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Guideline
All healthcare professionals must exercise their own professional judgement when using
guidelines. However any decision to vary from the guideline should be documented in the
patient records to include the reason for variance and the subsequent action taken.
Page 1 of 35
CONTRIBUTION LIST
Competencies required
These guidelines apply to all registered nurses. Nurses have an individual responsibility to
ensure they feel confident and competent in the knowledge and skills of practice in line with
their Scope of Professional Practice (NMC, 1992). They should inform their immediate line
manager if they feel they are not competent and discuss their training needs. The line
manager is responsible for ensuring that any training required is identified as appropriate, and
measures taken to ensure that the nurse is able to obtain competencies in this area of
practice.
Catheterisation should only be undertaken by staff specifically trained and competent in this
procedure.
Only appropriately trained staff who are competent and confident should change a supra-
pubic catheter.
The trained nurse should acquire knowledge and skills relating to catheterisation to ensure
competency, and adhere to good practice. This is to be conducted in conjunction with R.C.N
recommendations, and ACA Guidelines.
Each trained nurse acquiring knowledge and skills in urethral and supra-pubic catheterisation
should receive classroom tuition, which should include:
1. Consideration to Physical, Social, Sexual and Psychological aspects of catheterisation.
2. An understanding of the anatomy and physiology of micturition and reproduction in
males.
3. Assessment prior to catheterisation.
4. Complications of catheterisation.
5. Legal aspects of care provision.
6. Catheter selection.
7. Catheter maintenance.
8. Aspects of Intermittent Self Catheterisation.
It is not a formal requirement to prove competent practice, but it is suggested that
competency is achieved through observation and supervision.
Observed Supervised
Patients covered
These guidelines applies to all adult patients, at home or in one of the community hospitals,
being treated and cared for by staff employed by, or working on behalf of WPCT.
Children are usually seen at the Children’s Hospital or by the Community Paediatrician.
Consent to treatment
Patients should have the procedure explained to them, and consent obtained by the nurse
carrying out the catheterisation, in accordance with the WPCT Consent to Treatment Policy,
and documented in the patient’s notes.
• To instil drugs.
Choice of Catheter
The choice of catheter used should be governed by the length of time the catheter is likely to
remain in situ, taking into account the reason for catheterisation.
There are a limited number of silicone catheters licenced for supra-pubic use, due to their
potential of cuffing. 1
Charriere Size
The charriere is the outer circumference of the catheter in millimetres and is equivalent to
three times the diameter. To avoid discomfort and leaking choose the smallest sized catheter
possible.
Balloon Size
For the majority of patients 10ml balloons are satisfactory, and are less likely to cause
irritation of the bladder mucosa.
30ml balloons were developed to prevent haemorrhage following prostatectomy, which is their
intended use only
For patients with a self-retaining catheter the following principles must be followed to prevent
ascending infection.
• It is imperative to adhere to the procedure guidelines when emptying a urine drainage bag
(see appendix 7) and when changing a urine drainage bag (Appendix 8).
• The genital area should be thoroughly cleansed at least once daily with unscented soap
and water, and repeated after every bowel movement. Particular attention should be paid
to the catheter meatal junction, the folds of the labia and under the foreskin in the male.
• Following defecation, patients should be reminded to use soft toilet tissue, wiping from
front to back. Moist toilet wipes are extremely useful for this purpose.
• A closed ‘LINK’ system for urinary collection is essential, minimising the risk of ascending
infection. (see section below)
• Drainage bags should remain at a level BELOW the patient’s bladder at all times.
• In females it is advisable to fit a Holster or Sporran type garment to ensure the system is
not visible below skirt level.
• Patients should be advised, in addition to a high fluid intake, to eat a high fibre diet to
avoid constipation.
Supra-pubic catheters
The following principles apply where a patient has a suprapubic catheter in-situ.
• Regular wound care of the insertion site is imperative. A dressing should not be necessary.
• Over granulation (occasional overgrowth of the tissue from the insertion site), if not causing
concern, does not require intervention. It may respond to Silver Nitrate Cauterisation or
application of a foam dressing. Silver Nitrate should not be the first choice to treat over
granulation. 5
• When using Silver Nitrate, care should be taken to protect the catheter. DO NOT use
petroleum based ointments or creams.
• Movement of the suprapubic catheter into/out of the wound should be avoided by careful
fixation of the catheter and connection tubing at or below the insertion site.
• Traction on the catheter should be avoided at all times, by regularly emptying the urine
drainage bag and by the use of supporting straps/garments, bag stands or hangers.
• The drainage bag should always be kept below the level of the bladder to maintain
gravitational flow and prevent backflow of urine.
There is a clear correlation between the number of times the drainage system is disconnected
and the rate of infection. It is important, therefore, to keep the drainage system CLOSED at all
times. The bag should only be disconnected from the catheter when the following occurs:
The bag should be changed when there is an accumulation of sediment, leakage, when a
new catheter is inserted, or when the bladder has been irrigated. Bags should last for at least
5 to 7 days.
The changing of urine drainage bags on a daily basis incurs unnecessary expense and entails
disconnection of the system more often than is necessary.
A leg bag should be in situ for approximately 5 for 7 days, but changed more often if there is
infection present. The tap end of the leg bag should be wiped with a 70% Isopropyl Alcohol
Swab before fitting the night bag connector (2000ml). 2
A disposable night drainage bag should be used, and disposed of accordingly each morning.
N.B For patients who are bed bound, a drainable 2 litre drainage bag may be used only if
connected directly to the catheter, and left in situ for 5 to 7 days.
Catheter Change
Catheters need changing only if they become obstructed or a malfunction occurs. If a catheter
continues to drain adequately, LEAVE IT ALONE, until its 12 week life expires.
Urine Samples
Urine samples should always be taken from the sample sleeve on the drainage bag and
never from the catheter itself. (See Appendix 9)
Catheter Strap
It is preferable to use a catheter strap to anchor the catheter to the patient’s thigh. This
prevents the catheter pistoning and subsequent trauma.
The leg drainage bag should not be disconnected but should be emptied before bathing and
can either be immersed in the bath or placed on a suitable surface at the edge of the bath.
The use of showers is strongly recommended, since there is less risk of infection.
Clamping
If for any reason clamping of the system is necessary, use the drainage bag tubing for this
purpose, never the catheter.
Use of spigots
Spigots should never be used, as they must be removed from the catheter to allow drainage,
thereby breaking what is essentially a closed drainage system and increasing the risk of
infection.
Catheter valves
Catheter valves are designed to ensure a free flush of urine through the catheter. This gives
less opportunity for blockage and, because the valve remains permanently connected to the
catheter, the chances of ascending infection are greatly reduced. Catheter valves should be
in situ for 5/7 days.
Bladder irrigation is the process of flushing the bladder with a sterile fluid. It is performed for
the following reasons:
• To prevent formation and retention of blood clots, tissue debris, pus and calculi
There is strong evidence that return to a normal voiding pattern occurs more rapidly if
catheters are removed at midnight.
Monitoring Tool
Standards
Aspect % Exceptions
Britton Petra M, Wright Elizabeth S, (1990) Nursing care of catheterised patients. The
Professional Nurse
Gentry H, Cope S (2005) Using silver to reduce catheter-associated urinary tract infections.
Nursing Standard. 19,50,51-54. Date of acceptance: June 20 2005
Getliffe, K. (1996) Care of urinary catheters. Nursing Standard. Vol 11, no.11.
Glenster, H. (1987) The passage of Infection Nursing Times. June 3-9,(22), 68-73Associated
Infections (Jan 2001), Vol 47
Lowthian, P. (1998) The dangers of long term catheter drainage. British Journal of Nursing
1998. Vol 7, no.7.
Mulhall AB, King S, Lee K, Wiggington E (1993) Maintenance of closed urinary drainage
systems: are practitioners more aware of the dangers? Journal of Clinical Nursing Vol.2 135 -
140
Pomfret, I. (1994) An Unsuitable Job for a woman? Nursing Times. Vol, 90 no.22.
Winn, C. (1996) Catheterisation : extending the scope of practice. Nursing Standard. Vol 10,
no.52.
2. Male Catheterisation
5. Female Catheterisation
6. Supra-pubic Catheterisation
Normal saline
Catheter
Apron
Patient’s notes
Procedure Notes
Cleansing of area prior to procedure. If possible the patient should have a bath or
shower prior to catheter insertion, or,
alternatively, a thorough wash with soap and
water of the genital area.
Prepare clean working surface, ensuring Failure to adhere to strict aseptic technique
good light. Wash hands and put could lead to the patient acquiring a urinary
disposable plastic apron on. Open packs tract infection which would mean pain and
and prepare equipment required. Do not discomfort.
remove inner wrapper from catheter at
this stage.
The foreskin is then retracted and the This area must be cleaned thoroughly, as it
glans penis cleaned with soap and water can harbour many bacteria.
or normal saline
Holding the penis upright, retract foreskin WAIT a minimum of 4 minutes (as per
if necessary, local anaesthetic gel is then manufacturer’s instructions) before carrying on
instilled slowly into the penis. with procedure.
When urine drains back, slowly insert the If a specimen of urine is required it should be
required amount of water in balloon. taken at this stage. Ensure the outlet tap of the
bag is n the closed position.
Apply drainage bag.
When the catheter is in situ, the foreskin This is to prevent phimosis occurring.
must be drawn back over the glans penis.
GP REVIEW
BLOODS REQUIRED:
PSA, U&E, CREATININE
*(NEXT WORKING DAY)
CHECK BLOOD PRESSURE COMPLICATIONS EMERGENCY
START ALPHA BLOCKERS** UROLOGY REFERAL
(EG: Alfuzosin Hydrochloride)
SUCCESSFUL TWOC
IF PSA WAS ABNORMAL RECATHERISE and REFER
REPEAT IN 6 WEEKS TO UROLOGY
Patient presenting at A&E should be catheterised and follow pathway with referral
to community clinicians (see contacts)
High risk patients include: Ca Prostate, Elderly frail, Living alone, Heart valves
If admission required for infection, elderly unable to cope, social care, high risk (as
above) explore community beds in locality before acute admission
GP review within 24 hours. Take bloods, check Blood Pressure and start Alpha
Blockers (e.g. Alfuzosin Hydrochloride)
Outpatient referrals for failed TWOC will be seen within 4-6 weeks as agreed by
Urology Department. These should be marked as URGENT
Page 18 of 35
Appendix 4: Trial without Catheter
The healthcare professional will instruct the patient to record fluid intake and
output on the attached form
An emergency contact telephone number should be given for the during the
day in case the patient has voiding difficulties
Re-visit patient mid-afternoon and review patient output during the TWOC
If in any doubt refer to the Continence Advisory Service for further advice
NAME:____________________________DOB_______________
_
PATIENT INSTRUCTIONS
1. Please drink at regular intervals through out the day to comfortably fill your bladder.
2. Please measure and record all fluids drunk and all urine passed.
3. If at anytime during the day you cannot pass urine and it becomes
uncomfortable, please contact the District Nurse on the emergency number given.
Signature of Nurse_____________________________
Date __________________________
Insert Anaesthetic Lubricating Gel. A Lubricating the urethra reduces friction and
small amount placed around the urethral trauma to the urethral mucosa. Use of a local
meatus will help to dilate the urethra anaesthetic minimises the patient’s discomfort.
Page 22 of 35
When urine drains back, slowly insert If a specimen of urine is required, it should be
required amount of water into balloon. taken at this stage. Ensure clamp is closed at
Apply drainage bag. the end of bag.
Procedure Notes
Explain fully to the patient why Failure to adhere to strict aseptic technique could
and how the procedure will be lead to the patient acquiring a urinary tract
carried out. infection which would mean pain and discomfort
Gently attach syringe nozzle to Make a mental note of the length of catheter
the valve on the inflation channel removed from the abdomen.
and deflate the balloon steadily
and unhurriedly, i.e. 10-20
seconds.
N.B. It has been noted that the catheter balloon is less likely to cuff, if you do not pull back on
the syringe when deflating the balloon. This is currently being researched.
Withdraw the catheter from the You may need to corkscrew it a bit and there may be
tract Note the angle that it a gush of urine as you withdraw it, have some gauze
comes out at. Put catheter to ready?
one side so that it can be
examined later on.
NOTES:
• Nurses worry about getting the catheter in the peritoneal space rather than in the bladder.
If the catheter is not far enough into the bladder, résistance will be felt when attempting to
fill balloon, and patient will feel pain. If this happens, deflate the balloon and advance the
catheter in further before re-inflating. There may not be any urine drained straight away,
but you should see some in the next ½ hour.
• A small amount of blood may be apparent at supra pubic catheter changes, but this should
stop in the next 24 hours.
Equipment Required:
• Appropriately sized catheters
• Clean catheter
• Mirror
Procedure Notes
Ask the patient to insert the To reduce risk of infection and ease insertion of
catheter into the urethra, using catheter.
non-touch technique.
Equipment Required:
• Appropriately sized catheters
• Clean catheter
NB.
It is advisable that the patient has a bath or shower prior to catheterisation.
Procedure Notes
Clean the glans penis. If To reduce risk of infection and ease insertion of catheter.
the foreskin covers the
penis it will need to be
retracted during the
procedure.
Requirements:
Plastic Apron
Latex/Vinyl Gloves
Suitable Receptacle e.g. Jug, Bottle, Urinal etc (single patient use only)
70% Isopropyl Alcohol Swab
Procedure:
• Close drainage outlet and wipe with 70% Isopropyl Alcohol Swab.
• Dispose of urine.
The bag should be changed when there is an accumulation of sediment, leakage, and a new
catheter is inserted, or when the bladder has been irrigated. Bags should last for at least 5 to
7 days. It is false economy to employ cheap bags and change them daily.
Requirements
Latex/Vinyl Gloves
Plastic apron
Sterile urine drainage bag
70% Isopropyl Alcohol Swab.
Procedure
• Protect bed/chair
• Apply gloves
• Pinch catheter 3-5 cms from end and disconnect ‘OLD’ drainage bag, raising end of
tubing to drain residue urine into bag
• Remove used bag, measure and record volume of contents where appropriate
• Wash hands
• Write up notes
Requirements
Sterile 5 ml syringe and needle (BLUE no.12 recommended)
Plastic apron
Latex/Vinyl Gloves
70% Isopropyl Alcohol Swab
Sterile urine specimen bottle
Laboratory request card and bag
Clamp or artery forceps (if required)
Procedure
• Clamp tubing approximately 5 cms BELOW self sealing band on drainage tubing
• Attach needle to syringe, insert the needle at an angle of 45 degrees through the
sample sleeve
• Aspirate 5 mls of urine, remove the needle from the syringe, and place the specimen
into the sterile container
• Label Specimen, complete card, send to laboratory using Boric acid urine container
• Wash hands
• Write up notes
Requirements
Latex/Vinyl Gloves
Plastic Apron
10 ml syringe
Citric Acid 6% (e.g Solution R) if appropriate
Suitable receptacle for collection
Note: Exercise extreme care to prevent urethral trauma
Once the balloon has been deflated, the patient may remove his own catheter under
supervision.
Procedure
• If patient is bed bound, protect the bed
• Apply plastic apron
• Wash hands, apply gloves
• Gently attach syringe nozzle to valve on the inflation channel and deflate the balloon
steadily and unhurriedly, i.e 10-20 seconds at least
N.B. It has been noted that the catheter balloon is less likely to cuff, if you do not pull
back on the syringe when deflating the balloon. This is currently being researched.
• If standard deflation procedure fails, do not cut off the inflation funnel
• Check whether the non-return valve on the inflation channel is sticking.
If so :
• Use a syringe and needle to aspirate the inflation arm just above the arm.
• If unsuccessful, refer for Medical Advice
• Dispose of syringe and needle (if used) in sharps box
• Remove catheter very gently and unhurriedly
• Inspect catheter on removal for encrustation, damage etc., and establish future
catheter selection and optimum time for next catheter change
• Clear away equipment, wash hands and chart observations
a) To prevent formation and retention of blood clots, tissue debris, pus and calculi
Plastic apron
Appropriate solution
Non-sterile gloves
Procedure Notes
Prepare solution in
accordance with
manufacturers instructions
Write up notes
Careful observation of patient, urine output and careful recording of fluid balance are
imperative
1. (a) Thoroughly wash hands (as per local infection control policy) and genital region,
including between the labia and in the folds under the foreskin.
(d) Use Boric acid urine container. This will preserve the specimen until it reaches the
laboratory.
2 Remove the cap from the sterile bottle and put it down on a clean surface, rim
upwards. Be careful not to touch the inside of the bottle or cap
3. Instruct the patient to take the bottle in one hand, separate the labia with the fingers of
the other hand, males retract the foreskin with the other hand, and then begin to pass
urine
4. After the patient has started to urinate, he or she should hold the bottle in the flow; the
bottle must then be removed before the flow ends.
5. Replace the cap firmly and shake the bottle well. Rinse and dry the outside of the
bottle. Label the bottle clearly with the name, address, date and time, record
appropriate information on laboratory form. Ensure that specimen reaches the
laboratory as soon as possible
N.B If the patient is elderly or has poor manual dexterity, a sterile receptacle may be used
to collect the specimen, and the specimen transferred to the urine collection bottle.