Urethral Catheterization

Indications:
1. Urinary retention (palpable, prominent urinary bladder)
2. To keep the patient dry and manageable when he is obtended or comatose
3. Management of incontinence of urine
4. To watch hourly urine output in intensive care situation.
5. As a part of urologic studies
and also managing post operative status.
6. To obtain a catheterized specimen of urine for culture and sensitivity when specially
required.

Requirements:
1. Water
2. Sterile Foley catheter bag
3. Betadine solution (povidone Iodine) – paint.c.

Procedure:

1. Preliminary hand wash and wearing of cap and mask recommended.

2. Patient should be in the supine position with legs slightly apart for the male and with
legs apart and knees flexed for the female patient.
3. A preliminary soap and water wash to the external genitalia is desirable.
4. Wear sterile gloves.
5. External preparation of genitalia is performed using betadine pain.
6. Provide privacy.
7. Appropriate catheter is picked up and the integrity of the balloon is checked by
introducing 5 cc of water into the balloon and deflated.
8. The sterile catheter is lubricated adequately with sterile jelly lubricant.

Catheterization of the male patient:

1. The penis is held with the left hand away from the scrotum and holding the catheter
firmly.
2. With the right hand the well lubricated catheter is gently passed through the external
urethral meatus.
3. When the catheter passes into the bladder, urine will be seen coming through the
catheter. At this point, it is advanced by another 1 to 2 cms and the balloon is inflated
with 5 cc or sterile water.
4. The Foley catheter after collecting specimens for urinalysis and culture is then
connected to the Foley bag.
5. The Foley catheter may be stabilized to the medial aspect of one of the thighs
using adhesive tapes. This prevents the Foley catheter advancing more towards the
bladder thereby carrying infection and also prevents it from unnecessary movements
causing discomforts.
Catheterization of the female patient:
1. The vulval outlet and labia are carefully washed and painted with betadine.
2. Appropriate sterile drapes are laid.
3. With the left hand exposing the urethral meatus by separating the labia with the
thumb and index fingers, the external urethral meatus is identified.
4. Previously lubricated catheter is carefully and gently advanced through it into the
bladder.
5. Care should be taken not to contaminate the catheter by touching the unprepared
parts of the genitalia and the vagina.
6. Once the catheter is well placed inside the bladder and the urine is seen coming out
of the tube the balloon is distended with 5 cc of sterile water and catheter connected
and fixed as described earlier.

Note:

Post Catheterization management has to be carefully planned to avoid

infections. Except in selected patients, routine antibiotic administration is not
necessary. Catheter care and change of catheters when necessary should be
remembered. In a hospital set up, catheter induced nosocomial infections of the
urinary tract are fairly common. When prolonged catheterization is required
appropriate urological and where necessary neurological consultations are obtained to
plan long term management of the catheter dependent patient. Ambulatory patients
who have Foley catheters left in situ are given appropriate instructions and training in
the care of the catheters and also plan periodical visits to the doctors and health care
staff.
Consider – use of silicon coated catheter for long-term placements.
 Nasotracheal Intubation

Under most circumstances orotracheal intubation is adequate and is quicker

to accomplish. In select circumstances, and in particular, in a semi-alert patient with
head injury it may be beneficial to use nasotracheal intubation. Once placed properly
it is tolerated and retained by the patients much better and is unlikely to be coughed
up, chewed or spit.

Requirements:

The requirements for nasotracheal intubation is essentially the same. Xylocaine Jelly
is recommended for the lubrication of the nostril as well as the tube.
Contra indications:
1. Nasal and facial bone fracture
2. In apneic patients nasotracheal intubation would require to listen to breath sounds
and in apneic patients that is not possible.
3. In patients with basal skull fracture and CSF rhinorrhea.

Procedure:

1. Patient is placed in supine position

2. An Assistant is requested to hold the head and neck in neutral position.
3. Check all the gadgets (ET tube, Suction etc)
4. Ventilate well with face mask and Ambu bag.
5. Spray the nasal passage with local anesthetic or apply xylocaine jelly to the
nostrils.
6. Pass an appropriate size well lubricated endotracheal tube through the
nostril and gently advance this towards the pharynx.
7. First pass it through the nostril and then backwards towards Pharynx.
8. It may be helpful to align the curve of the tube to facilitate the passage and
use of stylet is recommended to maintain this curvature.
9. Once the tube is in the pharynx listen to the airflow through the tube and
gradually position the end of the tube close to the glottis where the air flow
is maximal.
10. At a point when the patient is inhaling pass tube quickly into the trachea
and advance into it to an optimal position. This could be further helped if a
gentle pressure is made on the thyroid cartilage prior to introduction of the
tube.
11. Once the tube is in place use the Ambu to inflate the chest and make
sure there is good bilateral chest movements and also with the
stethoscope auscultate both sides of the chest.

Note:
However, it is always better to confirm the position of the endotracheal tube with a
chest x-ray taken as soon as possible.
 Orotracheal Intubation

Requirements:
a. Laryngoscope
b. Endotracheal tubes (stylet included)
c. Suction machine
d. 10 cc Syringe
e. Ambu bag / ventilator
f. Stethoscope

Position:
Endotracheal intubation in emergencies is done with a patient in recumbent posture
and where neck injury is suspected, an assistant to hold the neck in neutral position
without hyperextension or flexion is recommended.

Procedure:

1. Make sure that the suction is functional.

2. Make sure the laryngoscope is ready with functional bulb.
3. Make sure the cuffed endotracheal tube is intact and cuff is not leaking by
injecting air and checking it.
4. As a first step if the patient is breathing with face mask, ventilation and
oxygenation is to be continued.
5. The laryngoscope with a curved blade is introduced into the oral cavity.
6. The mouth and pharynx is opened enough to suction quickly and clear any
secretions.
7. With the laryngoscope in the left hand, it is applied into right side of the
patient’s mouth, the blade displacing the tongue towards the left.
8. At this point, it is possible to visualize the epiglottis and the vocal cords.
9. Gently insert the endotracheal tube into the trachea without injuring the
oral cavity with the scope.
10. Once the tube is comfortably placed inside the trachea, inflate the cuff with
a few ccs of air to provide a leak proof seal.
11. Using an ambu bag inflate the lungs through the endotracheal tube and
check for breath sounds on both sides of the chest in all areas with a
stethoscope. This is a very vital step as it is important to make sure that
the tube has not passed beyond the carina to one bronchus (thereby
cutting of the ventilation to the other lung).
12. Once a satisfactory placement is accomplished the orotracheal tube can be
fixed with adhesive tapes and ventilation carried utilizing ambu bag or
ventilator.
13. A chest x-ray if available could be obtained to make sure that the position
of the tube within the trachea is acceptable.