Urinary Catheterisation and Catheter Care in Adults Guidelines

Urinary Catheterisation and Catheter Care in Adults Guidelines
Director Responsible: Name of Author: Target Audience: Name of Responsible Committee: Version: Supersedes: Supporting Procedure(s): Nancy ONeil Chief Operating Officer Kath Wilkinson and Maria Moor All health workers with a responsibility for the care of individuals undergoing urinary catheterisation Safety and Care Governance One The Royal Marsden Clinical Policies Infection Prevention and Control Management Policy Consent to Examination and Treatment Policy Kath Wilkinson Service Managers. All staff with a responsibility for the care of individuals undergoing urinary catheterisation
Contact for further details: Dissemination:
Date Approved: Date Ratified: Date Issued: Review Date: ?2012
Contents
Section 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 12.1 12.2 12.3 12.4 12.5 12.6 12.7 12.8 13 14 15 16 Topic Introduction Scope of guideline The risks of urinary catheterisation Indications for catheterisation Assessment of patients prior to catheterisation Medical or nursing decisions to catheterise Primary catheterisation Consent Documentation Responsibilities and training: who can catheterise? Infection prevention and control Indwelling urethral catheterisation Catheter selection Catheter materials recommended for short term use (approx 28 days) Catheter materials recommended for long term use (approx 12 weeks) Drainage systems Lubrication Procedure for inserting an indwelling urethral catheter into adults Removal of indwelling urethral catheter Problem solving with indwelling urethral catheters Supra-pubic catheterisation Catheter care Urine sampling Catheter maintenance solutions Page 4 4 4 5 5 6 6 6 6 7 7 8 8 9 9 9 10 11 16 17 18 21 21 22
BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010
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17 18 19 20 21 22
Autonomic dysreflexia Permanent removal of catheter Intermittent self catheterisation Equality and Diversity Glossary of Terms Reference list Checklist for the review and approval of documents Plan for dissemination of documents Version control sheet
24 26 26 29 30 31 33 36 37
Appendix 1 Appendix 2 Appendix 3
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1.
Introduction
This document provides evidence based guidance to support the delivery of a high standard of clinical care to patients undergoing urinary catheterisation. It encompasses intermittent, urethral indwelling and suprapubic indwelling catheters in male and female adults.
2.
Scope of guideline
The guideline applies to all Bradford and Airedale Community Health Service (BACHS) staff with a responsibility for the catheterisation and catheter care of adults over the age of 18 years. It excludes children. It is recommended that the guideline is also adopted in independent care homes within the boundary of BACHS, in order to promote consistency of practice.
3.
The risks of urinary catheterisation

Urinary catheterisation is an intervention performed by health care workers to enable emptying of the bladder, to facilitate instillation of a solution or medication, or to dilate a urethral stricture by insertion of a catheter. Catheterisation is a common procedure, yet it carries many risks including trauma, urinary tract infection, encrustation, urethral perforation, bladder calculi and neoplastic changes (Lowthian, 1998). It should therefore be the therapy of choice only when all other interventions are deemed to be inappropriate or have been unsuccessful (Winn, 1998). Patients having a catheter inserted as part of their clinical care are in significant danger of acquiring a catheter associated urinary tract infection (CAUTI). The risk of CAUTI is associated with the method and duration of catheterisation, the quality of catheter care and host susceptibility (Pratt et al 2007). The commonest site for healthcare associated infection is in the urinary tract and 80 percent (%) of urinary infections are traceable to indwelling urinary catheters. These infections arise because catheters traumatise the urethra as well as providing a pathway for bacteria and other organisms to enter the bladder. The longer a catheter is in situ the higher the risk of infection. About 50% of patients catheterised for longer than 7-10 days contract bacteriauria. Although frequently asymptomatic, 20 to 30% of patients with catheter-associated bacteriauria will develop symptoms of CAUTI. Once a CAUTI has developed there is a 1 to 4% risk of developing bacteraemia with an associated mortality rate of 13 to 30% (Pratt et al, 2007). Each hospital-acquired CAUTI results in an average increased length of stay of five to six days in hospital and costs 1,327 to treat (Plowman et al, 1999). Patients who develop CAUTIs in primary care settings have greater contact with their general practitioner (GP), visit the hospital more frequently for outpatient appointments and receive more visits from district nurses.
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4.
Indications for catheterisation
Indications for catheterisation include: patients with neurological disease or injury who have difficulty in completely emptying the bladder patients with outlet obstruction who may be unfit for, or are awaiting surgical repair patients who are chronically incontinent, often with associated debility or confusion where other methods are inappropriate or unsuccessful bladder drainage pre-, peri- and post-operatively acute or chronic retention of urine investigations where measurement of residual urine (see glossary) is required. However bladder scanning is the preferred method of measuring residual volume instillation of prescribed drugs in to the bladder monitoring urine output terminally ill patients where catheterisation is deemed appropriate in exceptional circumstances urinary catheterisation may be necessary to avoid wound contamination and facilitate wound dressing to allow optimal conditions for healing, e.g. sacral pressure ulcers. Catheters may be self retaining for continuous or intermittent drainage, or intermittent for periodic insertion.
5.
Assessment of patients prior to catheterisation
Assessment and the decision to catheterise must be clearly documented in the patients records, including the reason(s) for catheterisation and type of catheterisation chosen. A comprehensive clinical assessment of the individual taking into account physical, psychological, social and environmental factors must be carried out before catheterisation. The assessment must encompass the following: the reason for the insertion of the catheter medical history mental health or cognitive function which may affect the individuals ability to give informed consent the patients or carers ability to manage the catheter fluid intake bowel function the patients environment and risk factors that may contraindicate catheterisation skin integrity sexuality and sexual function (where appropriate) patients level of understanding. The need for the catheter must be reviewed and agreed at a minimum of every planned catheter change.
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6.
Medical or nursing decision to catheterise

The decision to catheterise a patient urethrally, either with an indwelling catheter or intermittently, can be made by a doctor, nurse practitioner, nurse consultant or continence nurse specialist. This decision should be made in conjunction with, or delegated to, the nurse who will perform the catheterisation. Patients requiring a suprapubic catheter should be referred to a urologist.
7.
Primary catheterisation
Registered nurses may insert primary catheters providing they have received training, consider themselves competent, and they have the permission of their employer (NMC, 2008). The first suprapubic catheter insertion is usually undertaken by an urologist. The first replacement may be undertaken by nurses who have the appropriate competencies, at the instruction of the responsible medical practitioner. The first insertion of an intermittent catheter may be undertaken by registered nurses who are competent in the procedure. Subsequent routine catheter changes may be delegated (in accordance with the CHSs delegation policy) to a trained (HCA) who has the competences and authority to undertake urinary catheterisation.
8.
Consent
The process of obtaining consent should be in line with the BACHS Consent to Examination and Treatment Policy. The instruction from the responsible medical or nurse practitioner and consent from the patient should be documented in the patients records prior to the first catheterisation A routine re-catheterisation or change of blocked catheter does not require medical consent. Consent from the patient should be obtained and the process recorded at every catheterisation. In order to ensure that consent is fully informed, a thorough explanation should be given to the patient and the patient offered a choice of a male or female practitioner.
9.
Documentation and audit

Catheterisation and all catheter care must be documented in accordance with the Nursing and Midwifery Council Guidance for Record Keeping (NMC, 2007)
This must include: Initial assessment Reason for catheterisation Evidence of patients informed consent for catheterisation. Type of catheterisation
BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010 Page 6 of 37
Type of catheter, material, manufacturer, length, Charriere (Ch) size, batch number and expiry date. Make and type of lubricating gel used, batch number and expiry date Date and time of insertion and by whom Volume of urine drained Any complications encountered Type of drainage system Evidence of any supporting literature or audio-visual information provided. Date of planned change / reassessment All staff are required to review their practice in urinary catheterisation annually in accordance with Essential steps to safe Clean Care DH 2007
10.
Responsibilities and training

Registered nurses who have received training and are competent may catheterise male or female patients. HCAs who have received training and been deemed competent within BACHS can undertake urinary catheterisation. The registered nurse responsible for patient care must ensure that delegation of catheterisation to the HCA is appropriate, and that the HCA maintains competencies. All nurses and health care assistants with a responsibility for urinary catheterisation must update themselves every 5 years by undertaking the BACHS catheterisation e learning module. The continence service within BACHS provides regular education for registered nurses and HCAs on urinary catheterisation. Information regarding training and the e learning module on urinary catheterisation is available via the continence service secretary on 01274 322171.
11.
Infection prevention and control

Good hygiene is essential to minimize the risk of catheter associated urinary tract infections (CAUTIs). Hand decontamination should always be performed in line the BACHS Hand Hygiene policy. Effective hand washing with liquid soap and running water, and drying hands with paper towels following the six steps (Taylor, 1978) removes the majority of transient micro-organisms. This should occur before and after catheterisation, emptying, disconnecting or changing the drainage system. Alcohol gel can be used as an alternative to liquid soap and water on visibly clean hands. Plastic aprons and sterile latex free gloves should be worn during catheter insertion to ensure personal protection and infection prevention and control. Personal protective equipment (PPE) is worn to prevent the transmission of micro-organisms to the patient and prevent the risk of contamination of the healthcare practitioners clothing and skin (Wilson, 2001). Catheter equipment must be stored unopened in a dry, cool place to ensure product integrity. A clean environment must be maintained in preparation areas and where stock is stored to prevent the transmission of micro-organisms that cause CAUTIs (Garner and Favero, 1985; Dancer, 1999). In patients own homes sterile and non-sterile equipment must
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be stored in clean and dry conditions off the floor, and away from potential damage. Check all stock regularly to ensure it is in date.
12.
Indwelling urethral catheterisation 12.1 Catheter selection 12.1.1 Diameter

The smallest catheter possible should be used, that still allows good drainage (Norton 1996). A larger catheter may be used to facilitate drainage if clots or debris have been or are likely to be a problem. The external diameter is measured in Charriere (Ch) size also known as French (Fr) gauge.
10-14 Ch for drainage of clear urine 14-16 Ch for urine containing debris or small clots 18 Ch or above if haematuria or large clots present and at doctors request (6-10Ch for paediatrics only)
12.1.2 Length
Catheters should be selected from the three available lengths to meet the assessed needs of individual patients: female length catheter 20-26cm (females only) although obese or chair bound patients may prefer a standard length catheter standard length catheter 40-45cm for male or female patients (males must always be catheterised with a standard length catheter) paediatric catheter 30-31cm (not to be used for adults).
12.1.3 Balloons
Indwelling catheters are kept in place by inflating a balloon, after the catheter is in the bladder. Catheter balloon sizes come in three different volumes: 3-5ml for paediatric use 10ml for adult routine drainage 30ml for post-urological procedures only and not for routine catheterisation. Balloons must be filled with the exact amount of sterile water stated. Over or under inflation of the balloon can cause distortion which can deflect the catheter tip and interfere with drainage or cause irritation. Balloons should be inflated according to manufacturers instructions. Some balloons require inflation with a syringe and sterile water, others are pre-filled.
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12.2 Catheter materials recommended for short term use (up to 28 days)
Ensure that you always check manufacturers recommended duration
Catheter material
Plastic/PVC (Should not be left in situ for longer than 7 days). Silver alloy hydrogel coated latex (Certain brands may be left in situ for longer than 28 days). PTFE coated latex
Advantage
Large Internal diameter allows good drainage postoperatively.
Disadvantage
Rigid and inflexible May cause urethral discomfort.
Inhibits bacterial growth, reduces incidence of UTI (Saint, 1998) Low surface friction and improved patient comfort (Pratt et al, 2007). Smoother outer surface - reduces tissue damage and more resistant to encrustations
Unsuitable for people with latex allergies.
12.3 Catheter materials recommended for long term use (up to 12 weeks)
Ensure that you always check manufacturers recommended duration
Catheter material
Hydrogel coated latex
Advantages
More compatible with body tissue, less trauma Low surface friction, improved patient comfort Suitable for patients with a latex allergy Smooth internal and external surfaces. May reduce potential for encrustation Suitable for patients with a latex allergy Thin walled catheter with a larger lumen than a coated catheter.
Disadvantages
Hydrogel Coated silicone Silicone elastomer coated latex All Silicone
Rigid and can be uncomfortable Can be difficult to remove due to formation of a cuff on balloon deflation. Unsuitable for patients who are allergic to latex.
Rigid and can be uncomfortable Can be difficult to remove due to formation of a cuff on balloon deflation, and can be more difficult to remove supra-pubically.
12.4 Drainage systems

A huge range of leg bags, night bags, belly bags and valves are available on prescription. It is important to consider the individuals needs when selecting an appropriate drainage system.
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12.4.1 Leg bags

Points to consider when selecting the appropriate leg bag: capacity required, as bag volume can range from 350mls to 1300mls inlet tube length can be worn on the calf, knee or thigh type of support system can use leg straps or an elasticated sleeve security there are a number of devices available to hold the catheter securely in place, and reduce friction / rubbing
12.4.2 Belly bags

These may be suitable for less mobile individuals or those with suprapubic catheters. They are held in place by an adjustable belt.
12.4.3 Night drainage bags These bags usually hold 2 litres, and should not be used during the day on a mobile patient. A night drainage bag should be connected to the leg bag or catheter valve
to avoid breaking the closed system. The bag must be hung on a stand to prevent it from touching the floor In hospital or care homes, single use night drainage bags must be used to minimize cross-infection. In the individuals own home, a reusable night drainage bag may be used for up to 1 week in accordance with manufacturers instructions.
12. 4.4 Catheter valves

A catheter valve may be used as an alternative to a leg bag and allows the bladder to fill and empty periodically. The valve must be released regularly to prevent over distention of the bladder. Catheter valves are now widely used as a means of draining the bladder intermittently and can give patients greater comfort and independence (Getliffe & Dolman, 2003). When assessing the patients suitability for a catheter valve, bladder function, manual dexterity, lifestyle and cognitive function should be considered. Patients with an overactive bladder, impaired bladder sensation or cognitive impairment may not be suitable for a valve All drainage systems must be changed in line with manufacturing guidelines
12.5 Lubrication
NICE (2003) state that an appropriate lubricant from a single-use container should be used during catheter insertion to lubricate the urethra adequately to minimize urethral trauma and infection. There is research to support the use of an anesthetic lubricating gel containing lidocaine to minimise pain and discomfort in both men (Sidarias et al, 2004) and women (Chung et al, 2007).
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12.5.1 Lubrication gels available

Instillagel (CliniMed) contains lidocaine hydrochloride2%, chlorhexidine gluconate solution 0.25% in a sterile lubricant basis in a disposable syringe. It is available in two sizes - 6ml (female) and 11ml (male). Cathejell with Lidocaine (Teleflex Medical) is a lubricant gel with 2% lidocaine and 0.05 % Chlorhexidine in an accordian tube for a completely controlled instillation available in 8.5gm (female) and 12.5gm (male) In the event of a patient having a known contra-indication or allergy to anaesthetic lubricating gel, a plain lubricating gel may be used, eg Cathejell Mono.
12.5.2 Risks of using anaesthetic lubrication gels

It is important to be aware of the risks of using lubrication gels containing lidocaine, although topical usage is considered to pose a minimal risk to the patient. Both Instillagel and Cathejell with Lidocaine are contraindicated in patients with known sensitivities to any of the active ingredients, and in those patients who have damaged or bleeding urethral membranes. This is due to the increased risk of systemic absorption of lidocaine hydrochloride which may exacerbate ventricular arrhythmias and cause hypotension (Katzung 1995). Lidocaine should also be used cautiously in patients taking antiarrhythmic medication or patients with impaired cardiac conditions, hepatic insufficiency and epilepsy (BNF 2007). The MHRA (2005) reported 34 reactions to Instillagel, with eight of these being anaphylactic in nature, and none of them fatal. Addison (2000) advised caution in regard to the use of lidocaine particularly on patients with an increased risk of the systemic effects of lidocaine, advising that if the patients pulse or breathing rate are slow, consider using a gel not containing lidocaine.
12.6 Procedures for inserting an indwelling urethral catheter into adults 12.6.1 Equipment required:
sterile catheterisation pack two pairs of latex free sterile gloves selection of appropriate catheters sterile anaesthetic lubrication gel alcohol hand gel sterile water, syringe and needle sodium chloride 0.9% disposable plastic apron suitable drainage bag and support system.
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12.6.2 Procedure for females Action

Explain and discuss the procedure with the patient. Obtain and document informed consent Wash hands in line with BACHS policy. Ensure that the patients genitalia have been washed with soap and water. Prepare the environment, and ensure there is a clean flat surface close to the bed To ensure patient's privacy and dignity. To allow dust and airborne organisms to settle before the sterile field is exposed.
Rational
To ensure that the patient understands the procedure and gives her valid consent. To reduce risk of infection.
Assist the patient to get into the supine position To enable the genital area to be seen. with knees bent, hips flexed and feet resting about 60 cm apart. If not possible consider suitable alternative position. Ensure that a good light source is available. Wash hands again, alternatively use alcohol gel. Put on a disposable apron. Open the catheterisation pack on to the prepared surface. Using an aseptic technique open the packages of equipment onto the sterile field and fill the syringe with sterile water, if required. Re wash hands , alternatively use alcohol gel. Put on latex free sterile gloves. Place sterile towels between the patients thighs. Using gloved fingers of one hand, separate the labia minora so that the urethral meatus is To enable genital area to be seen clearly. To reduce risk of cross-infection. To reduce risk of cross-infection from microorganisms on uniform To maintain an aseptic procedure. To reduce the risk of introducing infection into the urinary tract. Hands may have become contaminated by handling of outer packs, etc. To reduce risk of cross-infection and allergic reaction. To create a sterile field. This manoeuvre provides better access to the urethral orifice and helps to prevent labial
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seen.
contamination of the catheter.
Clean around the urethral orifice with 0.9% sodium chloride, using single downward strokes. Insert the nozzle of the anaesthetic lubrication gel into the urethra. Squeeze 6ml into the urethra, remove the nozzle and discard the tube. Wait 5 minutes for it to take effect.
To reduce the risk of cross-infection. Inadequate preparation of the urethral orifice is a major cause of infection following catheterisation. Adequate lubrication helps to prevent urethral trauma. Use of a local anaesthetic minimizes the patients discomfort.
Place the catheter, in the receiver, between the To provide a temporary container for urine as it patients legs. drains. Gently introduce the tip of the catheter into the urethral orifice. Advance the catheter 5-6cm or until urine starts to flow, then advance it a further 6-8cm Inflate the balloon according to the manufacturers directions, having ensured that the catheter is draining adequately. Withdraw the catheter slightly until the balloon is sitting at the bladder neck, and connect it to the drainage system. Support the catheter, if the patient desires by using a specially designed support. Ensure that the catheter does not become taut when patient is mobilizing. Ensure that the catheter lumen is not occluded by the fixation device. Make the patient comfortable and ensure that the area is dry. Measure the amount of urine. This prevents the balloon from being trapped in the urethra.
Inadvertent inflation of the balloon within the urethra is painful and causes urethral trauma. Maintain patient comfort and prevent urethral trauma. To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma.
If the area is left wet or moist, secondary infection and skin irritation may occur. To ensure volume of urine in bladder at time of catheterisation is recorded. (During routine re catheterisation there should be a minimal amount of urine in the bladder). To prevent environmental contamination.
Dispose of equipment according to BACHS Waste Management policy. Remove gloves and rewash hands. Record details of catheterisation contemporaneously in relevant documents.
Infection prevention and control. To ensure accountability.
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12.6.3 Procedure for males Action

Explain and discuss the procedure with the patient. Obtain and document informed consent. Wash hands in line with BACHS policy. Ensure the genitals are washed thoroughly with soap and water. Prepare the environment, and ensure there is a clean flat surface close to the bed. To ensure patient's privacy. To allow dust and airborne organisms to settle before the sterile field is exposed.
Rationale
To ensure that the patient understands the procedure and gives his valid consent. To reduce the risk of infection.
Assist the patient to get into the supine position To ensure the genital area is easily accessible. with the legs extended. Wash hands in line with BACHS policy Put on a disposable plastic apron. Open the catheterisation pack on to the prepared surface. Using an aseptic technique, open the packages of equipment onto the sterile field and fill the syringe with sterile water, if required. Rewash hands clean with alcohol gel. Put on sterile latex free gloves. Place sterile towels across the patient's thighs. Wrap a sterile topical swab around the penis. Retract the foreskin, if necessary, and clean the glans penis and meatus with sterile 0.9% sodium chloride. Insert the nozzle of the lubricating gel into the urethra. Slowly squeeze minimum of 10mls of
To reduce risk of infection. To reduce risk of cross-infection from microorganisms on uniform To maintain an aseptic procedure. To reduce the risk of introducing infection into the urinary tract.
Hands may have become contaminated by handling the outer packs. To reduce risk of cross-infection and allergic reaction. To create a sterile field. To reduce the risk of introducing infection to the urinary tract during catheterisation.
Adequate lubrication helps to prevent urethral trauma. Use of a local anaesthetic minimizes
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gel into the urethra, remove the nozzle and discard the tube. If anaesthetic gel has been used wait approximately 5 minutes. Grasp the penis behind the glans, raising it until it is almost totally extended. Maintain grasp of penis until the procedure is finished. Place the receiver containing the catheter between the patient's legs. Insert the catheter for 1525 cm until urine flows. If resistance is felt at the external sphincter, increase the traction on the penis slightly and apply steady, gentle pressure on the catheter. If resistance is still felt, try pausing for a few seconds or ask the patient to cough or strain gently as if passing urine and continue to insert the catheter. When urine begins to flow, advance the catheter almost to its bifurcation. Gently inflate the balloon according to the manufacturer's direction, having ensured that the catheter is draining properly beforehand. Withdraw the catheter slightly and attach it to the selected drainage system. Support the catheter, if the patient desires by using a specially designed support. Ensure that the catheter does not become taut when patient is mobilizing or when the penis becomes erect.. Ensure that the glans penis is clean and then reposition the foreskin. Make the patient comfortable and ensure that the area is dry.
the discomfort experienced by the patient. To allow the anaesthetic gel to take effect. This manoeuvre straightens the penile urethra and facilitates catheterisation (Stoller, 1995). Maintaining a grasp of the penis prevents contamination and retraction of the penis. The male urethra is approximately 18 cm long.
Some resistance may be due to spasm of the external sphincter, or an enlarged prostate. Straining gently or coughing helps to relax the external sphincter.
Advancing the catheter ensures that it is correctly positioned in the bladder. Inadvertent inflation of the balloon in the urethra causes pain and urethral trauma. To ensure that the catheter is correctly positioned in the bladder. To maintain patient comfort and to reduce the risk of urethral and bladder neck trauma.
Retraction and constriction of the foreskin behind the glans penis (paraphimosis) may occur if this is not done. If the area is left wet or moist, secondary infection and skin irritation may occur. To ensure volume of urine in bladder at time of catheterisation is recorded. (During routine re catheterisation there should be a minimal amount of urine in the bladder).
Measure the amount of urine.
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Dispose of equipment according to BACHS Waste Management policy Remove gloves and wash hands using liquid soap and running water. Record information contemporaneously in relevant documents (Adapted from Dougherty and Lister, 2004)
To prevent environmental contamination.
Infection prevention and control. To ensure accountability.
Note: beware of patient having a vasovagal attack. This is caused by the vagal nerve being stimulated so that the heart slows down, leading to a syncope faint. If it happens, lie the patient down in the recovery position and seek medical help.
12.7 Removal of indwelling urethral catheters 12.7.1 Equipment: Action

Explain procedure to patient and obtain informed consent. Discuss care plan following removal of catheter. Wash hands using liquid soap and running water. If not available use alcohol gel. Prepare the environment. Ensure genitalia have been cleaned with soap and water prior to catheter removal. Release catheter drainage support system and empty catheter drainage bag. Having checked volume of water originally inserted into balloon (see patient documentation), use syringe to deflate balloon. Nb The amount removed may be less than that inserted due to the semi porous nature of the balloon. Gently remove catheter. If resistance is felt, To relax pelvic floor muscles and facilitate disposable latex free gloves and apron syringe for deflating balloon.
Rationale
To ensure that the patient understands the procedure and gives informed consent. Infection prevention and control. To ensure that the patient is comfortable and privacy and dignity is maintained. To reduce risk of infection. For easier removal and disposal of catheter and drainage system. To ensure balloon is completely deflated before removing catheter.
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ask the patient to cough. If removal of the catheter is difficult seek medical help. Ensure patient is comfortable. If catheter is not being replaced, ensure appropriate advice and information is given. Document voiding pattern.
catheter removal. To ensure patient safety. To ensure patient is aware of management plan. If available, a portable bladder scanner should be utilised to measure residual volumes in the first few days after catheter removal and action taken, if problems arise. To prevent environmental contamination. Infection prevention and control.
Dispose of equipment according to BACHS Waste Management Policy. Remove gloves and apron, wash hands
12.8 Problem solving with indwelling urethral catheters Problem

Urine bypassing
Cause
Balloon/catheter gauge too big. Catheter blocked by debris.
Action
Select 10ml balloon or smaller gauge catheter Remove and re-catheterise After removal, cut catheter in half and check for encrustation. Consider a programme of catheter maintenance solution (see section) Consider anticholinergic medication. Increase fluid intake, dietary fibre advice, prescribe laxatives if needed. Remove and re-catheterise Cut catheter in half and check for encrustation. Assess suitability for a programme of catheter maintenance solution. Inspect the system and straighten any kinks Reposition catheter bag. Treat accordingly (see above). May need a smaller catheter Consider anti cholinergic medication Treat accordingly. Consider catheter maintenance solutions
Bladder spasm / instability. Constipation. Urine does not drain Blocked catheter.
Kinked drainage tubing. Leg bag above the level of the bladder. Constipation. Bladder Spasm. Dehydration.
Catheter is encrusted
Micro-organisms sticking to catheter surface.
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Non deflating balloon
Valve port and balloon inflation channel may be compressed. Faulty valve mechanism
Check no external compression problems Remove the syringe and try another one, always aspirate slowly or the valve mechanism may collapse A few ml of sterile water can be added to the valve to clear any obstruction but do not over inflate the balloon Do not cut the catheter during removal Seek medical help if unable to remove catheter. Observe output, encourage fluids Treat infection if symptomatic. Ensure catheter and drainage bag is appropriately secured and supported. Seek medical advice
Haematuria
Trauma or infection. Tension on catheter due to inadequate support. Persistent haematuria.
13.
Supra-pubic catheterisation
For some people a supra-pubic catheter may be indicated for the following reasons: where urethral catheterisation is not possible (ie urethral stricture) it is the patients preferred choice protection of the urethra from trauma greater freedom for expressing sexuality improved patient comfort and easier management of catheter changes where limb contractures make urethral catheter insertion and management difficult post-operatively for bladder drainage or to monitor residual volumes Contraindications for suprapubic catheterisation include: unexplained haematuria previous lower abdominal surgery history of bladder tumours blood clotting disorders ascites suspicion of ovarian cyst very obese patients The insertion of the first suprapubic catheter is usually performed in hospital by a urology specialist; thereafter the catheter is usually changed by a nurse. The size of catheter used should be no smaller than 16Ch in adults with a 10ml balloon, unless otherwise specified by an appropriate specialist. A larger charriere size may be used if the catheter persistently blocks. Catheters used must be licensed for suprapubic use. Individual choice must be considered regarding the length of the catheter as longer catheters may be easier for some individuals to manage, whilst others will prefer the option of a shorter, more discreet catheter.
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If the catheter becomes dislodged it should be replaced within 30-45 minutes or the tract may be difficult to re-catheterise. Community patients and carers in the community should have spare equipment and the relevant contact telephone numbers. If the catheter becomes blocked or dislodged within the first four weeks of initial insertion expert medical advice should be sought (Quality Improvement Scotland 2004).
13.1 Lubrication in suprapubic catheterisation

Anaesthetic / lubrication gel may be instilled into the stoma or applied to the new catheter as required (ACA, 1995) to allow smoother passage of the catheter and reduce trauma. Removal of a suprapubic catheter may be facilitated by the insertion of lubrication gel down the side of the catheter to lubricate the tract (McMahonParkes, 1998).
13.2 Procedure for supra-pubic catheter change

13.2.1 Equipment:
sterile catheterisation pack two pairs of latex free sterile gloves selection of approved catheters sterile lubrication gel alcohol hand gel sterile water, two syringes and needle sterile saline disposable plastic apron suitable drainage bag and support system.
Action
Explain and discuss the procedure with the patient. Wash hands with liquid soap and running water, or alcohol gel in line with BACHS policy. Prepare the environment, and ensure there is a clean, flat\ area close to the bed. Assist the patient to get into a comfortable position on the bed. Expose the catheter entry site. Empty the catheter bag. Wash hands in line with BACHS policy Put on a disposable plastic apron. Empty the contents of the sterile packages on to the prepared surface. Fill the syringe with the appropriate amount of sterile water if required.
Rationale
To ensure that the patient understands the procedure and gives his valid consent. Infection prevention and control. To ensure patients privacy. To allow dust and airborne organisms to settle before the field is exposed. To ensure the catheter site is easily accessible. Infection prevention and control. To reduce risk of cross-infection from microorganisms on uniform. To maintain an aseptic procedure and reduce the risk of introducing infection into the urinary tract.
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Deflate the existing catheter balloon using a second syringe. Holding a gauze swab with one hand, remove the catheter with the other hand, noting the direction and length of catheter that was inserted. Place the gauze swab over the site to absorb any leakage. Observe removed catheter for encrustation. Dispose of removed catheter and used equipment according to waste disposal policy. Remove gloves. Wash hands in line with BACHS policy Put on sterile latex free gloves. Place sterile towels across the patient's abdomen. Clean the suprapubic catheter site with sterile saline, using a single wipe with each swab. Place the receiver containing the catheter on to the patients thighs. Apply lubricating gel to the tip of the catheter and suprapubic site. Holding the catheter with the sterile gauze insert it in to the suprapubic catheter site, to the same distance as the removed catheter plus 4 centimetres. Inflate the balloon with sterile water according to manufacturers instructions. Ensure that the catheter is mobile in the tract. Attach drainage bag and suitable support system or catheter valve. Apply dressing to catheter insertion site if necessary Make patient comfortable and give advice on fluids. Observe drainage of urine from catheter. Dispose of equipment according to local waste policy and dispose according to BACHS policy. Remove gloves and apron, and wash hands in line with BACHS policy Record information contemporaneously in relevant documents according to CHS policy.
To deflate balloon to allow catheter removal. To facilitate comfortable removal and replacement of catheter.
To ensure infection prevention and to prevent environmental contamination. Infection prevention and control. To reduce risk of cross-infection and allergic reaction. To create a sterile field. To reduce the risk of introducing infection to the urinary tract during catheterisation. To minimise trauma and discomfort.
To ensure that the catheter is positioned safely in the bladder.
To ensure that catheter is correctly positioned in to the bladder. To maintain a closed system. To absorb any exudate. To promote catheter drainage To ensure catheter correctly positioned. To prevent environmental contamination. Infection prevention and control. To ensure accountability.
14. Catheter care

Patients are encouraged to bath or shower daily (Pratt et al, 2007), and to wash their hands thoroughly with soap and water before and after handling their catheter and / or drainage system. Frequent meatal cleansing with antiseptic solutions is unnecessary, and may increase the risk of infection. Indwelling catheters are connected to a closed drainage system which should be maintained as much as possible to reduce the risk of infection (Pratt et al, 2007) Urine drainage bags are to be emptied regularly (usually when two-thirds full) and positioned below the level of the bladder. Catheters and attached drainage systems are to be properly secured in a comfortable position for the individual The exception is the Belly Bag which can be worn around the patients abdomen and does not require to be positioned below the level of the bladder. Body worn drainage bags are generally changed weekly or according to the manufacturers instructions. The bag should be fixed to the leg appropriately to avoid kinking and pulling. Trauma to the neck of the bladder may be caused if the catheter and bag are not fixed correctly. Adhesive tapes should be avoided as they can cause damage to the catheter (Pomfret, 1991). A separate clean container is used for each individual at the time of bag emptying. Contact between the drainage tap and container is avoided. Leg bags may also be emptied directly into the toilet. Health workers must wear non-sterile latex free gloves to empty drainage bags and change the gloves after hand washing between each patient. When an overnight bag is required a new, single-use 2 litre bedside bag is used and is emptied and discarded each morning in the hospital and nursing home setting. In the patients own home a drainable bag may be used. This will usually need changing weekly, but always check with the manufacturers guidelines. Overnight drainage bags should be supported above the floor level, but below the level of the bladder, to ensure the maintenance of flow of urine and helps to prevent harmful reflux If a symptomatic urinary tract infection is suspected, a catheter specimen of urine (CSU) should be taken for analysis (see section 15 for the procedure). If a catheter is blocked with blood, pus or debris, normal saline solution 50-100mls can be used to irrigate it. If the catheter is blocking regularly due to encrustation, catheter maintenance solutions are recommended (see section 16).
15. Urine sampling

Urine samples are only taken from catheters for a valid reason, such as to confirm a suspected symptomatic infection. If the patient is asymptomatic, treatment for colonisation is not indicated (Warren, 1997). Breaches in the closed system, such as taking a urine sample, increase the risk of catheterrelated infection (Wilson et al, 1997) so samples must be collected from the bag sample port using aseptic technique. Prior to obtaining a catheter sample of urine, the port is cleaned with an isopropyl alcohol 70% impregnated swab and allowed to dry thoroughly. Wash hands or apply alcohol gel. Using a sterile syringe and needle (if necessary) aspirate the required amount of urine from the access point and empty it in to the appropriate sample bottle. 16. Catheter maintenance solutions
Some patients may benefit from the use of catheter maintenance solutions to prolong the life of their catheter, avoiding the trauma of re-catheterisation. However, catheter maintenance solutions should only be used following careful assessment rather than as routine practice, and in accordance with manufacturers instructions. There are many potential causes of catheter blockage, and treatment should be based on clinical evidence, following thorough assessment. Records of catheter history must be maintained including: problems associated with bowel habit debris in urine crystals on catheter tip at removal urinary pH. In a first time blockage, where there is no evidence of the cause of the blockage, the catheter should be removed, examined, and the urine tested to explore the possible causes of blockage. The findings should be recorded. This will give a basis for obtaining a prescription for an appropriate catheter maintenance solution. Where a catheter maintenance solution may be beneficial, the solution used must be appropriate to the condition being treated, holistic to the patients needs. However, the administration of catheter maintenance solutions requires breakage of the closed drainage system increasing the risk of introducing infection, and antibiotic solutions are not usually effective in treating CAUTIs. Records must be kept of the solution used, its effect on catheter drainage, any adverse effects and ongoing catheter history.
16.1 Selection of catheter maintenance solutions

Solution Citric acid 3.23% Solution G (pH 4) Citric acid 6% Solution R (pH 2) Mandelic acid 1% (pH 2) Product Licence For the dissolution of struvite crystals which form on the catheter tip under alkaline conditions (pH 7.5-9.5). Stronger citric acid solution for more persistent crystallisation. For the reduction of microorganisms which produce urease creating alkaline conditions (mostly proteus species). Practice Notes/Cautions Charting of urinary pH over time will allow development of an individual catheter care plan. Strongly acidic potential mucosal irritation. Acidic pH also counters the effect of proteus on the urinary pH. Strongly acidic potential mucosal irritation. Evidence shows that 19 days treatment of twice daily instillations are required to effect treatment, but the licence is for maximum 14 days use. Will not dissolve crystal formation.
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Sodium chloride
For the washing of debris (blood,
0.9% Chlorhexidine 0.02%
mucus, pus) from the catheter. For the treatment of pseudomonas infections. Limited value as the infections will exist in a biofilm which resists surface washing of antibiotics. Likely to lead to flourishing of resistant organisms.
16.2 Recommendation
It is sensible to start off with solution G (3.23% citric acid) once a week, increasing as necessary. Try a single instillation of either 50ml or 100ml solution. If ineffective at the next washout try a sequential 50ml washout of the same solution before increasing to a stronger solution. (Getliffe, 2000). Catheter maintenance solutions should not be used in patients with spinal injury due to the possibility of autonomic dysreflexia (see section 17)
16.3 Procedure for insertion of catheter maintenance solution

16.3.1 Equipment: disposable apron new drainage bag prescribed maintenance solution latex free disposable gloves sterile dressing pack absorbent sheet
Method
Explain the procedure to the patient, obtain their informed consent. Make the patient comfortable in a semi prone position. Wash hands using liquid soap and running water. Ensure hands are dried using paper towels. Alternatively use alcohol hand gel. Put on apron. Remove leg bag straps and position leg bag beside patient. Prepare the aseptic field and remove outer packaging from the catheter maintenance solution and place on sterile field.
Rationale
To ensure valid consent is obtained.
Infection prevention and control.
Infection prevention and control.
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Expose the length of the catheter and observe To prepare patient for the procedure and check for for signs of leakage and meatal problems. catheter displacement. Place absorbent sheet under catheter drainage bag junction. Wash hands using liquid soap and running water. Ensure hands are dried using paper towels. Alternatively use alcohol hand gel. Put on latex free sterile gloves. Disconnect the drainage bag (or valve) , attach catheter maintenance solution and instil in accordance with the manufacturers instruction. If the fluid is to be retained for a period of time, close the clamp, and place the bag on the bed. Ensure that the client is warm and comfortable for the required time. When the solution is removed ensure the new catheter bag (or valve) is firmly attached and below the level of the bladder and draining. Make the patient comfortable. Remove and dispose of equipment (See BACHS policy). Remove gloves. Wash hands using liquid soap and running water. Ensure hands are dried using paper towels. Alternatively use alcohol hand gel. Remove apron. Document that the catheter maintenance solution has been administered and note any complications encountered with the procedure. To facilitate drainage. Infection prevention and control.
Correct instillation of solution.
To maintain dignity. To prevent environmental contamination Infection prevention and control.
To maintain accurate records.
17. Autonomic dysreflexia (also known as autonomic hyperreflexia)

When catheterising people with injury to the spinal cord at or above the level of the 6th thoracic vertebrae the healthcare professional must be aware of the symptoms and treatment for autonomic dysreflexia (AD). It is a serious life threatening condition. The syndrome develops secondary to any noxious stimulus below the level of injury. As the spinal cord is damaged, signals cannot pass normally to the brain, therefore, the body produces exaggerated abnormal nerve signals which cause problems above and below the level of the spinal injury. Below the injury, blood vessels go into spasm causing the blood pressure to rise. Above the level of injury, the body senses the high blood pressure and tries to relax the blood vessels (but can only influence the blood vessels above the level of injury).
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Bladder problems are the most common cause of AD, these include: an overfull bladder kidney or bladder stones high pressure voiding urinary tract infection blocked catheter defective drainage system (eg kinked tubing or leg bag too full)
17.1 Symptoms
These may be mild or severe and patients may present with one or more of the following: pounding headache profuse sweating flushing and/or blotching above the level of cord damage pallor below the level of injury slowed heart rate palpitations goosebumps blurred vision or seeing spots before your eyes stuffy nose feeling of doom and gloom anxiety apprehension elevated blood pressure. Under normal circumstances a tetraplegic person may have a low blood pressure (eg 90/60). A rise of 20mmHg can be quite significant; therefore if the BP rises to 120/80mmHg it could become an emergency situation. Therefore it is good practice to monitor and record the baseline blood pressure of patients known to be at risk of AD. Hypertension may be severe enough to lead to seizures, stroke or ultimately death.
17.2 Treatment
Identify the source of the noxious stimulus. Removing the stimulus will help the symptoms to settle. Reduce the blood pressure by returning the patient to bed and place in a sitting position. (If bladder problems suspected only sit the patient to 45 degrees. Sitting at 90 degrees may cause increased pressure on the full bladder.) Check the bladder. If the patient is not catheterised and the bladder appears full, catheterise immediately using an anaesthetic gel and leave on free drainage. If catheterised, empty the leg bag and untwist any kinked tubing. If the catheter appears blocked, change the catheter immediately. DO NOT ATTEMPT A BLADDER WASHOUT - this will only distend the bladder further with potentially fatal consequence. If infection is suspected commence antibiotic therapy. Check bowel and check for other potential causes and treat appropriately. (NHS Quality Improvement Scotland, 2004).
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18. Permanent removal of the catheter Catheters are only removed following thorough assessment of the individuals ongoing condition and after consultation with the individual and other healthcare staff responsible for their care. There may be clinical reasons why the catheter must remain in situ. When the assessment indicates that a catheter may be safely removed, the individuals condition after removal is to be carefully monitored and action taken if problems arise. If possible a portable bladder scanner can be used to measure any urine residual that may be present.
19. Intermittent self-catheterisation

Intermittent self-catheterisation is the preferred alternative to indwelling catheterisation for individuals in whom bladder emptying is incomplete, providing this is acceptable to them. Intermittent self- catheterisation is recognised as a safe and effective procedure (Bakke et al, 1997) and carries a reduced risk of infection compared to indwelling urinary catheterisation (Wyndaele, 1990; Bakke and Diganes, 1991). The bladder must have the capacity to store urine adequately between catheterisations, and the individuals and/or carers must be motivated, have the manual dexterity and the ability to carry out the procedure. When patients, partners or close family members are taught to carry out intermittent self-catheterisation, they are taught a clean procedure, and should be observed performing the procedure competently. When paid carers or healthcare professionals are performing this procedure an aseptic technique must be employed. The patient must be instructed on how many times a day they need to perform the procedure (this is determined from the size of the bladder residual, the reason for carrying out the procedure, bladder capacity and assessment of the bladder diary). Patients should be instructed to measure and record the volume of urine drained at each catheterisation. Intermittent catheterisation may be used as a technique to manage urethral strictures by acting as a dilating mechanism to prevent recurrence. Individuals will be given guidance on the frequency of catheterisation and the size of catheter to be used. When patients are competent at the procedure independently, they must be made aware of whom to contact for advice. Single use pre lubricated catheters or reusable nelaton catheters are available. It is now recommended that a pre - lubricated single use catheter is used; size 10 12 Ch for women and 12 14 Ch for men. Documented evidence must consist of consent for treatment, full assessment, reason for catheterisation, patient understanding, type and size of catheter and any patient information given (eg videos, DVDs, information leaflets).
19.1 Procedure guidelines for patients: intermittent self-catheterisation with a pre lubricated catheter 19.1.1 Equipment: mirror (for female patients if teaching self catheterisation) appropriately sized single use pre-lubricated catheters for male/female
patients
suitable container for collecting urine if required

19.1.2 Procedure for females Action

Wash hands using liquid soap and running water or alcohol gel. Healthcare workers must wear latex free sterile gloves. Patients or partners performing the procedure do not need to wear gloves when self-catheterising, however good hand hygiene is essential. Assist the patient to take up a comfortable position, depending on mobility (eg sitting on toilet, standing with one foot placed on toilet seat). Spread the labia and wash genitalia from front to back with soap and water, and then dry. If the patient is performing the procedure where this is not possible, e.g. public toilet the use of disposable wet wipes is recommended. Open the catheter packaging or container. Follow manufacturers instructions to activate lubricated coating (Nb some catheters require activating with water or gel, others are ready to use). Find the urethral opening above the vagina. A mirror can be used to help to teach the patient to identify the urethral opening. Gently insert the catheter into the urethra approximately 5cm or until urine drains, taking care not to touch the part of the catheter entering the body. Drain the urine into the toilet or suitable container. When the urine stops flowing slowly remove the catheter, pausing if more urine starts to flow. Dispose of the catheter and any equipment used according to BACHS policy. Wash hands with liquid soap and running water, or use alcohol gel.
Rational
To prevent infection.
To facilitate insertion of intermittent catheter.
To reduce the risk of introducing infection.
To prepare catheter and to ease insertion. To prevent urethral trauma.
To reduce risk of introducing an infection.
To ensure that the bladder is completely emptied.
To prevent environmental contamination. To reduce the risk of infection.
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19.1.3 Procedure for males Action

Wash hands using liquid soap and running water or alcohol gel. Healthcare workers must wear latex free sterile gloves. Patients or partners performing the procedure do not need to wear gloves when self-catheterising, however good hand hygiene is essential. Take up a comfortable position, depending on mobility. Patients with large abdomens may find it helpful to use a mirror. Wash the penis with soap and water. If the foreskin covers the glans it will need to be retracted during the procedure. Open catheter packaging or container. Follow manufacturers instructions to activate lubricated coating (Nb some catheters require activating with water or gel, others are ready to use). Hold the catheter with the dominant hand, being careful not to touch the part of the catheter entering the body, and gently insert it into the opening of the urethra. Advance the catheter into the bladder. Slight resistance may be felt as the catheter passes through the prostate gland and into the bladder. Only gentle pressure should be used. It may be a little uncomfortable on the first few occasions. If there is more than slight resistance or discomfort, do not continue. Withdraw the catheter and seek medical advice. Drain the urine into the toilet or suitable container. When the urine stops flowing slowly remove the catheter, pausing if more urine starts to flow. Dispose of the catheter and any equipment used according to BACHS Waste Management Policy. Wash hands with liquid soap and running water, or alcohol gel.
Rationale
To prevent infection.
To facilitate insertion of intermittent catheter.
To reduce risk of infection.
To prepare catheter and to ease insertion. To prevent urethral trauma.
To reduce the risk of introducing an infection.
The prostate gland surrounds the urethra just below the neck of the bladder and consists of much firmer tissue. This can enlarge and cause an obstruction, especially in older men. To prevent urethral trauma.
To ensure that the bladder is completely emptied.
To prevent environmental contamination. Infection prevention and control
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20. Equality and Diversity

The service aims to meet the needs of all individuals, respecting culture, diversity, ethnicity and sexuality. An interpreting service is available for ethnic minority clients, also written audio visual material in several Asian languages to promote better understanding.
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21. Glossary of terms

Term Anti-cholinergic Assessment Aseptic technique Autonomic dysreflexia Bacteraemia Bacteriuria Catheter valve Carer Definition Medication that reduces bladder spasm. A thorough review of the patients condition, by questioning, observation, physical examination and investigations. A method of carrying out sterile procedures so that there is minimum risk of introducing infection. Sterile equipment is used and sterile gloves worn or a no-touch technique is used. A syndrome that affects those with a spinal cord lesion above the midthoracic level. It is characterised by acute and rapid onset of hypertension triggered by painful stimuli below the level of the injury. The presence of bacteria in the bloodstream. The presence of bacteria in the urine. A valve connected to the outlet from the catheter allowing the bladder to be drained intermittently by opening the valve at regular intervals. A person who may be paid or unpaid, who regularly helps another person with all forms of care, often a relative or friend. This term incorporates spouses, partners, parents, guardians, paid carers, other relatives, and voluntary carers who are not health professionals. The presence of blood in the urine. Pertaining to new and abnormal growth of the tissue A scale which gives the acidity or alkalinity of the urine. pH <7 is acidic and pH >7 is alkaline Retraction and constriction of the foreskin behind the glans penis The amount of urine remaining in the bladder after voiding. This can be estimated using a bladder ultrasound scanner or an intermittent catheter. This includes disposable aprons and gloves. insertion of a catheter in to the bladder through a tract the abdominal wall Narrowing of the urethra causing inhibition of urinary flow
Haematuria. Neoplastic pH Paraphimosis Post micturition residual volume of urine PPE Personal protective equipment Suprapubic catheterisation Urethral strictures
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22. Reference list

Addison R. 2000. Catheterisation using Lignocaine Gel Nursing Times, 96 (41): 43-44. Ayliffe G, Fraise A, Geddes A et al editors. 2000. Control of Hospital Infection - A Practical Handbook. 4th ed. Arnold: London Bakke A and Digranes A. 1991. Bacteriuria in Patients Treated with Clean Intermittent Catheterisation Scandanavian Journal of Infectious Diseases , 23 (5): 577-582 Bakke A, Diganes A and Hoisaeter P. 1997. Physical Predictors of Infection in Patients Treated with Clean Intermittent Catheterisation: a Prospective 7 Year Study. British Journal of Urology 79 (1): 85-90 British National Formulary. 2007. BNF 54 BMJ Publishing Group: London Chung C, Chu M, Paoloni R, O'Brien M and Demel T . 2003 Comparison of lignocaine and water-based lubricating gels for female urethral catheterisation: A randomized controlled trial. Emergency Medicine Australasia. V19 issue 4 p315-319 Dancer S. 1999. Mopping up Hospital Infection Journal of Hospital Infection 43 (2):85-100 Department of Health(DH) 2007 Essential Steps to Safe, Clean Care . Produced by COI for the Department of Health Department of Health (DH) 2001. Reference guide to consent for examination or treatment. Dougherty L and Lister S editors. 2004. The Royal Marsden Hospital Manual of Clinical Nursing Procedures 6th Edition Blackwell Publishing: Oxford Garner J and Favero M. 1986. CDC Guideline for Handwashing and Hospital Environmental Control, 1985. Infection Control, 7 (4): 231-243. Getliffe K 2000. Dissolution of Urinary Catheter Encrustation. British Journal of Urology 85: 60-65. Getliffe K and Dolman M. 2003. Promoting Continence 4th edition. Balliere Tindall: Edinburgh Katzung BG 1995. Basic and Clinical Pharmacology 9th edition Lowthian P. 1998. The dangers of long term drainage British Journal of Nursing 7(7): 36679. Medicine and Healthcare products Regulatory Agency (MHRA) 1995 NICE. 2003. Infection Control:Prevention of Healthcare Associated Infection in Primary and Secondary Care Norton C. 1996. Nursing for Continence. Beaconsfield Publishers Ltd Beaconsfield.
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Nursing and Midwifery Council (NMC). 2008. The Code: Standards of conduct, performance and ethics for nurses and midwives NMC. 2007. Guidance for Record Keeping http://www.rcn.org.uk/__data/assets/pdf_file/0004/112792/NMC_Record_Keeping_Guidanc e_Advice_Sheet.pdf Plowman R, Graves N and Griffin M. 1999. The Socio-Economic Burden of Hospital Acquired Infection. London: Public Health Laboratory Service. Pomfret I. (2000) The Catheter Debate. Nursing Times 84 (4) P.66-69. Pratt RJ, Pellowe CM, Wilson JA, Loveday HP, Harper PJ, Jones SRLJ, McDougall C and Wilcox MH. 2007. EPIC 2: National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England. Journal of Hospital Infection 65S:S1 S64 Quality Improvement Scotland (QIS). 2004. Urinary Catheterisation and Catheter Care: Best practice Statement. Saint S, et al. 1998. The efficacy of silver alloy coated urinary catheters in preventing urinary tract infection: A Meta Analysis. American Journal of Medicine. 105: 236-241. Siderias J, Guadio F, Singer AJ 2004 Comparison of topical anesthetics and lubricants prior to urethral catheterisation in males: a randomized controlled trial Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Taylor, L. 1978 An Evaluation of Handwashing Techniques Nursing Times January 12th: 5455. Warren W. 1997. Catheter-Associated Urinary Tract Infections. Infectious Disease Clinics of North America, 11(3): 609-622. Wilson J, Taylor L, Cookson B & Glynn A. 1997. Preventing Hospital-Acquired Infection: Clinical Guideline. London: Public Health Laboratory Service. Wilson J. 2001. Infection Control and Clinical Practice. 2nd ed. Balliere Tindall: Edinburgh Winn C. 1998. Complications with urinary catheters. Professional Nurse 13(5) S7-S10. Wyndaele J and Maes D. 1990. Clean Intermittent Self-Cathterisation: a 12-year Follow Up. Journal of Urology 143(5): 906-908
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Appendix 1 - Checklist for the review and approval of documents To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval.
Title of document being reviewed: 1. Title Is the title clear and unambiguous? Is it clear whether the document is a guideline, policy, protocol or standard? 2. Rationale Are reasons for development of the document stated? 3. Development process Is the method described in brief? Are people involved in the development identified? Do you feel a reasonable attempt has been made to ensure relevant expertise has been used? Is there evidence of consultation with stakeholders and users? 4. Content Is the objective of the document clear? Is the target population clear and unambiguous? Are the intended outcomes described? Are the statements clear and unambiguous? 5. Evidence base Is the type of evidence to support the document identified explicitly? Are key references cited? Are the references cited in full? Are supporting documents referenced? 6. HumanrResources If appropriate have the joint Human Resources/staff side committee (or equivalent) approved the document? Yes/No/ Unsure Comments
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Title of document being reviewed: 7. Summary of Guidance Is there a quick reference guide, key recommendations or flow chart summarising the document? (not obligatory, but may be helpful for some documents) 8. Format Is the document in an easily readable font? Is there an appropriate footer on each page? Is it easy to find sections within the document? 9. Patient Information Does the document require patient information? If so, does it make clear what information and how this should be presented? 10. Dissemination and Implementation Is there an outline/plan to identify how dissemination and implementation will be done? Does the plan include the necessary training/support to ensure compliance? 11. Process to Monitor Compliance and Effectiveness Are there measurable standards or KPIs to support the monitoring of compliance with and effectiveness of the document? Is there a plan to review or audit compliance with the document? 12. Overall responsibility for the document Is it clear who will be responsible for coordinating the dissemination, implementation and review of the document?
Yes/No/ Unsure
Comments
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Individual approval If you are happy to approve this document, please sign and date it and forward to the chair of the committee/group where it will receive final approval. Name Signature Committee approval If the committee is happy to approve this document, please sign and date it and forward copies to the person with responsibility for disseminating and implementing the document and the person who is responsible for maintaining the organisations database of approved documents. Name Signature
Acknowledgement: Cambridgeshire and Peterborough Mental Health Partnership NHS Trust
Date
Date
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Appendix 2 - Plan for dissemination of documents

To be completed and attached to any document which guides practice when submitted to the appropriate committee for consideration and approval. Acknowledgement: University Hospitals of Leicester NHS Trust. Title of document: Date finalised: Previous document already being used? If yes, in what format and where? Proposed action to retrieve out-of-date copies of the document: To be disseminated to: How will it be disseminated, who will do it and when? Paper Comments or electronic Yes / No (Please delete as appropriate) Dissemination lead: Print name and contact details
Dissemination record - to be used once document is approved. Date put on register of documents Date due to be reviewed
Disseminated to: (either directly or via meetings, etc)
Format (i.e. paper or electronic)
Date Disseminated
No. of Copies Sent
Contact Details / Comments
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Appendix 3 - Version control sheet

Version Date Author Status Comment
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Urinary Catheterisation and Catheter Care in Adults Guidelines

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Urinary Catheterisation and Catheter Care in Adults Guidelines

Contact for further details: Dissemination:

Date Approved: Date Ratified: Date Issued: Review Date: ?2012

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Appendix 1 Appendix 2 Appendix 3

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

The risks of urinary catheterisation

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Indications for catheterisation

Assessment of patients prior to catheterisation

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Medical or nursing decision to catheterise

Documentation and audit

Responsibilities and training

Infection prevention and control

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Indwelling urethral catheterisation 12.1 Catheter selection 12.1.1 Diameter

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Unsuitable for people with latex allergies.

Unsuitable for people with latex allergies.

Hydrogel Coated silicone Silicone elastomer coated latex All Silicone

12.4 Drainage systems

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

12.4.1 Leg bags

12.4.2 Belly bags

12. 4.4 Catheter valves

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

12.5.1 Lubrication gels available

12.5.2 Risks of using anaesthetic lubrication gels

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

12.6.2 Procedure for females Action

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

contamination of the catheter.

Infection prevention and control. To ensure accountability.

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

12.6.3 Procedure for males Action

Measure the amount of urine.

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

To prevent environmental contamination.

Infection prevention and control. To ensure accountability.

12.7 Removal of indwelling urethral catheters 12.7.1 Equipment: Action

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

12.8 Problem solving with indwelling urethral catheters Problem

Micro-organisms sticking to catheter surface.

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

Non deflating balloon

Trauma or infection. Tension on catheter due to inadequate support. Persistent haematuria.

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

13.1 Lubrication in suprapubic catheterisation

13.2 Procedure for supra-pubic catheter change

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

To ensure that the catheter is positioned safely in the bladder.

14. Catheter care

15. Urine sampling

16.1 Selection of catheter maintenance solutions

For the washing of debris (blood,

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010

0.9% Chlorhexidine 0.02%

16.3 Procedure for insertion of catheter maintenance solution

Infection prevention and control.

Infection prevention and control.

BACHS Urinary Catheterisation Guidelines 2009 BACHS 2010