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Guidelines for the Urinary Catheterisation of Male and Female Patients in Primary care Prepared by: Responsible Area: Approval Information:

Lead Director:

Reference to Standards for Better Health Domain

ZOË GREENWOOD, CONTINENCE NURSE ADVISOR JOANNE WHITELEY, CONTINENCE SERVICE MANAGER Patient Care & Professionals Date Approved: COMMITTEE:-

17th October 2007 PEC

Sheila Dilks Version No approved:

Two

Review Date:

February 2009

Department of Health 2004 Standards for Better Health First domain Safety Fourth domain Patient focused Core Standard C4 C13b C14 Development standards D1 D9 D10

Core/Development standard Performance indicators

1.number of incident forms involving catheters Version 1 – Superseded 2006

History of Document


CONTENTS Section No.

Page No’s

1.

History of Document

4

2.

Introduction

4

3.

Associated Policies and Procedures

4

4. 5. 6. 7. 8. 9.

Aims & Objectives Key Principles Indwelling Urethral Catheters Indications For Catheterisation Types of Catheter Principles of Catheterisation

5 5 6 7 7 9

10.

Who Should Catheterise

9

11.

Training and Education

10

12. 13.

Catheter Management Types of Drainage System

10 11

14. 15. 16. 17.

Catheter Changes Supra-pubic Catheters Supra-pubic Catheter Management Trouble Shooting

13 13 14 15

18. 19. 20. 21.

Removal of an indwelling catheter Catheter maintenance solutions Intermittent Catheterisation Reasons for Intermittent Catheterisation

16 17 19 19

22. 23. 24. 25.

Urinary Tract Infections Children and Young People Catheter Management Outcomes Audit

21 21 22 23

26. 27.

References & Bibliography Appendices: 1 Catheterisation documentation 2 Competencies for catheterisation 3 Catheter audit tool 4 Mid Yorks guidance on silver alloy 5 Mid Yorks record sheet

23 27 35 38 41 43

NICE Guidance Once NICE guidance is published, health professionals are expected to take it fully into account when exercising their clinical judgement. However, NICE Guidance does not override the individual responsibility of health professionals to make appropriate decisions according to the circumstances of the individual patient in consultation with the patient and/or their guardian or carer.

2


Document Compiled By: ZoĂŤ Greenwood Continence Nurse Advisor Kirklees Primary Care Trust Ann E Hill, Continence Nurse Specialist, Eastern Wakefield Primary Care Trust Linda Pickersgill, Clinical Nurse Specialist, Mid Yorkshire Hospitals NHS Trust Keeley Pickering, Continence Nurse Specialist, Eastern Wakefield Primary Care Trust Jane Spencer, Continence Nurse Specialist, Eastern Wakefield Primary Care Trust Sharon Stoner, Eastern Wakefield Primary Care Trust Joanne Whiteley, Continence Service Manager, Kirklees Primary Care Trust

Reviewed by : Joanne Whiteley, Continence Service Manager, Kirklees Primary care Trust

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1 History of Document Version 1 – superseded 2006

2 Introduction These guidelines have been developed to provide Health Care Professionals. in the primary care setting with an evidence based framework on which to base clinical decisions about the catheterisation of clients. Where evidence of practice has been unavailable, consensus of expert opinion has been drawn upon. They are designed to be used for the process of catheterisation and the care of the client regardless of whether the catheterisation is short term, intermittent, or long term. Primarily aimed at nursing staff; however, it is recognised that other health care professionals who are involved in urinary catheterisation would benefit from accessing them

3 Associated Polices and Procedures For further guidance refer to The Marsden Manual sixth edition Chapter sixteen pages 330-347 •

The guidelines support the National Service Framework (NSF) for older people (DoH 2001a)

Kirklees PCT, Trial without Catheter Policy 2007 (awaiting ratification)

The guidance has incorporated the recommendations of the epic project (Pratt et al 2001) for developing national evidence-based guidelines for preventing healthcare associated infections.

Records Management policy (Kirklees PCT)

Consent policy (Kirklees PCT)

Infection Control policy (Kirklees PCT)

Urinary Incontinence The management of urinary incontinence in women (NICE 2006)

Reference guide to consent for examination or treatment (DoH 2003)

Epic Two Guidelines – National Evidence Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England (updated 2007)

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4 Aims and Objectives 4.1 Aim To improve the quality of care, by providing, a clear evidence base where evidence is available. To provide a uniform process for all clients who undergo urinary catheterisation thus reducing the risk of adverse events 4.2 Objectives • Support the education of pre registration health care professionals • Support the education of post registration health care professionals • Contribute to Professional and Clinical Development of the health care professionals involved in urinary catheterisation. • Support professionals in achieving and maintaining clinical competence.

5 Key Principles •

The client must be fully informed and give verbal consent, where able, prior to the procedure. (DoH 2003)

The first catheterisation normally requires medical consent from Consultant, GP or Continence Specialist Nurse. All information should be clearly documented in the patient’s notes stating the date, time and name of the health professional who has gained consent.

Urinary catheterisation should only be performed after alternative methods of management have been considered.

Only Healthcare Professionals who can demonstrate they have achieved key competencies should be allowed to practice urinary catheterisation.

Promoting optimum client comfort during urinary catheterisation is fundamental. A client’s privacy and dignity should be respected at all times.

The product selected must be appropriate to the clients needs; it is recommended that where appropriate the client is involved in product selection.

Select the smallest gauge urethral catheter that allows urinary flow (see specific advice for supra-pubic catheters section 15).

It is recommended that clients/carers are given the appropriate level of information, written and verbal to allow them to continue to care for the urinary catheter safely, thus reducing risk of infection and preventing hospital admission.

Reducing the infection risk is paramount, this is achieved by: o Maintaining a sterile closed urinary drainage system. o Ensuring that the connection is not broken without good clinical indication. 5


o Decontaminating hands and wearing appropriate protection i.e. apron and gloves before manipulating a client’s catheter. o Not changing catheters or urinary drainage bags unnecessarily. o Positioning urinary drainage bags below bladder level, ensuring it does not come in contact with the floor, with the exception of the ‘Belly Bag’, a specialist drainage bag. o Health professionals adhering to aseptic technique when performing the procedure of catheterisation. •

Catheterisation and catheter care is a key component of nursing care. Advice from specialised professionals, usually the Continence Specialist Nurse, should be sought when further guidance is required.

Discharge of clients with catheters from hospital to community: It is recommended that clear documentation is instigated so as to improve communication between primary and secondary care. Appropriate equipment should be provided to allow continuation of care when a client is transferred from or to secondary care (Appendix 1)

6 Indwelling urethral Catheters Choosing the right catheter system for each client will be influenced by the results of a comprehensive individual assessment that should include the anticipated duration of the catheter, any history of latex allergy and the client’s preference (Pellowe 2004) 6.1 POINTS TO CONSIDER •

General Health – will catheterisation enhance, or cause detriment to, the client’s quality of life?

Bladder capacity – identify whether the client has an unstable bladder which could lead to the catheter being expelled or complications such as bypassing – consider the previous use of anti-cholinergics i.e. Oxybutynin, Tolterodine etc. Bowel management – assess to exclude constipation, as this could put pressure on the lumen of the catheter, thereby affecting drainage and may cause the catheter to bypass or be expelled.

Dexterity – Has the client got the ability to manage the catheter independently or would additional carer involvement be required?

Comprehension – has the client got the cognitive ability to manage the catheter? Is this an acceptable form of management for the client? e.g. consider whether the client will remove the catheter due to lack of understanding, as to why the catheter is in situ.

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Sexual activity – consideration should be given to the client’s sexual needs. It is necessary to inform the client/partner how sexual activity can continue with an indwelling catheter in situ. (Getliffe & Dolman 2005)

Acute or Chronic Retention – discuss necessity for hospital admission with GP and suitability for catheterisation. Urological opinion may be necessary.

7 Indications for Catheterisation

• • • • • • • • •

To relieve acute or chronic retention of urine To preserve bladder and renal function. Long term management of residual urine where intermittent catheterisation is not appropriate or possible. To irrigate the bladder. For the instillation of drugs. Pre and post operatively Wound management – short term use To obtain an accurate record of urinary output. To manage intractable incontinence where all other methods have failed and client has received all relevant information to make an informed choice

Selection of the catheter type and system following comprehensive assessment will include the anticipated duration of the catheter, any history of latex allergy and the client’s preference. (Pellowel 2004) Consideration to be given to material; size, length, and balloon fill volume of catheter. Make, type, length, ch/fg size and balloon type should be specified on the prescription. If the original reason for Catheterisation resolves – remove the catheter. (See trial without catheter).

8 Types of catheters These determine length of time a catheter can remain in situ. However, it is the product liability stated by manufacturer that should be followed. Some companies have different warranties dependent on where the catheter is used e.g. urethrally or supra-pubic. Nice guidelines state: - For urethral and supra-pubic catheters, the choice of catheter material and gauge will depend on an assessment of the patient’s individual characteristics and predisposition to blockage (NICE 2003)

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8.1 Catheter materials o

Plastic/PVC – used for residual urine and bladder irrigation, the catheter is quite rigid and may be uncomfortable it may be left in situ for up to seven days.

o

PTFE (Polytetrafluroethylene) bonded latex catheter, used for up to twenty- eight days, smoother than plain latex, therefore more resistant to encrustation.

o

Silicone elastomer coated latex combines the advantages of silicone and latex and has a bonded surface. It is smooth and therefore less likely to lead to encrustation and may be left in situ for up to twelve weeks.

o

Hydrogel coated latex – more compatible with human tissue, comfortable and easier to insert, it is also more resistant to encrustation and bacterial colonisation, and may be left in situ for up to twelve weeks. All silicone catheters – more rigid, have a larger internal lumen and therefore minimises encrustation and tissue irritation. (Ryan-Wooley 1987) These catheters are essential for use with clients who have a latex allergy and can be left in situ for up to twelve weeks.

o

Silver Alloy coating and bard hydrogel (should not be left longer than 28 days). Inhibits bacterial growth. Reduces incidence of urinary tract infections within acute care settings (Saint 1999). Anti bacterial properties are demonstrated for up to 28 days. (Bard 2005). See Appendix 4.

o

8. 2 Expiry Date Take note of the expiry date on the catheter to be used; will it cover the length of time the catheter is to be in situ? 8.3 Sizes The external diameter of a catheter is measured in charriere (Ch) – one ch equals ⅓ mm, therefore 12Ch equals 4 mm. The smallest size should be chosen to provide adequate drainage. Larger sizes can cause irritation and bypassing of urine around the catheter. The larger sizes are usually reserved for clot drainage (post operatively) and stricture dilatation. In any other situation their use should be questioned. The range of sizes that are acceptable to use are: • • •

Paediatric – 6 – 10 ch Female – 10 – 14 ch Male – 12 – 16 ch

Dependent on why the catheter needs to be in situ the following guide maybe useful: • 10 – 14 ch for clear urine. • 16 – 18 ch for persistently significantly cloudy urine with debris present. • 18ch+ for haematuria, clots and irrigation – under the supervision of a Consultant Urologist

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8.4 Length Available in paediatric, female, and standard lengths (for male and supra-pubic use). A female length should always be used in women; however consideration should be given to client’s lifestyle, ie, wheelchair user, as standard can be used for male and female. 8.5 Balloon Size • Routine 10 ml • Post-prostatic surgery (to aid haemastasis) 30 ml not to be used in community • Paediatric 3 – 5 ml Catheter balloons should be filled as specified by the manufacturer. They should never be over or under filled as this can lead to a mis-shaping of the balloon that could interfere with urine drainage. The balloon is not designed to occlude the internal urethral meatus to prevent leakage – this is prevented by the bladder neck and sphincters gripping the catheter lumen – but merely to gently retain the catheter in the bladder to prevent it from falling out. Few catheters need more than 10 ml of fluid for this purpose. 30 ml balloons should only be used in specific circumstances such as post prostatic surgery, but their use should always be questioned. The heavier weight and larger balloon may cause bladder spasm and irritation of the trigone. The balloon should always be filled with sterile water, never: • • •

air, as the balloon would float above the urine, preventing drainage tap water as it contains soluble salts that may precipitate out of the solution and block the inflation channel. saline as crystals of salt may form in the inflation channel preventing deflation of the balloon at a later stage. (Getliffe & Dolman 2005)

9 Principle of Catheterisation All catheterisations performed by a health care professional should be aseptic procedures, although it is not necessary to use aseptic preparations to clean the urethral meatus prior to catheter insertion. The use of a sterile single use lubricant or anaesthetic gel will minimise trauma and discomfort. (DeCourcy–Ireland 1993). It is therefore essential that anaesthetic gel is used. Instillagel is recommended; it is essential that 6mls is used for females and 11mls for males.

10 Who should catheterise? Any Registered Nurse who deems themselves competent and confident to undertake the procedure. Consideration should be given to their professional accountability and code of practice. Acquisition of competence will be by observation and supervision within the clinical setting. 9


Male/female urethral and supra-pubic catheterisation can be undertaken by any Registered Nurse who deems themselves competent and confident to undertake the procedure following the relevant training. Where appropriate a carer or relative may undertake re-catheterisation. The Registered Nurse responsible for the client ensures knowledge and competence of carer/ relatives. This should involve observation of procedure. Written management guidelines will also be provided to ensure that a carer undertakes the procedure in line with PCT policy.

11 Training and Education Many Health Professionals are employed in positions where urinary catheterisation management is part of their role. To ensure high quality care for the patients undergoing urinary catheterisation it is imperative that all staff undertaking this procedure are educated to the same level to protect the interests of the patients. The Registered Practitioner is accountable for the patient care provided. It is the responsibility of the Health Professional to ensure they have current knowledge and skills to allow them to practice the role expected of them (NMC 2004). Catheterisation training to be provided by Continence Team in conjunction with team leaders/caseload managers. Responsibility: The Team Leaders are to ensure the key competencies are obtained. It is recommended that Health Professionals attend updates every two years.

12 Catheter Management When in situ, how a catheter is managed will have an effect on the health and wellbeing of the client. However, every client with a long term indwelling catheter (urethral/supra-pubic) will develop bacterium, but this is usually asymptomatic Symptomatic infection can easily occur but the risks can be minimised by: • Limiting the use of catheters – changing only when clinically indicated or required by Manufacturers’ guidelines. • Maintaining a closed drainage system. • Hand washing and use of gloves to reduce risk of cross infection. (NICE 2003). • The meatus should be washed daily with soap and water. (NICE 2003) If a client does become ill the infection will have to be treated. Symptoms may include fever, rigors, loin pain, significant haematuria, and, in the elderly, the onset of sudden unexplained confusion. The catheter may have to be removed or changed for treatment to be successful – the length of time the catheter is out may vary, consider the reason for catheterisation i.e. retention and presenting symptoms Antibiotics will not kill microorganisms in the bio-film. 12.1 Obtaining urine sample from a urinary catheter: Urine samples must be obtained from a sampling port using an aseptic technique (N.I.C.E. 2003). 10


The risk of infection when taking a urine sample can be minimised by choosing a drainage system with a self-sealing sample port (Godfrey and Evans 2001). 12.2 Fluid intake: It is recommended that the client be encouraged to drink 1.5 – 2 litres of fluid per day this maintains the flow of urine through the bladder and helps prevent constipation. Medical reasons or current physiological conditions may lead to a restriction of fluids. 12.3 Cranberry juice: Often recommended for the prevention and treatment of urinary tract infections as it may prevent the adherence of bacteria to the bladder wall. However, there is no evidence regarding dosage (Averon 1994). It has been suggested that 300 ml daily may be beneficial. Cranberry juice should be avoided by clients taking Warfarin due to possibility of interaction (Suvarna et al, 2003).

13 Types of Drainage System The choice of drainage equipment is particularly important for the promotion of client independence and self-care, and it is a nursing responsibility to match choice with the individual client (Getliffe & Dolman 2005). A wide range of products are available and wherever possible clients should have the opportunity to trial different systems. 13.1 Catheter valves – consideration should be given to the use of catheter valve in preference to a catheter bag. This is viewed as good practice as it assists in maintaining bladder tone. The individual requiring the valve will need to meet the following criteria (Addison 1999) - have appropriate: • Manual dexterity • Mental awareness • Bladder sensation The benefits to the client of using a valve are: • Maintains bladder tone • Greater independence • More discreet • More natural voiding process • Minimises bladder trauma (less weight) • Bladder capacity • Creates a flushing effect Problems that the client may experience: • Bypassing – consider use of anti-cholinergics • Urgency – unstable bladder • Frequent emptying – may indicate small capacity bladder 11


13.2 Catheter bags – Should be positioned below the level of the bladder with the exception of the Belly Bag by Rusch (which is worn on the abdomen). Suction can be created if the bag is positioned too low, causing damage to the bladder mucosa. 13.3 Bag emptying – It is important that the client should be instructed and encouraged to empty their own bag when possible, in order to maintain their dignity and independence. If the client is unable to empty their own drainage bag, single use powder free gloves, an apron followed by strict hand washing (Gibbs1986) should be worn by the nurse or carer to prevent cross infection. Ensure the drainage tap is off the floor at all times. Bags should be emptied when they are approximately three quarters full to avoid accidental trauma due to the weight of the bag. Consider the use of a sleeve to assist management. 13.4 Changing the bag The bag should be changed in accordance with manufacturer’s recommendations and Department of Health Guidelines i.e. 5 – 7 days or earlier if the bag is damaged (Drugs Tariff, Oct 2004), the Rusch belly bag 28 days. However, frequent changes will break the closed drainage system, presenting an increased risk of infection. It has to be noted that most products are single use only therefore if the closed drainage system is broken at any time the products used should not be reconnected in any circumstances. It is important that the bag is emptied appropriately to avoid it becoming too heavy, and it is adequately supported so it cannot pull on the catheter and cause urethral trauma. 13.5 Principles to consider: •

Clients should be encouraged to have a catheter valve if they meet the appropriate criteria (stated in 13.1)

Consider the use of a 500 ml leg bag if the bladder capacity is known to be small or the client is cognitively impaired.

Clients, who require some assistance with Activities of Daily Living, should be encouraged to use a catheter valve where possible.

Clients who are managed in bed could have a two-litre drainage bag attached directly to the catheter and this must be well supported on a catheter stand.

Liaison with the Continence Service should take place if further guidance is needed. 13.6 Link Systems Clients who require a higher capacity drainage bag overnight should not disconnect the leg bag from the catheter, but attach the two litre non-drainable bag to the catheter valve or the leg bag. It is recommended that a catheter stand or hanger be used.

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14 Catheter Changes Should always be planned following an assessment of client’s history, circumstances and need. All changes should be clearly documented in the client’s notes. (Appendix 1). Frequent catheter changes may increase trauma and infection. It should be recognised that some clients have problems with their catheter blocking. It is advisable to monitor these clients, to establish a pattern, to allow proactive management to take place. •

‘Blockers’ – defined as those clients who consistently and repeatedly develop extensive encrustation of their urinary catheters within a few days to a few weeks, resulting in shorter catheter life because of diminished flow and leakage.

‘Non-blockers’ – defined as those clients who do not form encrustations when the catheter is left in place for weeks to months (Kunin et al 1987).

A problem that occurs during re-catheterisation should be documented and appropriate advice sought from a GP/Urologist/Continence Specialist Nurse.

even

15 Supra-pubic Catheters A urinary catheter that is inserted, through an artificial tract in the abdominal wall, just above the pubic bone, and into the dome of the bladder. The initial insertion of a suprapubic catheter is performed by a Doctor under local anaesthetic, in a hospital setting, as an aseptic technique. 15.1 Advantages: • • • • •

Does not interfere with clients’ sexual activities Reducing the risk of urethral trauma Reducing the risk of necrosis to the bladder neck and urethra Reducing catheter induced urethritis Reduced urinary infection rates in comparison to urethral catheters

15.2 Supra-pubic catheterisation is suitable for the following clients: • • • • • • •

Chronic retention with renal impairment Unable/unwilling to perform intermittent self catheterisation (I.S.C.) Persistent expulsion of urethral catheter Client comfort and sexual expression Anatomically difficult to catheterise urethrally Greater comfort for clients who are chair bound Intractable incontinence

13


15.3 Supra-pubic catheterisation is contra indicated for clients who have: • • • • •

A history of a bladder tumour Blood clotting disorders Ascites Severe obesity Suspicion of ovarian cyst

15.4 Types of supra-pubic catheter A long term catheter that is licensed for use (see manufacturer’s guidelines). A Hydrogel catheter should be used in preference to an all silicone catheter however for clients with a latex allergy an all silicone catheter must be used. Sizes Generally size 14ch to 18ch for adult management but consideration should be given to smaller sizes for children. Length The length used is mostly dependant on client preference, standard length is the most usual, but a female length is acceptable providing the person using the catheter has sufficient length to connect to a bag or valve.(Addison & Mould, 2000) Consider: • Obesity • Mobility • Clothing A 10 ml balloon should be used at all times.

16 Supra-pubic Catheter Management The entry site should be checked by the client/carer on a daily basis and cleansed with mild soap and water, this may require more frequent cleansing if there is any leakage/discharge. In some clients there may be over-granulation of the insertion site, this can be improved by altering the direction of the lay of the catheter and treating the over-granulation with Allevyn foam dressing, well secured It is the pressure that reduces the over-granulation. Management is otherwise the same as for urethral catheters. 16.1 Changing the catheter Any Registered Nurse competent in undertaking the procedure may change a supra-pubic catheter whether it is the first change or not – as the abdominal channel becomes established at about four weeks. Relevant training should have been attended.

14


After four weeks there is no rationale for the first change to be done in the hospital setting, this change can be done in the clients own home or clinic setting. A newly inserted catheter is usually changed at 4 – 6 weeks and then at intervals between 4-10 weeks, or as recommended by manufactures (Getliffe & Dolman 2003). This guidance is for scheduled changes only, not for catheters that have become blocked or have been inadvertently removed. If this occurs before four weeks, please refer to urology consultant for advice or the urology ward from which the patient has been discharged. If a problem occurs during re-catheterisation, liaise with the General Practitioner or Continence Specialist Nurse re: future management. 16.2 Points to remember • Obtain clients consent • It is useful to observe how much of the catheter was in the abdominal cavity upon removal, to use as a guide for re-insertion. • A small amount of blood may be apparent at supra-pubic catheter changes this should stop within 24 hours.

17 Troubleshooting Urethral/Supra-pubic Catheterisation 17.1 Encrustation – recurrent catheter blockage caused by encrustation affects around 50% of long term catheterised clients. It can be distressing to clients and carers and costly to Health Services, in terms of time and resources. A pattern of catheter life can be identified for many clients and changes can be planned accordingly; in some circumstances this may be as frequent as a weekly change, - use the catheter management record to obtain this information. Catheter encrustation is caused by magnesium ammonium phosphate and calcium phosphate (struvite) which precipitate from the urine in alkaline conditions. If indicated, the use of a catheter maintenance solution could be considered. This may not be a suitable form of management for all clients. 17.2 By-passing • Check that the drainage tube is not kinked • Check that the client is not constipated • Check fluid intake is adequate • Check for systemic symptoms of infection • Consider anti-cholinergic medication • Review and if necessary change the catheter, checking for encrustation and blockage • Replace the catheter with a smaller charriere size, with appropriate 10 ml balloon as larger sizes can cause by-passing

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17.3 Expulsion of catheter If the catheter is frequently expelled, consider whether it is the most appropriate form of management for the client. 17.4 Haematuria Trauma or infection may produce small amounts of blood loss seen in urine; if severe seek medical help urgently. 17.5 Cramping pain Common when catheter is first inserted; pain should subside within 24 hours, if this persists there may be bladder spasm and anti-cholinergic medication should be considered. 17.6 Urethral bypassing This usually occurs when the urethral and closing pressure is less than any bladder contraction (spasm). In female clients this may be resolved by surgical occlusion of the urethra (Addison & Mould 2000).

18 Removal of Indwelling Catheter (IDC) Removal of an indwelling catheter needs to be done with caution, ensuring the balloon is fully deflated to prevent trauma. Antibiotic prophylaxis when changing catheters should only be used for patients with a history of catheter associated urinary tract infection following catheter change, or for patients who have a heart valve lesion, septal defect, patent ductus prosthetic valve. Following removal of an IDC by a Healthcare professional trained in the procedure, it is important to document the time of the first void, the volume and colour of urine passed, and if pain was experienced on micturition. 18.1 Time of removal There is limited research about the optimum time of IDC removal in the community setting. In hospital, generally they are removed following instruction from the medical staff and the times vary from one speciality to the other. Recent evidence (Kelleher 2002) suggests that removal of an IDC at midnight: • • •

Reduces anxiety about need to void, invariably the patient continues to sleep. The bladder is more compliant when filling slowly overnight and allows for larger first void. There is an earlier resumption of normal voiding patterns

The removal of an IDC at midnight is also supported by Noble et al (1990), Chillington (1992), Crowe et al (1993) and Downey et al (1997).

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18.2 Removal of all silicone catheters Due to ‘cuff’ formation on deflation of the balloon, this may cause pain, trauma and bleeding on removal. To reduce “cuff” formation leaving the syringe attached to the inflation port for a few minutes may allow the water to drain spontaneously. All silicone catheters seem to ‘stick’ within the tract requiring more traction to remove them. A hydrogel-coated catheter may be preferable where there is no identified latex allergy. 18.3 Client Information Leaflets Information leaflets are available from the PCT regarding urinary catheters and drainage systems,that assist patients with their own catheter care and management.

Leaflets can be accessed via: The Continence Service, Eddercliffe Centre, 01924 351568, or Huddersfield, 01484 347764

19 Catheter Maintenance Solutions Use of catheter maintenance solutions continues to be a subject for discussion. Regular use of catheter maintenance solutions can have a detrimental effect on the bladder urothelium. It has been shown to increase shedding of urothelial cells with no significant reduction in crystal formation or encrustation (Kennedy et al 1992). Use of a catheter maintenance solution is to bathe the lumen of the catheter not irrigate the bladder. Their use is a matter for professional assessment of the needs of the individual client. If the client is newly catheterised, it is wise to monitor how long the first catheter remains in situ before showing signs of blockage without the interference of prophylactic ‘washouts’ (B.J.N 1999,). N.B. The breaking of the circuit may lead to an increased risk of infection. 19.1 Assessment A full client assessment needs to be carried out to determine whether a catheter maintenance solution is required – catheters block for a variety of reasons:• • • • •

Constipation Client’s position Bladder spasm Kinked drainage system Drainage system above the level of the bladder

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19.2 pH Levels Check the pH of the urine normal, - pH is 6 – 7 (slightly acidic) if the pH is alkaline, encrustation is the most likely cause of the catheter blocking. In these cases a maintenance solution would be recommended. Best practice indicates that with problem catheters, urine should be tested weekly to monitor the pH, record and chart the pH of urine in care plan (see section 12i for obtaining urine sample) (Kholer – Ockmore & Feneley 1996). 19.3 Guidance for using Catheter Maintenance Solutions 1.

A maintenance solution can be used daily on a heavily encrusted catheter when there are heavy deposits of encrustation present. Once an acute episode of blocking has subsided, a weekly maintenance with the chosen solution is acceptable. (For further advice on individual regimes, contact the Continence Service).

2.

It must be remembered that regular opening of the closed drainage system is likely to cause infections; therefore, the closed drainage system must be changed after every treatment to ensure that each new system is both sterile and acceptable to the client. There is a clear correlation between the number of times the drainage system is disconnected and the rate of infection . (Getliffe & Dolman 2003).

3.

Daily use of catheter maintenance solutions should only be used for a limited period of time, e.g. between one to two weeks. After this there should be a decrease in the frequency of use as the encrustation will have dissolved. The aim is to decrease the frequency of use to maintain the catheter life.

4.

Some clients may only have an acute episode of catheter blockage and in these clients it may be possible to discontinue the use of catheter maintenance solutions.

5.

If weekly use of catheter maintenance solution is required then these need to be co-ordinated to coincide with the changing of the catheter valve/ drainage system. Remember the majority of clients should not require the use of catheter maintenance solutions Catheter maintenance solutions may prolong catheter life, but can cause trauma (mechanical or chemical )to the bladder mucosa (Bregenzer et al 1997)

6.

Where catheter maintenance regimes appear to be ineffective then regular or more frequent catheter changes should be considered.

7.

Always warm the solution prior to instillation. This is to prevent the bladder going into spasm if the solution is too cold.

8.

Ensure correct non-touch technique when undertaking catheter maintenance. This includes washing hands correctly using liquid soap before and after insertion. Clean examination gloves should be used when carrying out the technique to prevent cross contamination. A plastic apron should be used to prevent crossinfection and contamination of clothes. 18


9.

Clients who are managed with a catheter bag as opposed to a catheter valve, will have a decreased bladder capacity. It is advisable to use a smaller volume of catheter maintenance solution, using as little as 15 ml to gently bathe the lumen and the tip of the catheter. Smaller amounts also given sequentially, give a Better dissolution than one larger volume of solution, (Getliffe & Dolman 2003).

10. For some clients who experience blockage on an intermittent basis it may be beneficial to use a catheter maintenance solution as a prophylactic measure. This must be monitored on an individual basis by each practitioner and documented accordingly.

20 Intermittent Catheterisation Definition A catheter is passed intermittently into the bladder to assist in the drainage of urine where normal voiding is not possible. This is an aseptic technique if undertaken by a health professional but can be a clinically clean technique if undertaken by a client. This technique can also be undertaken by a relative or carer following full consent from the client and relative/carer education. Intermittent Self-catheterisation Intermittent Self Catheterisation (I.S.C) is performed by a client and should be used in preference to an indwelling catheter if it is clinically appropriate and a practical option for the client (N.I.C.E. 2003). The aim of intermittent catheterisation is to drain the residual urine before the bladder is over distended and before incontinence occurs. Whilst the advantages of this ‘clean’ technique are self-evident, the client must find the procedure acceptable, have sufficient cognitive abilities to understand instructions and sufficient dexterity to carry out the procedure. In younger clients residual volume is usually nil immediately after micturition, although a volume of up to 50 mls is generally accepted, as not being significant. In the older population (over 75 yrs) up to 100 mls is considered to be within normal limits. Clients with greater volumes should be investigated for a voiding problem (Norton 2001). A bladder scan should be requested if it appears that a client is not emptying the bladder fully.

21 Reasons for Intermittent Catheterisation 21.1 Neurogenic bladder – An abnormality of the nerve supply to the bladder, preventing bladder from emptying completely. This may be due to a number of causes: 19


• • • • • •

Obstetric trauma/childbirth Constipation and straining at stool Congenital abnormality Abdominal surgery or trauma Anal surgery or injury Spinal/Head injury

21.2 Outflow Obstruction - More commonly found in males and is often associated with prostatic enlargement or urethral stricture. 21.3 Urethral Stricture & Prostatic enlargement More commonly found in males but a urethral stricture can occur in females. This is a narrowing of the urethra resulting from scar tissue following an infection or trauma. (Following dilation or surgical intervention for stricture clients may have to use intermittent catheterisation to retain urethral patency). 21.4 Detrusor Hypoactivity – The bladder is unable to sustain or provide an adequate contraction; this results in a failure to empty completely. The sensation of the bladder filling may be absent or reduced and often the bladder has an enormous capacity. Large residuals may present as overflow incontinence, with or without frequency. This condition is usually the result of some nerve damage and can be mostly found in those whose primary condition is diabetes, pelvic floor injury, multiple sclerosis, (Fowler 1996) and prostate surgery (Guttmann and Frankel 1966). 21.5 Reflex Incontinence – Reflex incontinence occurs when there is spinal cord damage, the normal impulses do not pass between the sacral reflex arc level and the brain (the sacral reflex arc controls micturition). 21.6 Surgical Procedure – Surgical procedures particularly colpo-suspension may necessitate clients to perform I.S.C. However those with a high risk of bladder dysfunction post-operatively are generally taught the procedure prior to surgery. Similarly, any major surgical bladder reconstruction e.g. clam cystoplasty may also require I.S.C. as part of a long-term management plan, or insertion of Tension Free Vaginal Tape (T.V.T.) 21.7 Who should teach Intermittent Catheterisation? Following individualised assessment, guidance should be sought before I.S.C. is initiated. Consideration should be given to the practicalities within the home environment. Any registered Nurse who deems themselves competent and confident to undertake the procedure can teach the client/carer Intermittent Catheterisation. Specific areas need to be considered including giving of information, role of consent and especially child/adult protection issues, whether physical, psychological or sexual. The nurse needs to be both supportive and skilled, stressing the positive values of I.S.C. Intermittent Catheterisation is an intimate technique and the nurse should consider the client psychosexual awareness, verbal and non-verbal behaviour and adopt a sympathetic approach at all times.

20


21.8 Frequency of Intermittent Self-catheterisation The frequency of intermittent self-catheterisation is determined by the client’s individual needs. A useful guide is based upon the measurement of voided volume and residual volume. Residual volumes that exceed 250 mls can potentially lead to recurrent Urinary Tract Infections (UTI.’s). If the client is wet between catheterisations they may require more frequent catheterisations. If the client experiences symptoms of urgency they may require I.S.C and anticholenergic therapy. It is advisable to complete a Continence Bladder Diary for two weeks to ensure that the correct management plan has been implemented and to establish that the client is drinking the recommended amount of fluid per twenty-four hours e.g. 1½ - 2 litres. 21.9 Types of Intermittent Catheters • Hydrophilic • PVC (single client use/used with a lubricant) There are a number of self-lubricating hydrophilic coated catheters available, which have been shown to be safe and comfortable for client use (MDA 2000). The catheters are single use only. There is less trauma to the urethra using low friction catheters than pvc catheters (Hellstrom et al 1991). When the client is proficient in the technique, it is important that they choose their own brand of catheter, as the differences may seem a small but not insignificant, this can be a determining factor for the user regarding comfort and compliance. Choice of catheter should be guided by the available literature and research.

22 Urinary Tract Infection Research (Lindenhall et al 1994) has shown that there is a reduction in the incidence of urinary tract infections associated with intermittent self-catheterisation. Bacteria may be present however in most instances, the client is asymptomatic. Treatment with antibiotics is not recommended. The presence of bacteria in the urine may be the result of poor technique and /or an increase in the residual urine volumes. Cranberry juice has been shown to be of benefit to clients undertaking intermittent self-catheterisation by preventing certain types of E-coli bacteria from adhering to the bladder wall.

23 Children & Young People Catheter Management There is a small though not significant number of children who require regular catheterisation during the course of the day, per urethra or via an artificial channel i.e. mitrofanoff (Mitrofanoff/continence urinary diversion – a catheterisable stoma into the bladder). With adequate training and suitable facilities many children are able to carry out Intermittent Self Catheterisation themselves on a toilet or from a wheelchair. 21


Good inter-agency working between Health, Education and Social Services in partnership with the child and parents is essential for effective care. The care plan should be designed to achieve continence by encouraging as much independence as possible, thereby ensuring respect for the child’s dignity and privacy. Services are respectful to children and young people and seek consent from them for their treatment. Professionals ensure that consent is explicit, specific to an individual’s treatment and is sought with the involvement of the child or young person taking into account their development age (DoH. 2004). For intermittent catheterisation to be successful the following criteria must be met: • The child and/or carer must be able to understand the benefits, procedure and technique. • The child and/or carer must be highly motivated. • A high level of support must be available if required. • Regular follow-up must be carried out Finding the right physical position in privacy for the child/or carer to carry out the procedure at school is a vital part of the assessment. It is for this reason that the assessment and care planning in school is essential even if the child is initially taught the technique at home or in hospital. (DoH 2003) Children and Young People with a neurological deficit and associated problem may have difficulty holding the catheter and accurately inserting it in to the urethra, because of poor dexterity. It is also important to consider the child/young person’s mobility, motivation and cognitive ability (Faulkes, et al undated). All staff involved in the care and/or management of children and young people must be aware of local child protection policies. Promoting independence and individual care planning give the child/young person ownership of his/her own body. Care should be taken to protect the child/young persons self esteem, body image, self-awareness and sexuality as these can be easily undermined.

24 Outcomes In adhering to these guidelines: • Safe practice will be ensured • Good consistent evidence-based management of urinary and supra-pubic catheters will be ensured • Problems will be identified by assessment • Management of common problems will be consistent and evidence-based • Trial without catheter will be successfully performed in community and not necessitate hospital admission 22


25 Audit Compliance with the procedures will be measured by the use of audit. It is proposed that audit will be undertaken 12 months following the introduction of these guidelines.

REFERENCES Addison R , Mould C (2000) Risk assessment in supra –pubic catheterisation Nursing Standard 14:36,43-46 Addison R,(1999) Catheter valves a special focus on the bard flip-flow catheter 8-9 576580 AveronJ Monane M Gurwitz J, Glynn R (1994) reduction in Bacteriuria and pyuria after ingestion of cranberry juice JAMA 271, 571-574 Bard (2005) The Role and Management of Catheters and Collection Systems C R Bard inc Bregenzer T , Frei R , Wider A F et al (1997) low risk of bacteremia during catheter replacement in patients with long term urinary catheters Archives of Internal Medicine 157,5521-525 British Journal of Nursing (1999)– Catheter Maintenance Solutions vol 8, No 11, pp 708 – 715. Chillington (1992) Early removal advances, discharge home; Comparison of midnight and early morning catheter removal following prostatectomy. Professional Nurse Vol. 8 No.2 p84-89 Crowe H, Clift R, Duggan G, Bolton DM, Costello AJ (1993), Randomized study of the effect of midnight versus 0600 removal of urinary catheters. British Journal of Urology Vol. 71 No.3 pg306-308. De Courcy–Ireland K (1993) An issue on sensitivity Professional Nurse 8;11Aug p738742 Department of Health and National Assembly for Wales (2004) Drug Tariff, October, London: The Stationary Office Department of Health (2000) Good Practice in Continence Services London DoH. Department of Health (2001a) National Service Framework for older people London DoH Department of Health (2004) Standard 3 National Service Framework for Children London H Department of Health 2003 Reference Guide to Consent for examination or treatment London DoH 23


Downey P Dean M, Hayes J (1997), Perfect timing, Nursing Times Vol.93 no.5 pg89-90. Faulkes,S Oliver,H White,M (undated) Guide to Intermittent Catheterisation in Schools. Astra tech limited Fowler C J (1996) Investigation of neurogenic bladder Journal neuarological neurosurgery Psycharity 60:6-13 Getliffe, K.A. Dolman (2003) Care of urinary catheters, Getliffe, K. Dolman M (2005) Care of urinary catheters. Nursing Standard 11 (11) 57-60. Getliffe, K. Dolman M (2005)(Eds.) Promoting continence: A clinical and research resource. London Bailliere Tindall. Gibbs H (1986) Catheter toilet and urinary tract infection Nursing Times Journal of infection Control Supplement 23,82 75-76 Godfrey, H. and Evans, A. (2001) Management of long-term urethral catheters: Minimising complications, British Journal of Nursing, 9 (2) 74-81. Guttmann,L Frankel H (1996) the value of intermittent catheterisation in early management of traumatic paraplegia and tetraplegia Paraplegia 4:63-64 Healthcare Competence (2004a)CHS 8 Insert and secure urethral catheters and monitor and respond to the effects of urethral catheterisation August Healthcare Competence (2004b)CHS 9 Undertake care for individuals with urinary catheters August Hellstrom P Tammela T Lukkarien O Knotture,M (1991) Efficiency and safety of clean intermittent self catherterisation in adults Eurapean Urology 20:117-121 Hedelin H, Bratt C.G, Eckerdal G. Lincoln K. (1991) Relationship between ureaseproducing bacteria, urinary pH and encrustation on indwelling urinary catheters. British Journal of Urology 67 (5) 527-531. Kennedy A Brocklehurst JC Lyle MDW(1983) Factors related to long-term catheterisation Journal of Advanced Nursing 8,202-212 Kunin C M ,Chin Q F ,ChambersS (1987) formation of encrustation on indwelling catheters in the elderly, a comparison of different types of catheter material in blokers and none blokers Journal of Urology 77, 5 pg 716-718 Kunin, C.M.(1980) Urinary tract infections. Surgical Clinics of North America 60, 1, 223231. (Kennedy et al 1992). Kelleher MMB (2002), Removal of urinary catheters; midnight versus 0600hrs. British Journal of Nursing Vol. 11 No.2 pg84-90. 24


Kohler-Oackmore J, Feneley RC (1996) Long term catheterisation of the bladder, prevalence and morbidity. British Journal of Urology. 77(3):347-351. Lindenhall B et al (1994)long term intermittent catheterisation: the experience of teenagers and young adults with myelomeningocele Journal of urology 152 page187 189 Lowthian P. (1998) The dangers of long-term catheter drainage. Nursing 7 (7) 366-79.

British Journal of

McNeill SA. (2004) and members of the Alfaur Study Group, ‘Alfuzosin once daily facilitates return to voiding in patients in acute urinary retention’. The Journal of Urology 171 2316-20. MDA (2000) Hydrophilic coated catheters for intermittent self catheterisation Medical Devices Agency ISBN 1-85839-902-5 Jan 2000 NICE (2003) Guidlines: Prevention of health care associated infections in primary and community care. Nice (2006) Urinary incontinence The management of urinary incontinence in women Nice clinical guideline 40 NMC (2004) Code of professional conduct Standards for Conduct Perfomance and ethicsNMC, London Noble JG, Menzies D, Cox PJ, Edwards L (1990), Midnight removal; an improved approach to removal of catheters. British Journal of Urology Vol 65 No6 pg615-617. Parker L.Y (1999). Urinary catheter management: minimising the risk of infection: British Journal of Nursing Vol. 8, No.9 Pg. 563-64, 566,568,570,572,574. Pellowe C, (2004) Urology News Volume 9 no 1 page 13. Pomfret I (2000), Catheter care in the community, Nursing Standard Vol. 14, No 27, pg46-51. Pomfret I.J. (1996) Catheters: design, selection and management. British Journal of Nursing 5 (4) 245-51. Pratt R.J., Pellow C., Loveday H.P., Robinson N., Smith G.W.(2001) The epic Project: Developing National Evidence based Guidelines for Preventing Healthcare associated Infections. Journal of Hospital Infection 47 (Supplement): S3-S4 Rew M, Woodward S. (2001) Troubleshooting common problems associated with longterm catheters. British Journal of Nursing vol. 10, No 12 764-774. Rigby D (1998) Long term catheter care. 13(5):S14-15.

Professional Nurse (study supplement)

Ryan Wooley B (1987) Urinary Catheters :Aids for the management of incontinence King’s Fund Project Paper 65 pg 24-34 King’s Fund London 25


Saint (1999) preventing catheter related bacteria American Journal of Medicine 105:236-241 Suvarna R Pimohamed M Henderson L (2003) Possible interaction between warfarin and cranberry juice British Medical Journal 327:1454

26


APPENDIX 1

Catheterisation documentation Catheter recording sheet

27


CALDERDALE AND HUDDERSFIELD NHS FOUNDATION TRUST KIRKLEES PCT CALDERDALE PCT CATHETER RECORDING SHEET NOTE:

All details on this form must be recorded at each catheterisation or change of device to ensure accountability and that products can be identified in the event of any difficulty or adverse reaction. Boxes should not be left blank, ie a negative response (N/A) should be used if necessary. If patients are discharged with a catheter for District Nursing care a copy of this form should go with the patient.

Patient Details:

Reason for catheterisation:

Date: Catheter

Type Size Batch No Expiry Date Balloon Size Anaesthetic Gel Type Batch No Expiry Date Leg Bag Type Batch No Night bag Type Batch No Catheter Valve Type Batch No Bladder Instillation Type Batch No Date of next change of catheter Signature


Date

Evaluation of Catheterisation Procedure and Management

Signature

Discharge planning: Recording sheet copied and sent to District Nurses

Y

N

Team:

Catheter sent with patient on discharge

Y

N

Size

Starter pack of bags provided

Y

N

Written advice on care of catheter provided

Y

N

Type

Signed: Date:

30


CHS8 Insert and secure urethral catheters and respond to the effects of urethral catheterisation About this workforce competence The workforce competence covers the insertion of urethral catheters, including re-catheterisation, following agreed protocols and procedures. It also covers regular monitoring and care of the urethral catheter after insertion. It does not include supra-pubic catheterisation. Links This workforce competence links with the following dimensions and levels within the NHS Knowledge and Skills Framework (August 2004) Dimension: Health and Well-Being 7 – Interventions and treatments related to the structure and function of physiological and psychological systems. Level: 2 ORIGINS This is a new workforce competence developed for Clinical Healthcare Support by Skills for Health

Key words and concepts Additional protective equipment

Includes: types of personal protective equipment such as visors, protective eyewear and radiation protective equipment

Contaminated

Includes items contaminated with body fluids, chemicals or radionuclides. Any pack/item opened and not used should be treated as contaminated the individual is anyone who has been assessed as requiring urethral catheterization. In the context of this competence the individual will always be an adult

Individual

Personal protective clothing

Includes items such as plastic aprons, gloves - both clean and sterile, eyewear, footwear, dresses, trousers and shirts and all-in-one trouser suits and gowns. These may be single use disposable clothing or reusable clothing

Protocol

a set of guided instructions on the action to be followed in relation to catheterization, usually developed and quality assured through and by your employing organisation

Scope Adverse effects

include: a) fear/apprehension b) pain c) failure to pass the catheter d) lowered blood pressure e) haematuria


Appropriate action

Includes: a) reporting immediately to a person more competent to deal will the situation

Drainage system

includes: a) drainage bag b) night drainage bag, c) urometers d) closed drainage systems

Equipment and materials

includes: a) cleaning fluids b) local anaesthetic agents c) catheters d) syringes e) drainage bags f) fluid balance charts g) sterile gloves

Reasons for catheterisation

include: a) prior to surgery b) to prevent skin break down c) urinary retention d) burns e) diagnostic procedures f) renal failure g) acutely ill individuals

Relevant information

includes: a) urine output b) type of catheter used c) method used for securing catheter in position d) methods used for securing external tubing e) recording documentation f) written procedures and protocols

33


Standard precautions and health and safety measures

a series of interventions which will minimise or prevent infection and cross infection, including: a) hand washing/cleansing before during and after the activity b) the use of personal protective clothing and additional protective equipment when appropriate it also includes: a) handling contaminated items b) disposing of waste c) safe moving and handling techniques d) untoward incident procedures

34


APPENDIX 2

Competencies for catheterization and catheter care

35


Performance criteria You need to: 1. apply standard precautions for infection control and take other appropriate health and safety measures 2. comply with the correct protocols and procedures relating to urinary catheterisation. 3. insert the catheter safely and correctly, according to manufacturer’s instructions and with minimal trauma to the individual 4. secure the catheter after insertion according to instructions and adjust it correctly 5. attach the catheter correctly to the appropriate drainage system, confirm it is functioning correctly and measure and record the amount of urine collected immediately after insertion 6. make the individual as comfortable as possible following the procedure 7. monitor the individual’s condition, promptly recognise any adverse effects and take the appropriate action 8. seek assistance promptly from an appropriate person should it be required 9. record clearly, accurately, and correctly any relevant information in the necessary records 10. check that all catheterisation equipment and materials are functioning correctly and take appropriate action to remedy any problems 11. maintain cleanliness of the catheter and surrounding area through regular hygiene care 12. empty drainage bags and measure and record urinary output whenever necessary and as instructed by the professional involved 13. educate the individual as far as possible on the care of the catheter and attachments

Knowledge and understanding You need to apply: Legislation, policy and good practice K1 A factual awareness of the current European and national legislation, national guidelines and local policies and protocols which affect your work practice in relation to carrying out urethral catheterisation K2 A working understanding of your responsibilities and accountability in relation to the current European and national legislation and local policies and protocols K3 A factual awareness of the importance of working within your own sphere of competence when and seeking advice when faced with situations outside your sphere of competence K4 A working understanding of the importance of applying standard precautions and the potential consequences of poor practice K5 An in-depth understanding of the conditions and constraints which might denote who undertakes this procedure and why Anatomy and physiology K6 An in-depth understanding of the anatomy of the male and/or female genito-urinary System K7 An in-depth understanding of the physiology of the genito-urinary system Care and support of the individual K8 A working understanding of adapting communication to meet individual’s needs.

36


K9 An in-depth understanding of the effects of catheterisation on the individual’s comfort and dignity, and ways of minimising any adverse effects K10 An in-depth understanding of the ethical issues surrounding catheterisation, as applied to males and females K11 A working understanding of the need for chaperones, individual awareness and consent K12 A working understanding of potential adverse effects and appropriate actions K13 A working understanding of the importance of offering effective verbal and non-verbal support and reassurance to patients when you perform urethral catheterisation K14 A working understanding of the effective methods of providing verbal and non-verbal support and reassurance to patients Materials and equipment K15 An in-depth understanding of the types of catheters that can be used and why you should select the appropriate catheter K16 A working understanding of the local anaesthetic agents available Records and documentation K17 A working understanding of the importance of keeping accurate and up to date records K18 A working understanding of the importance of immediately reporting any issues which are outside your own sphere of competence without delay to the relevant member of staff Healthcare Competence CHS 8 Insert and secure urethral catheters and monitor and respond to the effects of urethral catheterisation August 2004 Page 1 of 7

37


APPENDIX 3

Catheter Audit Tool


CATHETER AUDIT TOOL Male F 1.

Female

F

Urethral

F

Suprapubic F

Reason for Catheterisation To monitor output F To determine residual urine F To relieve retention of urine or incomplete bladder emptying F To bypass an obstruction F Installation of drug therapy F To relieve urinary incontinence when no other means is practicable F Other please specify ………………………

2.

Which type of catheter was used? All Silicone

F

Hydrogel

F

Other please specify

………………………

3.

What size of catheter was used?

………………………

4.

What balloon size was used?

………………………

5.

6. 7.

What length of catheter was used? Standard

F

Female

F

Was a closed system of drainage maintained?

No

F

No

F

What supporting accessories were used? Straps

F

Sleeve

F

Other please specify 8.

Yes F

………………….

Was a catheter valve used?

Yes F

39


9.

Was the procedure explained to the patient?

Yes F

No

F

10.

Was consent obtained?

Yes F

No

F

11.

Was an aseptic technique used?

Yes F

No

F

12.

Were gloves changed during the procedure?

Yes F

No

F

13.

What was used for cleaning the patient?

……………………………

14.

Was instillagel used?

Yes F

a) b) c)

15.

No

F

6ml

F

No

F

F 6 – 10 mins

F

Yes F

No

F

Yes F

No

F

What amount? 11 ml F Was there a time lapse to allow anaesthetic to take effect? Yes F How long?

1 – 5 mins

Were there any problems when inserting the catheter If yes what problems occurred?

16.

Were there any problems when removing the catheter? If yes what problems occurred?

40


APPENDIX 4

Mid Yorks Guidance on Silver Alloy Catheters

41


Please note: New guidance included in Mid Yorks catheter guidelines. Patients may be discharged with liver catheters although these will not be prescribed in Primary Care. Silver alloy catheters As previously stated, first make sure that the person is assesses as to whether they need a urinary catheter inserted or not. If a catheter is required for less than 48 hours, the normal catheters should be used. If a person has a known, or suspected, latex allergy then the silver catheters must not be used. Silver catheters are for short-term use only, ie more than 48 hours but 28 days or less. For people who require a long-term catheter, ie over 28 days, silver is not the appropriate product and an alternative long-term catheter should be used. It is not always immediately apparent that a person may need a long-term catheter. The following groups of people who require a urinary catheter will have a BARD silver alloy coated urinary catheter inserted: o o o o

All persons over 65 years of age All persons with MRSA All persons with artificial heart valves and prosthetic joints All persons admitted who have been commenced on intravenous antibiotics, as they are suspected of having an infection.

- Any other patient requiring a catheter will have the products supplied by Roche - No restriction on usage in general theatres, urology department etc - Paediatric wards are not to be included.

42


APPENDIX 5

Catheter Management Record

43


Catheter Management Record Name ________________________

D.O.B _____________ GP ______________

Address ______________________

Named Nurse Community_______________

______________________________

Ward ________________________

______________________________

Consultant ___________________

Postcode ______________________

Ward________________________

Unit Number ___________________ Reason for catheterisation _______________________________________________ Duration Long/Short ____________________________________________________ Appointment made for Trial without catheter

Date ________________________

Follow up appointment with consultant

Date ________________________

METHOD Urethral

Suprapubic

Intermittent

Change in community YES/NO Reason for not changing in community _____________________________________ _______________________________________________________________________ Catheter used Brand/Make________________________________________________ Catheter sent on discharge _______________________________________________ Material __________________________ Leg/belly bag ________________________ Size _____________________________ CH _________ Night bag ______________ Catheter inserted by _________________________________ Date_______________ Any difficulty

YES/NO

Residual volume______________mls

Information for community supplied YES/NO Name of contact ________________________________________________________ Information given to patient verbally/written

YES/NO

Information given to patient verbally/written

YES/NO

Form completed by ______________________________________________________

Please print name _______________________________________________________ 44


http://www.kirklees.nhs.uk/uploads/tx_galileodocuments/District_Wide_Catheterisation_policy