Season 4, Episode 6 All Things Urinary Catheters Show Notes

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Your first year as a registered nurse is challenging. This podcast is hosted by Kati Kleber, BSN RN CCRN and Elizabeth Mills, BSN RN CCRN and features experienced nurses from FreshRN.com, who discuss the basics of that first year. From nursing orientation, code blues, tricks of the trade, and personal experiences, to time management, delegation, patient deaths, and more.

Download the Season 4, Episode 006 show notes or view them below

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 infections
• Small minority of patients are at higher risk for CAUTI.
  • Be aware of patient’s factors.
• Most CAUTI are preventable
• Best prevention is not to have them
• Changing mentality of why/when patients need catheters
  • Not using as frequently
  • More specific rationale for 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 bed for easier transfers for patients with limited mobility
• Speci-Hats – Placed in toilet to capture urine, but sometimes difficult to put in perfect spot to avoid
  misses
• Female Urinals – Shaped differently, with 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 perineum, but not high
    enough to cause tissue damage
  • Use for appropriate patients (not those who are constant wiggle worms)
  • Cannot be used during menses, nor for patients having frequent stools.

Universal Considerations

• Diapers – Many facilities now avoid them
  • Can lead to skin breakdown, as moisture is captured against skin
• Disposable Pads
  • Some weigh disposable pads (the pads patient’s lay on for repositioning) to calculate output
    (like diapers in NICU)
• Does your patient need to have accurate I/O?
  • Some patients can simply be assisted to the bathroom with no need for measurement
• Although non-invasive methods may create more work for the nurse/nursing assistant, we must weigh
  the risks associated with an indwelling catheter.
• An indwelling urinary catheter, just by being there, is a risk of infection.
• 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 skin can (or body excretions) can adhere to the catheter and find a route
    into the bladder, even if insertion was perfectly sterile.
• Diarrhea is particularly concerning with catheters, especially in females, because 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 for 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 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 urethra
• Enlarged prostate
  • Consider coude catheter.
    • Has curved tip and is more rigid, curves past enlarged prostate easier
    • May require specific MD order
• Hypospadias
  • Uretheral opening may appear to be in normal position, but there is no open pathway.
  • Actual uretheral opening is on the under side 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
• Treatment of CAUTI is expensive.
  • According to article published in the American Journal of Infection Control in July of 2018, costs
    can range from $1,000 – $10,000.
• Can be fatal – think urosepsis, amongst other complications
• Risk of CAUTI increases each day the catheter remains in place
  • According to 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 proper position
  • Urine should not flow uphill before draining into the bag
    • Leads to retrograde flow
• No dependent loops, whether the 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 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?

Preventing Catheter-Associated Urinary Tract Infections: Build an Evidence-Based Program To Improve Patient OutcomesCatheter-Associated Urinary Tract Infections: Evidence-Based Best Practices for NursesThe 2019-2024 World Outlook for Urinary CathetersMinimize The Microbial Load On Urinary Catheters

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