Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required:
Catheter-Associated Urinary Tract InfectionsCatheter-associated urinary tract infections (CAUTI) are a common complication of indwelling urinary catheters and have been associated with increased morbidity, mortality, hospital cost, and length of stay (Gould et al., 2009). Urinary drainage systems are often reservoirs for multidrug-resistant organisms (MDROs) and a source of the transmission of microorganisms to other patients (Gould et al., 2009). The most important risk factor for developing a CAUTI, a health care associated infection (HAI), is the prolonged use of a urinary catheter (Centers for Disease Control and Prevention [CDC], 2015). Urinary tract infections (UTIs) are the most commonly reported HAIs in acute care hospitals and account for more than 30% of all reported infections (Gould et al., 2009). Catheters in place for more than a few days place the patient at risk for a CAUTI. A health care provider must assess patients for signs and symptoms of CAUTIs and report immediately to the primary health care provider. Signs and symptoms of a CAUTI include:
The following are practices for preventing CAUTIs (Perry et al., 2014):
Urinary CatheterizationUrinary catheterization refers to the insertion of a catheter tube through the urethra and into the bladder to drain urine. Although not a particularly complex skill, urethral catheterization can be difficult to master. Both male and female catheterizations present unique challenges. Having adequate lighting and visualization is helpful, but does not ensure entrance of the catheter into the female urethra. It is not uncommon for the catheter to enter the vagina. Leaving the catheter in the vagina can assist in the correct insertion of a new catheter into the urethra, but you must remember to remove the one in the vagina. For some women, the supine lithotomy position can be very uncomfortable or even dangerous. For example, patients in the last trimester of pregnancy may faint with decreased blood supply to the fetus in this position. Patients with arthritis of the knees and hips may also find this position extremely uncomfortable. Catheterization may also be accomplished with the patient in the lateral to Sims position (three-quarters prone). The male urinary sphincter may also be difficult to pass, particularly for older men with prostatic hypertrophy. There are two types of urethral catheterization: intermittent and indwelling. Intermittent catheterization (single-lumen catheter) is used for:
Indwelling catheterization (double- or triple-lumen catheter) is used for:
The steps for inserting an intermittent or an indwelling catheter are the same, except that the indwelling catheter requires a closed drainage system and inflation of a balloon to keep the catheter in place. Indwelling catheters may have two or three lumens (double or triple lumens). Double-lumen catheters comprise one lumen for draining the urine and a second lumen for inflating a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation and for instilling medications into the bladder; the additional lumen delivers the irrigation fluid into the bladder. Indwelling urinary catheters are made of latex or silicone. Intermittent catheters may be made of rubber or polyvinyl chloride (PVC), making them softer and more flexible than indwelling catheters (Perry et al., 2014). The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the tube. Recommended catheter size is 12 to 16 Fr for females, and 14 to 16 Fr for males. Smaller sizes are used for infants and children. The balloon size also varies with catheters: smaller for children (3 ml) and larger for continuous bladder irrigation (30 ml). The size of the catheter is usually printed on the side of the catheter port. An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine. Make sure that the urinary bag hangs below the level of the patient’s bladder so that urine flows out of the bladder. The bag should not touch the floor, and the patient should carry the bag below the level of the bladder when ambulating. To review how to insert an indwelling catheter, see Checklist 80.
Video 10.2Video 10.3Removing a Urinary CatheterPatients require an order to have an indwelling catheter removed. Although an order is required, it remains the responsibility of the health care provider to evaluate if the indwelling catheter is necessary for the patient’s recovery. A urinary catheter should be removed as soon as possible when it is no longer needed. For post-operative patients who require an indwelling catheter, the catheter should be removed preferably within 24 hours. The following are appropriate uses of an indwelling catheter (Gould et al., 2009):
When a urinary catheter is removed, the health care provider must assess if normal bladder function has returned. The health care provider should report any hematuria, inability or difficulty voiding, or any new incontinence after catheter removal. Prior to removing a urinary catheter, the patient requires education on the process of removal, and on expected and unexpected outcomes (e.g., a mild burning sensation with the first void) (VCH Professional Practice, 2014). The health care provider should instruct patients to
Review the steps in Checklist 81 on how to remove an indwelling catheter.
If a patient is unable to void after six to eight hours of removing a urinary catheter, or has the sensation of not emptying the bladder, or is experiencing small voiding amounts with increased frequency, a bladder scan may be performed. A bladder scan can assess if excessive urine is being retained. Notify the health care provider if patient is unable to void within six to eight hours of removal of a urinary catheter. If a patient is found to have retained urine in the bladder and is unable to void, an intermittent/straight catheterization should be performed (Perry et al., 2014). Video 10.4
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