Urology – Catheter Insertion and Management, Bladder ...
Canberra Health ServicesClinical Procedure Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (TURP)Contents TOC \h \z \t "Heading 1,1,Heading 2,2" Contents PAGEREF _Toc529890542 \h 1Purpose PAGEREF _Toc529890543 \h 4Alerts PAGEREF _Toc529890544 \h 4Indications for Catheter insertion PAGEREF _Toc529890545 \h 4Clinical Contraindications PAGEREF _Toc529890546 \h 4Scope PAGEREF _Toc529890547 \h 4Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients) PAGEREF _Toc529890548 \h 5General Information PAGEREF _Toc529890549 \h 5Alert PAGEREF _Toc529890550 \h 5Community Based Patients PAGEREF _Toc529890551 \h 5Section 2 – Indwelling Urinary Catheter Management: Inpatient and Community PAGEREF _Toc529890552 \h 7Alert PAGEREF _Toc529890553 \h 7Equipment PAGEREF _Toc529890554 \h 72.1 Insertion of Indwelling Catheter PAGEREF _Toc529890555 \h 82.2 Perineal/penile care PAGEREF _Toc529890556 \h 102.3 Urinary Drainage Bag Management: Inpatient and Community PAGEREF _Toc529890557 \h 102.4 Closed Drainage System PAGEREF _Toc529890558 \h 112.5 Catheter Valve System PAGEREF _Toc529890559 \h 112.6 Removal of Indwelling Urinary Catheter PAGEREF _Toc529890560 \h 12Section 3 – Suprapubic Catheter Procedures for Inpatients and Community Based Patients PAGEREF _Toc529890561 \h 12Alert PAGEREF _Toc529890562 \h 123.1 Insertion PAGEREF _Toc529890563 \h 12Equipment PAGEREF _Toc529890564 \h 123.2 Dressing Change PAGEREF _Toc529890565 \h 143.3 Changing Suprapubic Catheter: Inpatient PAGEREF _Toc529890566 \h 143.4 Removal Suprapubic Catheter PAGEREF _Toc529890567 \h 163.5 Management of Supra Pubic Catheter: Community Based Patient PAGEREF _Toc529890568 \h 16Section 4 – Intermittent Catheterisation in the Adult Inpatient PAGEREF _Toc529890569 \h 19Alert PAGEREF _Toc529890570 \h 19Equipment PAGEREF _Toc529890571 \h 19Procedure PAGEREF _Toc529890572 \h 20Section 5 – Clean Intermittent Catheterisation: Self Catheterisation PAGEREF _Toc529890573 \h 20Equipment PAGEREF _Toc529890574 \h 20Procedure PAGEREF _Toc529890575 \h 21Catheter types PAGEREF _Toc529890576 \h 22Catheter supplies PAGEREF _Toc529890577 \h 22Catheter care PAGEREF _Toc529890578 \h 22Section 6 – Catheter Flushing for Adult Community based patient PAGEREF _Toc529890579 \h 22Equipment PAGEREF _Toc529890580 \h 23Procedure PAGEREF _Toc529890581 \h 23Section 7 – Trial of Void: Community based patient PAGEREF _Toc529890582 \h 24Note PAGEREF _Toc529890583 \h 24TOV (SPC and IDC Pathway) PAGEREF _Toc529890584 \h 24Section 8 – Trans Urethral Prostatectomy (TURP) PAGEREF _Toc529890585 \h 24Alert Patients on anticoagulation therapy require further medical investigation, advice and support and nursing observation PAGEREF _Toc529890586 \h 25Admission PAGEREF _Toc529890587 \h 25Preoperative PAGEREF _Toc529890588 \h 25Post Operative PAGEREF _Toc529890589 \h 25Post-operative Day 1 PAGEREF _Toc529890590 \h 26Post-operative Day 2 PAGEREF _Toc529890591 \h 26Discharge PAGEREF _Toc529890592 \h 27Section 9 – Bladder Irrigation PAGEREF _Toc529890593 \h 27Note PAGEREF _Toc529890594 \h 27Equipment PAGEREF _Toc529890595 \h 289.1 Continuous Bladder Irrigation Procedure PAGEREF _Toc529890596 \h 289.2 Manual Bladder Irrigation Procedure PAGEREF _Toc529890597 \h 299.3 Document in Patient’s Clinical Record: PAGEREF _Toc529890598 \h 29Section 10 – Pre and Post-Operative Management of patients undergoing a Nephrectomy and Percutaneous Nephrolithotomy PAGEREF _Toc529890599 \h 30Note: PAGEREF _Toc529890600 \h 30Admission PAGEREF _Toc529890601 \h 30Preoperative PAGEREF _Toc529890602 \h 30Postoperative or Receiving patient from Intensive Care Unit (ICU) PAGEREF _Toc529890603 \h 31Ward management PAGEREF _Toc529890604 \h 32Discharge planning PAGEREF _Toc529890605 \h 32Section 11 – Management of patients admitted with pre-existing Continent Urinary Reservoirs/Neobladder during routine hospital admissions PAGEREF _Toc529890606 \h 32Implementation PAGEREF _Toc529890607 \h 33Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc529890608 \h 33References PAGEREF _Toc529890609 \h 34Definition of Terms PAGEREF _Toc529890610 \h 35Search Terms PAGEREF _Toc529890611 \h 36Attachments PAGEREF _Toc529890612 \h 36Attachment A: Catheter selection PAGEREF _Toc529890613 \h 38Attachment B: How to care for your Urinary Catheter PAGEREF _Toc529890614 \h 39Attachment C: Source of information and/or suppliers for urinary catheter equipment PAGEREF _Toc529890615 \h 41Attachment D: Insertion of Urinary Catheter Sticker PAGEREF _Toc529890616 \h 42Attachment E: Stat Lock – Foley Stabilisation Device PAGEREF _Toc529890617 \h 43Attachment F: Troubleshooting guide for urinary catheters PAGEREF _Toc529890618 \h 44PurposeThe Urology Assessment and Management Procedures describe practice which will be performed by registered nurses, medical staff and allied health. New staff, or students (within their defined scope of practice) will be required to perform these skills under the direct supervision of a competent practitioner. Clinicians providing assessment and education for clinical procedures must have current theoretical and clinical knowledge in continence management. To provide best practice in managing, educating and supporting patients requiring short/ long term management of urinary catheters.Back to Table of ContentsAlerts Indications for Catheter insertionClinicians should only consider catheterisation for the following indications:Management of urinary retention that is confirmed by bladder scannerClot retention associated with gross haematuriaMonitoring for sepsis, trauma, renal function, electrolyte or fluid balanceInjury or surgery affecting urinary functionInvestigation, diagnostic or treatmentUrinary incontinence managementLabour or birth managementClinical ContraindicationsUrethral strictureUrethral orifice that cannot be identified or accessedUrethral reconstructionKnown or urethral traumaFractured pelvis with bleeding from the urethral meatusAcute prostatitisBack to Table of ContentsScopeThis document applies to the following staff working within their scope of practice:Medical Officers Nurses and Midwives Allied Health Students under direct supervision.Back to Table of ContentsSection 1 – Catheter Management for Adults (Inpatients and Community Based Patients)General InformationPatient assessment should be done prior to catheterisation that include the exploration of possible patient’s cultural values and beliefs that may influence healthcare practices and consistent with Intimate Body Care and or Examination of Patients or Clients by Health Care Workers Procedure.Verbal consent should be obtained as per Consent and Treatment Policy.Indwelling catheters and slow bladder decompression are recommended for patients with large capacity bladder. No more than 600mL is to be withdrawn from the bladder unless otherwise indicated by the medical officer as this may induce a syncope episode. AlertSeek expert advice for patients with artificial heart valves who grow Enterococcus species in the urine prior to the procedure. Patients with spinal lesion at or above T6 requires monitoring for Autonomic dysreflexia.Patients who are taking high dose of anti-coagulants should be monitored for bleeding.Patients with a history of recent surgery, cancer or radiotherapy should be monitored as they are risk of urinary tract damage. Community Based PatientsMedical Officer’s Orders for Urinary Catheter Management form on the clinical forms register (form no. 40950) must be completed for all urinary catheter management in the community setting. Medical Officers orders for catheter management should be reviewed every three (3) years.Catheters should be appropriate, comfortable, easy to insert and remove and must minimise secondary complications such as tissue inflammation, encrustation and colonisation by micro- organisms (See Attachment A)The smallest gauge catheter suitable for the patient needs should be used and balloons should generally be 5 to 10mL in size. Patients with a lesion above T6 should use a size 18 to 20 Fr to avoid blockage and complications of autonomic dysreflexia. Community Nurses will identify patients with spinal lesions at or above T6 and monitor for autonomic dysreflexia during catheterisation. Where applicable first line emergency management should be provided to those patients. Care provided should be consistent with Autonomic Dysreflexia clinical procedure.All catheters become colonised with bacteria after a few days. If a catheter specimen of urine (CSU) is required this should only be obtained on change of the catheter not taken from the urine collection munity nurses will document the management on a ‘Urinary Catheter Management Chart’ form, available from the clinical forms register (form no.60535)Patients and/or carers should be educated on how to care for their catheters and also be provided with the pamphlet How to care for your urinary catheter, found on the Policy Register (see sample at Attachment B)Catheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter.Manual bladder irrigation or washout involves instilling large amounts of fluid into the bladder withdrawing fluids for the purpose of removing debris and mucus from the bladder. This procedure should be done under medical supervision and is not suitable to be done in the community. Patients with long - term catheter requirements are responsible for the provision of ongoing equipment (catheters, leg bags, overnight bags, catheter straps, catheter valves). These patients may be able to access funding from:Continence Aids Scheme (CAPS)ACT Equipment Subsidy Scheme (ACTES) Rehabilitation Appliances Program (RAP) of Department of Veterans Affairs (DVA)National Disability Insurance Scheme (NDIS)If the patient is not eligible for any of these schemes, they may source equipment from supplies either locally or interstate (see Attachment C) Where possible, liaison should occur with the medical practitioner or management team who inserted the catheter if there are any concerns regarding catheter management in the community. Where possible patients should be encouraged to access one of the Community Health Centres ambulatory clinics for their routine catheter change.Where difficulties are experienced or anticipated, contact the continence Clinical Nurse Consultant (CNC) or General Practitioner (GP); if the matter is urgent call an ambulance.If a catheter requires permanent removal, medical orders should be obtained from the treating doctor and documented in client’s file (refer to Removal of Catheter) attached. Back to Table of Contents Section 2 – Indwelling Urinary Catheter Management: Inpatient and CommunityShort term indwelling catheterisation should be used when bladder drainage is required for up to 14 days. However; the catheterisation is patient and procedure dependent.AlertNurses and midwives must have completed the eLearning course Indwelling Urinary Catheter and the competency assessment form in the Capabiliti before inserting panies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters are to be changed 6 to 12 weekly or as per manufacturer’s recommendations.Strict aseptic technique is essential to prevent infection.In patients with an Indwelling Urinary Catheter, it is important to remove any obvious signs of encrustations from around the urethral meatus. To achieve this, the catheter must be washed gently with warm soapy water at the start of the procedure and during the patient’s daily wash/shower. Avoid back and forth movement of the catheter at the urethral meatus as this may cause unnecessary trauma or irritation and may increase the risk of infection or pressure injury. Observation for any signs of pressure areas or trauma at the urethral meatus is necessary. Document findings in patient clinical record.EquipmentDisposable catheter pack (includes extra gloves) 0.9% Sodium Chloride 60mL Lubricant sachet (female) or 2% Lignocaine gel (male)Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16 FrSterile urinary drainage bag to meet patients’ needsOne x 10mL syringeOne x 10mL Sterile Water for InjectionSecurement deviceMeasuring jug if requiredProcedural under padClean gown Sterile gloves Safety glasses or gogglesSterile specimen jar, if requiredPersonal Protective Equipment (PPE)Inpatient specific: Foleys Statlock device pack including skin preparationCommunity specific: Urinary Retaining StrapSterile gloves x two non sterile gloves 2.1 Insertion of Indwelling Catheter2.1.1 Female Insertion ProcedureThe medical officer must document the order for catheter insertion and removal in the patient’s clinical record.Identify the patient and patient’s allergies against clinical notes and stickers.Explain the purpose of the procedure and obtain consent as per Consent and Treatment PolicyEnsure the patient has their privacy maintained throughout the procedure.Prepare equipment and place procedural pad underneath patient’s buttocks.Don safety PPE and attend to hand hygiene as per Healthcare Associated Infections ProcedurePosition the patient supine with knees flexed drawn up soles of feet together, or knees wide apart.Remove the protective cover from the tip of the catheter ONLY. Lubricate, leaving the catheter cover in place.Place the catheter in the dish.Cleanse Labia Majora with 0.9% Sodium Chloride and expose the labia minora and urethral meatus. Using a downward stroke, clean the labia minora and the meatus. Discard forceps and first pair of gloves. Drape patient with fenestrated sheet to establish sterile area. Perform hand wash and procedure in line with Aseptic Technique Procedure.Put on sterile gloves.Separate the labia and identify the urethra with free hand, hold labia apart until catheterisation is complete.Ask the patient to take a deep breath to relax the sphincter then insert the catheter. If there is an obvious urine flow, advance 2.5cm further into the orifice. Collect sterile urine specimen or perform urinalysis if required. Inflate the balloon with the required amount of sterile water (see balloon hub) Remove the protective cap from the urinary drainage bag, seal outlet tube and attach to the catheter. Drain 600mL only then clamp the catheter for one (1) hour.Ensure the patient is comfortableDiscard equipment and clean the area.Record output, clarity, colour and odour on the patient's Fluid Balance Chart (FBC) and clinical record. Inpatient specific: Record the procedure in the patient's clinical record (Attachment D):Date and time of procedureType and catheter size Amount of water in the balloon Indication and scheduled date for removal or changeCommunity specific: Record the procedure using the ‘Urinary Catheter Management Chart’ form on the clinical forms register (form no.60535)2.1.2 Male Insertion ProcedureA catheter introducer for the introduction of a catheter for male patients is only used by a medical officer. In male catheterisation:Do not proceed if patient has an erection. Slightly increase the traction on the penis and apply steady gentle pressure if resistance is felt at the external sphincter. Ask the patient to attempt to void to relax the sphincter. The Medical Officer must document the order for catheter insertion and removal in the clinical record.Identify the patient and the patient’s allergies against clinical notes and stickers.Explain the purpose of the procedure. Obtain consent and provide privacy. Put on PPE and attend to hand hygiene.Remove the protective cover and lubricate the tip, leaving the catheter cover in place. Perform hand wash and procedure in line with Aseptic Technique Procedure.Place the catheter in the dish and drape the genital area around the penis.Position fenestrated drape to provide sterile field.Use non dominant hand to hold the penis. Retract the foreskin and swab head of the penis including the urethral meatus and glans with Sodium Chloride 0.9%.Hold penis at a right angle (90 degree) to the body and gently instil 2% Lignocaine gel into the urethra. Wait 4-5 minutes to allow anaesthetising of urethra.Holding penis at a 90 degree angle, gently insert and advance catheter to the Y hub. If resistance is felt at the bladder neck, lower the penis slightly. If resistance continues, withdraw catheter and insert more anaesthetic gel. Re-insert sterile catheter after a further three to five minutes. If further resistance is encountered, seek advice from CNC, Continence CNC or Medical Officer.If there is an obvious urine flow, inflate the balloon with the required volume as per manufacturer’s instructions. Attach sterile drainage bag and drain 600mL only then clamp urine drainage for an hour.Where present, replace foreskin to natural position. Discard equipment and clean the area.Perform urinalysis and obtain specimen if necessary.Perform hand hygiene when leaving the patients environment as per the 5 moments of hand hygieneRecord output, clarity, colour and odour on the patient's FBC and clinical recordInpatient specific: Record the procedure in the patient's clinical record using the Urinary Catheter Label: (See Attachment D): Date and time of procedureType and catheter sizeAmount of water in the balloon Indication and scheduled date for removal or changeCommunity specific: Record the procedure using the ‘Urinary Catheter Management Chart’ form on the clinical forms register (form no.60535)2.2 Perineal/penile care Explain procedure to patient and ensure the patient’s privacy is maintained.Ensure catheter is securely anchored at all times (See Attachment E)Routine perineal/ penile care is performed daily. The drainage bag must be kept below the patient’s waist to prevent reflux of urine back up the Indwelling catheter (IDC).Perform Hand hygiene. Have soap, wash cloth and basin ready prior to procedure.Clean the patient’s genitals from the cleanest area to the less clean area.Discard equipment into the proper waste disposal. Encourage the patient to aim for a two to three litre fluid intake unless contraindicatedRecord urine output, including the clarity, colour and odour, and watch out for haematuria in patients with chronic urinary retention. Obtain a urine specimen or perform urinalysis if needed. Adjust the Patient Accountability and Care Plan (PCAP) to indicate IDC insitu and associated peri-toilets required for hygiene needs.2.3 Urinary Drainage Bag Management: Inpatient and CommunityNote:Ensure that there are no dependent loops in the tubing to prevent stasis of the urine in the tubing.The catheter and the tubing should not be disconnected unless absolutely necessary. Urinary drainage bags should be positioned below the level of the bladder to prevent harmful reflux of urine.Leg bags can be placed on the thigh or calf and secured to the leg using straps provided, to prevent urethral trauma and damage to the bladder wall.Urinary drainage bags should be emptied when half to two thirds full.Urinary drainage bags should be replaced as per manufacturer's recommendations; every seven days for regular bags or at the time of catheter change for long life leg bags.Leg bags are available in a range of capacities: 350mL, 500mL, and 750mL.Tubing on leg bags is available in different lengths, (5cm to 40cm) and can be tailored to individual patient's requirements (adjustments can be made with extension tubing and connecting pieces).A catheter valve may be used in place of a urinary drainage bag, allowing bladder filling and intermittent drainage (Urologist recommendation should be sought)Catheter valves are recommended as single use only items and should not be reused.Catheter valves are inappropriate for clients with detrusor instability, lack of bladder sensation or clients who are confused.In removing catheter, do not cut the balloon lumen as the balloon may not be fully deflated. Statlock device are used to secure catheter and must be changed every 7 days.EquipmentSterile urinary drainage bag Alcohol swab Clamp Foleys Statlock device Safety glasses or gogglesClean gown and glovesExplain procedure to patient, obtain consent and ensure that privacy is maintained.Prepare equipment and the patient.Attend hand hygiene and don PPE.Ensure the drainage system is closed. Remove the protective cap from the drainage tube, clamp the catheter and clean the catheter tubing junction with alcohol swab. Disconnect the catheter from the old tubing and connect the catheter to the new tubing without contaminating the end of the catheter.Unclamp the catheter, and establish drainage by securing the tube. Leave patient comfortable and maintain an appropriate level of the drainage bag.Discard equipment and perform hand hygiene.Document the urinary bag change in the patient’s clinical record, FBC and Patient Accountability and Care Plan.2.4 Closed Drainage SystemClosed link system is used to facilitate overnight drainage.Closed drainage systems are available in drainage bags with a two litre capacity and drainage bottles with a four litre capacity.Daily cleaning of the drainage system should be maintained to minimise bacterial growth. 2.5 Catheter Valve SystemManufacturer's instruction regarding frequency of change should be observed. Bard catheter valves are changed weekly, Coloplast Simpla catheter valves are changed at the time of catheter change. For clients/ carers to use this system, they need to have:The cognitive ability to learn strategies to prevent infection and complicationsAn understanding of the principles associated with catheter management The awareness of bladder sensation and recognition of bladder fullness, and manual dexterity to manipulate the outlet tap.Instructions for patient/carer regarding changing and cleaning of drainage bags/valves:Attend hand hygiene before and after procedure.Disconnect old bag/valve and connect new bag/valve to catheter avoid contamination of the connections.Rinse the disconnected bag/valve with cold water to prevent agglutination of urinary proteins.Wash the disconnected bag/valve with warm soapy water (dishwashing liquid).Allow bag/valve to drain and dry (by hooking bags onto a wire coat hanger from a bathroom rail). ‘Urosol’, a deodorant and detergent cleansing agent, may be used to dissolve urinary crystals. Vinegar or bicarbonate of soda may be used as a substitute.Use of bleach should be avoided as it may damage rubber and plastic.2.6 Removal of Indwelling Urinary CatheterObtain treatment order from the medical officer, explain procedure to the patient and ensure privacy.Patient identification and allergy band are checked against clinical notes and stickers. Prepare equipment and place patient in supine position.Check balloon capacity in the patient’s clinical record. Adhere to hand hygiene and don appropriate PPE.Detach catheter from Foleys Statlock device, attach syringe to catheter balloon lumen and aspirate fluid slowly to deflate. Inform patient to breathe slowly and gently pull the catheter out. Check catheter tip is intact, if not inform medical officer immediately. Remove Foleys Statlock device from patient’s body with Alcohol swabs and clean skin area as required (See Attachment E).Discard equipment and adhere to hand hygiene.Document procedure including patient response in the patient’s clinical record.Back to Table of Contents Section 3 – Suprapubic Catheter Procedures for Inpatients and Community Based PatientsThe first insertion of suprapubic catheter (SPC) is an invasive procedure where the catheter accesses the bladder directly through the abdomen. AlertThe patient will be required to have a full bladder for the initial insertion to prevent perforation of the bowel. The insertion of SPC for gynaecology patients on the ward may be performed under ultrasound. Once the SPC insertion site is healed, it does not require dressing. The site may be cleaned with warm soapy water. Statlock device must remain insitu to anchor the SPC to avoid dislodgement. Maintain a closed drainage system as much as possible to prevent infection. Avoid using talcum powder, creams or strongly scented soaps. 3.1 InsertionEquipmentBasic dressing packSterile dressing towels x twoSterile gown and glovesPPESterile water x 20 mL10mL syringes x three21g needle1% Lignocaine x10mLDrain sponge dressingFoleys Statlock deviceSuture material (as per medical officer’s preference)Suture setSuprapubic catheter introduction kit available from the operating roomsSterile urinary drainage bag50mL bladder syringe500mL bottle 0.9% Sodium Chloride at room temperatureChlorhexidine skin preparationAdhesive tape of choiceSafety goggles or shieldsProcedure underpadClean gownBladder ScannerThe medical officer must document the need of SPC insertion.Identify the patient and patients’ allergies against clinical notes and stickers.Explain the purpose of the procedure, gain consent as per Consent and Treatment Policy.Ensure the patient’s privacy is maintained.Ensure the patient has adequate analgesic cover prior to procedure if required or requested. Assist patient into the supine position, placing procedure underpad beneath the patient’s buttocks.Clean trolley and set up equipment on trolley at the patient’s bedside.Don PPE and open sterile pack.Expose the patient’s suprapubic area.Attend hand hygiene.Open further equipment required and pour chlorhexidine skin preparation into sterile tray following the Aseptic Technique Procedure.Provide assistance to the medical officer during the insertion of the SPC.Once SPC inserted, attach the urinary drainage bag, ensuring drainage system is closed.Place drainage bag below the patient’s waist height.Ensure Foleys Statlock device is securely attached to the patient’s skin. Apply drain sponge around SPC and secure with tape. Discard equipment into clinical waste receptacle and clean trolley. Ensure patient is comfortable with dressing and understands when the dressing change will be attended.Record urine output, clarity, colour and odour on the patient's FBC Document in the patient’s clinical record using the Urinary Catheter Label:Date of SPC insertionType and size of catheterAmount of water in the balloonAmount of urine drainedPatient’s response to the procedure.3.2 Dressing ChangeAttend steps 1 to 9 of Insertion of SPCOpen the basic pack and pour sodium chloride 0.9% on the trayDon clean gloves and expose SPC siteRemove and discard the soiled dressing into the clinical waste receptacle.Inspect the SPC site for clinical signs of infection and healing; notify Medical officer if required. Discard gloves.Attend hand hygiene and don clean gloves as per Aseptic Technique Procedure.Use wound cleansing solutions at body temperature .Irrigate with sodium chloride 0.9% solution to remove debris and contaminantsSwab the site gently in a single direction and let area dry Ensure the site is dry before applying new dressingApply new dressing and secure with adhesive tape or bandagesStatlock device must remain insitu to anchor the SPC to the body to avoid dislodgementDiscard equipment into clinical waste receptacle and clean trolleyEnsure patient is comfortable with new dressing change and understands when the next dressing change will be attendedChange dressing or appliances as frequently as required to effectively remove excessive exudate or infected materialDocument in the patient’s clinical record and wound care chart:A description of the woundType of dressing appliedAny change of dressingThe reason for the change3.3 Changing Suprapubic Catheter: InpatientSPC should be changed four to six weeks post initial insertion. Medical Officers or Registered Nurses may perform suprapubic catheter changes, where the catheter is a balloon catheter (Foley) or a Bonanno (Pigtail) utilising aseptic technique unless otherwise specified by the Urologist.In cases of symptomatic urinary tract infection is suspected and patient is not on antimicrobial therapy, consider the need for change of SPC before clarification of infection status. If change is still required, consult the medical team for immediate treatment ensuring a mid-stream urine is obtained once the new catheter is inserted.Note:Latex SPC’s must be changed every two weeks and Silastic SPC’s must be changed every six weeks. The patient’s SPC is to be clamped for 30 to 60 minutes prior to SPC change to ensure bladder volume for easier palpation. Clamping of SPC is not recommended for patients with spinal cord injury at or above T6 or patients with Autonomic Dysreflexia.Changing of a SPC requires 2 staff members.ProcedureAttend steps 1 to 7 of SPC Dressing procedureDon sterile glovesSterile catheter is placed in the sterile kidney dishSwab around catheter site with 0.9% Sodium Chloride and gauze swabPlace sterile towels around SPC siteSecond person to withdraw fluid using 20mL syringe from catheter balloon insituCatheter is then gently withdrawn; gentle rotation of the catheter may assist in removalDiscard into clinical waste receptacleSwab fistula site with 0.9% Sodium Chloride and gauze swabCatheter is inserted through the fistula at a 90 degree angle to the abdominal wallInsert the catheter approximately 8 to 10cm or until there is an obvious backflow of urineInflate the balloon with the sterile water and 10mL syringe following manufacturer’s instructions (5 to 10mL)Connect the drainage bag to the catheter ensuring closed systemApply drainage tube dressing if required and secure the catheter to the abdomen with Foleys Statlock deviceDiscard equipment into clinical receptacle and clean the trolley.Patient education should be done including the next due SPC change and to report any significant changes in the site. Document in the patient’s clinical record using the Urinary Catheter Label:Date of SPC changeType of catheter and sizeThe amount of water in the balloonThe condition of the fistulaThe patient’s response to the procedure.3.4 Removal Suprapubic CatheterPrior to the removal of the SPC ascertain if the patient is able to void by clamping the catheter for two hours prior to the removal procedure. Check the urine residual using a bladder scanner. The tip of the SPC is sent to pathology for analysis following removal when ordered by a Medical Officer.Note:It is not unusual for a small amount of leakage at the fistula site on removal of SPC. Regularly change the dry dressing and reassure the patient that this may continue for a few days, however, no medical intervention is required.ProcedureAttend steps 1-6 of SPC Dressing ChangeDon sterile glovesRemove the suture (if present) holding the catheter in placeIf the SPC has a balloon, deflate using the relevant size syringeGently withdraw the catheter in a steady continuous motionUsing sterile scissors cut the tip off the catheter into a sterile specimen jar and send to pathology for analysis if required Use cleansing solutions at body temperature to clean the wound and irrigate the area with sodium chloride 0.9% solution, to remove debris and contaminatesSwab gently in one direction and allow site to dry before applying new dressing. Apply new dressing and secure with adhesive tape or bandageDiscard equipment into clinical waste receptacle and clean trolley with detergent impregnated wipesEnsure patient is comfortable with dressing and understands when the next dressing change will be attendedDocument inpatient’s clinical record using the Urinary Catheter Label:Date and time of the SPC removedCondition of fistulaIf the catheter tip is sent for Microscopy, culture and sensitivity (MC&S)Patient’s reaction to the procedure.3.5 Management of Supra Pubic Catheter: Community Based PatientGeneral InformationFollowing initial insertion, the tract will take 10 days to four weeks to become established. If the catheter becomes blocked or dislodged within this initial phase, expert medical advice should be sought as soon as possible. The patient should return to the treating hospital for management.Prior to first change of a suprapubic catheter the ‘Medical Officer’s Orders for Urinary Catheter Management’ form on the clinical forms register (form no. 40950) must be completed and signed by the referring medical officer. Community nurses may perform the first and subsequent suprapubic catheter changes, where the catheter is a balloon catheter (Foley) and NOT a Bonanno (Pigtail)First change of suprapubic catheters can be performed in the ambulatory clinic or in the client’s own home unless otherwise documented by specialist or GP The size of the catheter should be no smaller than 16Fr in adults with a 10mL balloonEnsure patient has had adequate fluid intake prior to procedureCatheters should not be clamped prior to removalAlways endeavour to re-insert same size catheter where possibleIf unable to re-insert a catheter, insert a Nelaton catheter to keep stoma open and arrange prompt transport to treating hospital for catheter reinsertionUrinary catheters need to be changed at intervals that meet each client’s specific needs and comply with manufacturers’ recommendations (usually 6 to 12 weeks). Careful evaluation of each catheter change will enable the nurse to establish each patient’s individual catheter change routine. Use a Urinary Catheter Management Chart on the clinical forms register (form no: 60535) to assist with this process Stabilising the catheter to the abdomen as well as to the upper thigh with a securement device is vital to reduce adverse events such as dislodgement, tissue trauma, hyper-granulation, inflammation and infectionSPC stoma sites do not routinely require a dressing after the first 24 hours of initial insertion. If the site has a discharge a temporary sterile gauze dressing should be applied Ensure the patient is informed of the procedure should the catheter become dislodged and that contact numbers are in place for Community Nursing team leader, the LINK after hours service and the treating hospital Where difficulties are experienced or anticipated seek medical assistance Where a catheter is required to be removed permanently, medical orders should be obtained from the treating doctor and documented in the patient’s fileMedical Officer’s Orders for Urinary Catheter Management should be reviewed every 3 years If the Supra pubic catheter becomes dislodged it should be replaced within 30 - 45 minutes to prevent the stoma closing over. Patient with spinal lesions at or above T6Patients with spinal lesions above T6 require monitoring for Autonomic Dysreflexia (do not clamp catheter prior to change). The following conditions do not preclude catheterisation but extra care should be taken when: The client is taking high dose anticoagulants as these increases the risk of haemorrhage.There is a history of recent surgery, cancer or radiotherapy to the lower urinary tract.Consult with medical officer if in doubt.Equipment:Sterile catheter packUrinary catheter to meet patient’s specific needs (size 16 or above)Sterile Normal Saline (cleansing solution) Sterile gloves Non-sterile glovesWater soluble lubricating gel. (Lignocaine 2% gel for patient with SCI and/ or bladder spasms) 10 ml syringeDrainage equipment to meet patient’s specific needsSafety gogglesDisposable GownAntimicrobial hand gelSmall sterile dry dressing may be required Procedure:Read medical order, identify correct client for catheter removal and re-insertion, explain procedure and obtain consent from patientPosition patient appropriately for their comfort, condition and delivery of care: clinic/homeDon safety eyewear and gown.Deflate balloon, do not remove catheter (allow balloon to deflate without drawing back on syringe to prevent balloon distortion)Hand hygiene and don sterile gloves. Drape with sterile towel.Lubricate tip of catheter. (Lignocaine 2% gel for patient with SCI and/ or history of bladder spasms)Clean around catheter insitu with normal salinePlace sterile fenestrated drape over areaGrasp the catheter with non dominant hand under the drape and remove catheter from bladder. Note: Position, angle and length of the catheter from the stoma exit to the catheter hubInsert new catheter immediately using your dominant hand at the angle and length of catheter previously removedAdvance the catheter into the tract a further 3 cm (not more) to prevent the catheter tip irritating the bladder wall and to ensure the catheter passes into the urethra. If no urine drains gently apply pressure over the symphysis pubis area Once urine drains, insert the catheter approximately 3 cm further to ensure the catheter is in the bladder and not the suprapubic tractSlowly inflate balloon with required volume of sterile water (according to manufacturer’s instructions), check patient for any ongoing discomfort or painWithdraw the catheter slightly and attach sterile drainage bagSecure catheter to patient’s abdomen and the top of the thigh with securement device then secure the drainage bag to the leg with leg straps. Discard equipment and attend hand hygieneDocument the procedure in the client’s clinical and on Urinary Catheter Management Form Care of the Suprapubic Catheter:See Troubleshooting guide for urinary catheters (Attachment F)The suprapubic catheter emerges at a right angle to the abdomen and needs to be supported in this position It is not necessary to rotate the catheter at the insertion site between catheter changesObserve the SPC site for signs of infection and/ or over granulationDressings should not be routinely used. If a dressing is required it must be sterile and applied using an aseptic techniqueHygiene is important and once healed the site should be washed with warm soapy water, preferably twice daily. Cleaning should be directed away from the insertion siteTalcum powder, creams and strongly perfumed soaps should be avoided.Patients should be made aware of the importance of hand washing both before and after handling the catheter drainage systemSupply of catheter equipment: The treating nurse will educate the client on how to access the necessary supplies. (See Urinary Drainage System Management for Community Based Patient)Back to Table of Contents Section 4 – Intermittent Catheterisation in the Adult InpatientIntermittent ‘in / out’ catheterisation should be considered when a urinary catheter is required to be inserted and removed immediately after the completion of drainage. Intermittent ‘in / out’ catheterisation is appropriate for the alleviation of urinary retention or obstruction (e.g. neurogenic bladder) or for certain investigations (e.g. collection of a catheter urine specimen).AlertSpecific Spinal Cord considerations: Do not clamp the catheter for patients who has spinal cord injury at or above T6. Ascertain if patient is on anticoagulants prior to procedure. Seek medical advice for patients with artificial heart valves. Be cautious in inflating the catheter balloon and monitor for haematoma, haemorrhage, rupture or necrosis. Repeated intermittent catheterisation may be undertaken, however repeated insertions may increase the risk of trauma to the insertion site and urethra and may increase the risk of introducing microorganisms into the bladder. Ensure that the catheter is well lubricated to minimise insertion trauma.Intermittent catheterisation an aseptic procedure and is different to clean intermittent ‘in / out’ self-catheterisation, which is normally done by the patient or their carer and is not an aseptic procedure.EquipmentDisposable catheter pack Short term Nelaton catheter of correct size (female 12-14 Fr/male 14-16Fr) i.e. smallest size suitable0.9% Sodium Chloride 60mL Lubricant sachet Measuring jug Procedural under padClean gown Sterile gloves PPESterile specimen jar, if required. ProcedureFollow the insertion procedure as noted for either female or male catheterisation, however, you do not require anchoring device, urinary drainage bag or syringe and water for injection.If there is an obvious urine flow, hold the catheter in place until the urine ceases to flow. Withdraw the catheter gently until urine recommences flowing. Once urine flow ceases gently withdraw catheter completely.Leave the patient comfortable and lower the height of the bed.Discard equipment and perform hand hygiene.Document findings and record the procedure in the patient's clinical record: Date and time of procedureType and catheter size Reason for insertionPerform urinalysis or obtained specimen if necessary.Back to Table of Contents Section 5 – Clean Intermittent Catheterisation: Self CatheterisationThe purpose of this section is to provide procedural information for nurses to assist in supporting and educating patients in the procedure of clean intermittent catheterisation.Registered Nurses who educate clients in the procedure for Clean Intermittent Catheterisation (CIC) must have current theoretical knowledge and be clinically competent in the procedure. A student nurse may undertake the procedure under the direct supervision of a competent clinician.EquipmentIntermittent (Nelaton) catheter, recommended sizes 8 to 10Fr children, 12 to 14Fr adults. Male 400mm length and female 160mm lengthWarm water and a clean face washer (or moist towelettes)Water soluble lubricant or anaesthetic gelContainer to collect and measure urine (e.g. measuring jug, kidney dish, slipper pan)Appropriate light sourceHand held mirror for females (initial use only)Cotton tip (initial use only)Protective sheet (initial use only)ProcedureA Medical Officer or Nurse Practitioner must order intermittent catheterisationThe patient’s ability to perform catheterisation and adhere to a schedule is essential to the success of the CIC program. They must have adequate hand dexterity, mobility and cognition to learn the procedure and understand the principles of management. Age is not a barrier to learning self-catheterisation where the above points are notedNurses must utilise a clean technique when teaching and performing intermittent catheterisationBoth nurse and patient must comply with hand hygiene before and after the procedure. Utilise clean working surfaces for the procedurePatient should be placed in comfortably sitting position.Female:Instruct patient to separate the labia majora with the non-dominant hand to expose the urethral opening, and with the dominant hand, wash this area with warm water or moist towelettes. Start at the top and work downwardsWith the labia still separated by the non-dominant hand, using the first and third fingers, the nurse uses the cotton bud and mirror to point out the anatomy of the clitoris, urethral opening and the vaginaPatient then palpates the urethra with the second finger (feels like a small hole or donut) and leaves it over the urethral meatus. The client then takes the catheter in the dominant hand, holding it two to three cm away from the tip, and gently inserts into the urethra, sliding it under the palpating finger in a gentle upwards and backwards motion.Male:Instruct patient to grasp the penis at the sides (so as not to compress the urethra) with the non-dominant handIf the patient is not circumcised, instruct to gently retract foreskinWash the end of the penis gently with a clean sponge or moist towelettesHold the penis upright at 45/90o angle from abdomen, grasp the catheter about 7 cm from the tip and gently insert the catheter into the urethra until urine starts to flow.Allow urine to drain into container and apply gentle pressure over the suprapubic area when flow ceases. This will ensure the patient’s bladder is emptyGently withdraw the catheterMeasure amount and consistency of urineDocument the procedurePatient education will include anatomy and function of the urinary system, infection control, fluid balance, bowel management and the management of complications.Once the technique is mastered, the patient may work towards performing the procedure without a mirror and in any position that suits the client. Assistance in determining this routine may be obtained from Continence Advisors, Continence CNC, Medical Officer or Urologist.Catheter typesCatheters for self-catheterisation do not require a retention balloon and comprise of a plastic (PVC) tube with two eyes at the tip and a funnel at the other endGenerally, the types of PVC catheters used are either coated or non-coated cathetersUncoated catheters require separate lubrication to enter the urethra easily and prevent soreness and discomfort. Most of these catheters are single use only, though the ‘CLINY’ brand can be cleaned and reusedCoated catheters feature a special coating that means lubrication is not required for insertion, check manufacturers’ instructions as may need water to activate lubricant They are generally well tolerated and more comfortable than non-coated catheters, but also more expensive and single use onlyCatheters are available in paediatric, female and male lengths.Catheter suppliesCatheters can be obtained via:Continence Aids Payment Scheme (CAPS) - ACT Equipment Scheme (ACTES)Department of Veteran Affairs Rehabilitation Appliance Program (RAP)Medical and Surgical wholesalersSome pharmaciesCatheter careCatheters should be used according to manufacturer’s instructions, as many catheters are labelled for ‘single use only’. The symbol for single use only is Where catheters are labelled single use only, ACT Health is obliged to recommend that a new sterile catheter, in a sealed package within the use by date, be used for each catheterisationCatheters that are not labelled ‘single use only’ see manufacturers’ guidelines for instructions regarding cleaning and reuse.Back to Table of Contents Section 6 – Catheter Flushing for Adult Community based patientCatheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter. This procedure requires aseptic technique as the breakage to the close urinary drainage system can be a high risk factor in the development of UTI. Treatment order should be obtain from the medical practitioner and requires the following equipmentSodium chloride 0.9% solutionMaximum of two consecutive flushes of 20mL eachManagement of catheter if unable to flushReview date of treatment/blockageAlertsUrology team should be informed of the blocked catheters.Catheter that is blocked for >2weeks may be replaced by flushingCatheter that remains to be obstructed after a flush and catheters that remain patent only when flushed should be replaced.Catheter flush is not considered safe practice on patients who have undergone renal transplant or open bladder surgery. EquipmentPPE and sterile glovesDisposable catheter pack50mL catheter tip syringe (to ensure low pressure on the catheter)Blue under sheetOne pair sterile glovesOne alcohol wipeSodium Chloride 0.9% solution at body temperature (never use cold solution to flush catheter as it can induce a bladder spasm) ProcedureTreatment order and informed consent should be obtained before the procedure. Prepare sterile setup, place 0.9% Sodium Chloride in catheter tray and draw up the required amount using a sterile 50 mL catheter tip syringePlace blue sheet under the catheter and drainage bag connectionDon PPE and sterile glovesPlace sterile towel under site where urinary catheter and drainage bag are attachedClean catheter and drainage bag connection with alcohol wipe (allow to air dry) Disconnect and wrap the drainage bag end with a sterile gauze and pinch the end of the tubing about an inch. Carefully insert the syringe and flush it with 20mL Sodium Chloride 0.9% to evacuate the debris. Pinch the end of the tubing and carefully pull to remove the catheter tip syringeReconnect and secure catheter to drainage bag without contaminating either connectionEvaluate outcome and document in the patient’s clinical record. Back to Table of Contents Section 7 – Trial of Void: Community based patientA trial of void (TOV) assesses the emptying ability of the bladder by recording voided volumes and measuring the post void residual (See Continence Assessment and Management Procedure for information on Bladder Scan). NoteConstipation in past 24 hours should be corrected before catheter removal.Obtain history that can affect the ability to void (e.g. medications)Discuss with senior clinicians regarding any conditions that may affect catheter removal (e.g. immunological diseases, bleeding tendency, UTI, congestive cardiac diseases, etc.)Medical authorisation is required prior to TOV Medical Officer should also assess the patients prior to TOV, and complete the Medical Officer’s orders for Urinary Catheter Management form (available from the Clinical Records Forms Register). TOV (SPC and IDC Pathway)Treatment order and informed consent must be obtained IDC: Removal of catheter is normally between 6:00am (LINK team) or 8:00 to 8:30am (community nurse)SPC: If catheter is on free drainage-disconnect the drainage bag and insert catheter valve into the catheter.Advised patient to maintain fluid intake of 200-250mL per hour unless contraindicated.If the patient feels the urge to void, instruct patient to void through urethra, and measure and record the amount of output. Perform bladder scan 4-5 hours after removal of catheter. Follow medical officer’s instructions as outlined in the Medical Officer’s orders for Urinary Catheter Management form.Discard equipment into proper receptacle bins.Document procedure in client’s clinical record.Back to Table of Contents Section 8 – Trans Urethral Prostatectomy (TURP)A Trans Urethral Prostatectomy is a surgical procedure performed via urethra to debulk prostatic adenoma and relieve obstruction. A transurethral resection removes only enlarged prostatic tissue such as Benign Prostatic Hypertrophy (BPH). Normal prostatic tissue and its outer capsule are left intact.The patient usually attends preadmission clinic (PAC) and is admitted on the day of surgery (DOSA). Investigations attended in the PAC are as follows:Baseline observations, including usual Systolic BPHeight, weight and urinalysisBloods – Urea, Electrolytes and Creatinine (UEC), Full Blood Count, COAG’s, cross – match (2-4 units), Liver Function Tests (LFT), Electrocardiograph (ECG), Chest X-ray, as per hospital policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeletonMicro culture & sensitivity of urine (MSU) one week prior to surgeryAlert Patients on anticoagulation therapy require further medical investigation, advice and support and nursing observationAdmission Patient identification and allergy band are checked against clinical notes/ stickers. Ensure consent is gained as per Consent and Treatment policy.Ensure UTI therapy has been completed prior to surgery as per recommendations in the latest version of the Therapeutic Guidelines: Antibiotic, Prophylaxis: urological surgeryAdmit the patient as per Admission to Discharge – Canberra Hospital and Health Services Procedure.Ensure that patient is informed and educated in relation to fasting guidelines as per Fasting Guidelines for Patients Requiring Sedation or Anaesthesia or specific medical orders. Document care provided in the patient’s clinical record. Inform Food Services via DIETPasAdminister bowel preparation if orderedPreoperativeAttend to all documentation including Pre-operative Checklist found on the clinical forms registerMeasure and fit knee length Anti-embolic stockings and ensure documentation on Medication Chart if not already in stiuEnsure patient has early morning shower and is dressed in theatre gown with no underwear onUsual medications are given at 0600.Post Operative Receive handover from Post Anaesthesia Care Unit (PACU) staff and assess patient as per Post Operative Handover and Observations – Adult Patients (First 24 Hours) procedureDon PPE as requiredPatient identification and allergy band are checked against clinical notes/ stickers. Practice to reflect Patient Identification and Procedure Matching Policy and ProcedureReview of post-operative vital signs, Fluid balance chart and any devices attached to the patients.Ensure that continuous bladder irrigation (CBI) and indwelling urethral catheter (IDC) are patent – only 0.9% Sodium Chloride 2000mL solution to be used as irrigate for CBIEnsure Bladder Irrigation Chart is maintained- balances to be recorded on FBCIDC to be anchored with Statlock unless the surgeon specifically documents request for Statlock not to use.Ensure traction is maintained on IDC to provide maximum pressure on the prostatic bed and helps to control bleeding and risk of bladder neck damage. Check post-operative orders regarding the use of traction and the length of time traction is to be applied, usually only for the first 24 hoursIf clotting occurs, nurse to initiate manual irrigation using aseptic technique Urine output is to be recorded hourly for 48 hours postoperatively Medications to be given as ordered (e.g. antibiotics, antihypertensive)Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) Educate and encourage deep breathing and leg exercisesEnsure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)Post-operative Day 1Attend to general observations fourth hourlyReview by Medical OfficerMedical Officer will cease CBI depending on consistency and type of urine outputGeneral post-operative dietCease Intravenous (IV) fluids if oral intake is adequateContinue oral analgesia as requiredPatient may shower if stable, or assist sponge Encourage patient to sit out of bed for a few hoursContinue discharge planning – contact Discharge Liaison Nurse (DLN) if appropriateContinue patient educationCommence ambulation and ensure anti embolic stockings are in situ. Continue deep breathing and coughing, and leg exercisesAttend to blood specimens – FBC and UEC’s as ordered by Medical OfficerRequest Medical Officer to commence Discharge summary document in preparation for discharge.Post-operative Day 2Continue fourth hourly observationsIDC removed at 2400 or 0600 hours or otherwise ordered by Medical OfficerCBI ceased if not attended to during day oneTrial of void (TOV) – document when patient voids – amount, consistency, pain, colour etc., and attend bladder scan post voidReview by Medical Officer after three consecutive bladder scans post voidPatient to attend to self-careComplete patient education prior to discharge and provide written instructions.Ensure patient has received adequate education, and is self-caring with leg bag should discharge occur with IDC in situ.DischargeAdvise patient to organise own follow-up appointment with Visiting Medical Officer (VMO) if seeing Urologist privatelyFollow up in Outpatient Department Clinic (OPD) is usually in 4 weeks. Notification to OPD of patient’s details is completed by RMO completing the Discharge summary Discharge with analgesia if deemed necessary by Medical OfficerEducate the patient regarding the VMO’s post-operative instructions – no driving, heavy lifting or sexual intercourse, etc., until reviewed at follow-up appointmentContact Discharge Liaison nurse for community nursing referral required if patient fails Trial of Void.Back to Table of Contents Section 9 – Bladder IrrigationBladder Irrigation (BI) is the continuous flushing and draining of the bladder designed to prevent the formation and retention of blood clots following transurethral resection of the prostate or where blood clot retention of the bladder occurs.Bladder irrigation is used to:Remove any residual urine and/or bladder sediment to ensure IDC patencyRemove blood clots that may develop post bladder, kidney or prostate surgeryEnsure debris removal from an infected or diseased bladderIntroduce medicated irrigation to soothe an irritated bladder so as to promote healing, and/ or to treat disease.Alert: Patients receiving Epirubicin: Clinical Handovers must reflect when Chemotherapy has been administered and that cytotoxic precautions will be required for seven days post administration. Where Chemotherapy precautions are actioned, dispose of urinary catheter bags with urinary output directly into the Cytotoxic bin.Where Chemotherapy precautions are actioned, don non-permeable gown, and gloves. Please refer to Chemotherapy Care of the Adult Patient (eviQ) Clinical Procedure.NoteEnsure that the irrigation is not running too fast or too slow. The irrigation rate is dependent on the urine colour/ opacity. Refer to medical orders for any contraindicationsAll patients with an Indwelling Catheter in situ are required to have an Insertion of Urinary Catheter sticker placed in their clinical record (See Attachment D). If the input and output balance is negative notify the CNC/Team Leader and medical officer to review the patient immediatelyA medical officer must prescribe continuous bladder irrigation (CBI) and a silicone three way-indwelling catheter (22Fr or 24Fr) must be inserted prior to the commencement of continuous bladder irrigation (CBI)In the event of a genitourinary tract infection, infection control will collate and present data for reporting purposesEquipment Dressing TrolleySterile dish x twoJugs x two50mL Bladder Syringes x twoGloves: two pairs x sterile, one box clean gloves500mL bottle of 0.9% Sodium Chloride (at room temperature)Procedure under pads (small and large) e.g. Smart Barrier Touch Dry absorbent padSafety goggles or shield and gownPortable, adjustable IV poleCytotoxic Spill Kit where EPIRUBICIN or where patient is receiving Cytotoxic treatmentCytotoxic Bin where Cytotoxic precautions are requiredGeneral and clinical waste receptacleCBI:Plain stickers to label consecutive irrigation bagsFoleys Statlock Device-Not for Dr Chan’s patients2000mLs 0.9% Sodium Chloride irrigation fluid bags x four or five bags (at room temperature)Y-type CBI tubing (closed system where available)Three-way indwelling catheter9.1 Continuous Bladder Irrigation ProcedureCheck patients clinical record for any medical orders and explain procedureObtained consent as per Consent and Treatment Policy and maintain the patient’s privacy throughout the procedure.Place patient in a comfortable position, preferably supine position.Don PPE.Place under pad beneath patient and across patient’s thighs to prevent fluid leak whilst connecting to the irrigation fluid.Connect and commence irrigation and maintain a steady flow rate. Hang irrigating fluid bags on portable IV pole, 60cms above the level of the bladderLabel with number each bag when commencing and maintain bladder irrigation chart and output records. Prior to commencing next irrigation fluid bag, completely empty the current IV irrigation fluid bag into the urinary drainage bag. Calculate and record the difference of the fluid administered to the output of the patient. Avoid resting urinary drainage bag on the floor at all timesAccurate documentation of the urine output and the irrigation bag should be maintained at all times. Complete four hourly general observations and monitor the patient for signs of sepsis. Regular and frequent perineal toilets must be attended whilst indwelling catheter is in situ, see Section 2. 9.2 Manual Bladder Irrigation ProcedureCheck patients clinical record for any medical orders and explain procedureObtained consent as per Consent and Treatment Policy and maintain the patient’s privacy throughout the procedure.Place patient in a comfortable position, preferably supine position.Don PPE.Place under pad beneath patient and across patient’s thighs to prevent fluid leak whilst connecting to the irrigation fluid.Prepare Sterile dish with approximately 200mLs 0.9% Sodium Chloride or open a 500mL bottle of 0.9% Sodium Chloride.Open syringe and turn off the irrigation. Place a jug ready at the bedside and disconnect tubing from Statlock device if present.Attend hand hygiene and don appropriate PPE.Using aseptic technique, detach the drainage bag from the IDC and attach syringe filled with 0.9% Sodium Chloride and flush into bladder.Apply suction to the IDC with the syringe to clear any clots from the IDC.Disconnect syringe, dispose of any fluid in the syringe and fill with a further 40mLs of 0.9% Sodium Chloride, reconnect to IDC and flush bladder.Where closed system is in use:Do not disconnect indwelling catheter to manually irrigate. Clamp the tubing below the bulb and firmly squeeze the bulb to commence manual irrigationRepeat process until clear urine is flowing at a steady rateIf no urine backflow after manually irrigating IDC, contact medical officerReconnect the IDC to the drainage bag and reset the irrigation fluidSecure tubing with appropriately placed Statlock device (Attachment E) to prevent movement and urethral traction unless contraindicated (as per Dr Chan’s orders)Regular and frequent perineal toilets must be attended whilst indwelling catheter is in situ. Discard equipment to appropriate binsLeave the patient comfortable with call bell within reach.9.3 Document in Patient’s Clinical Record: The patient’s response to the procedureThe urine input and output on the fluid balance chart and bladder irrigation chart respectively. The amount and size and frequency of irrigated clotIf any complications occurred during or after the procedureFourth hourly general observation whilst IDC is insituAny signs of sepsis or suprapubic distention or discomfort that indicates fluid retentionAdjustment to Patient accountability and care plan.Back to Table of Contents Section 10 – Pre and Post-Operative Management of patients undergoing a Nephrectomy and Percutaneous NephrolithotomyNote:For patients with Nephrostomy drainage, do not instil more than 10 mL of Sodium Chloride 0.9% at one time (See NSW Agency for Clinical Innovation. ACI Urology Network 2012, p. 8).For patients with Nephrostomy drainage, flush the tube very slowly. Do not apply force as over distension of the renal pelvis could cause renal tissue damage. PreadmissionPatient usually attends preadmission clinic (PAC) and is admitted on the day of surgery (DOSA). Investigations attended in the PAC are as follows: Bloods – UEC, Full Blood Count, COAG’s, cross match (2-4 units), LFT’s, serum ferreting assessment, ECG and Chest X-ray. Additional tests such as CT, MRI and or bone scan are to be done if needed to determine probability of metastasis to the body and the skeleton.AdmissionCheck the patient has a completed consent form. Patient identification and allergy band are checked against clinical notes/ stickers as per Patient Identification and Procedure Matching procedureAdmit the patient as per Admission to Discharge – Canberra Hospital and Health Services procedureObtain baseline observations, height, weight and urinalysis should be doneOn the day before surgery, instruct patient to maintain clear fluids until mid-night and fasting from midnight onwards as per Fasting Guidelines for Patients Requiring Sedation or Analgesia Guideline. Inform Food Services regarding nil by mouth (NBM) via DIETPas.Bowel preparation should be completed if orderedPreoperativeAttend to all documentation including Pre-operative Checklist, found on the Clinical Forms RegisterReconfirm consent prior to surgery Measure and fit knee length Anti-embolic stockings and ensure documentation on Medication ChartEnsure patient has early morning shower and dressed in theatre gown with no underwear onUsual medications are given at 0600 hours.Postoperative or Receiving patient from Intensive Care Unit (ICU)If receiving the patient from PACU then complete hand over as per Post Operative Handover and Observations – Adult Patients (First 24 Hours) procedureAlert: If the patient had an epidural or spinal anaesthetic and their respiration rate is 12 or less than 12 per minutes and they complain of a headache within the first 24 hours post operation, notify the anaesthetist or anaesthetic registrar immediately.Vital signs for patients who are under General/Epidural/Spinal Anaesthetic:Completed half hourly for two hours (30mins x two hours). If MEWS ≥ 4, continue half hourly Adult Vital Signs and Early Warning Score procedure’) When MEWS <4, hourly for four (4) hours (60 mins x four hours), then fourth hourly for a minimum of 48 hours.Where an Epidural is in situ patient assessment is performed following the Epidural Analgesia Chart Adult and Paediatric Insert found on the Clinical Forms Register and the Acute Pain Management Techniques Procedure on the Policy Register.If receiving the patient from ICUDon PPE as requiredICU staff to complete handover as per Clinical Handover ProcedurePatient identification and allergy band are checked against clinical notes/stickers. Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles), if airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer reviewConfirm oxygen flow rate as orderedClarify the operative procedure performed. IDC must be anchored with Statlock unless the surgeon specifically requests Statlock not to use. Check any drains attached to the patient and document output in the progress notes. Medications that are administered are documented on medication chart review.Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if any). Do not remove theatre dressing unless there is an order to do so. Any pain management devices including Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions and single shot analgesia technique should be monitored at all times, as per Acute Pain Management Techniques Procedure. All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ epidural morphine etc.)Position the patient in accordance to post-operative instructions.Ensure that the call bell is within reach and lower bed and bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bedEducate and encourage deep breathing and leg exercises.Ward managementThe patient remains NBM until reviewed by medical team. The patient may progress to Free Fluids to Light Diet if they have passed flatus or if approved by medical staff. Inform Food Services via DIETpas for any changes and update bed cardCommence diet and fluids as ordered (continue to monitor tolerance of diet)Maintain hourly input and output, drain output and change drainage bag at midnight.Maintain fourth hourly vital signs and observations required with Epidural/PCAObserve the wound dressing for ooze or blood loss fourth hourlyUrine output is to be recorded hourly for 48 hours postoperatively On Day 2 post operation the patients drains will be shortened and/ or removed at the discretion of medical officer. Ward Management for Patients Undergoing Percutaneous Nephrolithotomy:Medical Officer may order a Nephrostogram to confirm the patency of the urinary tract post-operativelyDepending on Nephrostogram results the Medical Officer may request the Nephrostomy tube to be clamped for six to eight hours prior to removalWhen Nephrostomy tube clamped-observe patient for pyrexia and flank pain, contact the Medical Officer if either occur.Discharge planningEnsure Medical Officer (MO) has documented discharge in the patient’s clinical recordFollow the Admission to Discharge – Canberra Hospital and Health Services C to refer to the Discharge Liaison Nurse for wound care and/or staple removal at daily multidisciplinary (MDT) meetingClarify with the medical team if this patient is to see the VMO in their private rooms,Educate the patient regarding the VMO’s post-operative instructions – no strenuous activity for four to six weeks until reviewed. Ensure adequate fluid intake i.e. two litres per day.Back to Table of Contents Section 11 – Management of patients admitted with pre-existing Continent Urinary Reservoirs/Neobladder during routine hospital admissionsA continent urinary reservoir, also known as a neobladder, is a procedure in which a false bladder is created from a section of the patients’ bowel. The neobladder is continent due to the positioning of the opening in the abdominal wall. The patient is required to self catheterise several times each day in order to release the stored urine. Continent urinary reservoirs / neobladder can also be known as Studor, Kock’s, Indianan or a Charleston Pouch.Patients who are admitted to Canberra Hospital with a pre-existing continent urinary reservoir require individualised management of the reservoir for the duration of the inpatient admission. On admission of the patient it will be necessary to:Obtain a review by the Surgical Urology Registrar to initiate and formalise a treatment plan of the individual reservoirInform the Stoma Therapist of the patient’s admission.Senior nursing staff from the Urology Ward are available 24 hours per day to provide further advice and guidance relating to continent urinary reservoirs if required. Back to Table of Contents Implementation The procedure will be available to all staff on the Policy Register. All staff working in the Urology ward are to read the procedure and sign the Procedure Register. CNC and Clinical Development Nurse (CDN) are responsible for monitoring the Procedure Register to ensure all staff have read the procedure every 12 months. Staff will be informed of this procedure as part of their Orientation.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPoliciesHealth Waste Management Health Consent and Treatment Health Nursing and Midwifery Continuing Competence Patient Identification and Procedure Matching Patient Identification-Surgical Safety Checklist Medication Handling ProceduresHealthcare Associated Infections Aseptic Technique Patient Identification and Procedure Matching Wound Management Post Operative Handover and Observations - Adult Patients (First 24 hours)Cytotoxic Precautions (inc. Epirubicin Instillation)Chemotherapy Care of the Adult Patient (eviQ)Guidelines Fasting Guidelines for Patients Requiring Sedation or AnaesthesiaLegislationHealth Practitioner Regulation National Law (ACT) Act 2010Health Records (Privacy and Access) Act 1997Human Rights Act 2004Privacy Act 1988Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Powers of Attorney Act 2006Back to Table of ContentsReferencesThe Joanna Briggs Institute, 2008, Canberra Hospital Procedure Manual 2008, 27 July 2006, pp 207-208GMCT Urology Network-Nursing, Catheters (Male and SPC), September 2008, p 20Prevention of Indwelling Catheter Associated Urinary Tract Infections, Dailly, Sue, Nursing Older People 23.2, March 2011Bard StatLock? Universal Plus Stabilization Device. Accessed 13 November 2013.NSW Agency for Clinical Innovation. ACI Urology Network – Nursing. Nursing Management of Patients with Nephrostomy Tubes. Guidelines and Patient Information Templates. 2012.Siddiq M and Darouiche R. Infectious complications associated with percutaneous nephrostomy catheters: Do we know enough? International Journal of Artificial Organs. 2012;35(10):898-907.The Australian Council on Healthcare Standards (ACHS). [Homepage of ACHS] [Online] – last updated 19 April 2011. Available: .au/ [6 July 2011].NS485 Madeo M, Roodhouse AJ (2009) Reducing the risks associated with urinary catheters.Nursing Standard. 23, 29, 47-55. Date of acceptance: February 11 2009.Tucker, S.M., Canobbio, M.M., Paquette, E.V. and Wells M.J. (2000) Patient Care Standards: Collaborative Planning and Nursing Interventions, 7th Edition Monahan, Mosby (2010) Manual of Medical-Surgical Nursing, 7th EditionLe, V. The Joanna Briggs Institute (2011) Bladder Irrigation Post Transurethral Resection of the ProstateMikel L. Gray, PhD, Securing the Indwelling Catheter- American Journal of Nursing, December 2008Australian Infection Control Association-Position Statement, “Preventing Catheter Associated Infections Inpatients”, November 2010Timby, B. Fundamentals of Nursing: Nursing Skills and Concepts. 9th ed Lippincott, Williams and Wilkins. 2008Jones, S. et al Care of urinary catheters and drainage systems. Nursing Times; 103:42. 2007Getliffe K & Dolman M, Promoting Continence, A Clinical Research Resource, Bailliere.2006NHS Quality Improvement Scotland, Best Practice Statement June, Urinary Catheterisation & Catheter Care.2007 National Institute for Clinical Excellence June 2003, "Infectious Control: Prevention of healthcare-associated infection in primary and community care" Standard 1.2.5.1, 1.2.5.7, 1.2.5.3, Clinical guideline 2, Guidelines for prevention of Catheter –Associated Urinary Tract Infections. CAUTI Guidelines. 2009 Wasson, D., (1998-2002), Perspectives–Transurethral Resection of the Prostate, http: vin3/wasson.htmlTucker, S.M., Canobbio, M., Paquette, E. V., & Wells, M. F., (2000), Patient Care Standards – Collaborative Planning and Nursing Interventions, pp633–635.Bladk, J., & Matassarin–Jacobs, E., (1997), Medical–Surgical Nursing – Clinical Management for Continuity of Care, 5th edition, pp 2350–2363.The Joanna Briggs Institute, Canberra Hospital – Acute Care Practice Manual 2008, supra-pubic catheter site dressing, 5.2.2007, p195-197‘World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare.Farrell, M., Smeltzer, S & Bare, B., (2005) Smeltzer & Bare’s Textbook of Medical-Surgical Nursing, Lippincott Williams & Wilkins Pty. Ltd, Australian & New Zealand Edition, pp 1360-1361Back to Table of ContentsDefinition of Terms TermDefinitionAutonomic dysreflexiaAutonomic dysreflexia is a sudden and severe rise in blood pressure resulting from overactivity of an isolated sympathetic nervous system below the lesion, triggered by a nociceptive stimulus that can result intracranial haemorrhage, fits, arrhythmias, hypertensive encephalopathy and even deathBPHBenign Prostatic HypertrophyCAUTICatheter-associated urinary tract infectionsCBIContinuous Bladder IrrigationClinical indicationRationale to justify a clinical procedure or treatmentClosed systemA closed urinary drainage system consists of a catheter inserted into the urinary bladder and connected via tubing to a drainage bag. The catheter is retained in the bladder by an inflated balloon. CredentialingA process used to verify the qualifications and experience of primarily medical practitioners to determine their ability to provide safe, high quality health care services within a specific health care setting.CSUCatheter specimen of urineFrFrench gaugeIDCIndwelling catheter. Also known as indwelling urinary catheter or IUC.In / out catheterisationAlso known as intermittent. Involves brief insertion of a non-balloon urethral catheter into the bladder through the urethra to drain urine. May be on once- off or at intervals.MSUMid stream urineNSQHSStandards National Safety and Quality Health Service StandardsPCAPatient Controlled AnalgesiaPHOPublic Health Organisation(s). This term refers to Local Health Districts, statutory health corporations or an affiliated health organisation in response of its recognised establishments and recognised services, as defined in the Health Services Act 1997.PPEPersonal protective equipmentShort term indwellingcatheterisationFor the purposes of this guideline, short term indwelling catheterisation isconsidered to be ≤ 14 daysSPCSuprapubic catheterUTIUrinary tract infectionBack to Table of ContentsSearch Terms Urology, catheter, urine, urinary reservoirs, neo-bladder, Percutaneous nephrolithotomy, nephrectomy, indwelling catheter, suprapubic, catheterisation, void, Urinary drainage bag, TURP, transurethral prostatectomy, bladder irrigation, IDC, SPC.Back to Table of ContentsAttachmentsAttachment A: Catheter selectionAttachment B: How to care for your Urinary CatheterAttachment C: Source of information and/ or suppliers for urinary catheter equipmentAttachment D: Insertion of Urinary Catheter StickerAttachment E: Stat Lock – Foley Stabilisation DeviceAttachment F: Troubleshooting guide for urinary cathetersDisclaimer: This document has been developed by Canberra Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Canberra Health Services assumes no responsibility whatsoever.Policy Team ONLY to complete the following:Date AmendedSection AmendedDivisional ApprovalFinal Approval 14/11/2018Entire documentED, SAOHCHS Policy CommitteeThis document supersedes the following: Document NumberDocument NameAttachment A: Catheter selectionCatheter MaterialsRecommended UsageAdvantagesDisadvantagesPolyvinyl Chloride (PVC)PVC non balloonShort term use only, maximum 7 daysIntermittent catheterisationLarge internal diameter allows good drainage postoperativelyUncomfortable for long-term useRigid and inflexiblePolytetrafluoroethylene (PTFE) or Teflon coated with latex coreShort term, up to 28 daysSmoother on external surfaces for insertion – reduces tissue damageMore resistant to encrustationIf left in situ for too long Teflon coating may wear thinUnsuitable for clients allergic to latexSilver-alloy coated Catheter expected to be in situ for up to 14 daysProtective against bacteriuria when used for 5days Not so effective at 14 days - not proven for long term effectivenessSiliconeAll silicone BARDAll silicone CLINYLong term up to 12 weeksWide lumen for drainage. Suitable for clients with latex allergy‘Cuffing’ of balloon can occur on deflation and can be more difficult to remove suprapubicallyReleen 100% SiliconeLong term up to 12 weeksReduced urethritis/inflammation of urethra. Wide lumen – reduced encrustation. Integrated balloon – less ridgingHydrogel coated latexBiocath? Foley CatheterLong term use up to 12 weeksMore compatible with body tissue, less trauma. May resist colonisation of bacteria and reduce infectionDoes contain latex – unsuitable for clients allergic to latexSilicone elastomer-coated latex (silicone bonding to outer and inner surfaces)Long term use up to 12 weeksMay help to reduce potential for encrustationUnsuitable for clients allergic to latexHydrogel coated siliconeLubri-sil? (BARD)Long term use up to 12 weeksSuitable for clients with latex allergyRigid; may be uncomfortable for clientsAttachment B: How to care for your Urinary Catheter center2456180Sample00Samplecenter2642235Sample00SampleAttachment C: Source of information and/or suppliers for urinary catheter equipmentContinence Aids Payment Scheme (eligibility criteria applies):ACTES ACT Equipment Scheme If client is eligible for CAPS and has used their allowance they may be eligible for assistanceG.P. MEDICAL30 Colbee Court, Phillip, 2606 ACT Ph. 6282 0059INDEPENDENT LIVING CENTRE 24 Parkinson St. Weston, 2600, ACTPh. 6205 1900Fax (02) 62051906Provides information and advice about products.INDEPENDENCE SOLUTIONS 6 Holker St. Newington, NSW, 2127Customer service number: 1300 788 855Fax: 1300 788 811BRIGHT SKY ( proceeds support ParaQuad NSW programs)6 Holker St (corner of Avenue of Africa)Newington NSW 2127Phone 1300 88 66 01 Fax 1300 88 66 02Email: orders@.auWebstore: .au LOCAL PHARMACIES may order relevant equipment for clientsMOBILITY MATTERS PTY LTD33-35 Townsville St. FyshwickPh. 6239 1381Attachment D: Insertion of Urinary Catheter Stickercenter1691005SAMPLE00SAMPLESticker available on order through Corporate ExpressID 18838521ACT Hth Ins of Urinary Cath Lbls Roll 500Attachment E: Stat Lock – Foley Stabilisation DeviceAttachment F: Troubleshooting guide for urinary cathetersTroubleshooting guide for urinary cathetersProblemPossible CauseWhat to doCatheter Leakage(Bypassing)Check PlumbingIs the catheter or tubing kinking - check bag and/or valve connections, check line and connection of tubing. Use catheter securing device.Faecal Impaction / ConstipationAssess, alleviate and prevent by review of bowel management.Catheter too largeA urethral catheter that is greater than 18Fg may need to be gradually downsized.Women IDC: 12 -14Fg/10mL balloonMen IDC: 14- 16Fg /10mL balloonSPC: 16 -18 Balloon too largeA 5-10mL balloon is advised. Authorisation from an Urologist is required for long-term use of a catheter with a 30 mL balloon, given it may contribute to bladder neck erosion.Catheter blockageIf a catheter is blocked and has been insitu for >2 weeks it may be replaced and documented on Urinary Catheter Management Chart. Determine the blocking agent and consult with Medical Officer re indications for antibiotic therapy or refer for a urological review. Bladder spasmSee Bladder SpasmBladder PainBladder spasmConsider concentrated urine – increase fluids Bladder DistensionAssess and action as per No Urine DrainingTraction on CatheterSecure with tape or strapBladder infection - SymptomaticSee InfectionBalloon too large or Catheter too large5-10 mL balloon advised (as per manufacturer’s recommendations IDC – less than 18Fg advisedBladder Spasm (Cramps)Traction on catheter with movementEnsure catheter is not under tension. Recommend use of catheter strap.Faecal Impaction / Constipation Alleviate and prevent. Review bowel management.Bladder infectionSee InfectionOveractive bladderDiscuss use of anticholinergic medication with Medical Officer. Consider use of topical oestrogen for urethritis in femalesNew Catheter in situSpasms should settle within 24-48 hours, Reassure patient they should resolve.BleedingTraumaEnsure catheter is not under tension, check securement devices. Some clients may experience a small amount of bleeding following SPC change.InfectionSee InfectionPersistent HaematuriaUrgent referral to medical officer / Urological consultNo Urine Draining +/- urinary leakageKinked tubingCheck for correct lie and connection of tubingLow fluid intakeRecommend fluid intake of between 2-3 litres daily unless otherwise stated by Medical Officer.Faecal Impaction / ConstipationAssess, alleviate and prevent by review of bowel management.Drainage bag above bladder levelLower bag, ensure bag is below bladder level to assist gravity. Catheter is blocked with mucous or debrisIf a catheter is blocked and has been insitu for >2 weeks it may be changed. Catheter Flush:may be indicated if a client has a history of blocked catheteris prescribed by a medical practitioner and requires a treatment order is a short term management option only and the cause of the blockage should be investigated. A Urology review must be in place. (See Catheter Flushing SOP)No Drainage Of Urine After Several HoursCheck as above.Check for palpable bladder i.e. blocked catheter. Check the catheter position in the bladder by deflating the balloon and slightly rotate and push catheter in.Check for sediment and document characteristics.Replace catheter.If anuria is identified (urinary output of less than 100-250mLs in 24 hours), immediately refer client to nearest local hospital emergency department.InfectionReview catheter management; ensure closed link system is being maintained.Clients with symptomatic catheter related infection should be treated as per local prescribing procedure or the latest version of the Therapeutic Guidelines: Antibiotic if not availableConcerns regarding persistent infective symptoms should be referred to a Medical Officer.Pain and Discomfort Around The Catheter, Bleeding, Itching and SorenessBladder and/or urethral irritationAlleviate urethral traction trauma and potential for pressure necrosis; secure catheter with catheter retaining strap. Liaise with Medical Officer.See INFECTIONDiscuss with medical officer possible use of Topical oestrogen for urethritis (in post-menopausal women) with Medical Officer.Allergy to catheter materialChange catheter typeHyper granulation of supra pubic site due to pulling or tension.Prevent catheter traction and alternate the side the catheter is taped to on a weekly basis.Keep stoma clean and dry. Silver nitrate treatment may be required (See Wound Care Manual).Infection of stomaArrange for wound swab, treat as required (See Wound Care Manual)Catheter Falls OutCatheter balloon deflates prematurely Balloon faultyBalloon intactInsert new catheter. Nelaton catheter to keep site open until Foleys availableCheck balloon of dislodged catheter for faults. Anchor inadequate, or trauma at transferUrine is Cloudy, Offensive SmellingInfectionSee InfectionLow fluid intakeRecommend fluid intake: 2-3 litres daily unless otherwise stated by Medical Officer.Difficult Removal Ridging of deflated balloon or hysteresis’Allow balloon to spontaneous deflate Select appropriate catheter materials: all-silicone catheters have a tendency to cuff, consider all-silicone catheter with integrated balloon (Releen In-Line Foley catheter or hydrogel coated catheter (Bard Biocath). Consider latex allergy status of clients. Where cuffing is suspected, consider instilling 1mL of sterile water back into the balloon (after complete deflation). Consider the use of anaesthetic gel prior to the removal of the catheter. Difficult RemovalBladder Spasm Anxiety Apply lubricate to stoma site.A fair degree of pull may be required, holding the catheter close to stoma, apply consistent firm pressure whilst supporting the abdomen with the non-dominant hand until the catheter releases.Encourage relaxation, allay anxiety Unable To Insert SPCSpasm of tract/bladderApply anaesthetic gel (Lignocaine 2%) to stoma site.Place catheter in stoma, apply firm constant pressure to catheter whilst waiting release of spasm. Insert Nelaton intermittent catheter to maintain tract, then remove and quickly insert usual catheter, or try smaller size Foley catheter. Report to medical practitioner, antispasmodic/muscle relaxant therapy may be required.Where unsuccessful, send patient to hospital within 30 to 45 minutes for management. Not following tractRe-attempt at correct angle. Always observe the angle of tract during catheter removal.No Drainage After Catheter InsertionCatheter /balloon not in bladder Advance catheter a little further. Once in the bladder SPC should not be advanced more than 10 cm in total.Check/consider the tip of catheter is not located in the urethra.No Urine in BladderDehydration Give extra fluids. Ensure drainage before inflating balloon. Advise increased fluids prior to planned catheterisation. ................
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