries of the genitourinary system, as well as with acute inflammatory processes in the urinary tract.

Bladder catheterization in women – procedure and its features

It was said above that due to the structural features of the female genitourinary system, catheterization is much easier for patients than for men. This also explains the main risks of this procedure – after all, a wide and short urethra simplifies the access of pathogens to the upper urinary tract. The strict avoidance of this is the original, distinctive feature of female catheterization. It is ensured by the exact compliance of this procedure with the basic rules of hygiene, antiseptics and disinfection. Catheterization does not require prior preparation and is performed without anesthesia.

Before starting the procedure, it is necessary to carefully treat the hands with a special solution for disinfection and then perform the following steps:

– release the entrance to the urethra, for which gently spread the labia with your fingers, then treat its outer surface with a cotton-gauze ball with a disinfectant solution

– using sterile tweezers, remove the catheter, then treat its insertion part with glycerin or vaseline

– gently insert the catheter into the urethra and move it forward to the bladder

– if catheterization is carried out correctly, after reaching the bladder, urine should appear at the opposite end of the catheter

– the catheter should be connected to the urinal, and after the end of urine drainage, press on the lower abdomen for the final emptying of the bladder

– if it is necessary to measure the amount of discharge, urine must be poured into a measuring container, and if it is necessary to wash the bladder, introduce a disinfectant solution

Catheter care and removal

The catheter can be installed to the patient for very different periods of time. Basically, it depends on its material: silicone-coated latex catheters can last a week, all-silicone catheters last a month, and silicone-silver catheters can last up to three months without replacement.

All installed catheters need constant and careful care to avoid infection of the urinary tract. The skin around the catheter should be washed with soap and warm water at least twice a day. Hygiene care after a bowel movement should be carried out in such a way as to prevent infection from the anus. The urinal should be placed below the level of the bladder to prevent backflow of urine, and should be emptied of accumulated secretions at least every three to four hours.

If the catheter becomes clogged, it must be regularly flushed with sterile saline or antiseptic solution.

The patient is able to remove the catheter on her own, but it is better to entrust this to a specialist in order to prevent possible complications. The catheter should be removed until the bladder is completely empty so that the remaining urine can flush out the urethra, which frees it from accumulated microorganisms.

To remove the catheter, follow these steps:

– remove the urinal for emptying

– the patient should lie on her back, bend and slightly spread her legs, treat the entrance to the urethra with a cotton-gauze ball with a disinfectant solution

– first empty the balloon holding the catheter in the bladder cavity, for which you can use a 10 ml syringe

– now you can get the catheter itself

– after removing the catheter, it is recommended to drink more liquid to thoroughly flush out pathogens, as well as take sitz baths with disinfectant solutions

Possible complications of catheterization

Infection of the urinary tract is considered the most common complication from an installed catheter – it occurs in half of patients with an installed catheter. Therefore, the installation of a catheter implies almost mandatory antibiotic therapy.

Another common complication of catheterization is empty bladder syndrome.