III-701 Urinary Catheterization/Bladder Irrigation Original Date: 3/1/1977 Last Review Date: 10/28/2004 Purpose A. Allow for precise measurement of urine output. B. Collect a sterile urine specimen. C. Empty the bladder of urine. D. Prevent bladder distention after certain surgical procedures. E. Maintain urinary continence in certain urologic conditions. F. Preserve kidney function in certain disorders. G. Instill pharmaceutical or radiographic contrast material into the bladder according to standard protocol for the diagnostic test or procedure to be performed. H. Irrigate and aspirate debris from the bladder. *RN only Personnel A. RN B. LPN C. EMT-P D. Nursing students under the direct supervision of nursing instructor. E. Medical Technologists F. Phlebotomists G. Radiology/Nuclear Medicine Technologists Equipment and Preparation A. Catheter Size Choose the catheter size according to age and gender. Girls can accommodate larger catheters than boys, as the female urethra is more flexible than the male urethra. The larger the catheter diameter, the quicker the urine will drain. When choosing a catheter, it is best to use a tube specifically made for the urinary tract. It is best not to choose a feeding tube. The exception to
the rule is during radiologic procedures when it is necessary to use a tube with a radiopaque marking. The following is a guideline for choosing catheter size. Male Female Premature Infants 5 or 6 Fr 5 or 6 Fr Newborn 5, 6, or 8 Fr 5, 6 or 8 Fr 1-2 years 8 Fr 8 Fr 3-5 years 8 or 10Fr 8 or 10 Fr 6-10 years 8 or 10 Fr 8 or 10 Fr 11-12 years 10 or 12 Fr 12 Fr 13 years and older 12 or 14 Fr 12 or 14 Fr B. Insertion Length Guidelines Male Female Newborn 6 cm (+/-2 cm) 1.5-2 cm 2 years 8 cm (+/-2 cm ) 1.5-3 cm 5 years 10 cm (+/-2 cm) 1.5-3 cm (+/-2 cm) 10 years 12 cm (+/-2 cm) 1.5-3 cm (+/-2 cm) 12 years 16-20 cm (+/-2 cm) 4-6 cm (+/-2 cm) C. Type of Catheter 1. Double lumen indwelling catheter - double lumen indwelling catheter with inflatable balloon. 2. Intermittent - single lumen, used one time and removed after urine is obtained. a. straight b. coude D. Equipment - Refer to The Lippencott Manual of Nursing Practice, 7th Edition, pages 692-696. - Pharmaceutical solution if ordered.
Procedure - Refer to The Lippencott Manual of Nursing Practice, 7th Edition, pages 692-697. Notes: When inserting a catheter into a female uretha, angle the catheter in a downward fashion. This will allow the catheter to follow the angle of the urethra when the child is lying supine. Never forcefully push a catheter into a urethra. When inserting a catheter into male urethra, resistance is very likely to be met at the external sphincter. By holding firm steady pressure against the sphincter, the muscle will eventually fatigue, and you will feel a release of pressure. When this happens, continue pushing the catheter into the bladder. It is important to remember to never force a catheter against resistance. When urine appears into the catheter, insert the catheter a little further (1-2cm) in order to assure the catheter tip is fully within the bladder. When inserting a foley catheter, it may be inserted up to the hub in order to assure that the balloon will not be inflated within the urethra. After balloon inflation, gently tug on the catheter to bring the balloon down to the bladder neck before taping the tube in place. If, when catheterizing a boy, you do not feel a release of pressure (entering into the bladder) and feel continuing resistance, the catheter may be doubling back on itself inside the urethra. If this occurs, remove the catheter and choose a bigger size. The first choice may be too small and not be exerting enough pressure on the sphincter to push through. If you are in doubt about the proper placement of a catheter, DO NOT inflate the balloon. Call a physician or nurse from the Urology Service for assistance. If unable to advance catheter into bladder, or if difficulty is met during insertion, stop procedure and contact a urology nurse or resident. Indwelling Catheter Care A. Connect catheter to drainage tubing connected to urine drainage bag. B. Place bag in a position lower than the bladder to allow gravity drainage of urine. Secure tubing to inner thigh leaving enough slack to allow full movement of leg without dislodging catheter. C. Empty the closed drainage bag every shift and as necessary. D. Cleanse the exposed catheter twice daily with soap and a damp cloth. E. A leg bag can be used during the day if the patient is ambulatory. To switch bags, complete a 15-second alcohol scrub of the connection between the catheter and drainage tubing. Disconnect and insert the leg bag tubing into end of catheter. Cover the exposed end of the drainage bag tubing with sterile gauze pad and store in a clean safe area. F. Change the drainage bag every week or if it becomes soiled, after catheter changes and prn.
G. The catheter does not have to be changed routinely. Collaborate with the physician if a change is indicated. H. Urine specimens should NEVER be obtained from the drainage bag. Complete a 15- second alcohol scrub of the port and obtain specimen through needle entry or complete a 15-second alcohol scrub at the catheter and drainage tube junction or separate the catheter from the drainage tubing and drip urine into a cup. I. Be sure to inform patient and parents to keep bag below the level of the bladder. Catheterization - Urinary diversions (vesicostomy, intestinal conduit, cutaneous ureterostomy, Mitrofanoff) For initial catheterization of urinary diversion, or if you have questions regarding catheter, nurse should ensure that patient/family have received individual instruction by urology staff before proceeding. When catheterizing a urinary diversion, use sterile technique and cleanse the stoma just as you would with a urinary meatus. Utilizing betadine swabs or betadine soaked gauze, cleanse in a circular fashion working from the center of the stoma outwards. Cleanse stoma in this manner with three swabs. If there is an allergy to betadine, benzalkonium chloride or castille soap swabs may be used. If the family will be using soap at home to cleanse the stoma, soap may be used in the hospital setting as well. Sterile cotton balls or sterile gauze pads may be used with the soap. Consult the urology nurse specialist for size and type of catheter to be used. Insert the catheter slowly just until the flow of urine begins. The distance inserted will depend upon the size of the child. In general, the larger the child, the further the catheter will need to be inserted. Do not force the catheter. It should slide in easily. Do not attempt to bag or otherwise obtain a clean catch specimen from a diversion as the specimen will be contaminated. If the need arises to obtain a urine culture from an intestinal conduit, consult the urology nurse specialist as a special technique is used to prevent contamination. Parents and children may continue to catheterize a urinary diversion using clean technique if they have done so at home. They must use a new sterile catheter each time. Used catheters may be rinsed out and sent home with the family. Clean Intermittent Catheterization (CIC) Clean intermittent catheterization is straight catheterization done by a child or parent using clean rather than sterile technique. It is used at home to improve continence, prevent infection, and preserve urinary tract function. This technique can be continued during hospitalization. The only difference from the home procedure is that a new catheter must be used for each catheterization. Used catheters may be rinsed out with water and sent home with the family. If a nurse is catheterizing a child normally on a CIC routine, sterile technique is followed. This is done to reduce the risk of nosocomial infection.
Documentation A. Document the type of catheter, any comments regarding difficulty with catheterization, and abnormal characteristic of urine in the electronic medical record. B. Document the date, time and amount of urine from the catheterization within the Intake and Ouput in the electronic medical record. Balloon Deflation If difficulties are encountered in deflating the balloon of an indwelling catheter, the nurse may call a urology nurse practitioner. The catheter itself should never be cut. If the water does not leak out by cutting the balloon port, a urology resident must be called. The nondeflation of a catheter balloon is not considered to be an emergency. Once the urology resident arrives, he/she will attempt to deflate the balloon with other measures. Bladder Irrigation (RN only) A. The purpose of bladder irrigations are to: 1. Test the patency of the catheter lumen. 2. Help combat infection when antibiotic solutions are used. 3. Flush blood and other debris from the bladder. 4. Instill pharmaceutical, radiopharmaceutical, or radiographic contrast for diagnostic testing. B. Equipment 1. Sterile basin 2. Catheter tipped syringe 3. Alcohol sponges 4. Irrigating solution 5. Measuring cup 6. Sterile gauze pad 7. Rubber band Process 1. Pour irrigating solution into sterile basin. 2. Draw solution into syringe. Leave syringe propped in sterile basin. 3. Complete a 15-second alcohol scrub of the catheter and drainage tube junction, disconnect, and attach syringe to catheter.
4. Wrap sterile gauze pad over end of connecting tubing to maintain its sterility. Secure with rubber band. 5. Inject irrigating solution into bladder using gentle pressure. 6. Follow physician's order for draining solution. 7. Repeat procedure until the ordered amount of solution has been used. 8. Keep track of the returned solution. The amount returned should be approximately equal to that infused. 9. Reattach catheter to the drainage bag tubing. Documentation Within Intake and Output in the electronic medical record place date, time, solution, amount irrigated, color and consistency of solution returned. References: Nursing Procedures, Springhouse Publishing Co., 3rd ed., 2000, Mosby. Pediatric Nursing Procedures, Vicky R. Bowden and Cindy Smith Greenbers, Lippincott Williams and Wilkins Publishers, 2003.