Urology – Catheter Insertion and Management, Bladder ...
Canberra Hospital and Health ServicesClinical ProcedureUrology – 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 _Toc440886545 \h 1Purpose PAGEREF _Toc440886546 \h 3Alerts PAGEREF _Toc440886547 \h 3Scope PAGEREF _Toc440886548 \h 3Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients) PAGEREF _Toc440886549 \h 4Section 2 – Insertion of Female Indwelling Catheter (IDC) PAGEREF _Toc440886550 \h 6Section 3 – Insertion of Male Indwelling Catheter (IDC) PAGEREF _Toc440886551 \h 8Section 4 – Suprapubic Catheter (SPC) Procedures for Inpatients and Community Based Patients PAGEREF _Toc440886552 \h 104.1Insertion of Suprapubic Catheter PAGEREF _Toc440886553 \h 114.2Changing Suprapubic Catheter: Inpatient PAGEREF _Toc440886554 \h 144.3Removal Suprapubic Catheter PAGEREF _Toc440886555 \h 164.4 Management of Supra Pubic Catheter: Community Based Patient PAGEREF _Toc440886556 \h 17Section 5 – Catheterisation Intermittent in the adult Inpatient PAGEREF _Toc440886557 \h 19Section 6 – Catheter Intermittent: Patient Education PAGEREF _Toc440886558 \h 20Section 6 – Catheter Flushing for Adult Community based patient PAGEREF _Toc440886559 \h 24Section 7 – Trial of Void: Community based patient PAGEREF _Toc440886560 \h 25Section 8 – Indwelling Urinary Catheter Management: Inpatient and Community PAGEREF _Toc440886561 \h 278.1Emptying a Urinary Drainage Bag: Inpatient specific PAGEREF _Toc440886562 \h 288.2Urinary Drainage Bag Management: Community Specific PAGEREF _Toc440886563 \h 298.3Removal of Indwelling Urinary Catheter PAGEREF _Toc440886564 \h 30Section 9 – Trans Urethral Prostatectomy (TURP) PAGEREF _Toc440886565 \h 31Section 10 – Bladder Irrigation PAGEREF _Toc440886566 \h 3510.1Continuous Bladder Irrigation PAGEREF _Toc440886567 \h 3510.2Manual Bladder Irrigation PAGEREF _Toc440886568 \h 37Section 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy PAGEREF _Toc440886569 \h 39Section 12 – Management of patients undergoing a Percutaneous Nephrolithotomy PAGEREF _Toc440886570 \h 44Section 13 – Management of patients admitted with Pre-Existing Continent Urinary Reservoirs/Neobladder during routine hospital admissions PAGEREF _Toc440886571 \h 50Implementation PAGEREF _Toc440886572 \h 50Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc440886573 \h 51Search Terms PAGEREF _Toc440886574 \h 51References PAGEREF _Toc440886575 \h 51Attachments PAGEREF _Toc440886576 \h 53Attachment A: Stat Lock – Foley Stabilisation Device PAGEREF _Toc440886577 \h 54Attachment B: Insertion of Urinary Catheter Sticker PAGEREF _Toc440886578 \h 55Attachment C: How to care for your Urinary Catheter PAGEREF _Toc440886579 \h 56Attachment D: Troubleshooting guide for urinary catheters PAGEREF _Toc440886580 \h 58Attachment E: Source of information and/or suppliers for urinary catheter equipment PAGEREF _Toc440886581 \h 67Attachment F: Catheter selection PAGEREF _Toc440886582 \h 68PurposeThe Urology Assessment and Management Procedures describe practice which will be performed by registered nurses, medical staff and allied health. New nursing or medical 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, education and 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 ContentsAlertsStrict hand hygiene should be adhered to at all times when performing all clinical procedures as per Healthcare Associated Infections Procedure-Section 2 Infection Prevention & Control StrategiesConsent must be gained for all interactions with patients and care provided consistent with Intimate Body Care and Examinations by Health Care workers Standard Operating ProcedureAll staff to adhere to Patient Identification and Procedure Matching Clinical PolicyScopeThis document applies to:Medical Officers (MO)Nurses and Midwives who are working within their scope of practice Students under direct supervision of a registered nurse.Note: A medical officer/ nurse/ midwife is assessed as competent when they have:Observed the procedurePerformed the procedure at least once under the supervision of a competent medical officer/ registered nurse/ midwifeBeen assessed as competent by another competent registered nurse/midwife, medical officer nominated by the Clinical Nurse Consultant (CNC) or CDN. Back to Table of ContentsSection 1 – Catheter Management for Adults (Inpatients and Community Based Patients)General Information:It is recommended that nursing staff who are inserting urinary catheters and/or caring for and/or removing urinary catheters from patients complete the eLearning course Indwelling Urinary Catheter and the competency assessment form, accessible via Capabiliti.To introduce a urinary catheter to drain urine from the bladder. If a latex catheter is to be inserted determine the patient’s latex allergy status.Patient assessment prior to catheterisation should include the exploration of possible patient’s cultural values and beliefs that may influence healthcare practices and consistent with ‘Intimate Body Care and Examinations by Health Care Worker SOP’ . Verbal consent should be obtained especially where catheterisation of males by a female nurse or female catheterisation by a male nurse is required.For patients with large capacity bladders, indwelling catheters and slow bladder decompression are recommended. No more than 600mls is to be withdrawn from the bladder at any one time unless otherwise indicated by the medical officer as this may induce a syncopic munity Based Patients:Contraindications for Catheterisation in the CommunityAcute prostatitis. Suspicion of urethral trauma. ‘Medical Officer’s Orders for Urinary Catheter Management’ clinical record form (form no. 40950) must be completed for all urinary management in the community setting. Medical Officers orders for Catheters should be reviewed every three (3) years.Catheters should be appropriate, comfortable, easy to insert and remove and must minimize secondary complications such as tissue inflammation, encrustation and colonisation by micro- organisms (See Attachment F)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 20Frg 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 SOP’ 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 the munity nurses will document the management of a patients ‘Urinary Catheter Management Chart’ clinical record form (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’, which can be found on the Policy Register (see sample at Attachment C)Catheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheterManual 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. Consider funding sources such as:Continence Aids Scheme (CAPS)ACT Equipment Subsidy Scheme (ACTES) Rehabilitation Appliances Program (RAP) of Department of Veterans Affairs (DVA)If the patient is not eligible for any of these schemes, they may source equipment from supplies either locally or interstate (see Attachment E) 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 CNC or 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. Alerts:Seek expert advice for patients with artificial heart values who grow Enterococcus species in the urine prior to the procedurePatients with spinal lesions at or above T6 require monitoring for Autonomic Dysreflexia: refer to ‘Autonomic Dysreflexia SOP’ for management pathway Do not clamp catheter prior to change The following conditions do not preclude catheterisation but extra care should be taken when: The Patient is taking high dose anticoagulants increasing the risk of haemorrhage. If there is a history of recent surgery, cancer or radiotherapy to the lower urinary tract, as there is increased risk of damageConsult with Medical officer or CNC if in doubtBack to Table of ContentsSection 2 – Insertion of Female Indwelling Catheter (IDC)Equipment:Disposable catheter pack (includes extra gloves) 0.9% Sodium Chloride 60ml Lubricant sachet Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16FSterile urinary drainage bag to meet patients needsOne x 10ml syringeOne x 10ml Sterile Water for InjectionSecurement deviceInpatient specific: Foleys Statlock device pack including skin prepCommunity specific: Urinary Retaining StrapMeasuring jug if requiredProcedural under padClean gown Sterile gloves Community specific: Sterile gloves x twoCommunity specific: non sterile glovesSafety glasses or gogglesSterile specimen jar, if required Procedure:The medical officer must document the order for catheter insertion and removal in clinical recordCommunity Specific: Medical Officers Catheter ManagementExplain procedure to patient and ensure privacyPatient identification and allergy band are checked against clinical notes and stickers.Prepare equipmentDon safety gogglesInpatient specific: Raise bed to the appropriate height Position the patient supine with knees flexed drawn up soles of feet together, or knees wide apartPlace procedural under pad beneath the buttocksDon clean gownDon sterile gloves (separate) then gloves from catheter packRemove the protective cover from the tip of the catheter ONLY. Lubricate, leaving the catheter cover in placePlace the catheter in the dishUsing a clean swab each time, cleanse the labia majora with 0.9% Sodium Chloride using downward strokesSeparate the labia with free hand, using gloved handCleanse the labia minora and urethral meatusDiscard forceps and first pair of gloves. Drape patient with fenestrated sheet to establish sterile areaSeparate the labia with free handMaintain the separation until the catheterisation is completePlace the dish containing the catheter between the patient's thighsIdentify the urethraAsk the patient to take a deep breath to relax the sphincterGently insert the catheter until urine flows, then advance 2.5cm further into the orifice using the sterile catheter sleeve. Note: Do not use forceRemove the sterile catheter sleeve and drain urine into the dishCollect sterile urine specimen 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 Inpatient specific: Attach statlock (dated) to the leg to anchor urinary catheter bag (Attachment A)Community specific: Catheter Retention StrapDrain 600ml only then clamp for one (1) hourLeave the patient comfortableLower the patient’s bedDiscard equipment Inpatient specific: Record the procedure in the patient's clinical record (Attachment B):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’ clinical record form (form no.60535)Record output, clarity, colour and odour on the patient's FBC and clinical record Perform urinalysis and document on General Observation Chart and clinical recordRecord if a specimen is sent to pathology Watch for haematuria and diuresis in patients with chronic urinary retention Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated perineal toilets required for hygiene needsAlert: Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weekly. Stabilisation of Urinary Catheters:Prepare skin with protectant and allow to dryAlign anchor pad over securement site (arrow towards body)Press catheter into anchor and close lidPosition on anterior thigh or abdomenPeel away paper backing and place on skin (See Attachment A)Back to Table of ContentsSection 3 – Insertion of Male Indwelling Catheter (IDC)Equipment:Disposable catheter pack (contains extra gloves)Community specific: sterile gloves x twoInpatient specific: Betadine (check for Iodine allergy)0.9% Sodium Chloride 60ml 10ml Lignocaine gel syringe Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16F Sterile urinary drainage bag1 x 10ml syringeCommunity specific: two x 10ml syringe1 x 10mls Sterile Water for InjectionSecurement devicesInpatient specific: Foleys Statlock deviceCommunity specific: Catheter Retention StrapInpatient specific: Measuring jug Procedural under pads (one large & one small)Clean gown Community specific: non sterile glovesSterile gloves Community specific: two x sterile glovesSafety glasses or gogglesSterile specimen jar, if required Sterile catheter introducer, if required (to be used by Medical Officer only).Alert: A catheter introducer for the introduction of a catheter for male catheterisation is only to be used by a medical officerProcedure:Inpatient specific: The medical officer must document the order for catheter insertion and removal in clinical recordCommunity specific: Medical Officers Catheter ManagementExplain procedure to patient and ensure privacyRemove the protective cover from the tip of the catheter only. Lubricate, leaving the catheter cover in placePlace the catheter in the dishDrape the genital area around the penisDon safety eyewear and gownInpatient specific: Raise bed to appropriate heightWash hands and don sterile gloves x twoPosition fenestrated drape to provide sterile fieldUse non dominant hand to hold the penis. Where present retract the foreskin and swab head of the penis paying particular attention to the urethral meatus and glansHold penis at a right angle (90 degree) to the body and gently instil Xylocaine lubricant into the urethra: Gentle pressure underneath the head of the penis will minimise lubricant leaking out. Allow sufficient time for anaesthetic to work (three to five minutes). Note: Do not proceed if patient has an erection, wait until this subsidesAfter this time you may:Remove outer pair of sterile gloves if contaminated during the procedureHolding penis at 90 degree angle, gently insert and advance catheter to the Y hub. If resistance is felt at the bladder neck, lower the penis slightly and suggest that the patient breathe slowly whilst pretending to pass urine. The catheter should never be forcedIf 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 OfficerWhen urine begins to flow,(at least 15-20mls ) re-check the position of the catheter to ensure it is still in the bladder, then inflate balloon with required volume of sterile water (according to manufacturer’s instructions)Alert: If resistance is felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask the patient to attempt to void in order to relax sphincterAttach sterile drainage bagWhere present, replace foreskin to natural position Secure bag to patients requirementsInpatient specific: Attach statlock to the leg to anchor urinary catheter bag (See Attachment A)Community specific: Attach Catheter Retaining StrapDrain 600ml only then clamp for one hourLeave the patient comfortableDocumentation: Inpatient specific: Record the procedure in the patient's clinical record using the Urinary Catheter Label: (See Attachment B): 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’ clinical record form (form no.60535)Record output, clarity, colour and odour on the patient's FBC and clinical notesPerform urinalysis and document on General Observation Chart and clinical notesInpatient specific: Record if a specimen is sent to pathology Community specific: Contact GP if signs of infection presentObserve for haematuria and diuresis in patients with chronic urinary retention. Inpatient specific: Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated penile toilets required for hygiene needsPerform hand hygiene when leaving the patients environment as per the 5 moments of hand hygieneAlert: Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weeklyBack to Table of ContentsSection 4 – Suprapubic Catheter (SPC) Procedures for Inpatients and Community Based PatientsBackground:An SPC may be used for:The management of long-term urinary incontinence or retention of urineThe drainage of urine post operatively in urological or gynaecological patientsPatients with urethral and/ or pelvic trauma where the utilisation of a urethral catheter is not possiblePatients with ongoing problems associated with urethral catheters such as irritation or continued blockageThe purpose of this is to provide guidelines for the management of a Suprapubic Catheter (SPC) including:InsertionCatheter ChangeInpatientCommunity based patientDressing ChangesRemovalManagement in the CommunityThis document pertains to adult patients requiring management of a SPC at the Canberra Hospital and Community based patients4.1Insertion of Suprapubic CatheterInitial insertion of a SPC may only be performed by a Medical Officer. Further catheter changes may be attended in the community by nursing staff.Equipment:Alcohol based hand rub (ABHR)Basic dressing packSterile dressing towels x twoSterile gown and glovesSterile 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 syringe500mls bottle 0.9 Sodium Chloride at room temperatureChlorhexidine skin preparationAdhesive tape of choiceSafety goggles or shieldsProcedure underpadClean gownAlert: The patient will be required to have a full bladder for initial insertion to assist in the palpation of the bladder and to prevent perforation of the bowel. A full bladder is not required for routine subsequent changes.Procedure: Inpatient: The medical officer must document the order for the SPC insertion and removal in the clinical recordCommunity specific: Medical Officers Catheter ManagementObtain the verbal consentExplain to the patient the process and purpose of the procedureAsk the patient if they have any allergies to dressings or tapes.Ensure the patient has adequate analgesic cover prior to procedure if required or requested Assist patient to the supine position, placing procedure underpad beneath the buttocksDon PPEClean trolley with detergent impregnated wipes and disposable towel, wipe drySet up equipment on trolley at the patient’s bedsideDon clean gown prior to opening sterile equipmentOpen the procedure pack Assist the medical officer with gowning after performing a procedural wash Don clean glovesExpose the suprapubic areaAttend hand hygiene by either hand washing or using ABHROpen further equipment required, such as the catheter pack, local anaesthetic, water for balloon, suture materialPour chlorhexidine skin preparation into sterile trayThe medical officer will insert the SPC, provide assistance if requiredReassure patient throughout the procedure whilst maintaining privacyOnce SPC inserted, attach urinary drainage bag, ensuring drainage system is closedPlace drainage bag below the patient’s waist heightA leg bag may be utilised, however is not advised at initial insertion timeEnsure Foleys Statlock device is securely attached to the patient’s skin and secure the catheterApply drain sponge around SPC and secure with tape Discard equipment and gloves into clinical waste receptacleClean trolley with detergent impregnated wipes Ensure patient is comfortable with new dressing change and understands when the next dressing change will be attendedDocument 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 procedureChange dressing as frequently as requiredNote: The insertion of a SPC for gynaecology patients on the ward may be performed under ultrasound.Dressing ChangeEquipment:Alcohol based hand rub (ABHR)Basic dressing packSterile drain dressing0.9% Sodium Chloride (30ml)Adhesive tape of choicePersonal protective equipment (PPE) including clean gloves and safety goggles or shield General waste receptacleClinical waste receptacleStat lock (optional)Procedure:Attend steps 1 to 14 of Insertion of SPCDon PPE prior to opening sterile equipmentOpen the basic pack and position equipment using the setting up forcepsPour normal saline to trayDon clean glovesExpose the SPC siteRemove the soiled dressing with setting-up forcepsDiscard the dressing and forceps and gloves into the clinical waste receptacleInspect the SPC site for clinical signs of infection and healing If signs of infection notify the Medical Officer and consider swab Note: Once the SPC insertion site is healed, it does not require a dressing. The site may be cleaned with warm soapy water during daily hygiene routines. Statlock device must remain insitu to anchor the SPC to the body to avoid dislodgement.Don clean glovesUse wound cleansing solutions at body temperature .Irrigate with normal saline solution to remove debris and contaminantsSwab gently and in one direction onlyEnsure 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 and gloves into clinical waste receptacleClean trolley with detergent impregnated wipesEnsure 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 changeUrinary bags are to be emptied and cared for as per Urinary Bladder ManagementEnsure the patient is involved in the care and management of the SPC in preparation for discharge Alert: Maintain a closed drainage system as much as possible so as to prevent infection. Do not use talcum powder, creams or strongly scented soaps near the catheter site to avoid irritation.4.2Changing Suprapubic Catheter: InpatientFirst SPC change following initial insertion must be attended four to six weeks post insertion.Medical Officers or Registered nurses may perform the first and subsequent suprapubic catheter changes, where the catheter is a balloon catheter (Foley) or a Bonanno (Pigtail) utilising aseptic technique unless otherwise specified by the Urologist.If symptomatic urinary tract infection is suspected and patient is not on antimicrobial therapy then reconsider need for change of SPC prior to clarification of infection status. If change is still required then consult the medical team for consideration of treatment immediately after change ensuring a mid-stream urine is obtained once the new catheter is inserted.Alert: Size 16 and above catheters are recommended for Suprapubic catheterisations:Latex SPC’s must be changed every two weeksSilastic SPC’s must be changed every six weeks Hydrogel coated and 100% silicone catheters can remain insitu for up to 12 weeks It is recommended that Catheter changes are based on clinical indications such as infection, obstruction, or when the closed system is compromised within the manufacturers recommend time frame. Equipment:ABHRSterile dressing towels x twoSterile gown and glovesClean gownCatheter of choice – preferably silasticBasic dressing packGauze swabs x two packs0.9% Sodium Chloride 30 to 60mlsSterile water 20mlSyringe 10mlSyringe 20mlSterile urinary drainage bagDrainage tube dressingFoleys Statlock deviceSterile kidney dishClean clampProcedure underpadSafety glasses or gogglesAdhesive tape of choice (if required)General waster receptacleClinical waste receptacleAlert: The patient’s SPC is to be clamped for 30 to 60 minutes prior to the procedure so as to allow the bladder to fill for easier palpationCommunity specific: Patient to consume oral liquids 30- 60 minutes prior to SPC change to ensure bladder volume. Clamping of SPC not required in community setting. Clamping of SPC not recommended in patients with spinal cord injury at T6 level or above or patients with a diagnosis of Autonomic DysreflexiaAn assistant is required to assist gowning and to open further equipment such as the catheter, sterile water and drainage bagProcedure:Attend steps 1 to 14 of SPC DressingDon 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 removalDiscarded into clinical waste receptacleSwab fistula site with 0.9% Sodium Chloride and gauze swabSterile dish containing catheter is placed on the sterile fieldCatheter is inserted through the fistula at a 90 degree angle to the abdominal wallInsert the catheter approximately 8 to 10cm or until urine is returnedUrine specimen may be collected if required Inflate the balloon with the sterile water and 10ml syringe following manufacturer’s instructions (5 to 10mls)Connect the drainage bag to the catheter ensuring closed systemApply drainage tube dressing if requiredSecure the catheter to the abdomen with Foleys Statlock deviceDiscard equipment and gloves into clinical waste receptacleClean trolley with detergent impregnated wipes Ensure patient is comfortable with new SPC and dressing change and understands when the next SPC and dressing change will be attended. Advise patient of signs and symptoms of infection and to notify to the medical officer in charge of their case and notify of any changes in the patients clinical condition post procedure.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.4.3Removal 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 where ordered by a Medical Officer.Equipment:Basic dressing packSterile glovesStitch cutter or fine suture removal set, if requiredSyringe one x 20ml0.9% Sodium Chloride 30 to 60mlsSterile specimen jarDry absorbent dressingAdhesive tape of choiceSafety glasses or goggles (need to ensure this included in the steps)Procedure underpadBladder scannerProcedure:Attend steps 1-13 of SPC Dressing ChangeCollect catheter specimen of urine (if required) Don sterile glovesRemove the suture (if present) holding the catheter insituIf 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 into a sterile specimen jar and send to pathology for analysis if required Use wound cleansing solutions at body temperature irrigate with normal saline solution, to remove debris and contaminatesSwab gently and in one direction onlyEnsure the site is dry before applying new dressingApply new dressing and secure with adhesive tape or bandageDiscard equipment and gloves into clinical waste receptacleClean trolley with detergent impregnated wipes Ensure patient is comfortable with new dressing change 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 MC&SPatient’s reaction to the procedure.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 required4.4 Management of Supra Pubic Catheter: Community Based PatientAlert: If the Supra pubic catheter becomes dislodged it should be replaced within 30 - 45 minutes to prevent the stoma closing over.Following 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’ clinical record form (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 General Practitioner (GP) The size of the catheter should be no smaller than 16Fg in adults with a 10ml balloonEnsure patient has had adequate fluid intake prior to procedureCatheters should not be clamped prior 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’ 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 is discharging 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 Inpatient’s fileMedical Officer’s Orders for Urinary Catheter Management should be reviewed every 3 years Patients 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 Suprapubic Trouble shooting guide (Attachment D)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 system Supply 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 ContentsSection 5 – Catheterisation Intermittent in the adult InpatientThe purpose of this section is to introduce a catheter into the bladder to completely empty the bladder or to measure residual urine volumeEquipment:Disposable catheter pack Short term Nelaton catheter of correct size (female 12-14 Fg/male 14-16Fg) i.e., smallest size suitable0.9% Sodium Chloride 60ml Lubricant sachet Measuring jug Procedural under padClean gown Sterile gloves Safety glasses or gogglesSterile specimen jar, if required. Procedure:Follow 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 injectionOnce the catheter is inserted and urine starts to drain, hold the catheter in place digitally 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 Lower the patient’s bed Discard equipment. Record the procedure in the patient's clinical record: Date and time of procedureType and catheter size Reason for insertionRecord output, clarity, colour and odour on the patient's FBC Perform urinalysisRecord if a specimen is sent to pathologyAlert: Specific Spinal Cord Considerations. Do not clamp the catheter in spinal cord injured patients above T6. Ascertain if patient is on anticoagulants prior to procedure. Seek expert advice for patients with artificial heart values who grow Enterococcus species in the urine prior to the procedure. Potential risk of creating a false passage associated with forced instrumentation. Balloon inflated in urethra/ tract resulting in haematoma, haemorrhage, rupture or necrosisBack to Table of ContentsSection 6 – Catheter Intermittent: Patient EducationThe 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.This applies to all nurses and contains information on Documentation and patient education requirementsSelf catheterisation procedure and equipmentCatheter equipment Procedure:A Medical 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 notedThe aim of the technique is to achieve bladder emptying at regular intervals, to reduce urinary tract infections, to promote bladder function and maintain continenceNurses must utilise a clean technique when teaching and performing intermittent catheterisationUtilise clean working surfaces for the procedureUrinary volumes, both voided and residual (where appropriate) should be recorded until a pattern has been established. If large amounts urine (more than 500mls) is drained consider more frequent catheterisationPatient Accountability and care plans will document a personalised timetable of self-catheterisationPatient 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 UrologistEquipment:Intermittent (nelaton) catheter, recommended sizes 8 to 10Fg children, 12 to 14Fg 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)Female Procedure:Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and lubricate catheterPlace patient in a comfortable sitting position, back supported, knees apart and legs bent so that the perineum is visible in a mirrorInstruct 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 motionAllow urine to drain into container and apply gentle pressure over the suprapubic area when flow ceases. This will ensure the bladder is emptyWithdraw catheter slowly, stopping if urine begins to flow againMeasure and record amount of urineNurse and patient to wash hands thoroughly and clean upDocument Inpatient fileOnce the patient is efficient and confident, the procedure may be carried out on the toiletNote: it is not harmful should menstrual blood be introduced into the bladder during this procedureMaleProcedure:Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and thoroughly lubricate the first 15cm of the catheter tipPatient sits in a comfortable position with legs separatedInstruct 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 towelettesInstruct the patient to hold the penis upwards and outwards from the body at a 90? angle with thumb and finger on either side of the penis. Instruct patient to grasp catheter about seven cm from tipIdentify the urethral meatus and insert well-lubricated catheter and gently advance until urine flow is observedResistance may be felt when catheter reaches the bladder neck. This may be overcome by encouraging the client to take a deep breath, exhale slowly and relax. Encourage the client to void and at the same time applying firm pressure to the catheter (this helps open up the bladder neck)Once the catheter is inserted, hold in place whilst urine flows. The penis and catheter are now in a dependent position. Toward the end, ask the client to cough or strain or apply gentle suprapubic pressure to assist with complete emptying. Gently withdraw the catheter, stopping whenever urine begins to flow againMeasure and record amount of urineNurse and patient to wash hands thoroughly and clean upDocument Inpatient fileOnce the patient is efficient and confident, the procedure may be carried out on the toiletCatheter types:Catheters 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 lengthsCatheter supplies:Catheters can be obtained via:Continence Aids Payment Scheme (CAPS) - ACT Equipment Scheme Department of Veteran Affairs Rehabilitation Appliance Program (RAP)Medical and Surgical wholesalersSome pharmaciesCatheter care:Catheters 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 reuseBack to Table of ContentsSection 6 – Catheter Flushing for Adult Community based patientConsiderationsCatheter 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 fluid 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 communityCatheter flushing:May be indicated if a patient has a history of blocked catheterIs an aseptic procedure as the closed urinary drainage system is being broken which is a high risk factor in the development of a UTI.Is prescribed by a medical practitioner; a treatment order is required stating: Normal Saline 9% (is the preferred solution)Maximum of two x consecutive flushes of 20mls each (no more than 40mls)Management of catheter if unable to flush Review date of treatment practice is a short term management option only and the cause of the blockage should be investigated.A Urology review must be in placeIf a catheter is blocked and has been insitu for >2 weeks it may be replaced without flushingCatheters that remain obstructed after second flush and catheters that remain patent only with repeated flushing should be replaced and Urology team informedNursing Alert: Catheter flush is not considered safe practice following renal transplant, or open bladder surgery: Patients with long term catheters are prone to develop decreased bladder capacity. Caution should be practiced when performing catheter flush in these patients with only the prescribed amount of fluid used and if a second flush is needed, adequate care must be taken to ensure previous fluid volume has been drained outEquipment:Personal Protective Equipment (PPE) and sterile glovesDisposable catheter pack50ml catheter tip syringe (to ensure low pressure on the catheterBlue under sheetOne pair sterile glovesOne alcohol wipeNormal Saline 9% (N/S) solution at body temperature (never use cold solution to flush catheter as it can induce a bladder spasm Procedure:Treatment orders are required for a catheter flush Explain the procedure to patientGain verbal consent and document in the nursing notesPrepare sterile setup, place N/S 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 in a sterile gauze swab, if possible give to the patient to hold. Keep connection end sterile.Pinch the end of the tubing about an inch from the end of the catheter, and carefully insert catheter tip syringe Using up to 20mls of N/S flush the catheter to evacuate any debris. Do not withdraw fluid. If resistance is encountered allow syringe to refill by gravity, discard fluid and repeat flush. (If resistance remains the catheter should be replaced as per catheter management policy)Pinch the end of the tubing about an inch from the end of the catheter, and carefully pull to remove the catheter tip syringeReconnect catheter to drainage bag without contaminating either connectionSecure catheter to the abdomen/thigh Evaluate outcome and document in the nursing notes Back to Table of ContentsSection 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 CHHS Continence Assessment and Management Procedure for information on Bladder Scan) TOV with IDC Pathway:Plan procedure with patientRemoval of the catheter is normally between 6:00am (LINK Team) or community nurse 8:00am to 8.30am Drain the bladder and remove catheter Document time of catheter removal and urine volume Advise patient to maintain fluid intake of 200mls/hour capped at 1000mls over four to five hours (unless contraindicated)Advise the patient to void urethrally when they have the desire to void, measure and record all voided volumes on the bladder diary If anytime the patient becomes uncomfortable and is unable to void it is recommended the patient contact the RN (through the Team Leader) and be re-catheterised (as per medical orders) as soon as possible.The attending nurse to contact the patient for progress call within three hours. (e.g. if catheter is removed by LINK team at 6am call at 9.00am)After the four to five hours from catheter removal , the attending nurse returns - request the patient to void Measure residual bladder volume by bladder scanner Interpretation of TVO: successful or unsuccessful Document outcome Inpatients’ records and inform Medical Officer at Urology Out Patients UnitThe Medical Officers TVO order is only valid for 24 hrs post removal of catheter. If the patient has a new episode of retention or other related urinary symptoms they should be referred back to the Urologist or treating hospital. TOV with SPC Pathway:Explain the procedure to patient (nurse contact details should be provided)If catheter is on free drainage – disconnect drainage bag and insert catheter valve into catheterAdvice the patient to maintain fluid intake of 250mls hour during the day (unless contraindicated) and record on chart providedMeasure and record each urethrally voided urine. Immediately following urethral voiding release the valve and drain the bladderMeasure and record any residualIf the client is unable to void advice the client to release the valve, drain the bladder, measure and record volume of urine. Resume timed emptying of the bladder via the valveAdvise the client to void urethrally:if they experience a strong desire to voidif they feel uncomfortableVoid volumes and post void catheter residuals are compared to parameters set by medical officer’s guidelinesDocument outcome in client notes and follow medical instructions for either repeat TOV or removal of catheterEducational Notes:Bladder emptying occurs as a result of a complex interaction between the sympathetic and parasympathetic nervous system and physical structures of the bladder and urethra. Bladder dysfunction can result from a wide range of conditions, e.g.: Bladder outlet obstructionNeurogenic dysfunction Following childbirthFollowing some surgical procedures Medications e.g. anticholinergic can contribute to urinary retentionChronic constipation. Rectal examination may be required to assess for constipation Ensure that the client is not constipated at time of catheter removal as constipation can contribute to urinary retention and this may result in failed trial of voidMedical authorisation is required prior to TOV:Knowledge of client’s medical history is crucial Knowledge of the client’s usual urine production is recommended to facilitate correct Timing of the TVO e.g. day time urine production maybe significantly reduced in the elderlyA maximum total bladder capacity should not exceed 600mls (void volume + residual)An assessment prior TOV will anticipate the expected 24 hours urine production, e.g. some elderly clients will have low urine volume throughout the day and large volumes diuresis overnight Back to Table of ContentsSection 8 – Indwelling Urinary Catheter Management: Inpatient and CommunityAlert: 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. Observe for any signs of pressure areas or trauma at the urethral meatus. Document findings in appropriate patient recordsThe purpose of this section is to provide clinical care so as to:Maintain a patent urinary drainage system Prevent urinary tract infections Promote patient comfortProvide education for self management of urinary drainage systemsPerineal/ penile care: Inpatient specific procedure:Explain procedure to patient and ensure privacyEnsure catheter is securely anchored at all times (See Attachment A)Routine daily perineal/ penile care is performed Drainage bag must be kept below the patient’s waist to prevent reflux of urine back up the IDCEncourage a two to three litre fluid intake unless contraindicatedRecord output, clarity, colour and odourPerform and record urinalysis where indicatedObserve for HaematuriaWatch for Haematuria and diuresis in patients with chronic urinary retentionAdjust the Patient Accountability and Care Plan to indicate IDC insitu and associated peri-toilets required for hygiene needs8.1Emptying a Urinary Drainage Bag: Inpatient specificA closed urinary drainage system should be maintained. The catheter and tubing should not be disconnected unless absolutely necessary. This applies to:Urinary Drainage SystemsClosed Drainage SystemsCatheter Valve Drainage SystemsDuring urinary drainage bag changes, strict aseptic technique is essential to prevent infection. Ensure that there are no dependent loops in the tubing, where possible, to prevent stasis of the urine in the tubing.Urinary Drainage Bag Change: Inpatient specific:To change a urinary drainage bag in order to maintain a patent urinary drainage system To prevent contamination of the urinary drainage systemPromote patient comfortEquipment:Sterile urinary drainage bag Alcohol swab Clamp Foleys Statlock device Safety glasses or gogglesClean gown and glovesProcedure:Explain procedure to patient and ensure privacy is maintainedPrepare equipment and the patientDon safety glasses Attend hand hygiene before touching patient by either hand washing or using ABHR Don gloves Ensure the drainage system is closed, clamp off all clamps Remove the protective cap from the drainage tube Clamp the catheter above the tubing connector, and clean the catheter tubing junction with an alcohol swab Disconnect the catheter from the old tubing, being careful not to contaminate the end of the catheter, and connect the catheter to the new tubing Unclamp the catheter, and establish drainage by securing the tube and drainage bag to the bed at the appropriate level Leave patient comfortable and dispose of equipmentRemove gloves and perform hand hygiene after a procedure or body fluid exposure risk as per the five moments of hand hygieneDocument the urinary bag change in the patient’s clinical record, FBC and Patient Accountability and Care Plan 8.2Urinary Drainage Bag Management: Community SpecificProcedure:Types:Leg bags are available in a range of capacities: 350ml, 500ml, and 750mI.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).Management: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.Aseptic technique should be used when attaching urine drainage bags directly to the catheter.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 bagsClosed Drainage SystemTypes:Closed link system is used to facilitate overnight drainage and is appropriate for use with indwelling urethral and supra-pubic catheter drainage systems.Closed drainage systems are available in drainage bags with a two litre capacity and drainage bottles with a four litre capacity.Closed drainage systems are supplemented by the linking of a larger two litre capacity bag or urinary drainage bottle with a four litre capacity to the outlet of the sterile legThe linked overnight drainage system need not be sterile but must be cleaned daily to minimise the bacterial growth and extend the life of the bag. Manufacturer's instructions for cleaning should be observed (outlined below)Catheter Valve SystemA catheter valve may be used in place of a urinary drainage bag, allowing bladder filling and intermittent drainage. Catheter valves are recommended as single use only items and should not be reused. Manufacturer'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/or urinary complicationsAn understanding of the principles associated with catheter management The ability to independently manage their catheter care, or a carer who is willing to ensure safe management The awareness of bladder sensation and recognition of bladder fullness, and manual dexterity to manipulate the outlet tapAlert: Catheter valves are inappropriate for clients with detrusor instability, lack of bladder sensation or clients who are confused.Instructions for patient/ carer regarding changing of drainage bags/valves:Wash handsDisconnect bag/valve from catheterConnect new bag/valve to catheter - avoid touching clean/sterile connectionsWiping connection with alcohol wipe is not necessaryInstructions for patient/ carer regarding cleaning of overnight drainage:Rinse with cold water to prevent agglutination of urinary proteinsWash with warm soapy water (dishwashing liquid)Rinse with clean waterAllow to drain and dry (by hooking bags onto a wire coat hanger from a bathroom rail)Night drainage bottles may be left to dry in an upturned position on a clean towel‘Urosol’, a deodorant and detergent cleansing agent, may be used to dissolve urinary crystals. Vinegar or bicarbonate of soda may be used as a substituteUse of bleach should be avoided as it may damage rubber and plastic8.3Removal of Indwelling Urinary CatheterTo remove an indwelling urinary catheterEquipment:Clean glovesSafety glasses or gogglesProcedural under pad Syringe (10 or 20ml) Clean kidney dishProcedure:Inform the patient and ensure privacy is maintainedExplain procedure to patient and ensure privacyConsent must be gained for all interactions with patientsPatient identification and allergy band are checked against clinical notes and stickers Prepare equipment Place patient in supine position Check balloon capacity Inpatient’s clinical records Don safety glassesDon glovesDetach catheter from Foleys Statlock device Attach syringe to catheter balloon lumen and aspirate fluid slowly to deflate Gently pull catheter to check balloon is deflated Inform patient to breathe slow deep breaths then withdraw the catheter gently Check catheter tip is intact, if not inform medical officer immediately Place catheter in kidney dishRemove Foleys Statlock device from patient’s body with Alcohol swabs and clean skin area as required (See Attachment A)Discard equipment and ensure patient is comfortable Document procedure including patient response Inpatient’s clinical record Remove gloves and perform hand hygiene after a procedure or body fluid exposure risk as per the 5 moments of hand hygieneDocument the time and date of removal in the patient’s clinical record, Patient Accountability and Care Plan and FBC. Alert: Do not cut the balloon lumen, as the balloon may not be fully deflatedAlert: Patients undergoing a trial of void (TOV) must be provided with either a pan or urinal and inform nursing staff once they have voided. Nursing staff must check for residual urine with Bladder scanner, record on fluid balance chart and inform medical officer of results prior to dischargeBack to Table of ContentsSection 9 – Trans Urethral Prostatectomy (TURP)Surgical procedure performed via the urethra to debulk the prostatic adenoma and relieve obstruction. A transurethral resection removes only enlarged prostatic tissue, as in benign Prostatic Hypertrophy (BPH). Normal prostatic tissue and its outer capsule are left intact.Background: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 – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s ECG, CXR, 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 surgeryEnsure UTI therapy has been completed prior to surgery as per recommendations in the latest version of the Therapeutic Guidelines: Antibiotic, Prophylaxis: urological surgeryConsent completed reflecting the Consent to Treatment ProcedureCheck reason for admission Inpatient’s clinical record and length of stay as per Request for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge PlanningAlert: Patients on anticoagulation therapy require further medical investigation, advice and support and nursing observationAdmission Explain the process and purpose of the Patient Care and Accountability PlanPatient identification and allergy band are checked against clinical notes/ stickersDocument findings from Patient Care and Accountability Plan (PCAP) including Risk Assessments and management plans in clinical records, provide education and CHHS information booklet to patient and family regarding Patient’s Pressure Injury, fall and VTE Risks and management. Measure and fit patient with short leg TED stockingsAttend to height, weight and ward urinalysis and document in clinical records, Patient Care and Accountability Plan and Observation ChartObtain baseline observations, usual systolic BP and MEWS ScoreProvide patient with verbal and inform Pharmacist of patient’s admission and request Medication Reconciliation is completedEnsure that patient is informed and educated in relation to fasting guidelines as per guidelines or specific medical orders. Document care provided in clinical record. Inform Food Services via DIETPasCommence discharge planningEducate patient in deep breathing and coughing exercises, and leg exercisesCheck consent form completedBowel preparation if orderedPreoperative:Attend to all documentation including Pre-op ChecklistMeasure and fit knee length Anti-embolic stockings and ensure documentation on Medication ChartEnsure patient has early morning shower and dressed in theatre gownUsual medications are given at 0600Receiving the patient from PACU:Don PPE as requiredPatient identification and allergy band are checked against clinical notes/ stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct ProcedureCheck 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 reviewEnsure the oxygen is attached to wall oxygen outletConfirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)Ensure equipment has been plugged in and cords are positioned safely under bed or off the floorClarify the operative procedure performed. All actions to reflect Correct Patient, Correct Site, Correct ProcedureDiscussion of patient medical history and impacting co morbidities should occur whilst ensuring privacyThe PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of Handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:Review of post operative vital signs, including any interventions required for stabilisation Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on Fluid Balance Chart)Ensure that continuous bladder irrigation (CBI) and indwelling urethral catheter (IDC) are patent – only 0.9% Sodium Chloride 2000ml solution to be used as irrigant for CBIEnsure Bladder Irrigation Chart is maintained- balances to be recorded on FBCMaintain accurate fluid balance chart for input and output, ensuring CBI fluid included, and describe the type of output, for example, claret, rose or straw).IDC to be anchored with Statlock unless the surgeon specifically documents request for Statlock not to used as per Urinary Catheter Management ProcedureEnsure Indwelling Catheter is secured with appropriate device, e.g., StatlockEnsure traction is maintained on IDC to provide maximum pressure on the prostatic bed following surgery. This traction helps to control bleeding and decreases the 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 Ensure all output is documented on Fluid Balance Chart Medications administered and documented on medication chart reviewAny intravenous medications ordered and given (e.g. antibiotics, antihypertensive)Observe the Catheter site for ooze or blood loss. Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) including:Respiratory Rate (RR)Oxygen SaturationsTemperatureBlood Pressure (BP)Pulse (P)Level of Consciousness (LOC)Urine Output (UOP)All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. Continuous Bladder Irrigation etc). Ensure all of the above interventions are completed prior to PACU nurse leaving ward area and patient care is accepted. Complete Patient Care and Accountability Plan and action appropriately Record in the patient's clinical record all post-operative nursing care provided and the patients responseAdminister analgesia as per Medical Practitioner’s orders for pain and/ or spasmsAdminister IV antiemetic for nausea as per Medical Practitioner’s ordersOffer and attend to post-operative bed bath Dress in personal nightwear if desired Offer and attend to mouth care, replacing dentures if applicablePosition the patient in accordance to post operative instructionsEnsure 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 exercisesEnsure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side) Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the patient’s clinical record and escalate if required according to MEWS and MET criteriaRecord in the patient's clinical record all post-operative nursing care providedPost operative Day 1:Attend to general observations fourth hourlyReview by Medical OfficerMedical Officer will cease CBI depending on consistency and type of urine outputGeneral post-operative dietCease 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 (ensure patient has a functioning IV pole with tongue depressor taped to the pole for hanging the urinary bag)Continue deep breathing and coughing, and leg exercisesAttend to blood specimens – FBC and UEC’s as ordered by Medical OfficerEnsure anti embolic stockings are in situ, correctly measured and fitted with no creasesRequest Medical Officer to commence Discharge summary document in preparation for dischargePost operative Day 2:Continue 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 scansPatient to attend to self careComplete patient education prior to discharge and provide written instructions (Prostatectomy package)Ensure patient has received adequate education, and is self caring with leg bag should discharge occurs with IDC insituDischarge:Advise 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 Resident Medical Officer (RMO) to provide patient with Cystogram appointment details prior to dischargeDischarge 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 appointmentBack to Table of ContentsSection 10 – Bladder Irrigation10.1Continuous Bladder IrrigationContinuous Bladder Irrigation (CBI) 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 occursTo instil continuous bladder irrigation via a three-way IDC for the purpose of:Providing bladder washout to remove any residual urine and/or bladder sediment to ensure IDC patencyRemoving blood clots that may develop post bladder, kidney or prostate surgeryEnsuring debris removal from an infected or diseased bladderIntroducing medicated irrigation to soothe an irritated bladder so as to promote healing, and/ or to treat diseaseA medical officer must prescribe continuous bladder irrigation (CBI) and a silicone three way-indwelling catheter (22F or 24F) must be inserted prior to the commencement of continuous bladder irrigation (CBI)Equipment: Dressing TrolleySterile dish x twoPlain stickers to label consecutive irrigation bagsFoleys Statlock Device-Not for Dr Chan’s patientsJugs x two50ml Bladder Syringes x twoY-type CBI tubing (closed system where available)Three-way indwelling catheterGloves: two pairs x sterile, one box clean gloves500ml bottle of 0.9% Sodium Chloride (at room temperature)2000mls 0.9% Sodium Chloride irrigation fluid bags x four or five bags (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 requiredProcedure:Check patients clinical record for any medical ordersMaintain privacy and explain the procedure to the patientPlace patient supine and ensure comfort and dignityWhere Chemotherapy precautions are actioned, don non-permeable gown, and gloves. Please refer to Chemotherapy Care of the Adult Patient eviQ Clinical Procedure Don safety goggles or eye shield and gownPlace procedure under pad beneath patientPlace small procedure under pad across patients thighs to prevent fluid leaks whilst connecting the irrigation fluidCommence irrigation and maintain a steady flow rate Alert: Ensure that the irrigation is not running to fast or too slow. The irrigation rate is dependent on the urine colour/ opacity. Refer to medical orders for any contraindicationsHang irrigating fluid bags on portable IV pole, 60cms above the level of the bladderLabel and number each bag when commencingMaintain strict Bladder Irrigation Chart and Urine Output records. Prior to commencing next irrigation fluid bag, completely empty the current IV irrigation fluid bag into the urinary drainage bag so as to calculate and record the urine output. Empty the urinary drainage bag. Subtract two litre irrigation fluids from amount of fluid in the urinary drainage bag to calculate urine outputDo not rest urinary drainage bag on the floor at any timeRecord the number of irrigation bags used and urine output on the bladder irrigation chart and urine output on fluid balance chart at each bag change Ensure that the patient’s fluid input and urine output is measured and documented accuratelyAdjust the Patient Accountability and Care Plan to indicate Bladder Irrigation Monitor the patient with fourth hourly general observations by nursing staff whilst the indwelling catheter is insitu for signs of sepsisRegular and frequent Perineal toilets must attended whilst indwelling catheter is in situ- the frequency of which will be documented in the Patient Accountability and Care Plan In the event of a genitourinary tract infection, infection control will collate and present data for reporting purposesAlert: All patients with an Indwelling Catheter insitu are required to have a CHHS Insertion of Urinary Catheter in their clinical records (See Attachment B). If the input and output balance is negative notify the CNC/TL and medical officer to review the patient immediatelyEpirubicin Alert: Clinical Handovers must reflect that Chemotherapy has been administered and cytotoxic precautions will subsequently 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.10.2Manual Bladder IrrigationTo instil manual bladder irrigation via a three-way IDC for the purpose of:Removing blood clots or blockage that may develop to maintain patency of an IDCEquipment:Dressing TrolleySterile dish x twoJugs x two50ml Bladder Syringes x twoGloves: two pairs of sterile, one box clean gloves500ml bottle of 0.9% Sodium Chloride (at room temperature)Procedure under pads (small and large) e.g. KylieWhere Chemotherapy precautions are actioned, don appropriate PPE Safety glasses, goggles or shieldGeneral waste receptacleClinical waste receptacleProcedure:Maintain privacy and explain the procedure to the patientProvide adequate and appropriate analgesia Place patient supine and ensure comfortWhere Chemotherapy precautions are actioned, don appropriate PPEDon personal protective equipment (PPE) includes safety goggles or shield and gownPlace procedure under pad beneath patient Place small procedure under pad across patients thighs to prevent fluid leaks whilst connecting the irrigation fluidPrepare Sterile dish with approx 200mls 0.9% Sodium Chloride or open 500ml bottle of 0.9% Sodium ChlorideHave jug ready at the IDC siteOpen syringe Turn off irrigationDisconnect tubing from Statlock device if presentAttend hand hygiene by either washing or using ABHR and don sterile glovesUsing aseptic technique, detach the drainage bag from the IDC and attach syringe filled with 0.9% Sodium Chloride and flush into bladderApply suction to the IDC to clear clots from the IDCDisconnect syringe and fill with a further 40mls of 0.9% Sodium Chloride, reconnect to IDC and flush bladderContinue this procedure until return is clear and free of clots and/ or debrisWhere closed system is in use, do not disconnect indwelling catheter to manually irrigateClamp the tubing below the bulbFirmly squeeze the bulb to commence manual irrigationRepeat process until clear urine is flowing at a steady rate If no urine return after manually irrigating IDC, contact medical officerRepeat the above steps until urine is flowing at a steady rateReconnect the IDC to the drainage bag and reset the irrigation fluidSecure tubing with appropriately placed Statlock device (Attachment A) to prevent movement and urethral traction unless contraindicated (as per Dr Chan’s orders)Attend Perineal toilet-The patient will have regular and frequent Perineal toilets attended whilst indwelling catheter is in situ, the frequency of which will be documented in the Nursing Care Plan Discard equipmentWhere Chemotherapy precautions are actioned, dispose of urinary output directly into the Cytotoxic bin Leave the patient comfortable with call bell within reachDocument in patients clinical record: The patient's response to the procedureThe urine output on the Bladder Irrigation Chart & fluid balance chartThe amount, size and frequency of irrigated clotThe patient's indwelling catheter is patent with no complication during and following irrigationThe urinary drainage system is maintained as a sterile drainage systemThe patient's indwelling catheter is irrigated as prescribed by the medical officer according to the patient's clinical management needs with minimal discomfort and no complicationsIntake and output are balancedThe patient is to be monitored with fourth hourly general observations by nursing staff whilst the indwelling catheter is insitu for signs of sepsisThe patient is to be monitored for signs of suprapubic distension or discomfort indicating fluid retentionThe patient’s fluid input and urine output is measured and documented accuratelyAdjust the Patient Accountability and Care Plan to indicate Bladder Irrigation In the event of a genitourinary tract infection, infection control will collate and present data for reporting purposesBack to Table of ContentsSection 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy To provide guidelines for the pre and post operative management of patients undergoing a Nephrectomy, i.e., surgical removal of a kidneyAlerts:On transfer to ward, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities may be identified and managed as soon as possible. If the patient meets the MET criteria, activation of MET should occur.A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post transfer from ICU (Refer to ‘Adult Vital Signs and Early Warning Scores’).If respirations are twelve (12) or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record.Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.Determine if the patient is currently on medication and enquire if the patient has brought any medication to the hospital. If possible, family members must take all personal medications home after the sighting by the medical officer. If this is not possible, place the medications in a patient’s own medication green plastic bag, label and retain in the patient’s own medication cupboard until the patient is discharged- Patients Own Medication- Management ProcedureOn admission:Equipment:Alcohol based hand rub (ABHR)Patient clinical notes and observation chartsPersonal protective equipment (PPE) including safety goggles or shield and clean glovesStethoscopeWatch with a second handSphygmomanometer (blood pressure cuff)Oxygen saturation monitorThermometerIntravenous (IV) pole – mobileEmesis bagBedside emergency equipmentProcedure: Patient usually attends preadmission clinic (PAC) and is admitted the day before surgery or at times, on the day of surgery (DOSA). Investigations attended in the PAC are as followsBloods – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s, and serum ferreting assessment.ECG, CXR, as per hospital policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeleton. Micro urine (MSU)Consent completed reflecting the Consent to Treatment ProcedureCheck reason for admission Inpatient’s clinical record and length of stay as per Request for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge Planning.Obtain verbal consentExplain the process and purpose of the Patient Accountability and Care PlanPatient identification and allergy band are checked against clinical notes/ stickersDocument findings from patient Admission including Risk Assessments and management plans in clinical records, provide education and pamphlets to patient and familyAttend to height, weight and ward urinalysis and document in clinical records, care plan and Observation ChartObtain baseline observations, Usual systolic BP and MEWS ScoreProvide patient with verbal and CHHS information booklet regarding Patient’s Pressure Injury, Falls and VTE Risks and management. Document Inpatient Progress notes findings and actionsInform Pharmacist of patient’s admission and request Medication Reconciliation is completedDay before surgery, clear fluids until mid-night. Fast from midnight. Inform Food Services via DIETPasBowel preparation if orderedPreoperative:Attend to all documentation including Pre-op ChecklistMeasure and fit knee length Anti-embolic stockings and ensure documentation on Medication ChartEnsure patient has early morning shower and dressed in theatre gownUsual medications are given at 0600HrsBefore the patient is transferred from PACU/ICU to the ward:PACU/ICU Nursing staff to ensure:Receiving ward is aware of and has accepted patients admissionPatient oxygen delivery system has the patients identification label on itWard Nursing Staff to ensure:All emergency equipment is functioning and available, including oxygen and suctionReceiving patient from PACU/ICUEquipment:Don PPE as requiredPatient identification and allergy band are checked against clinical notes/stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct ProcedureCheck 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 reviewEnsure the oxygen is attached to wall oxygen outletConfirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)Ensure equipment has been plugged in and cords are positioned safely under bed or off the floorTransfer of care must reflect Clinical Handover ProcedureClarify the operative procedure performed. All actions to reflect Correct Patient, Correct Site, Correct ProcedureDiscussion of patient medical history and impacting co morbidities should occur whilst ensuring privacyThe PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:Review of post operative vital signs, including any interventions required for stabilisation Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on fluid balance chart)Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, etc (ensure hand hygiene is attended after contact with these devices) IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management ProcedureUrine output is to be recorded hourly for 48 hours postoperatively Check any drains insitu e.g. wound drains and output (ensure hand hygiene is attended after contact with these devices). Drainage bags to be changed and output documented on FBC and Inpatient progress notes daily at midnightCheck output of nasogastric tube for drainage or feeding. Ensure orders are clearly documented in the notes as to purpose, use and position of tube (ensure hand hygiene is attended when in contact with these devices)Ensure all output is documented on Fluid Balance Chart Medications administered and documented on medication chart reviewAny intravenous medications ordered and given (e.g. antibiotics, antihypertensive)Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if any), reinforce wound if required. Do not remove theatre dressingAny pain management devices including Patient Controlled Analgesia (PCA), Epidurals, Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc and single shot analgesia technique without pain management device i.e. single shot local anaesthetic block or intrathecal/epidural morphine single dose administration for post operative pain relief (refer to appropriate Pain Management Unit procedures) Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) 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)Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted Complete Patient Care and Accountability Plan and action appropriately Record in the patient's clinical record all post-operative nursing care provided and the patients responseOffer and attend to bed bath Dress in personal nightwear if desiredOffer and attend to mouth care, replacing dentures if applicablePosition the patient in accordance to post operative instructionsEnsure 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 exercisesEnsure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the Patient clinical record and escalate if required according to MEWS and MET criteriaRecord in the patient's clinical record all post-operative nursing care provided and the patients responseWard management:Ward Nursing Staff:Check patients clinical record for any medical ordersEnsure PrivacyExplain the process and purpose of the dressing changeObtain verbal consent for any interventionsGeneral/ Epidural/ Spinal Anaesthetic: Perform and document a Full set of Vital Signs and Modified Early Warning Score (MEWS): On return to ward, thenHalf hourly for two hours (30mins x two hours), if MEWS ≥ 4 continue half hourly (See ‘Adult Vital Signs and Early Warning Score SOP’) (excluding Day Surgery Unit) When MEWS <4, hourly for four (4) hours (60 mins x four hours), thenFourth hourly for a minimum of 48 hoursWhere an Epidural is in situ patient assessment is performed Following the guidelines of the Epidural (Adult and Paediatric ) Chart and Insert Documents and ProcedureThe Patient Accountability and Care Plan must be commenced within the postoperative periodRisk Assessments for Pressure Injury, Falls, VTE, Mobility/Manual Handling and Discharge must be completed, actioned and documented in the patient progress notes within the postoperative period as reflected in the Patient Accountability and Care Planning ProcedureWard Management Day 1:Check patient clinical records for medical ordersRemains NBM until reviewed by medical team, if dietary status changed, inform Food Services via DIETpas and update bed cardCommence diet and fluids as ordered (continue to monitor tolerance of diet)Maintain IV FluidsMaintain hourly urine output measuresDocument drain output and change drainage bag at midnightMaintain strict Fluid Balance ChartEnsure second hourly pressure area care and skin integrity checks are offered and performedMaintain fourth hourly vital signsMaintain observations as required with Epidural/ PCAAssist patient with sponge in bed Attend perineal/ penile careObserve the wound dressing for ooze or blood loss fourth hourlySit patient out of bedReapply TEDsNotify physiotherapistContinue discharge planning with Discharge Liaison Nurse (DLN) and allied health team as appropriateWard Management Day 2:Check patient clinical records for medical ordersMay progress to Free Fluids to Light Diet if passed flatus and approved by medical staffInform Food Services of changes via DIETpas and update Bed CardMaintain fourth hourly vital signsMaintain observations as required with Epidural/PCA- may be removed if tolerating fluids at the discretion of the APS. Motor Block observations maintained for 24 hours post removal of EpiduralAssist patient with showerAttend Perineal/ penile careObserve the wound for swelling, ooze and/ or redness fourth hourly. Dress as per medical ordersEncourage patient mobilisation with stand by assistanceContinue discharge planningDocument drain output and change drainage bag at midnightConsecutive post operative days continue as Day 2, drains will be shortened and/ or removed at the discretion of medical officer. Patient usually discharged on day six to eight depending on progressDischarge planning:Ensure Medical Officer (MO) has documented discharge Inpatient clinical recordEnsure discharge medications are scanned to pharmacyInform patient of usual discharge procedure, i.e., transfer to Discharge Lounge by 1000 on the day of dischargeCNC to refer to the Discharge Liaison Nurse for wound care and/or staple removal at daily MDT meetingBack to Table of ContentsSection 12 – Management of patients undergoing a Percutaneous Nephrolithotomy To provide guidelines for the pre and post operative management of patients undergoing a Nephrolithotomy, i.e., surgical removal of a kidney stones via a percutaneous tract using laparoscopic equipmentOn transfer to ward, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities may be identified and managed as soon as possible. If the patient meets the MET criteria, activation of MET should occur.A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post transfer from ICU (Refer to ‘Adult Vital Signs and Early Warning Scores’).If respirations are twelve or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record. Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.Nephrostomy drainage catheterDo 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).Flush the tube very slowly. Do not apply force as over distension of the renal pelvis could cause renal tissue damage. On admission:Equipment: Alcohol based hand rub (ABHR)Patient clinical notes and observation chartsPersonal protective equipment (PPE) including safety goggles or shield and clean glovesStethoscopeWatch with a second handSphygmomanometer (blood pressure cuff)Oxygen saturation monitorThermometerIntravenous (IV) pole – mobileEmesis bagBedside emergency equipmentProcedure: Patient usually attends preadmission clinic (PAC) and is admitted the on the day of surgery (DOSA). Investigations attended in the PAC are as followsBloods – UEC, FBC, COAG’s, X – MATCH (two to four units) ECG, CXR, KUB (kidneys, Ureters and Bladder-confirm position of calculi) X-ray as requiredAdditional bloods, CT, MRI as requiredMicro urine (MSU)Consent completed reflecting the Consent to Treatment ProcedureCheck reason for admission Inpatient’s clinical record and length of stay as per Request for Admission form to predict estimated date of discharge (EDD/PDD), i.e., commencement of Discharge Planning.Explain the process and purpose of the Patient Accountability and Care PlanPatient identification and allergy band are checked against clinical notes/ stickersDocument findings from patient Admission including Risk Assessments and management plans in clinical records, provide education and pamphlets to patient and familyAttend to height, weight and ward urinalysis and document in clinical records, care plan and Observation ChartObtain baseline observations, Usual systolic BP and MEWS ScoreProvide patient with verbal and CHHS information booklet regarding Patient’s Pressure Injury, Falls and VTE Risks and management. Document Inpatient Progress notes findings and actionsInform Pharmacist of patient’s admission and request Medication Reconciliation is completedDay before surgery, Nil by Mouth from Midnight or as per Urologist’s ordersPreoperative:Attend to all documentation including Pre-op ChecklistMeasure and fit knee length Anti-embolic stockings and ensure documentation on Medication ChartEnsure patient has early morning shower and dressed in theatre gownUsual medications are given at 0600Before the patient is transferred from PACU to the ward:PACU Nursing staff to ensure:Receiving ward is aware of and has accepted patients admissionPatient oxygen delivery system has the patients identification label on itWard Nursing Staff to ensure:Patient bed area has been cleanedAll emergency equipment is functioning and available, including oxygen and suctionReceiving patient from PACU:Don PPE as requiredPatient identification and allergy band are checked against clinical notes/stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Patient Identification and Procedure Matching Policy and ProcedureCheck 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 reviewEnsure the oxygen is attached to wall oxygen outletConfirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)Ensure equipment has been plugged in and cords are positioned safely under bed or off the floorTransfer of care must reflect Clinical Handover ProcedureClarify the operative procedure performed. All actions to reflect Procedure Matching Policy and Procedure Discussion of patient medical history and impacting co morbidities should occur whilst ensuring privacyThe PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of Handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:Review of post operative vital signs, including any interventions required for stabilisation Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on fluid balance chart)Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, Nephrostomy tubes etc (ensure hand hygiene is attended after contact with these devices) IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management ProcedureMaintain Nephrostomy tube patency as per Drain Management ProcedureNephrostomy to be anchored with Statlock deviceUrine output is to be recorded hourly for 48 hours postoperatively Check flank for swelling, bruising or ooze and ensure adequate pain relief Check any drains insitu e.g. wound drains and output (ensure hand hygiene is attended after contact with these devices). Drainage bags to be changed and output documented on FBC and Inpatient progress notes daily at midnightCheck output of nasogastric tube for drainage or feeding. Ensure orders are clearly documented in the notes as to purpose, use and position of tube Ensure all output is documented on Fluid Balance Chart Medications administered and documented on medication chart reviewAny intravenous medications ordered and given (e.g. antibiotics, antihypertensive)Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if any), reinforce wound if required. Do not remove theatre dressingPain management devices such as Patient Controlled Analgesia (PCA), to be managed as per appropriate PCA procedures 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)Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted Complete Patient Care and Accountability Plan and action appropriately Record in the patient's clinical record all post-operative nursing care provided and the patients responseOffer and attend to bed bath Dress in personal nightwear if desired Offer and attend to mouth care, replacing dentures if applicablePosition the patient in accordance to post operative instructionsEnsure 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 exercisesEnsure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the patient clinical record and escalate if required according to MEWS and MET criteriaRecord in the patient's clinical record all post-operative nursing care provided and the patients responseWard Nursing Staff:Check patients clinical record for any medical ordersExplain the process and purpose of the dressing changeObtain verbal consent for any interventionsGeneral/Epidural/Spinal AnaestheticPerform and document a Full set of Vital Signs and Modified Early Warning Score (MEWS): On return to ward, thenHalf hourly for two hours (30mins x two hours), if MEWS ≥4 continue half hourly (Refer to Vital Signs and Early Warning Score Procedure)When MEWS <4, hourly for four hours (60 mins x four hours), thenFourth hourly for a minimum of 48 hoursThe Patient Accountability and Care Plan must be commenced within the postoperative periodRisk Assessments for Pressure Injury, Falls, VTE, Mobility/Manual Handling and Discharge must be completed, actioned and documented in the patient progress notes within the postoperative period as reflected in the Patient Accountability and Care Planning ProcedureWard Management Day 1:Check patient clinical records for medical ordersUpdate diet when reviewed by medical team, if dietary status changed, inform Food Services via DIETpas and update Bed cardMonitor tolerance of dietMaintain IV FluidsMaintain hourly urine output measuresDocument drain output and change drainage bag at midnightMaintain strict Fluid Balance ChartEnsure second hourly pressure area care and skin integrity checks are offered and performedMaintain fourth hourly vital signsMaintain observations as required with PCAAssist patient with showerAttend perineal/ penile careObserve the wound dressing for ooze or blood loss fourth hourlySit patient out of bedReapply TEDsNotify physiotherapistContinue discharge planning with Discharge Liaison Nurse (DLN) and allied health team as appropriateWard Management Day 2:Check patient clinical records for medical ordersMonitor tolerance to diet and progression to full dietInform Food Services of changes via DIETpas and update Bed CardMaintain fourth hourly vital signsMaintain observations as required with PCA- may be removed if tolerating fluids at the discretion of the APS. Assist patient with showerAttend Perineal/ penile careObserve the wound for swelling, ooze and/ or redness fourth hourly. Dress as per medical orders and as per Drain Management ProcedureEncourage patient mobilisation with stand by assistanceContinue discharge planningDocument drain output-amount, consistency, colour, odour etcChange drainage bag at midnightMedical 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 painContact the Medical Officer if either occurConsecutive post operative days continue as Day 2, drains will be removed at the discretion of medical officerDischarge planning:Ensure MO has documented discharge Inpatient clinical recordEnsure discharge medications are scanned to pharmacyInform patient of usual discharge procedure, i.e. transfer to Discharge Lounge by 1000 on the day of dischargeCNC to refer to the Discharge Liaison Nurse for wound care of Nephrostomy tube site care post removal of Nephrostomy tube at daily MDT meetingFollow-up appointment is usually four to six weeks in the Outpatient Urology Clinic or in the VMO’s private rooms, please clarify this before patient is dischargedEducate 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 dayBack to Table of Contents Section 13 – Management of patients admitted with Pre-Existing Continent Urinary Reservoirs/Neobladder during routine hospital admissionsPurposeTo provide information on the clinical management of patients who are admitted into Canberra Hospital with a pre existing Continent Urinary Reservoir / Neobladder, to ensure care is consistent for each individual patient.A Continent Urinary Reservoir, also known as a Neobladder, is a procedure in which a false bladder has been developed from a section of the patients’ bowel. The bladder 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.Procedures: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 the treatment plan of the individual reservoirInform the Stomal Therapist of the patients admissionSenior 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 ContentsImplementation All staff working in the Urology ward to read and sign Procedure Register. CNC and CDN to monitor Register to ensure all staff are aware of appropriate care for patients undergoing Urology procedures every 12 months.Staff will be told where to access this Procedure as part of their Ward OrientationBack to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPolicies and ProceduresPerineal/ Penile Care SOPHealthcare Associated Infections Procedure Health Waste Management PolicyHealth Nursing and Midwifery Continuing Competence PolicyPatient Identification-Surgical Safety Checklist SOPPatient Identification and Procedure Matching procedureHealth Consent and Treatment Policy Health Consent and Treatment ProcedureWound Management ProcedurePost-operative Handover and Observations-Adult Patients (first 24 hours) SOPEpirubicin Chemotherapy use in Urological Surgery SOPChemotherapy Care of the Adult Patient eviQLegislationHealth Practitioner Regulation National Law (ACT) Act 2010Health Records (Privacy and Access) Act 1997Health Regulation (Maternal Health Information) Act 1998 Human Rights Act 2004Privacy Act 1988Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Powers of Attorney Act 2006 Back 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 ContentsReferences The 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 percutaneousnephrostomy 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 ContentsAttachmentsAttachment A: Stat Lock – Foley Stabilisation DeviceAttachment B: Insertion of Urinary Catheter StickerAttachment C: How to care for your Urinary CatheterAttachment D: Troubleshooting guide for urinary cathetersAttachment E: Source of information and/ or suppliers for urinary catheter equipmentAttachment F: Catheter selectionDisclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> 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 Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC ChairAttachment A: Stat Lock – Foley Stabilisation DeviceAttachment B: Insertion of Urinary Catheter StickerSticker available on order through Corporate ExpressID 18838521ACT Hth Ins of Urinary Cath Lbls Roll 500 Attachment C: How to care for your Urinary Catheter Attachment D: 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 balloon Men IDC: 14- 16Fg /10ml balloon SPC: 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 SPC Spasm 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.TROUBLESHOOTING 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 balloon Men IDC: 14- 16Fg /10ml balloon SPC: 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. Determine the blocking agent and consult with Medical Officer re indications for antibiotic therapy or a urological review.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 SPC Spasm 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.Attachment E: 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 F: 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 clients ................
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