URINARY CATHETERISATION AND CATHETER CARE GUIDELINES

CATHETER RECORD SHEET ZML 997 CATHETER MAINTENANCE SHEET ZML 996 CATHETER CARE BOOKLET ZML 998 Quality Improvement Scotland Urinary Catheterisation and Catheter Care www.nhshealthquality.org Continence Advisory Service Inverurie Hospital NHS Grampian January 2007 Date of review January 2009

If you have difficulty understanding the English language, this policy can be made available to you in a language of your choice. This policy can also be made available, on request in other formats e.g. in large print or on a computer disk. For all requests for copies of this policy in another language, or in alternative format, please call the Corporate Communications Team on 01224 554400

NHS GRAMPIAN RESOURCE PACK ON URINARY CATHETERISATION AND CATHETER CARE GUIDELINES CONTENTS
SECTION 1 (Pages 1-2) SECTION 2 (Pages 3) SECTION 3 (Pages 4 - 10) SECTION 4 (Pages 11 - 17) SECTION 5 (Pages 18 - 22) SECTION 6 (Pages 23 - 26) SECTION 7 (Pages 27 - 29) SECTION 8 (Pages 30 31) SECTION 9 (Page 32) SECTION 10 (Page 33) SECTION 11 (Pages 34 35) SECTION 12 (Page 36) SECTION 13 (Pages 37 42) SECTION 14 (Pages 43 46) SECTION 15 (Pages 47 52) SECTION 16 (Pages 53 54) SECTION 17 (Page 55) INTRODUCTION TO RESOURCE PACK

URETHRAL CATHETERISATION

INITIAL FEMALE CATHETERISATION & RE-CATHETERISATION

INITIAL MALE CATHETERISATION & RE-CATHETERISATION

SUPRA-PUBIC CATHETERISATION

INTERMITTENT CATHETERISATION

CATHETER VALVES

EMPTYING THE URINE DRAINAGE BAG

ATTACHING THE NIGHT DRAINAGE BAG REMOVAL OF NIGHT DRAINAGE BAG

CHANGING A URINARY DRAINAGE BAG

CATHETER HYGIENE

CATHETER INFORMATION BOOKLET

CATHETER MAINTENANCE SOLUTION

CATHETER PROBLEMS AND POSSIBLE SOLUTIONS

COLLECTION OF A CATHETER SPECIMEN OF URINE

USE OF INSTILLAGEL IN CATHETERISATION P.T.O.

CONTENTS CONTINUED

SECTION 18 (Pages 56 57)

BIBLIOGRAPHY .

APPENDIX 1 APPENDIX 2 -

THE USE OF GLOVES

GUIDELINES FOR THE USE OF DISPOSAL BAG AND THE DISPOSAL OF HEALTHCARE WASTE HOSPITAL/COMMUNITY GUIDELINES ON THE USE OF DISPOSABLE BEDPADS CATHETERS AVAILABLE FROM CENTRAL STORES

APPENDIX 3 APPENDIX 4 -

THE ABOVE APPENDIX STAFF WILL HAVE IN THEIR CLINICAL AREAS

URINARY CATHETERISATION AND CATHETER CARE PROCEDURES PRODUCED BY Wilma Nicolson Susan May Sheila Shearer

- Continence Advisor - Development Nurse for the Promotion of Continence - Continence Advisor

ACKNOWLEDGEMENTS The group would like to thank the following for reviewing and advising the group Roy Browning - Infection Control Nurse Ali Campbell - Urology Specialist Nurse Dawn Campbell - Urology Specialist Nurse

JANUARY 2007

The Procedures to be reviewed January 2009 Throughout the Procedures please refer to the appropriate guidelines in appendix
-1-

CATHETERISATION
1. Assessment of Incontinence and the patients needs should be undertaken to identify the underlying cause and reason for catheterisation. NOTES After assessing the reason for catheterisation as small a catheter size should be used to allow for good drainage in patients who have a urethral catheter Catheters with a 10ml balloon should be used whenever possible in urethral catheterisation Intermittent self-catheterisation should be commenced if possible before urethral catheterisation is undertaken 2. Before a patient has a urethral catheter inserted, the INITIAL PROCEDURE REQUIRES MEDICAL AGREEMENT, and the procedure should only be undertaken after the patient gives full consent and with the full approval of the person with continuing responsibility for the patient. Refer also to adults with Incapacity Act (Scotland 2000) The procedure can be carried out by nursing staff who have had training, are confident and are competent in the procedure of female, male or supra-pubic catheterisation Competence should be acquired through educational workshops followed by observation and supervision in the clinical setting A registered nurse must take into account their professional accountability NMC Code of Conduct Records and Record Keeping If there is any fault with equipment used e.g. catheter this should be reported to the Medical Device Agency 0131 275 7578

3.

4.

5.

6.

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URETHRAL CATHETERISATION
DEFINITION
Urinary catheterisation is the insertion of a hollow tube via the urethra into the bladder, using an aseptic technique, for the purpose of draining or instilling fluids.

INDICATIONS
MALE 1. To empty the contents of the bladder, e.g. before or after abdominal, pelvic or rectal surgery. 2. To relieve retention of urine 3. To bypass an obstruction 4. To enable bladder function tests to be performed 5. To allow irrigation of the bladder 6. To determine residual urine 7. To introduce cytotoxic drugs into the bladder for treatment of papillary bladder carcinoma 8. To measure urinary output accurately 9. To relieve incontinence when no other means is practicable FEMALE in addition to the above: 10. To empty the bladder before childbirth if thought necessary 11. To avoid complications during intracavity insertion of radioactive caesium

CONTRA-INDICATIONS
Nurses should not perform catheterisation without first seeking medical advice on the following: Patients who have a history of urethral stricture Patients who have undergone trans-urethral resection of the prostate gland in the previous 48 hours Patients with a phimosis (tight foreskin) Patients who have a past history of difficulty in catheterisation Undiagnosed haematuria Urinary tract infection with clinical symptoms

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INITIAL FEMALE CATHETERISATION

REQUIREMENTS Disposable plastic apron Sterile Procedure Pack 2 sterile catheters of suitable type, size and length (catheters should always be the
smallest suitable size to prevent irritation and trauma to the urethra) 2 pairs sterile gloves as per glove guidelines Cleansing agent Sterile water or normal saline Local anaesthetic lubricating gel 6ml 10ml ampoule of sterile water if required 10ml syringe and needle if required Drainage bag with straps, sleeve, stand or catheter valve (Section 7) Disposal bag as per healthcare waste policy Blanket or cover for upper half of body Bed protection/disposable pad Sharps box

RECATHERISATION
As above plus: 1 pair non sterile gloves as per glove guidelines 1 x 10ml syringe Disposable plastic apron

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INITIAL FEMALE URETHRAL CATHETERISATION

PROCEDURE Explain the procedure to the patient Provide privacy to patient Remove patients lower garments. Assist patient into supine position with legs bent, hips flexed if appropriate. Ensure good light source is available. Place bed protection on the bed. Cover patient Wash and dry hands thoroughly Put on disposable plastic apron Prepare work area with required equipment Open out sterile dressing pack using an aseptic technique. Pour normal saline/sterile water into container. Open supplementary packs e.g. gloves, gel, catheter Draw up 10mls sterile water with syringe and needle. If the catheter has a prefilled balloon follow manufacturers instructions Remove needle and dispose of in sharps container Remove cover from the patient and assist into suitable position Wash and dry hands thoroughly Put on sterile gloves and arrange the sterile drape from pack across the patients thighs Separate the labia minora so that the urethral meatus is visible

RATIONALE To ensure patient understands the procedure and gives valid consent Ensure patient comfort and dignity To allow access for catheterisation. To contain any leakage and ensure patient comfort and dignity

To reduce the risk of cross-infection To reduce the risk of cross-infection from micro-organisms on uniform To ensure all equipment is ready for procedure Create a sterile field

To enable the inflation of the balloon of catheter immediately following insertion

For the safe disposal of equipment to protect healthcare workers and others To allow access for catheterisation To reduce the risk of cross-infection To reduce the risk of cross-infection. To create a sterile field Provides better access to urethral orifice helps to prevent labia contamination of the catheter To reduce the risk of cross-infection

Cleanse the vulval area with sterile water/saline using single downward strokes Insert 6mls of anaesthetic gel slowly into To reduce urethral trauma and patient the urethral meatus WAIT 5 MINUTES. discomfort. Follow manufacturer's instructions Discard the anaesthetic gel syringe into disposal bag Remove and dispose of gloves as per To reduce the risk of cross-infection healthcare waste policy -5-

PROCEDURE Wash and dry hands thoroughly Apply 2nd pair of sterile gloves Position the sterile container to catch urine Open the inner cover of the catheter and expose 10cm of catheter Insert catheter into the urethra orifice until urine flows. The catheter tip should not touch the urethra. Advance the catheter a further 6-8cms Inflate the balloon slowly with 10mls sterile water. (If pre-filled follow manufacturers instructions) Observe patient for signs of distress. Ensure urine draining Withdraw catheter gently until resistance is felt Attach the catheter to closed drainage system and secure with appropriate straps/sleeve or catheter valve (Refer to Section 7) Make patient comfortable Measure the amount of urine drained Remove apron and gloves. Dispose of equipment as per clinical waste guidelines Wash and dry hands thoroughly Record details of the catheterisation procedure in the patients notes/catheter record sheet code number ZML 997 Type, size, length of catheter Lot/batch number Expiry date Amount of water removed/instilled Cleansing agent used Anaesthetic gel used, lot/batch number and expiry date Type of urine drainage system Any problems encountered with removal/insertion of catheter Amount of urine drained Signature of nurse performing procedure

RATIONALE To reduce the risk of cross-infection To reduce the risk of cross-infection Provide temporary container for urine as it drains To reduce the risk of contamination To reduce the risk of cross-infection To prevent the inflation of the balloon in the urethra To reduce the risk of cross-infection Prevent inflation of the balloon in the urethra

To ensure the balloon is inflated To ensure the correct use of device Maintain patient comfort and reduce risk of urethral/bladder neck trauma Ensure patient comfort and dignity To reduce the risk of cross-infection Reduce environmental contamination To reduce the risk of cross-infection To improve catheter management and provide a legal record

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PROCEDURE Provide patient with: Relevant patient leaflet Sufficient catheter equipment Contact number of Health Care Professional

RATIONALE

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RE-CATHETERISATION FEMALE
PROCEDURE Explain the procedure to the patient Provide privacy to patient Remove patients lower garments, assist patient into a supine position, legs bent, hips flexed if appropriate. Ensure a good light source is available. Place bed protection on the bed. Cover patient Wash and dry hands thoroughly Put on disposable plastic apron Prepare work area with required equipment. Open out sterile dressing pack using an aseptic technique. Pour normal saline/sterile water into container. Open supplementary packs e.g. gloves/gel/catheter Draw up 10mls sterile water with syringe and needle. If the catheter has a prefilled balloon follow manufacturers instructions Remove needle and dispose of in sharps box Uncover the patient and assist into a suitable position Wash and dry hands thoroughly Apply non-sterile gloves Connect empty syringe to the balloon port of the catheter in situ, withdraw the water from the balloon Gently remove the catheter observing the length of the catheter removed Remove syringe and dispose of syringe into sharps box. Take note of the amount of water removed Dispose of catheter, gloves and apron as per healthcare waste policy Put on disposable plastic apron Wash and dry hands thoroughly Put on sterile gloves and arrange the sterile drape from pack across the patients thighs RATIONALE Ensure patient understands the procedure and gives valid consent Ensure patient comfort and dignity To allow access for catheterisation. To contain any leakage and ensure patient comfort and dignity

To reduce the risk of cross-infection To reduce the risk of cross-infection from micro-organisms on uniform To ensure all equipment is ready for procedure

Enable inflation of balloon of catheter immediately following insertion

For the safe disposal of equipment to protect healthcare workers and others Allow access for catheterisation To reduce the risk of cross-infection To reduce the risk of cross-infection Deflation of the balloon allows the catheter to be removed To prevent trauma and allow for ease of insertion of the new catheter Safe disposal of equipment

To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection To prevent the risk of cross-infection. Create a sterile field

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PROCEDURE Separate the labia minora so that the urethral meatus is visible Cleanse the vulval area with sterile water/saline using single downwards strokes Insert 6mls of anaesthetic gel slowly into the urethral meatus WAIT 5 MINUTES. Follow the manufacturer's instructions. Discard the anaesthetic gel syringe into disposal bag Remove and dispose of gloves as per healthcare waste policy Wash and dry hands thoroughly Apply sterile gloves Position the sterile container to catch urine Open the inner cover of the catheter and expose 10cm of catheter Insert catheter into the urethral orifice in an upward and backward direction until urine flows. The catheter tip should not touch the urethra. Advance the catheter a further 6-8cms Inflate the balloon slowly with 10mls sterile water. (if pre-filled follow manufacturers instructions) Observe patient for signs of distress. Ensure urine draining Withdraw catheter gently until resistance is felt Attach the catheter to closed drainage system and secure with appropriate straps/sleeve or catheter valve (Refer to Section 7) Make patient comfortable Measure the amount of urine drained Remove apron and gloves. Dispose of equipment as per healthcare waste policy Wash and dry hands thoroughly

RATIONALE Provides better access to urethral orifice helps prevent labial contamination of the catheter To reduce the risk of cross-infection

To prevent urethral trauma and patient discomfort.

To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection Provide temporary container for urine as it drains To reduce the risk of contamination To reduce the risk of cross-infection Prevent inflation of the balloon in the urethra

To reduce the risk of cross-infection Prevent inflation of the balloon in the urethra

Ensure balloon is inflated Ensure correct use of device Maintain patient comfort and reduce risk of urethral bladder neck trauma Ensure patient comfort and dignity To reduce the risk of cross-infection and environmental contamination To reduce the risk of cross-infection

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PROCEDURE Record details of the catheterisation procedure in the patient's notes/catheter record sheet code number ZML 997 Type, size, length of catheter Lot/batch number Expiry date Amount of water removed/instilled Cleansing agent used Anaesthetic gel used, lot/batch number and expiry date Type of urine drainage system Any problems encountered with removal/insertion of catheter Amount of urine drained Signature of nurse performing procedure Provide patient with: Relevant patient leaflet (Section 13) Sufficient catheter equipment Contact number of Health Care Professional

RATIONALE Improve catheter management and provide a legal record

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INITIAL MALE CATHETERISATION

REQUIREMENTS Disposable plastic apron Sterile Procedure Pack 2 sterile catheters of suitable type, size and length (catheters should always be the
smallest suitable size to prevent irritation and trauma to the urethra) 2 pairs sterile gloves as per glove guidelines Cleansing agent Sterile water or normal saline Local anaesthetic lubricating gel 11ml 10ml ampoule of sterile water if required 10ml syringe and needle if required Drainage bag with straps, sleeve, stand or catheter valve (See Section 7) Disposal bag as per healthcare waste policy Blanket or cover for upper half of body Bed protection/disposable pad Sharps box

RECATHERISATION
As above plus: 1 pair non sterile gloves as per glove guidelines 1 x 10ml syringe Disposable plastic apron

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INITIAL MALE URETHRAL CATHETERISATION

PROCEDURE Explain the procedure to the patient Provide privacy to patient Remove patients lower garments Assist patient into a suitable position supine with legs extended Place bed protection on the bed Cover patient Wash and dry hands thoroughly Put on disposable plastic apron Prepare work area with required equipment Open out sterile dressing pack using an aseptic technique. Pour normal saline/sterile water into container. Open supplementary packs e.g. gloves/gels/catheter Draw up 10mls sterile water with syringe and needle. If the catheter has a prefilled balloon follow manufacturers instructions Remove needle and dispose of in sharps box Remove cover from the patient Wash and dry hands thoroughly Put on sterile gloves and arrange the sterile drape from pack across the patients thighs Hold the penis with a sterile swab, retract the foreskin if present and clean the shaft, glands and urethral meatus with sterile water/saline Insert 11mls of local anaesthetic lubricating gel slowly into the urethral meatus WAIT 5 MINUTES. Follow manufacturer's instructions. Discard the anaesthetic gel syringe into disposal bag Remove and dispose of gloves as per healthcare waste policy Wash and dry hands thoroughly Apply 2nd pair of sterile gloves

RATIONALE Ensure patient understands the procedure and gives valid consent Ensure patient comfort and dignity To allow access for catheterisation Enable good position for insertion of catheter Contain any leakage Ensure patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection from micro-organisms on uniform

Enable inflation of balloon of catheter immediately following insertion

For the safe disposal of equipment to protect healthcare workers and others Allow access for catheterisation To reduce the risk of cross-infection To reduce the risk of cross-infection. Create a sterile field Provide access to the urethral meatus To reduce the risk of cross-infection

To reduce urethral trauma and patient discomfort.

To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection

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PROCEDURE Position the sterile container to catch urine Open the inner cover of the catheter and expose 10cm of catheter Holding the shaft of the penis with a sterile swab raise it until almost fully extended. Maintain in position until procedure completed. Insert catheter into the urethra for 15-25cm until urine flows. If resistance is felt at the external sphincter slightly increase the traction on the penis and apply gentle steady pressure on the catheter. Ask the patient to strain slightly or cough. Inflate the balloon slowly with 10mls sterile water. (If pre-filled follow the manufacturers instructions). Observe patient for signs of distress. Ensure urine draining Withdraw catheter slightly until resistance is felt. Attach the catheter to closed drainage system and secure with appropriate straps/sleeve, or catheter valve (Refer to Section 7) Ensure glans penis is clean Replace the foreskin Remove apron and gloves. Dispose of equipment as per healthcare waste guidelines. Measure the amount of urine drained Make patient comfortable Wash and dry hands thoroughly

RATIONALE Provide temporary container for urine as it drains

Aid passage of catheter through prostatic urethra

Prevent inflation of the balloon in the urethra Aid the passage of the catheter through the prostatic urethra Relax the external sphincter

To reduce the risk of cross infection Prevent inflation of the balloon in the urethra

Ensure balloon is inflated Ensure correct use of device Maintain patient comfort and reduce risk of urethral/bladder neck trauma Prevent risk of Paraphimosis To reduce the risk of cross-infection

Ensure patient comfort and dignity To reduce the risk of cross-infection

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PROCEDURE Record details of the catheterisation procedure in the patients notes/catheter record sheet code number ZML 997 Type, size, length of catheter Lot/batch number Expiry date Amount of water instilled Cleansing agent used Anaesthetic gel used, lot/batch number and expiry date Type of urine drainage system Any problems encountered with insertion of catheter Amount of urine drained Signature of nurse performing procedure

RATIONALE Improve catheter management and provide a legal record

Provide patient with: Relevant patient leaflet (Section 13) Sufficient catheter equipment Contact number of Health Care Professional

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RE-CATHETERISATION MALE
PROCEDURE Explain the procedure to the patient Provide privacy to patient Remove patients lower garments Assist patient into a suitable position supine with legs extended Place bed protection on the bed Cover patient Wash and dry hands thoroughly Put on disposable plastic apron Prepare work area with required equipment Open out sterile dressing pack using aseptic technique. Pour normal saline/sterile water into container. Open supplementary packs e.g. gloves/gel/catheter Draw up 10mls sterile water with syringe and needle. If the catheter has a prefilled balloon follow manufacturers instructions Remove needle and dispose of in sharps box Remove cover from patient Wash and dry hands thoroughly Apply non-sterile gloves Connect empty syringe to the balloon port of the catheter in situ, withdraw the water from the balloon Gently remove the catheter observing the length of the catheter removed Remove syringes and dispose of syringe into sharps box. Take note of amount of water removed. Dispose of catheter, gloves and apron as per healthcare waste policy Put on 2nd disposable plastic apron Wash and dry hands thoroughly Put on sterile gloves and arrange the sterile drape from pack across the patients thighs RATIONALE Ensure patient understands the procedure and gives valid consent Ensure patient comfort and dignity To allow access for catheterisation Enable good position for insertion of catheter Contain any leakage Ensure patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection from micro-organisms on uniform

Enable inflation of balloon of catheter immediately following insertion

For the safe disposal of equipment to protect healthcare workers and others Allow access for catheterisation To reduce the risk of cross infection To reduce the risk of cross-infection Deflation of the balloon allows the catheter to be removed Prevent trauma and allow for ease of insertion of new catheter For the safe disposal of equipment to protect healthcare workers and others To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection. Create a sterile field

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PROCEDURE Hold the penis with a sterile swab, retract the foreskin if present and clean the shaft, glands and urethral meatus with sterile water/saline. Insert 11mls of local anaesthetic lubricating gel slowly into the urethral meatus WAIT 5 MINUTES. Follow manufacturer's instructions Discard the anaesthetic gel syringe into disposal bag Remove and dispose of gloves as per clinical waste guidelines Wash and dry hands thoroughly Apply 2nd pair sterile gloves Position the sterile container to catch urine

RATIONALE Provide access to the urethral meatus Reduce risk of cross-infection

Prevent urethral trauma and patient discomfort

To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection Provide temporary container for urine as it drains

Open the inner cover of the catheter and expose 10cm of catheter Holding the shaft of the penis with a sterile Aid passage of catheter through prostatic swab raise it until almost fully extended. urethra Maintain in position until procedure is completed. Insert catheter into the urethra for 15-25cm Prevent inflation of the balloon in the until urine flows urethra If resistance is felt at the external sphincter Aid the passage of the catheter through the slightly increase the traction on the penis prostatic urethra Relax external sphincter and apply gentle steady pressure on the catheter. Ask the patient to strain slightly or cough Inflate the balloon slowly with 10mls To reduce the risk of cross-infection sterile water. (if pre-filled follow Prevent inflation of the balloon in the manufacturers instructions) Observe urethra patient for signs of distress ensure urine draining Withdraw catheter slightly until resistance Ensure balloon is inflated is felt Attach the catheter to closed drainage Ensure correct use of device system and secure with appropriate Maintain patient comfort and reduce risk of straps/sleeve or catheter valve (Refer to urethral bladder neck trauma Section 7) Ensure glans penis is clean Prevent risk of Paraphimosis Replace the foreskin Make patient comfortable Ensure patient comfort and dignity Measure the amount of urine drained - 16 -

PROCEDURE Remove apron and gloves. Dispose of equipment as per healthcare waste policy Wash and dry hands thoroughly Record details of the catheterisation procedure in the patients notes/catheter record sheet code number ZML 997 Type, size length of catheter Lot/batch number Expiry date Amount of water removed/instilled Cleansing agent used Anaesthetic gel used, lot/batch number and expiry date Type of urine drainage system Any problems encountered with removal/insertion of catheter Amount of urine drained Signature of nurse performing procedure

RATIONALE To reduce the risk of cross-infection Prevent risk of cross-infection - Improve catheter management and provide a legal record

Provide patient with: Relevant patient leaflet (Section 13) Sufficient catheter equipment Contact number of Health Care Professional

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RE-CATHETERISATION OF A PATIENT WITH A SUPRA-PUBIC CATHETER

This is an aseptic procedure and can be carried out by Nursing Staff who have had training and are competent in this procedure. Follow manufacturer guidelines regarding choice of catheter suitable for use in the supra-pubic route. If the catheter requires to be changed before 6 weeks following insertion advice must be sought from Dr. After 6 weeks the nurse can reinsert catheter provided suitable training has been undertaken. If any problems are encountered during procedure seek medical advice.

DEFINITION
Insertion of a catheter into the bladder through the anterior wall of the abdomen using an aseptic technique.

CAUTION Previous difficulties that have required medical assistance Blood clotting disorder REQUIREMENTS

Disposable plastic apron x 2 2 pairs of non-sterile gloves as per Glove Guidelines 1 pair of sterile gloves as per Glove Guidelines Sterile Procedure pack 2 x Sterile Catheters of same type, size and length as catheter in situ size should be no smaller that 16 in adults 10mls balloon Cleansing agent Normal Saline/Sterile Water Sterile local Anaesthetic Lubricating Gel 2-4mls this can be used if patients find the procedure painful/uncomfortable 10 ml ampoule of sterile water if required Needle if required Sharps container Bed protection Drainage bag/night bag/sterile catheter valve Catheter strap/sleeve/stand Disposal bag as per Helathcare Waste Policy

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PROCEDURE FOR CHANGE OF SUPRA-PUBIC CATHETER

PROCEDURE Explain procedure to patient Provide privacy to patient Assist patient into a suitable position. Place the bed protection on the bed to contain any leakage. Expose the patients lower abdomen to allow access for catheterisation Wash and dry hands thoroughly Put on disposable plastic apron Prepare work area with required equipment Open out sterile dressing pack using an aseptic technique. Place sterile drape across lower abdomen. Pour normal saline/sterile water into container. Open supplementary packs e.g. gloves, gel and catheter Draw up 10mls of water with syringe and needle, dispose of needle in sharps box. If the catheter has a pre-filled balloon follow the manufacturers instructions Apply sterile gloves If a dressing has been used around the supra-pubic site remove and dispose of as per Healthcare Waste Policy Using swabs clean around the supra-pubic site with cleansing agent. Use swab once and wipe away from entry site. Wash and dry hands thoroughly Put on 2nd disposable plastic apron Apply pair of 2nd sterile gloves Connect a syringe to the balloon port of the current catheter in situ; withdraw the water from the balloon. Take note of amount of water removed RATIONALE Ensure patient understands procedure and gives valid consent Ensure patient comfort and dignity Enable good position for inserting catheter. To maintain patients comfort and dignity

To reduce the risk of cross-infection To reduce the risk of cross-infection To ensure all equipment is ready for procedure Create a sterile field

To enable inflation of balloon of catheter immediately following insertion Safe disposal of equipment To reduce the risk of cross-infection To reduce the risk of cross-infection

Remove exudate that may enter suprapubic tract during catheterisation To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection Deflation of balloon allows catheter to be removed

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PROCEDURE Dispose of syringe and needle in Sharps Box GENTLY REMOVE THE CATHETER OBSERVING THE ANGLE AND LENGTH OF CATHETER REMOVED - Dispose of catheter in Disposal Bag Apply 2-4mls anaesthetic lubricating gel to catheter tract IF REQUIRED wait 5 minutes Insert the catheter into the supra-pubic tract at the angle and length of catheter previously removed Check that urine is draining (this may take a few minutes to commence) Insert syringe into the catheter port and gently depress plunger of syringe until the water has been inserted to inflate balloon. If the catheter has a pre-filled balloon follow the manufacturers instructions for inflation (ensure catheter is draining before this) Gently withdraw the catheter until resistance is felt Attach the catheter to a previously selected drainage bag. Apply appropriate leg bag/straps/sleeve A catheter valve may be used, please refer to CATHETER VALVE PROCEDURE Section 7 for use of this device If there is discharge/bleeding from around the catheter site, clean the area with normal saline/sterile water and apply appropriate dressing if required. N.B. Take swab if necessary prior to cleaning Make the patient comfortable Take a urine specimen if this indicated Empty leg bag, measure the amount of urine if required. Dispose of urine as per healthcare waste policy. Remove apron and gloves Dispose of equipment as per Healthcare Waste Policy Wash and dry hands thoroughly

RATIONALE For the safe disposal of equipment to protect Healthcare workers and others Prevent trauma and to allow for ease of insertion of new catheter

To reduce the trauma during insertion of catheter To prevent the balloon from entering the urethra To ensure the balloon is in the bladder To allow for self-retention of catheter in the bladder

To ensure that the balloon is in the bladder Allow for free drainage and containment of urine. Maintain patient comfort and reduce risk of urethral and bladder neck trauma Ensure correct use of this device

To reduce the risk of cross-infection

Maintain patient comfort and dignity

To reduce the risk of cross-infection Leave area as it was found To reduce the risk of cross-infection

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PROCEDURE RATIONALE Record details of the catheterisation Improve catheter management and provide procedure in the patients notes/catheter a legal record record sheet code number ZML 997 Type, size, length of catheter Lot/Batch Number Expiry date Amount of water removed/instilled Cleansing agent if used Anaesthetic agent if used, Lot/Batch number, Expiry date Type of urine drainage system Any problems encountered with removal/insertion of catheter Signature of nurse performing procedure Provide patient with Relevant patient leaflet (Section 13) Ensure patient has sufficient catheter equipment for future changes Ensure patient knows how to care for catheter Contact number of Health Care Professional

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NOTES FOR INFORMATION

INDICATIONS FOR SUPRA-PUBIC CATHETERISATION
When it is not possible for a urethral catheter to be inserted e.g. stricture Where limb contractures make urethral catheter insertion and management difficult Improved patient comfort for wheelchair dependent patients and easier management of catheter change Minimises urethral trauma and development of mega urethra May be more acceptable in patients who are sexually active Can improve lifestyle of patient Where it is patients preferred choice Post operatively for bladder drainage or to monitor residual urine volume

CAUTIONS
Previous difficulties that have required medical assistance Haematuria of unknown diagnosis Bladder tumour Ascitis Blood clotting disorder Urethral leakage

NOTES
The new catheter requires to be inserted within 30-45 minutes of the removal of the old catheter as a delay can result in partial deterioration of the tract as the detrusor muscles contract. Community patients and carers in the community should have an emergency contact number. If there is resistance to balloon inflation or patient discomfort, this may indicate that the balloon has been pushed into the urethra, if so stop and withdraw water from the balloon, reposition the catheter and re-inflate the balloon. Bladder spasm may occur and resistance may be felt on insertion, wait until the bladder spasm has stopped and the bladder relaxes to ensure the catheter is easy to insert. If a patient has a BLOOD CLOTTING DISORDER or is on WARFARIN liaise with a Doctor prior to proceeding with the re-catheterisation. If the patient is experiencing problems with their catheter the old catheter should be examined to identify cause of the problems e.g. encrustation N.B. SEE CATHETER PROBLEMS AND POSSIBLE SOLUTIONS U14 If catheter becomes blocked or dislodged within first 2 weeks of initial insertion expert medical advice should be sought. - 22 -

INTERMITTENT CATHETERISATION
A full assessment of the individual and their needs is carried out before catheterisation. This includes identifying underlying causes for bladder emptying problems. If paid carers are taught to carry out intermittent self-catheterisation, this technique is carried out as an aspetic procedure. If partner or close family members are carrying out the procedure on a one to one basis for the patient this is undertaken as a clean procedure.

DEFINITION
To insert a single use catheter into the bladder to achieve regular and effective bladder emptying, and to measure residual urine for the purpose of assessment. INDICATIONS 1. 2. 3. 4. 5. 6. 7. 8. Retention chronic/acute Hypotonic/atonic bladder Measure residual urine Incontinence management, as a last resort Neurological disease or neuropathic bladder To administer intravesical medication Obtain a specimen of urine Part of a urodynamic investigations 9. Post urethrotomy for stricture therapy CONTRA-INDICATIONS Medical instructions not to perform procedure Urethral device (urethral stent, artificial sphincter) in situ Patients gains sexual satisfaction Cultural objections Consent not given/obtained Suspect/identified chronic retention in a community setting

NURSE PERFORMING PROCEDURE REQUIREMENTS Disposable plastic apron 1 pair of non sterile gloves as per Glove Guidelines 1 pair of Sterile gloves as per Glove Guidelines 2 x Single use Intermittent Catheter of appropriate size and length - Follow manufacturers instructions Sterile water/Normal saline Sterile procedure pack Anaesthetic gel if appropriate Container for urine e.g. Jug/Urinal Disposable Bag as per Healthcare Waste Policy Bed protection - 23 -

PROCEDURE Explain procedure to patient Provide privacy to patient Encourage patient to empty bladder before procedure Assist patient into a suitable position, dependent on mobility. Place the bed protection on the bed to contain any leakage Prepare work area with required equipment Wash and dry hands thoroughly Put on disposable plastic apron Open out the sterile dressing pack using an aseptic technique, pour normal saline/sterile water into container Open supplementary packs e.g. gloves/gel/catheter Apply sterile gloves FEMALE Separate the labia minora so that the urethral meatus is seen. Cleanse the vulva area with sterile water/saline using single downward strokes. MALE Hold the penis with a sterile swab, retract the foreskin (unless circumcised) clean the shaft, glands and urethral meatus with sterile water/ saline Remove gloves and dispose of as per Healthcare Waste Policy Wash and dry hands thoroughly Apply pair of sterile gloves
Dependent on catheter used follow the manufacturers instructions FEMALE Insert anaesthetic gel (if used) into the urethra, WAIT FOR 5 MINUTES then insert catheter following manufacturers instructions) into urethra for 6-8cms (2.5-3.5 inches), making sure the urine drains into a suitable container. When the urine stops flowing ask the patient to strain a little and try and push out any remaining urine, then insert the catheter one or two centimetres further. To remove the catheter, rotate slowly and gently. If at any stage more urine starts to flow, wait until it finishes before removal.

RATIONALE Ensure patient understands procedure and gives valid consent Ensure patient comfort and dignity To establish true residual urine measurement Enable a good position for inserting catheter Maintain patients comfort and dignity To ensure all equipment is ready for procedure To reduce the risk of cross-infection To reduce the risk of cross-infection Create a sterile field

To follow manufacturers instructions for lubrication To reduce the risk of cross-infection To reduce cross-infection and contamination

To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection Prevent trauma to urethra. To allow drainage of urine from bladder.

- 24 -

PROCEDURE MALE Hold the penis with a sterile swab, raise until it is almost fully extended. Insert the anaesthetic gel (if used) into the urethral orifice, WAIT FOR 5 MINUTES then insert the catheter following the manufacturers instructions into the urethra for 15-20 centimetres (6-10 inches). If resistance is felt at the external sphincter increase the traction on the penis ask the patient to cough and apply gentle pressure on the catheter. When urine begins to flow advance the catheter another 2.5 centimetres (1 inch) For removal as for FEMALE Make patient comfortable Measure the amount of urine drained Dispose of urine as per Healthcare Policy Remove gloves and apron and dispose of as per Healthcare Waste Policy Wash and dry hands thoroughly Record details of the procedure in the patient notes/catheter record sheet Code number ZML 997 Catheter, type, size, length Lot/batch number Expiry date Cleansing agent if used Anaesthetic agent if used, Lot/Batch number/expiry date Any problems encountered with insertion/removal of catheter Amount of urine obtained Signature of nurse performing procedure ENSURE PATIENT HAS Relevant literature, catheters for discharge home Contact number of Health care Professional

RATIONALE To prevent trauma to urethra. To allow drainage of urine from bladder

Maintain patient comfort and dignity Accurate measurement of urine in bladder To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection Provide a legal record To encourage patient to become independent with the procedure

- 25 -

NOTES
TEACHING PATIENTS Advantages of Intermittent Catheterisation for patients can be independence and selfcaring In certain circumstances relatives/carers can be taught how to perform this technique. This should be a sterile procedure. For teaching patient Intermittent self-catheterisation appropriate teaching tools e.g. video and leaflets are available from the Continence Advisors Samples of catheters are also available from the Continence Advisors When patients commence Intermittent Catheterisation, urine measurements may be necessary. The volume of urine needs to be recorded to assess the time and frequency of catheterisation. The residual should be no more than 400mls and not less than 150mls. (See guidelines below).

THE FREQUENCY OF CATHETERISATION DEPENDS INDIVIDUAL ASSESSMENT OF BLADDER FUNCTION. THESE ARE GUIDELINES ONLY
Less than 150mls 150-300mls 300-500mls Over 500mls Stop catheterisation Carry out catheterisation twice daily Carry out catheterisation three times a day Increase to four times daily and contact their Health Care Professional or Continence Advisor for further advice

ON

- 26 -

PROCEDURE FOR INSERTING /CHANGING A CATHETER VALVE

DEFINITION
To allow controlled release of urine from the bladder.

INDICATIONS
WARNING: THIS PRODUCT SHOULD NOT BE USED WITHOUT ASSESSMENT OF BLADDER FUNCTION BY AN APPROPRIATE MEDICAL/NURSING PROFESSIONAL The decision to use a catheter valve must be made by medical/nursing staff. The patient should be fully assessed when considering the use of a catheter valve and must have:1. Bladder capacity of a minimum of 200mls 2. Cognitive awareness of the need to drain the bladder at regular intervals to avoid over distension of the bladder 3. Sufficient dexterity to manipulate the device 4. Sufficient vision to manipulate device 5. Ability to comply with manufacturers recommendations NOTE: A PATIENT WITHOUT BLADDER SENSATION OR COGNITVE AWARENESS MAY HAVE THEIR CATHETER VALVE MANAGED BY A CARER WHO HAS RECEIVED INSTRUCTION ON THE USE OF THE DEVICE FOR THE INDIVIDUAL PATIENT CONTRA INDICATIONS 1. 2. 3. Reduced bladder capacity Uncontrolled Detrusor Instability Ureteric Reflux and Renal Impairment

WHERE POSSIBLE THIS SHOULD BE DONE BY THE PATIENT The procedure is as follows for nurses/carers Disposable apron 2 pairs of non sterile disposable gloves as per glove policy Sterile catheter valve Disposal bag as per Healthcare Waste Policy Container for urine (KEPT FOR THIS PURPOSE ONLY) e.g. Measuring jug/urinal

- 27 -

PROCEDURE Explain procedure to patient

RATIONALE Ensure patient understands procedure and gives consent Encourage patient to empty bladder To establish true residual urine before procedure measurement Provide privacy to patient Ensure patient comfort and dignity Assist patient into a suitable position. Maintain patient comfort and dignity Wash and dry hands thoroughly To reduce the risk of cross-infection Put on disposable plastic apron and To reduce the risk of cross-infection gloves Release the valve and empty urine into Reduce environmental contamination jug or urinal Measure amount of urine if necessary Provide legal record Dispose of urine as per healthcare waste To reduce the risk of cross-infection policy Remove and dispose of gloves To reduce the risk of cross-infection Wash and dry hands thoroughly To reduce the risk of cross-infection Put on 2nd pair of gloves To prevent the risk of cross-infection Open the catheter valve pack from the Maintain sterility of valve outlet end Do not remove Remove the old valve. Discard onto To reduce the risk of cross-infection paper or into disposal bag as per healthcare waste guidelines Immediately insert the new valve into the To reduce the risk of cross-infection end of the catheter ENSURING THAT NO HAND CONTACT IS MADE WITH END BEING INSERTED Ensure the valve is left in the closed Ensure containment of urine position Remove and dispose of gloves, apron and To reduce the risk of cross-infection valve as per healthcare waste policy Wash and dry hands thoroughly To Reduce risk of cross-infection Record the urine drained, date of change, Provide a legal record type of valve and valve batch/lot no. and expiry date in patient record Ensure the patient (or carer) has written Ensure patient/carer can access advice information and Health Care Professionals contact number Follow manufacturers guidelines and ensure patient or carer knows how to operate and maintain valve

- 28 -

NOTES FOR INFORMATION

CATHETER VALVES DEFINITION
A catheter valve is a small, discrete plastic appliance, similar to the outlet tap of a urine drainage bag, which may be attached to the outlet of an indwelling urethral or suprapubic Foley catheter as an alternative to a leg bag.

ADVANTAGES
Maintenance of bladder capacity over a period of time Retention of bladder tone and enhanced return to normal pattern of voiding post catheter removal May reduce infection rate due to "flushing" action when catheter released Discrete in use Decreased risk of trauma to the bladder, bladder neck and urethra due to reduction of traction on the catheter from leg bags more the 2/3 full Greater freedom in social and leisure activities e.g. swimming, sexual activities

MOST USEFUL IN
Benign Prostatic Hypertrophy when awaiting surgery or unsuitable/unwilling to have surgery Post operative voiding dysfunction, especially following urological, gynaecological or hip surgery Prior to removal of catheter in short term situation Patients capable of self care regarding bladder drainage Patients with suprapubic catheters who find bag positioning problematic

Most patients will drain their urine directly into a toilet. If using a urinal or other receptacle this must be kept for this purpose alone. Advice on frequency of drainage should be based on individual need following assessment of bladder function by an appropriate medical/nursing professional, taking account of fluid intake and output. Usual advice is to drain the bladder 2 3 hourly if the patient has reduced bladder sensation. If the catheter is not tucked into underwear advice should be given on how to secure it to prevent pulling. A catheter strap can be used. Consideration should be given to the length of urethral catheter in females when using a catheter valve. This is to allow for comfort and ease of drainage to reduce trauma. Overnight drainage bags may be connected if required (See Section 9)

- 29 -

EMPTYING URINE DRAINAGE BAG

DEFINITION
To empty and dispose of urine from drainage bag

INDICATIONS
1. To dispose of urine 2. To monitor urinary output 3. To prevent reflux to kidneys. (Leg bag should be emptied when two third full)

REQUIREMENTS
Disposable plastic apron Non-sterile disposable gloves as per Glove Guidelines Clean container for urine (KEPT FOR THIS PURPOSE ONLY) e.g. Measuring jug/urinal Tissue/Paper towel Disposal bag as per Clinical Waste Guidelines

Follow manufacturer guidelines on emptying, as this will vary PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on disposable gloves and apron Place container below outlet of drainage bag, open tap and drain urine NB care should be taken to avoid contact between the drainage tap and container Close tap of drainage bag Dry off excess urine from outlet with tissue/paper towel and dispose of as per Healthcare Waste Policy Make patient comfortable Measure urine if required, and record on completion of procedure Dispose of urine as per Healthcare Waste Policy RATIONALE Ensure patient understands procedure and gives consent Maintain patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection To dispose of urine To prevent reflux to kidneys

To ensure containment of urine Reduce environmental contamination

Maintain patient comfort and dignity Provide legal record To reduce the risk of cross-infection

- 30 -

PROCEDURE RATIONALE Wash container as per policy (Hospital To reduce the risk of cross-infection disposable containers are available and may be used and disposed of as per Local Policy) Remove and dispose of gloves and apron as To reduce the risk of cross-infection per Healthcare Waste Policy Wash and dry hands thoroughly Record amount of urine drained on completion of procedure To reduce the risk of cross-infection Provide a legal record

- 31 -

ATTACHING NIGHT DRAINAGE BAG

DEFINITION
To attach an additional drainage bag to the existing day time collection system

INDICATIONS
To allow free drainage of urine overnight when output exceeds capacity of leg bag and to maintain closed drainage system.

REQUIREMENTS
Disposable plastic apron Non-sterile disposable gloves as per Glove Guidelines Night drainage bag Night drainage bag holder Disposal bag as per Healthcare Waste Policy

PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on disposable gloves and plastic apron Remove cap of night drainage bag and insert tubing into the outlet of leg bag/catheter valve ensuring no hand contact with exposed end of drainage bag Open tap of leg bag/catheter valve Leg bag may either a) Remain loosely attached to leg b) Remove straps and position leg bag on the bed Attach night drainage bag to holder

RATIONALE Ensure patient understands procedure and gives consent Maintain patients dignity and comfort To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection

To allow urine to drain into night bag a) To reduce trauma b) Provide patient comfort To reduce hydrostatic pressure and reduce risk of cross-infection Maintain patient comfort and dignity To reduce the risk of cross- infection

Make patient comfortable Dispose of cap from night drainage bag tubing as per Healthcare Waste Policy Remove and dispose of gloves and apron as To reduce the risk of cross-infection per Healthcare Waste Policy Wash and dry hands thoroughly To reduce the risk of cross-infection

- 32 -

REMOVAL OF NIGHT DRAINAGE BAG

DEFINITION
Disconnection and disposal of Night Drainage Bag and urine

INDICATIONS
1. 2.

To dispose of urine drained overnight To re-establish day-time drainage system of urine

REQUIRMENTS
Disposable plastic apron Non-sterile disposable gloves Tissue/paper towel Appropriate disposal bag Hospital/Community

PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on disposable gloves and apron
Close tap of leg bag/catheter valve

Disconnect night drainage bag Dry off excess urine on leg bag/catheter valve tap with tissue/paper towel, dispose of as per Healthcare Waste Policy Re-attach legstraps/sleeves to leg bag, secure catheter Make patient comfortable Measure urine if required and record on completion of procedure Drain overnight bag as per manufacturers instructions Dispose of overnight drainage bag As per Healthcare Waste Policy Remove and dispose of apron and gloves as per Healthcare Waste Policy Wash and dry hand thoroughly

RATIONALE Ensure the patient understands the procedure and gives consent Maintain patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection Prevent leakage of urine Maintain closed drainage system Prevent environmental contamination

Reduce the risk of urethral and bladder neck trauma Maintain patient comfort and dignity Provide legal record Dispose of urine and prevent environmental contamination To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection

- 33 -

CHANGING A URINARY DRAINAGE BAG

DEFINITION
To replace the existing Urinary Drainage Bag

INDICATIONS
1. To comply with manufacturers recommendations 2. To reduce risk of infection

REQUIRMENTS
Disposable plastic apron Non-sterile disposable gloves Sterile Urinary Drainage Bag Tissue/Paper towel Disposal bag as per Healthcare Waste Policy

PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on plastic apron and apply disposable gloves Open the drainage leg bag pack Remove catheter straps/sleeve/stand Place tissue/paper towel on flat surface under urine drainage bag Remove cap from sterile bag Disconnect bag from catheter lay on tissue Immediately attach sterile drainage bag ensuring that there is no hand contact with exposed end of catheter Ensure the tap is in the closed position Secure the urine bag using straps/sleeve/stand Make patient comfortable Measure urine if required and record on completion of procedure. Document date of bag change

RATIONALE Ensure the patient understands the procedure and gives consent Maintain patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection

To allow change of drainage bag Prevent leakage of urine onto bed/chair Reduce risk of cross-infection Prepare for re-connection of drainage bag

To reduce the risk of cross-infection

Reduce environmental contamination Reduce risk of urethral and bladder neck trauma Provide patient comfort and dignity Provide legal record

- 34 -

PROCEDURE Dispose of urine as per Clinical Waste Guidelines Dispose of urinary drainage bag as per Clinical Waste Guidelines Remove and dispose of gloves and apron as per Clinical Waste Guidelines Wash and dry hands thoroughly

RATIONALE To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection

- 35 -

CATHETER HYGIENE
DEFINITION
Cleansing of catheter entry site to reduce risk of infection

INDICATIONS
To reduce risk of infection

REQUIREMENTS
Disposable plastic apron Non-sterile disposable gloves as per Glove Guidelines Warm water Unperfumed soap Towel Washing cloth/disposable wipes

PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on disposable gloves and plastic apron Wash around and away from the entry site of catheter with soap and water, rinse thoroughly and dry N.B. Male Gently retract the foreskin, wash and dry. Replace foreskin Female Wash from front to back to ensure bacteria from the anus does not enter the urethra Supra-pubic If dressing required please follow the dressing procedure A daily shower or bath is recommended WARNING DO NOT USE TALC OR CREAMS UNLESS PRESCRIBED Remove and dispose of apron, gloves and wipes if used as per Healthcare Waste Policy Wash and dry hands thoroughly

RATIONALE Ensure patient understands procedure and gives consent Maintain patient comfort and dignity To reduce the risk of cross-infection To reduce the risk of cross-infection To reduce the risk of cross-infection

To reduce the risk of cross-infection

To reduce the risk of cross-infection - 36 -

CATHETER INFORMATION BOOKLET

THE CATHETER:
Urine (water) is produced by the kidneys and passed down the two ureters (small tubes) to be collected in the bladder. When the bladder is full an urge to pass urine is felt. Urine is then passed through the urethra (the canal from the bladder to the outside of the body) to be expelled. Sometimes this does not happen and a catheter is inserted into the bladder to help drain the urine. There are two ways of inserting a catheter into the bladder. 1. Through the urethra see above. 2. Through the abdominal wall below the navel. (belly button) A catheter is a fine hollow, flexible tube that is inserted in the bladder. To prevent it from falling out a small balloon near the tip of the catheter is inflated. The most common reasons for using a catheter are; 1. Before or after surgery, especially on the bladder, prostate or other part of the urinary system. 2. Obstruction to the flow of urine. 3. The bladder does not function as well as it did, because of a medical condition or injury. The type of catheter you have been given will depend on whether it is for short or long-term use. Your catheter may be connected to a drainage system that collects your urine. This system consists of a leg drainage bag or valve, which is emptied at regular intervals during the day and a night drainage bag, which is removed each morning. A catheter valve is suitable for some people instead of a drainage system. It allows for regular emptying of the bladder. It can be connected to a drainage bag overnight.

- 37 -

LIVING WITH YOUR CATHETER

Having a catheter should not restrict your social or leisure activities or prevent you from going on holiday, particularly if using a catheter valve. For some it may be the start of more freedom and improving their health.

CHANGING THE CATHETER

The nurse will usually carry this out although some people learn to change their own.

DIET AND FLUIDS

A well balanced diet and adequate fluid intake are very important in minimising the risk of infection, preventing constipation and avoiding catheter blockage. Eat a well balanced diet to help prevent constipation. This will include fresh fruit, vegetables, fibre and carbohydrates. Constipation or a loaded bowel may press on the catheter and prevent urine from draining. The aim is to achieve a regular bowel movement without having to strain. To ensure a good drainage of urine it is advisable to drink at least 2litres/4pints of fluid each day. This can include; diluting juices, decaffeinated tea and coffee.

EXERCISE
Regular exercise such as walking will help to maintain free drainage of your urine.

MAKING LOVE SEXUAL HEALTH

Females with a urethral catheter are able to have penetrative sex by taping the catheter to their abdomen. A catheter valve may also be used instead of the catheter bag. To prevent pulling or friction on the catheter and vulva, a soluble lubricant such as KY Jelly should be use. Do not use petroleum jelly as it may react with the catheter material. For both males and females who are sexually active, they should consider the alternatives to a urethral catheter. The options include being educated on how to perform intermittent self-catheterisation. The other option available is to have a supra-pubic catheter inserted through the abdominal wall. These alternatives will allow more sexual freedom especially around the genital area. Please do not feel embarrassed to talk to your nurse or doctor for further information or advice if you are having concerns regarding your catheter and sexual intercourse. Useful Tel Numbers:Continence Advisor Inverurie Hospital Upperboat Road Inverurie AB51 3UL Tel:- 01467 672748

- 38 -

PERSONAL CARE:
Good personal hygiene is very important to avoid infection 1. 2. Always wash and dry your hands thoroughly before doing anything that involves your catheter or drainage system. Either have a daily shower, bath or daily wash. You can do this with an empty drainage bag attached to your leg, pay particular attention to the area where the catheter enters the body. Wash with unperfumed soap and warm water, rinse thoroughly. Avoid the use of talcum powder, creams or antiseptics unless they have been prescribed. FEMALES ensure you wash from front to back to keep the bacteria from the anus (back passage) away from the catheter. Dry in the same way. MALES carefully draw back the foreskin and wash the exposed skin, replace the foreskin. FEMALE/MALE - any discharge from where the catheter enters your body should be reported to your healthcare professional. SUPRA PUBIC ensure the area where the catheter enters your body is kept clean and dry. A small dressing may be required. CARERS always wash and dry your hands thoroughly before doing anything that involves the catheter. e.g. emptying or changing a drainage bag. You should also wear non-sterile disposable gloves.

3. 4. 5. 6. 7.

TYPES OF DRAINAGE BAGS:

Daytime bags This is usually worn on the leg, (leg bag) and is only disconnected from the catheter when it is changed every 5-7 days. If you have a catheter valve you will not need a daytime leg bag. Night bags This is used in conjunction with the daytime bag or catheter valve if necessary for the extra capacity of urine produced overnight.

ATTACHING THE LEG DRAINAGE BAG:

This is attached to either your calf or thigh by a pair of straps, a sleeve or a special holster. Ask your Healthcare Professional for details. How you wear the leg bag depends on what feels comfortable for you. The choice and size of the leg bag and the length of the tubing depend on where you want to wear it, your size and urinary output. If you wear trousers, the long-tubed leg bag is more convenient, as it is possible to roll up the bottom of the trouser leg and access the tap at the base of the bag for emptying the urine. Short-tubed leg bags can be worn on the thigh and are discreet under skirts.

EMPTYING THE LEG DRAINAGE BAG:

This will need to be emptied at regular intervals during the day. It is best to empty it when it is two thirds full. This will prevent the bag pulling on your catheter and causing discomfort. Wash and dry your hands before and after emptying this bag. You may need to remove the straps/sleeve from the leg drainage bag before you empty it. Open the outlet tap on the bag over the toilet and allow the urine to drain. If you cannot get to the toilet the urine can be emptied into a suitable container kept solely for this purpose. Wash the container with soap and water and dry after each use. After emptying the bag close the tap and wipe the outlet with a clean tissue or toilet paper and dispose of this in the toilet.

- 39 -

CHANGING THE LEG DRAINAGE BAG:

The Department of Health recommends that the leg bags should be changed once a week. Wash and dry your hands before and after changing your leg bag. Avoid touching the end of the catheter or the connecting end of the new bag that goes into the catheter. Carefully remove the old bag to prevent urine escaping. Remove the protective cap from the leg bag and immediately insert the connecting end of the new bag into the catheter.

NIGHT DRAINAGE BAGS:

This bag is attached to the bottom of the leg drainage bag. It can hold more urine so you don't need to get up during the night to empty your bag. After connecting the night bag ensure the tap on your leg drainage bag is in the open position to allow the urine to flow into the night bag. You can now either; loosen the straps of your leg drainage bag leaving it attached to your leg or remove the leg drainage bag from your leg and lie the bag on the bed ensuring it is below the level of your bladder. If you have a catheter valve connect your night bag to the outlet of the valve. Ensure the tap of the valve is in the open position to allow the urine to drain into the night bag. The night bag should be well supported on a stand or hanger - not placed on the floor. These can be obtained from your Healthcare Professional.

REMOVING THE NIGHT DRAINAGE BAG:

This bag is connected to either the leg drainage bag or the catheter valve and is disposed of each morning. 1. Wash and dry your hands before and after emptying this bag. 2. Close the tap on the leg drainage bag or catheter valve. 3. Disconnect the night drainage bag from the leg drainage bag or catheter valve. Wipe the end of the tap with a clean tissue or toilet paper and dispose of this in the toilet. 4. Empty the night drainage bag by opening the one way tap and disposing of the urine in the toilet. 5. Dispose of the empty night drainage bag by double wrapping in either paper or plastic bags before placing into the domestic dustbin.

- 40 -

CATHETER VALVES:
They are connected to the catheter and allow you to empty your bladder at regular intervals without wearing a daytime leg drainage bag. They are not suitable for everyone that has a catheter, your Healthcare Professional will advise you on this product.

CHANGING YOUR CATHETER VALVE:

The Department of Health recommends that valves should be changed once a week. It is important that the connection between the catheter and the valve remains unbroken except when valve is changed. 1 2 3 4 5 6 Wash and dry your hands before and after changing your valve. Open the packaging of the valve to expose the outlet tap. Carefully remove 'old' valve to prevent urine from escaping. Remove the 'new' valve from the packet by holding the outlet tap; do not touch the end that goes into the catheter. Insert immediately into the catheter. Ensure the tap is in the closed position.

YOUR HEALTHCARE PROFESSIONAL WILL GIVE YOU HELP AND ADVISE ON THE PROBLEMS BELOW.
1. 2. 3. 4. 5. 6. Bladder spasm or cramp this may cause urine leakage around the outside of the catheter (bypassing). Leg bag not staying in place securely (slipping down your leg). Catheter pulling. The feeling that you need to pass urine. Difficulty in emptying/changing your drainage bags. No urine in you leg bag. See helpful advice below.

IF NO URINE IS DRAINING, HERE ARE SOME THINGS YOU CAN DO BEFORE CONTACTING YOUR NURSE.
1. 2. 3. 4. Ensure there are no kinks in the catheter or drainage tubing. Check the drainage bag is below the level of the bladder. The straps of the leg bag are NOT over the inlet valve at the top of the bag. Ensure the catheter is not being pulled tight by the position of the leg bag. The use of a leg bag sleeve or strap or abdominal strap for a supra-pubic catheter may help prevent this. Make sure you are drinking enough fluid, at least 2 litres a day if possible. Walk around. This may help to relieve a blockage.

5. 6.

CONTACT YOUR HEALTHCARE PROFESSIONAL IF:

1. 2 3 4 5. You have prolonged pain. Urine is not draining. There is blood in your urine. Your urine is cloudy, smelly and you feel unwell. Urine keeps leaking around the catheter. - 41 -

HEALTHCARE PROFESSIONAL DETAILS: Name Contact number G.P Telephone number CATHETER DETAILS: Type. Size Balloon size

Code for ordering DRAINAGE BAG DETAILS: LEG BAGS Make. Capacity

Code for ordering. Tubing length

NIGHT BAGS Make VALVES Make SLEEVE Make Size.. LEG STRAP Make Size.. ABDOMINAL STRAP Make Size..

Code for ordering.

Code for ordering.

Code for ordering.

Code for ordering.

Code for ordering.

- 42 -

ADMINISTERING A CATHETER MAINTENANCE SOLUTION

This procedure should be carried out following a full assessment of the patient by a nurse who has had training and is competent in this procedure. Administration of catheter maintenance solution requires breakage of the closed drainage system increasing the risk of introducing infection. DEFINITION Instillation of a solution into an indwelling catheter INDICATIONS To minimise encrustation and the associated trauma this can cause to the lower urinary tract on catheter removal. To maintain the life of a catheter by preventing blockage To remove any obstruction in the catheter Antibiotic solutions are not effective in treating catheter associated urinary tract infections.

CAUTION IS ADVISED IN THE FOLLOWING check patients medical notes

A past medical history of haematuria Bladder cancer Bladder fistula Recent radiotherapy of the lower urinary tract Urological surgery Urinary tract infection (but see mandelic acid) Infection to organs related to the lower urinary tract Patients with spinal cord injury at risk of autonomic dysreflexia (a dangerous rise in blood pressure in response to a noxious stimulant below the level of spinal cord injury National Spinal Cord Injury Association) Allergies

TYPES, USES AND FREQUENCY

Solution G 3.23% Citric Acid Catheter Maintenance Solution 1. First line treatment for the prevention and treatment of catheter encrustation and crystallisation. 2. Where urinary pH is greater than 7.5(i.e. alkaline) which is an ideal environment for crystal formation. 3. To be instilled once weekly to once daily according to severity for 15-20 minutes; reduce time if patient experiences discomfort - 43 -

Solution R 6% Citric Acid Catheter Maintenance Solution Second line treatment for dissolving persistent encrustation and crystallisation if Solution G is unsuccessful. Unblock an encrusted catheter. Minimise trauma on removal of catheter. Instill until blockage is relieved, up to 20 minutes. Mandelic Acid 1% Catheter Maintenance Solution For mechanical cleansing and acidification when the bladder is contaminated with proteus or pseudomonas as evident on CSU laboratory result. Use 1 2 times daily depending on severity of infection as identified by CSU. Should not be used for more than 14 days Chlorhexidine 0.02% Catheter Maintenance Solution For mechanical cleansing and prevention of bacterial contamination in the bladder e.g. E Coli, Klabsiella. It may be used once weekly to once daily. It is of limited value as a catheter maintenance solution Sodium Chloride 0.9% Catheter Maintenance Solution For removal of clots and other debris in the catheter or bladder. It does not dissolve catheter encrustation or reduce catheter associated infection and has limited value as a catheter maintenance solution

Please note that infection control recommendation is that the closed catheter drainage system should not be opened more than once a week. If a solution is administered more frequently it must be because the benefit to the patient is greater than the risk of infection involved in opening the drainage system.

REQUIREMENTS FOR ADMINISTERING A CATHETER MAINTENANCE SOLUTION

Drug administration sheet Prescribed catheter maintenance solution Drainage bag/catheter valve Disposable apron 2 pairs non-sterile gloves as per Glove Guidelines Container of hand hot water Bed protection Blanket Disposal bag as per healthcare waste policy Watch/clock

- 44 -

PROCEDURE FOR ADMINISTERING A CATHETER MAINTENANCE SOLUTION

PROCEDURE Explain the procedure to the patient and gain verbal consent Wash and dry hands thoroughly Put on plastic apron and gloves Place the solution in hand hot water RATIONALE To ensure the patient understands the procedure and consents To reduce the risk of cross-infection To reduce the risk of cross-infection To minimise risk of bladder spasm on introduction of the solution Protect the bed and ensure patient privacy To ensure patient comfort and privacy Help patient into supine or sitting position, remove clothes from waist down To facilitate observation and cover with blanket Empty the urine bag and dispose of urine Reduce risk of cross-infection and gloves as per clinical waste guidelines Wash and dry hands thoroughly Reduce risk of cross-infection Put on second pair of gloves Remove outer packaging of solution pack and discard into disposal bag follow manufacturers instructions Close the clip on the solution pack To prevent fluid loss when the connection port is opened Remove the security ring on the solution pack connection port Loosen cap on solution pack but do not To prevent risk of cross infection by not remove. Place on bed protection exposing until ready to connect to catheter Remove catheter bag or valve from the catheter and dispose as per clinical waste guidelines Remove the cap from the solution pack and insert connection port firmly into the catheter. ENSURE NO HAND To reduce risk of cross-infection CONTACT IS MADE WITH THE CONNECTION PORT Open the clip on solution pack Drain the solution into the catheter by gravity. DO NOT SQUEEZE THE SOLUTION PACK SEE NOTES If the solution is to be retained close the clip for the specified time. Lay the bag on the bed protection and cover the patient To allow the solution to enter the catheter To avoid damage to the bladder mucosa

- 45 -

PROCEDURE FOR ADMINISTERING A CATHETER MAINTENANCE SOLUTION (continued)

PROCEDURE When the solution is to be removed open the clip to allow the solution to drain back into the bag Disconnect the solution bag and connect a new sterile urine drainage bag or catheter valve Apply catheter straps or sleeve to catheter bag if used Remove apron and gloves and dispose of all equipment as per clinical waste guidelines Wash and dry hands thoroughly Record details of the procedure on the prescription sheet and in patients notes/catheter maintenance sheet Code number ZML 996 Date and time Reason for instillation Type of solution Batch number and expiry date Outcome Follow up Signature of nurse performing procedure Provide patient with contact number of health care professional RATIONALE

Resume closed drainage system to reduce risk of infection For patient comfort and to avoid drag on the catheter bag and catheter which could cause trauma in the lower urinary system

To reduce risk of cross-infection To provide a legal record

NOTES A catheter lumen holds 4-5mls of fluid therefore small volumes of 10-20mls
should be instilled A solution should be introduced by gravity not pressure to avoid damage to the delicate mucosa of the bladder. Solution R (6% citric acid) can be instilled once weekly to once daily if Solution G (3.23% citric acid) has been tried and failed to resolve the blockage. A catheter history should be planned and documented to enable future care to be planned. It is suggested 3-5 consecutive catheters should be observed before commencement of catheter maintenance solutions. - 46 -

CATHETER PROBLEMS AND POSSIBLE SOLUTIONS

CATHETER BLOCKED URINE NOT DRAINING
SIGNS No urine in the leg bag Patient has abdominal discomfort Catheter is by-passing Patient has urgency to pass urine NB Patients with a spinal cord lesion above the mid-thoracic level can be affected by a syndrome known as autonomic dysreflexia, one of the most common causes of this syndrome is a distended bladder mainly due to catheter blockage. This must be relieved as soon as possible and the patient placed in an upright sitting position and their blood pressure monitored at 5-minute intervals.

CHECK FOR If the patient has been recently catheterised, check that the catheter is in the bladder and not in the urethra Kinked tubing Tap on the leg bag is open if attached to a night drainage bag Leg straps are not covering the inlet valve of leg bag Leg bag is below level of bladder The patient is not constipated Try standing the patient up and walking around The eyes of the catheter may be blocked by the bladder mucosa (the leg bag can be raised above the level of the bladder for 10-15 seconds to release the eyes of the catheter from the bladder mucosa) May be blocked by debris POSSIBLE REASONS FOR PROBLEMS Constipation Reduced fluid intake Medical history prostate disease, tumour, calculi Review catheter material Review size of catheter POSSIBLE SOLUTIONS Check patients notes for causes of any previous blockages Ensure leg bag is emptied when two thirds full Minimum fluid intake of 2 litres Treat constipation advise on appropriate diet Inspect the catheter for signs of encrustation. If there are crystals visible in the catheter lumen monitor the pH of the urine (normal 4.5-7.5) Cranberry juice/capsules may help to reduce the pH of the urine and resist encrustation Establish any pattern of blockages by accurate record keeping Catheter Maintenance Solutions to be used as a treatment only Sterile water if debris - 47 -

ENCRUSTATION
SIGNS
No urine in the leg bag Patient has abdominal discomfort, pain and bladder spasm Catheter by-passing Patient has urgency to pass urine Crystals visible in catheter/leg bag Increase in pH of urine

POSSIBLE REASONS FOR PROBLEMS

Reduced fluid intake Poor diet Infection Medication Medical condition

POSSIBLE SOLUTIONS
Minimum fluid intake of 2 litres Cranberry juice Advice on appropriate diet Test urine for infection Inspect the catheter for signs of encrustation. If there are crystals visible in the catheter lumen monitor the pH of the urine Check the patients notes for medication Establish any pattern of blockages/encrustation by accurate record keeping Catheter Maintenance Solutions to be used only as a treatment

CATHETER BY-PASSING
SIGNS
Urine leaking onto clothing/bedding

CHECK FOR
AS FOR SECTION ON BLOCKED CATHETERS POSSIBLE REASONS FOR PROBLEMS Catheter blocked Under inflation of balloon Bladder spasm/instability Traction on leg bag Constipation Infection - 48 -

POSSIBLE SOLUTIONS
Review size/length of catheter Review catheter material Consider use of anti-cholinergic medication (Bladder spasm) Use of catheter accessories e.g.straps/sleeve Check fluid intake and dietary fibre intake Treat constipation Test urine for infection obtain catheter specimen of urine using the sampling port Check drainage bag is in correct position i.e. below level of the bladder See catheter Encrustation solution section

BLADDER SPASM
SIGNS
Patient has abdominal discomfort, pain and bladder spasm Catheter by-passing Expulsion of catheter (Balloon intact)

CHECK FOR
The patient is not constipated Kinked tubing Tap on the leg bag is open if attached to a night drainage bag Leg straps are not covering the inlet valve off the leg bag Leg bag is below level of bladder

POSSIBLE REASONS FOR PROBLEMS

Traction on leg bag Constipation Reduced fluid intake Allergy Catheter too large Review catheter material Under inflation of balloon Infection Neurological conditions Overactive bladder

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POSSIBLE SOLUTIONS
Treat constipation Minimum fluid intake of 2 litres Cranberry juice Review size/length of catheter Review material of catheter Check drainage of leg bag - Ensure leg bag is emptied when two thirds full Use of catheter accessories e.g. straps/sleeve Test urine for infection Try anti-cholinergic medication

DISCOMFORT/PAIN
POSSIBLE REASONS FOR PROBLEM
The eyelets of the catheter may be occluded by urotheluim due to hydrostatic suction If the patient has been recently catheterised, check that the balloon is in the bladder and not in the urethra Catheter too large Allergy Traction on leg bag Infection Constipation

POSSIBLE SOLUTIONS
Raise the drainage bag above the level of bladder for 10-15 seconds only Review size/length of catheter Review material of catheter Check drainage of leg bag- ensure leg bag is emptied when two thirds full Test urine for organisms that could be causing infection Treat constipation If pain persists refer to Medical Staff

HAEMATURIA
SIGNS
Blood in urine bag

POSSIBLE REASONS FOR PROBLEM

Trauma/pulling of catheter post catheterisation Infection Renal calculi Prostatic enlargement Carcinoma - 50 -

POSSIBLE SOLUTIONS Observe input and document severity if haematuria Encourage fluid intake
Use of catheter accessories e.g. straps/sleeve Review size/length of catheter Review material of catheter Test urine for organisms that could be causing infection Refer to Medical Staff if it persists

NON DEFLATION OF BALLOON ON REMOVAL OF CATHETER

POSSIBLE REASONS FOR PROBLEM
Exclude constipation Valve port and balloon inflation channel may be compressed Faulty valve mechanism

POSSIBLE SOLUTIONS
Check no external compression problems Valve port should always be aspirated slowly, if this is done forcefully, the valve mechanism may collapse If attempts fail to deflate balloon, medical advice must be sought, cutting of the catheter along its length is not safe practice and may result in retraction of the catheter into the bladder Do not attempt to burst the balloon by introducing more water/air Try leaving the syringe in situ for a few minutes. The water may seep out over a period of time Refer to Medical Staff for advice

SIGNS OF INFECTION ANY PATIENT WHO HAS A URINARY CATHETER IS AT RISK OF INFECTION SIGNS
Fever not caused by other medical condition i.e. sore throat Pain/burning on passing urine Persistent passing of blood in urine Offensive smell Cloudy, thick urine

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POSSIBLE SOLUTIONS
Test urine for leukocytes, nitrates, blood, protein and if positive send specimen to Laboratory Liaise with Medical Staff for treatment as dependent on outcome of C.S.U Monitor pH of urine Fluid intake of 2 litres Cranberry juice/capsules if patient on Warfarin consult Dr for advice Closed drainage system Change leg bag weekly Change night bag daily Good personal hygiene

CLOSED SYSTEM
TO REDUCE INFECTION
Changing leg bag Good personal hygiene Wash and dry hands thoroughly Wear gloves/apron when dealing with catheter/urine from drainage system Change leg bag weekly or following administration of catheter maintenance solution Change leg bag if it becomes disconnected Night drainage bags overnight use Single use in community Wash and dry hands thoroughly Wear gloves/apron when attaching/removing

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COLLECTION OF A CATHETER SPECIMEN OF URINE

Breaking the closed drainage system to obtain a urine sample increases the risk of catheter related infection. The use of drainage bags incorporating a sample port removes the need to break the closed system.

DEFINITION
The collection of a specimen for examination from a patient with an indwelling urinary catheter

INDICATIONS
1. To exclude infection 2. Routine urinalysis

REQUIREMENTS
Disposable plastic apron 1 pair of non-sterile gloves as per Interim Glove Guidelines Specimen pack with completed laboratory form Medicated swab Syringe Needle Sharps box

PROCEDURE Explain procedure to patient Provide privacy to patient Wash and dry hands thoroughly Put on disposable plastic apron and nonsterile gloves Clean the access point with a swab saturated with 70% Isopropyl Alcohol allow to dry for 30 seconds thoroughly Follow Manufacturers instructions a. If a leg bag has a sampling port a syringe may be inserted into the port and urine obtained.THIS IS WHAT SHOULD BE USED b. Using a needle and syringe aspirate the required amount of urine from the access point on the leg bag.

RATIONALE Ensure patient understands procedure and gives consent Ensure patient comfort and dignity Reduce risk of cross-infection Reduce risk of cross-infection Reduce risk of cross-infection

To obtain sterile specimen

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PROCEDURE Place the specimen into the boric acid container up to the marked line. After closing, invert the container several times and label container correctly. COMMUNITY Place in plastic container and then in white sealed bag. HOSPITAL Place in a double pocketed specimen bag Make patient comfortable Dispose of syringe and needle in sharps container Remove gloves and apron as per Healthcare Waste Policy Wash and dry hands thoroughly Record details of procedure in patients notes/catheter record sheet

RATIONALE To ensure only organisms for investigation are preserved To activate the inhibitor To ensure accurate identification of the specimen

Ensure patient comfort and dignity For the safe disposal of equipment to protect healthcare workers and others To reduce the risk of cross-infection To reduce the risk of cross-infection To provide a legal record

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USE OF INSTILLAGEL IN CATHETERISATION

Refer to Manufacturers Guidelines

CONTRA-INDICATIONS Patients on Antiarrythmic Drugs/Beta Blockers Must not be used in patients who have damaged or bleeding mucous membranes because of risk of systemic absorption of Lidocaine Hydrochloride USE CAUTION IN PATIENTS WITH Impaired Cardiac Conditions Hepatic Insufficiency Epilepsy

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BIBLIOGRAPHY
1. 2. Adults with Incapacity (Scotland) Act 2000 Code of practice Scottish Executive Association for Continence Advice Notes on Good Practice. ACA 2003 B.A.U.N. British Association of Urological Nurses 2000/2001; Guidelines for Male and Female Urethral Catheterisation Blocked Indwelling Urethral Catheters Barbara Holtom, Journal of Community Nursing - March 2004, Volume 18, Issue 3 Catheter Care Audit A Strategy for Change Susan Brimelow Catheter Care Trouble Shooting Ian Pomfret Journal of Community Nursing June 1999, Vol 13, Issue 6 Catheterisation, A Guide to the Role of the Nurse, Intermittent Catheterisation Ray Addison, February 2001 Guidelines on Male Catheterisation The Role of the Nurse RCN Continence Care Forum, 1994 Guidelines for Records and Record Keeping and Code of Professional Conduct 2004 Nursing and Midwifery Council Improving Community Catheter Management Leslie Simpson, Professional Nurse September 1999, Vol 14, No 12, Pages 831-834 Long Term Catheterisation Ernie Bull Journal of District Nursing, December 1990 Management of Autonomic Dysreflexia Booklet The Queen Elizabeth national spinal Injuries Unit for Scotland, Glasgow Management of the Neuropathic Bowl Booklet 2001 The Queen Elizabeth National Spinal Injuries Unit for Scotland, Glasgow Management of the Neuropathic Bladder June 2006 The Queen Elizabeth National Spinal Injuries Unit for Scotland, Glasgow NHS Grampian Informed Consent Policy 1999 Patient Management Following Supra-Pubic Catheterisation Ian Peate British Journal of Nursing 1997, Vol 6, No10, Pages 555-562 - 56 -

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17.

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