PATIENT CARE MANUAL PROCEDURE

PATIENT CARE MANUAL PROCEDURE NUMBER VII-E-5 PAGE 1 OF 7 APPROVED BY: CATEGORY: Tri-site Nursing Policy and Procedures Review Committee Body Systems; Genitourinary 1.0 GOALS To influence patient care providers to think about urinary catheter care as a holistic activity which requires individual assessment and strategies. To move away from crisis management catheter care and to help prevent infectious complications that arise from long term indwelling catheters. 2.0 RATIONALE Catheterization of the urinary tract is the most common cause of hospitalacquired infections. Acquisition of urinary tract infection during indwelling bladder catheterization is associated with significant excess morbidity and costs and nearly a threefold increase in mortality among hospitalized patients. Studies indicate that both the intraluminal and extraluminal pathways are important in the development of catheter-associated bacteriuria. This suggests that both strict aseptic adherence to the care of a closed catheter drainage system and good meatal care are fundamental in the prevention of such infections. The only method of management left to nurses is to try to pre-empt the blockage of a catheter by changing it before it blocks. 3.0 CONTRAINDICATIONS Surgical patients where bleeding (i.e. blood clot) would be the first suspected cause of blockage. Delicate genito-urinary surgeries where re-introduction of a catheter would disturb the surgical procedure. Short term indwelling catheter (less than one week).

OF 7 4.0 BEST PRACTICE Management of an Indwelling Catheter 4.1 Size of Catheter A small diameter catheter (12 Fr or 14 Fr) is recommended because large sized catheters are associated with more problems such as bypassing. Catheters with a small balloon are recommended. Larger balloons (30cc) were designed to control bleeding following genito-urinary surgery. Catheter balloons should be filled to the maximum capacity recommended by the manufacturer. A partially filled balloon fills asymmetrically which increases the potential for erosion of the bladder mucosa. Recommended inflation capacities: 3cc balloon: use 5 ml sterile water 5cc balloon: use 10 ml sterile water 15cc balloon: use 20 ml sterile water 20cc balloon: use 25 ml sterile water 30cc balloon: use 35 ml sterile water 4.2 Type of Drainage System A closed system of drainage (not opened except for emptying the bag) is recommended by the Centre for Disease Control. 4.3 Frequency of Drainage bag changes There have been no studies on the frequency of drainage bag changes. The standard procedure has been to change the drainage bag with each catheter change. If the catheter is changed less than once a month, it is standard practice to change the drainage bag at least once a month.

OF 7 4.4 Frequency of Catheter changes Current clinical research does not support a standard routine frequency for catheter changes. Instead, client specific catheter change patterns are recommended as follows: For individuals who have no problems with sediment, systemic UTI, discomfort or bypassing the recommended frequency is every 8-12 weeks. For individuals who have problems with sediment, frequent catheter blockage, recurrent UTI, and bypassing the recommended frequency is at least monthly. To avoid crises the goal is to change the catheter before problems occur. 4.5 Treating an Infection If a patient develops a urinary infection, treat the infection by starting antibiotics and replacing the existing catheter. 5.0 BEST PRACTICE - Investigating Catheter Blockage Is the catheter blocked? YES? access the cause of blockage check for evidence of encrustation measure the ph of the patient s urine if there is evidence of symptoms, send MSU treat if necessary If cause is infective encrustation, take action: assess how often the catheter should be changed for that particular patient (see point 4.4) consider all-silicone catheters specialist referral if problem unresolved

OF 7 NO? check functional reasons assess bag position find out if the patient has constipation check if tube is kinked or compressed assess the internal position of the catheter tip find out if the patient is experiencing bladder spasm 5.1 Blockage The most common reason for indwelling catheters failing to drain is blockage of the catheter eye or lumen by encrustation. Two populations of bacteria exist in the catheterized urinary tract; those growing within the urine itself and those growing on the surface of the catheter. The following strategies are recommended to prevent catheter blockage: Use a silicone catheter. Silicone catheters have a larger opening in the lumen and cause less encrustation than latex or silicone-coated catheters. Establish an individual pattern for scheduled catheter change so that the catheter can be changed before it becomes blocked. 5.2 Encrustation Encrustation is caused by minerals which separate from alkaline urine (the alkalinity being caused by ammonia produced from the breakdown of urea). Avoidable contributing factors to alkalinity in urine include dietary factors and the use of antacids. Monitor the ph levels of urine. Encrustation is 10 times greater in individuals with a ph above 6.8. 5.3 Evidence of Symptoms Signs and symptoms of urinary tract infection (UTI) cloudy urine foul-smelling urine hematuria fever malaise tenderness over the bladder flank pain

OF 7 5.4 Treatment Identify contributory factors and so provide proactive care (eg. using litmus paper to monitor urinary ph). The use of silicone catheters with small diameters left in situ for as long as possible, less frequent changing of drainage bags and mobilization of patients whenever possible. 6.0 BEST PRACTICE Catheter Irrigation Catheter maintenance solutions should be used with reservation, and as a considered management tactic rather than as first-line treatment, with consideration given to individual variations between patients May be performed to maintain or restore the catheter s patency; eg. remove pus or blood clots that may block the catheter and prevent drainage. Requires strict sterile technique to prevent bacteria from entering the bladder Recurrent introduction of solution into the bladder can damage the bladder wall Solutions should be introduced by gravity only 50 ml is as effective as larger amounts Twice daily irrigation with any solution is inappropriate and a general rule not to irrigate more than every other day may be pertinent If you encounter resistance during instillation of the irrigating solution, don t try to force the solution into the bladder. Stop the procedure and notify the physician. 6.1 The closed method of irrigation is preferred may be intermittent or continuous use a triple lumen; the irrigating solution is infused through the irrigating port of the catheter and into the bladder and then is drained out through the catheter s drainage lumen 6.2 The open method of irrigation may be used occasionally for patients who develop blood clots or mucus plugs that occlude the catheter and when it s undesirable to change the catheter performed with a double-lumen

OF 7 Example: If a patient s catheter blocks q monthly, and you have followed the best practice guidelines, try changing the catheter q3 weekly or irrigate q daily to q weekly via a triple-lumen closed system catheter irrigation set-up. 7.0 PROCEDURE: Refer to Perry & Potter Textbook on unit, entitled Clinical Nursing Skills and Techniques, the Urinary Elimination Chapter 8.0 PATIENT TEACHING encourage catheterized patients not fluid restricted to increase intake to 3000 ml per day (3.2 qt.) encourage patient to eat foods containing ascorbic acid (eg. citrus fruits and juices, cranberry juice, and dark green and deep yellow vegetables) perineal care toileting self-care 9.0 DOCUMENTATION Minimum charting requirements: size of catheter used insertion time type of irrigation used (if any) time of catheter removal detail of amount voided and time of first voiding post catheter removal problems encountered

OF 7 10.0 REFERENCES Lippincott, Williams & Wilkins. (2003). Best practice: a guide to excellence in nursing care. Gates, A. (2000). The benefits of irrigation in catheter care. Professional Nurse. 835-838. Rubin, M., Berger, S.A., Zodda, E.M., Gruenwald, R. (1980). Effect of catheter replacement on bacterial counts in urine aspirated from indwelling catheters. The Journal of Infectious Diseases. Vol. 142, No. 2 Tenney, J. (1987). Bacteriuria in women with long-term catheters. The Journal of Infectious Diseases. 157, 199-202. Wilde, M.H. (1997). Long-term indwelling urinary catheter care: conceptualizing the research base. Journal of Advanced Nursing. 25, 1252-1261. Evans, A. & Godfrey, H. (2000). Bladder washouts in the management of long-term catheters. British Journal of Nursing. 9(14), 900-906. Best Practice; Evidence Based Practice Information Sheets for Health Professionals. (2000). Management of short term indwelling urethral catheters to prevent urinary tract infections. Volume 4, Issue 1, ISSN 1329-1874.