NHS Professionals. CG8 Guidelines for Continence and Catheter Care. Introduction

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1 NHS Professionals CG8 Guidelines for Continence and Catheter Care Introduction Continence has been defined as control of bladder and bowel function and continence care is the name given to the total care package tailored to meet the individual needs of patients with bladder and bowel problems (DoH 2003) Incontinence is the involuntary leakage of urine or faeces (Abrams et al, 2002). Incontinence, both urinary and faecal, can affect anyone at any age although in younger adults those with conditions such as multiple sclerosis or spinal injury may be more at risk. Incontinence is more prevalent in the elderly and particularly common in frail elderly people in long term health care settings such as hospital or nursing home (The Continence Foundation 2000). Both urinary and faecal incontinence are distressing and embarrassing problems and can cause difficulties in leading a normal daily life. The psychological effects of incontinence and using continence clothing and pads can be immense and must always be taken into consideration when caring for patients who experience incontinence. Many individuals have bladder and /or bowel problems without incontinence and it is important to be aware of the impact this can have on their daily lifestyle. Both urinary and faecal incontinence are symptoms of underlying problems and a continence assessment should aim to identify possible causes and enable the development of an appropriate treatment plan. Urinary Incontinence There are three main types of urinary incontinence: - stress incontinence is the involuntary loss of urine during physical exertion (Laycock et al 2002). It occurs due to a deficiency in the urethral closure mechanism during episodes of raised intra-abdominal pressure such as coughing, sneezing, running etc (Getliffe et al 2003). This is common in women, primarily due to multiple parity, prolonged difficult labours, forceps assisted deliveries, menopausal changes with the reduction of oestrogen and neurological damage to the pudendal nerve which supplies the pelvic floor muscles. - urge incontinence is when the person has a strong desire to pass urine and the instability of the bladder causes it to empty completely (Getliffe et al 2003). This is known as Detrusor instability or overactive bladder. Causes are varied and include infections of the bladder or urinary tract, neurological disorders affecting nerves around the bladder such as stroke, multiple sclerosis, Parkinson s disease and spinal cord injury. However there are a number of cases with no detectable causes identified. Increased fluid intake, particularly caffeine and alcohol are known to cause bladder instability and urgency. - mixed urinary incontinence where a patient has symptoms of both stress and urge incontinence. When planning treatment for these patients the dominant symptom should always be treated first. Other types of urinary incontinence include: Page 1 of 8

2 - overflow incontinence which is common in older men who often have a slightly enlarged prostate gland and the bladder regularly releases a small involuntary dribble of urine. - reflex bladder where there is no bladder control at all and which may be present throughout someone s life or may result from injury or illness. - hypotonic bladder which is a type of overflow incontinence giving residual volumes which is a cause of incontinence in the elderly and patients with multiple sclerosis. Urinary incontinence may occur as a result of physical disabilities or mobility problems that prevent the person getting to the toilet in time. It may also be a side effect of certain medications such as those that increase the production of urine and is often seen in untreated diabetes. Constipation may lead to urinary incontinence as a full rectum exerts pressure on the bladder. Faecal Incontinence Faecal incontinence is the uncontrolled loss of solid or liquid stools or gas with leakage and can affect anyone but is much more common in older people particularly those with long term health and mobility problems. Causes of faecal incontinence include a low fibre diet and constipation, diarrhoea, Irritable Bowel Syndrome, childbirth, age, certain medications, infections such as viral gastro enteritis and clostridium difficile and injury or damage to the lower bowel, nerves and/ or sphincter muscles. Scope This guidance applies to all flexible workers on assignments for NHS Professionals in any healthcare setting including Acute, Primary Care & Community NHS Trusts. It is not intended to replace local NHS policies/guidelines, which must be adhered to. NHS Professionals flexible workers must be familiar with local Trust documentation. This guidance is for adult patients only. For paediatric and neonatal continence care refer to local trust policy/ guidelines. Guidelines 1. Continence Care 1.1 Healthcare personnel must ensure that patients who need continence care, and their carers, are given the appropriate information or access to the information they require in line with their plan of care. This may include local patient support groups and information leaflets (DoH 2003). 1.2 Healthcare personnel must ensure that patients are listened to and given the time and encouragement to communicate their needs, concerns and preferences regarding continence care (DoH 2003). 1.3 Healthcare personnel must ensure that consent is obtained from patients prior to giving any care or treatment and that all procedures are explained thoroughly to them and their understanding is checked (DoH 2003). 1.5 Healthcare personnel must be aware that continence care, catheterisation and catheter care are key components of nursing care. A number of Continence and Urology nurse Page 2 of 8

3 specialists are in place in the primary and secondary healthcare sectors and advice from such professionals should be sought when further information is required 1.6 Healthcare personnel must be aware of the groups of patients who may be more at risk of developing continence problems. These include antenatal, postnatal, special needs, school age children, elderly, disabled and post operative patients. 2. Dignity and Privacy 2.1 Healthcare personnel must be aware of the potential embarrassment which the patient may experience related to continence problems and should always act in a professional, respectful and caring manner and try to anticipate their needs. Where possible the patient should be encouraged to be independent and should be treated with respect and their personal space protected. 2.2 Healthcare personnel must ensure that the environment is dignified and comfortable for the patient when providing continence care, for example closing curtains and doors, keeping the patient warm and covered as appropriate and providing hand washing facilities. Where possible the environment may be adapted to meet the individual needs of patients, for example with mobility problems (DoH 2003). 2.3 Healthcare personnel must give patients and carers sufficient time to communicate their views and should value, respect, listen to and act upon their needs and preferences (DoH 2003). 3. Continence assessment 3.1 Both urinary and faecal incontinence are symptoms of underlying problems and a continence assessment should aim to identify the underlying problems that can then be addressed through appropriate management or treatment. 3.2 Healthcare personnel should only carry out a continence assessment if they have the appropriate skills and have received appropriate training using the appropriate local trust protocol. If a continence assessment is carried out it should be recorded appropriately in the patient s record of care and the patient, and/or carers should be informed of the outcome of the assessment and any subsequent change to their plan of care should be fully explained. 4. Promotion of urinary continence Healthcare personnel should be aware of the following strategies which may be in a patient s plan of care and which may be used under the direction of the nurse in charge of the ward to help to promote continence: - Eat a high fibre diet to avoid constipation - Drink 1½ -2 litres of fluid per twenty four hours (sufficient to keep the urine a pale straw colour) - Limit caffeine intake - Do not leave it to the last minute to go to the toilet but empty bladder 4-8 times per day and empty bladder fully - Avoid being overweight and exercise regularly - Exercise the pelvic floor muscles - Prompting voiding and individual toileting regimes - Bladder retraining 5. Promotion of Faecal Continence Page 3 of 8

4 5.1 Healthcare personnel must be aware that patients who report or are reported to have faecal incontinence should be offered a baseline assessment to identify contributory factors before any treatment is considered (NICE 2007) 5.2 Healthcare personnel should recommend a diet that promotes an ideal stool consistency and predictable bowel emptying and should also consider the use of a food and fluid diary (NICE 2007). 5.3 Healthcare personnel should be aware of the following bowel habit interventions which may be part of a patient s plan of care: - Encourage bowel emptying after a meal to utilise the gastrocolic response - Ensure toilet facilities are private and comfortable and can be used in safety with sufficient time allowed - Encourage patients to adopt a sitting or squatting position where possible while emptying the bowel - Teaching people techniques to facilitate bowel evacuation and stressing the importance of avoiding straining (NICE 2007) 5.4 Healthcare personnel should be aware of the following information which may be given to patients as part of their plan of care: - Use of disposable body worn pads in a choice of styles and designs and use of disposable bed pads. (The use of reusable absorbent products in the management of faecal incontinence is not generally recommended) - Skin care advice that covers both cleansing and barrier products - Advice on odour control and laundry - Use of disposable gloves (NICE 2007) 5.5 Healthcare personnel should be aware that patients and their carers may require varying degrees of psychological and emotional support including referral to counsellors and/or therapists, contact details for support groups and advice on how to talk to friends and family 5.6 Assessment of the degree of faecal incontinence may involve observation of stools and classification of them using the Bristol stool chart. 6. Management of Incontinence Healthcare personnel must be aware of different methods which may be used to manage incontinence in all patients such as the use of pads, sheaths and intermittent catheterisation all of which result in fewer cases of hospital acquired infection than the use of long term indwelling catheters. 7. Urinary Catheterisation 7.1 Use of long term indwelling urethral catheters should be considered when the patient has skin wounds, pressure ulcers or irritations that are being contaminated by urine, the patient is distressed by the repeated disruption caused by bed linen and clothing changes or where a patient expresses preference for this form of management (NICE 2006). Short term indwelling catheters may be used in order to measure accurate fluid intake and output and also following certain surgical procedures. Page 4 of 8

5 7.2 Healthcare personnel should be aware that catheterising patients places them in significant danger of acquiring a urinary tract infection and the longer a catheter is in place, the greater the risk (Epic ) 7.3 Flexible workers who are unregistered must not insert urinary catheters unless local trust policy states otherwise and they have completed training and been deemed competent to carry out the procedure under the guidance of the nurse in charge. 7.4 Urinary catheterisation should only be carried out by staff who are trained and competent in the insertion of urinary catheters in order to minimise trauma, discomfort and the potential for catheter-associated infection (Epic ) Healthcare personnel must only carry out urinary catheterisation if they have the appropriate skills and have received appropriate training using the appropriate local trust protocol. However Registered nurses and midwives are personally accountable for their practice and answerable for actions and omissions, and must always be able to justify decisions made (NMC 2008). 7.5 Intermittent urethral catheterisation should be used for women with urinary retention who can be taught to self catheterise or who have a carer who can perform the technique (NICE 2006) 7.6 Healthcare personnel should ensure that consent is obtained from patients prior to carrying out urinary catheterisation and that the procedure is explained thoroughly to them and their understanding is checked (DoH 2003). It should never be assumed that people are not able to make their own decisions simply because of age or frailty and health care professionals must be aware that no one can give consent on behalf of adults who are not capable of giving consent for themselves. If a person is not capable of giving consent this should be discussed this with the nurse responsible for their care. Decisions should be made which both those close to the person and the healthcare team caring for the person agree are in the person s best interests and a written record should be made in the person s notes. (DH 2001) 7.7 The patient s comfort, dignity and privacy must be maintained at all times during urinary catheterisation by performing the procedure in a location which is private and free from interruptions 7.8 When carrying out urinary catheterisation it is good practice to select the smallest gauge urethral catheter that allows urinary flow (Epic ) and to select a catheter length and which is made from material (avoiding latex) which is the most appropriate for the patient. In patients with complicated medical conditions it is essential to seek appropriate specialist advice prior to starting the procedure. 7.9 Registered practitioners must ensure that local trust policy is adhered to when inserting a urinary catheter. General principles of good practice must be adhered to including the use of sterile equipment and an aseptic non touch technique and the use of an appropriate sterile, single use lubricant or anaesthetic gel in order to minimise urethral trauma, discomfort and infection (Epic ) 7.10 Registered practitioners should ensure that all procedures involving the catheter and drainage system including insertion, changes and care given are recorded in the patient s records (Epic ). 8. Infection Control 8.1 Healthcare personnel must ensure that the risk of infections occurring in patients with urinary catheters is reduced by adhering to the following principles: Page 5 of 8

6 - Cleaning the urethral meatus with sterile normal saline prior to the insertion of the catheter - Maintaining a sterile and continuously closed urinary drainage system. - Ensuring that the connection is not broken without good clinical indication. - Decontaminating hands and wearing a new pair of clean non-sterile gloves before manipulating a patient's catheter or emptying the drainage bag and decontaminating hands after removing gloves - Not changing catheters or urinary drainage bags unnecessarily. - If a catheter is not introduced into the bladder at the first attempt a new sterile catheter must be used for each subsequent attempt - Positioning the urinary drainage bag below bladder level, ensuring it does not come in contact with the floor. (Epic ) 8.2 Healthcare personnel should ensure that the urinary drainage bag is emptied frequently enough to maintain urine flow and prevent reflux using a separate and clean container for each patient and avoiding contact between the urinary drainage tap and container. (Epic ) 9. Obtaining a urine sample from a urinary catheter The risk of infection when obtaining a urine sample from a sampling port in a drainage system must be minimised by using an aseptic technique (Epic ) 10. Daily Care of the Patient with a Urinary Catheter 10.1 Healthcare personnel should ensure that patients and carers receive adequate information which may be written and/or verbal to allow them to continue to care for a urinary catheter safely. Patient education/ information should be specific to patient needs and take into account factors such as language, literacy, cultural, age and any special needs and include an explanation of the type of product selected, why it has been inserted, how to care for their catheter including personal hygiene, common problems and how to manage them, when and how to contact a health practitioner and dietary advice including fluid intake and avoidance of constipation Healthcare personnel should ensure that patients who are self caring are aware that the daily routine of bathing or showering is all that is needed to maintain meatal hygiene (Epic ) Healthcare personnel should ensure that meatal hygiene is maintained by the daily use of soap and water by patients who require assistance with hygiene needs (Epic ). Some patients may require more frequent genital hygiene Healthcare personnel should observe for and be aware of any of the following which may occur with patients who have a urinary catheter in place and report them to the nurse in charge of the ward as appropriate: - The patient experiences pain in the bladder or around the catheter site - There is any change in the colour or odour of the urine or any debris or clots are observed - There is a noticeable change in the amount of urine passed - There is a rise in body temperature which may indicate an infection - There is redness, inflammation and/ or discharge around the catheter site 10.5 Healthcare personnel should ensure that the urinary drainage bag is secured appropriately to prevent traction on the tubing which may result in local trauma and Page 6 of 8

7 ensure that the tubing is not kinked or occluded to encourage free drainage of urine and to ensure patient comfort Healthcare personnel should ensure that the connection between the catheter and the urinary drainage system is not broken except for good clinical reasons, (for example changing the bag in line with manufacturer s recommendations) Healthcare personnel should ensure that all procedures regarding the daily care of the catheter and drainage system are recorded in the patient s records (Epic ) 11. Removal of a Urinary Catheter 11.1 Healthcare personnel should only remove a urinary catheter if they have the appropriate skills and have received appropriate training using the appropriate local trust policy When removing a urinary catheter the balloon must be fully deflated to prevent trauma. Following removal of the catheter the time of the first void, the volume and colour of urine passed, and if pain was experienced on micturition must be recorded in the patient s records. References Abrams et al 2002: The standardisation of terminology of lower urinary tract function American Journal of Obstetrics & Gynecology. 187(1): , July DH 2001 Seeking Consent: working with older people Department of Health, London DoH 2003 The Essence of Care: Patient-focused benchmarks for clinical governance Department of Health, London Epic2: National Evidence-based Guidelines for Preventing Healthcare Associated Infections in NHS Hospitals in England 2007: Journal of Hospital Infection February 2007; 65S:S1-s64 Getliffe K, Dolman M (2003) Promoting Continence. A Clinical Research Resource. Balliere Tindall Laycock J, Haslam J (2002) Therapeutic Management of Incontinence and Pelvic Pain: Pelvic Organ Disorders. Springer Verlag London Ltd NICE 2006 Clinical Guideline 40 Urinary Incontinence: The Management of Urinary Incontinence in Women NICE 2007 Clinical Guideline 49 Faecal Incontinence: The Management of Faecal Incontinence in Adults NMC 2008 The Code: Standards of conduct, performance and ethics for nurses and midwives. Nursing and Midwifery Council, London. The Continence Foundation 2000: A Source Book for Continence Services VERSION HISTORY CG8 Version Date Status Author 1 March 2008 Document created Karen Barraclough, Clinical Governance and Risk Manager Page 7 of 8

8 Version Date Status Author 1 2 March 2008 March 2010 March 2012 Approved by Clinical Governance Committee Document reviewed and updated Review date Karen Barraclough, Senior Nurse Page 8 of 8