Urinary Catheterisation

Objectives

To provide indications for, outline the steps in carrying out urinary catheterisation and aftercare.

Scope

These guidelines outline the indications for urinary catheterisation as well as providing a procedural guide and information on prolonged management.

Audience

This guideline is intended for the use of registered healthcare professionals fulfilling a role in a forward medical location or in an emergency department on deployed operations.

Background

Patients who are critically unwell, traumatically injured or expected to remain immobile for a prolonged period may benefit from a urinary catheter. The following guidelines are designed to provide information on the indications for urinary catheterisation, procedural guideline and post procedure care requirements in the catheterised patient.

Indications

• Acute urinary retention – the patient is unable to pass urine and has a significant urinary volume in the bladder.
• Urine output monitoring – when accurate fluid balance monitoring is required, particularly in critically unwell and traumatically injured patients.
• Perioperatively – patients undergoing surgery of significant duration or undergoing urinary tract surgery may need a urinary catheter.
• To assist in wound healing when there is compromised skin integrity in the perineal/sacral areas in incontinent patients.
• Extended periods of immobility.

Preparation

Patient consent should be obtained where possible, and a chaperone offered and identified. A suitable area to perform catheterisation should be identified, mindful of the space requirements as well at preserving patient dignity as far as possible.

A sterile area should be set up prior to the start of the procedure with the following equipment:

• Sterile gloves - 2 pairs
• Sterile drape
• Cotton wool balls and/or sterile gauze
• 30ml normal saline (for cleaning)
• Lidocaine gel (Instillagel) – prefilled syringes
• Urinary catheter – usually 12/14/16Ch
• Syringe with 10ml sterile water (may be included in the catheter packaging)
• Gallipot
• Urine collection bag/urometer

A catheter pack may be available that includes many of the above components in a single pack.

Procedure

After the equipment is prepared, and with the chaperone present, the site of insertion should be exposed. This should be done as late as possible to maintain patient dignity.

Using the first pair of sterile gloves, a sterile drape should be placed over the insertion site. Fold a drape into quarters then cut or tear off one corner, so that unfolding leaves a hole in the centre of the sterile drape that can be sited over the external genital area. If the patient is uncircumcised then gently retract the foreskin to allow the opening to the urethral meatus and the surrounding area to be cleaned using sterile gauze or cotton wool balls soaked in 0.9% normal saline. The area should be cleaned from the meatus in an outward direction to avoid contamination.

If a double glove technique is used, the outer gloves should now be removed. If using a single glove technique, new sterile gloves should be donned at this point in the procedure.

The urethral meatus should be infiltrated with approx. 10ml lidocaine gel (Instillagel), which should be left to work for a minimum of 3 minutes prior to catheter insertion. This works both as a local anaesthetic and a lubricant for catheter insertion.

A 2-way foley catheter, usually 12/14/16Ch in size, can then be inserted into the urethral meatus. Do not force a large diameter catheter that does not pass easily: switch to a smaller size. The catheter should be passed until the whole length is inserted (especially in male patients with a significantly longer urethra) to ensure the catheter balloon is within the bladder and not still in the urethra at the point of balloon inflation. A collection tray may be helpful to prevent the initial flow of urine soiling the patient’s bedspace.

When the catheter is fully inserted, the balloon should be inflated. This must be with sterile water – DO NOT USE NORMAL SALINE as there is a risk of crystallisation. It is usually 10ml, but if there is a requirement for a larger volume, this will be specified on the catheter and packaging. Balloon inflation should be painless - stop if discomfort is caused, as this could indicate that the catheter tip is not in the urinary bladder.

The urometer/urinary collection bag should be attached as soon as possible to maintain an accurate measure of residual volume and to avoid urine soiling the patient’s bedspace.

The catheter should then, very gently, be pulled back to ensure the balloon rests at the bladder opening of the urethra. If the patient is uncircumcised then ensure that the retracted foreskin is replaced to avoid paraphimosis.

All equipment should be disposed of in the appropriate clinical waste bins.

Post-procedure care

The procedure should be documented after catheter insertion including:

• Details of consent gained for the procedure
• Healthcare professional performing the procedure
• Name and role of the nominated chaperone
• Indication for insertion
• Any difficulties on insertion
• Residual urinary volume after catheter insertion
• Amount of sterile water used to inflate the catheter balloon
• Any specific requirements for on-going catheter management

The catheter should be monitored regularly including:

• Drainage system integrity:
  • Catheter kinking
  • Urinary bypassing
  • Catheter bag being stored higher than the bladder
  • Overfull catheter collection bag/urometer
• Urine monitoring:
  • An accurate fluid output chart should be maintained to monitor urine output accurately.
  • Colour and clarity of urine should be noted and correlated with the patient’s condition. This may indicate infection or other issue, especially in the case of haematuria with clot formation.

Paediatric Considerations

Urinary catheterisation is used much less frequently in paediatric patients; weighing pads can provide a relatively accurate measure of urine output while avoiding an invasive procedure.

If catheterisation is needed then smaller catheters should be used, so that the diameter of the catheter is sufficiently small to easily transit the urethra.

Prolonged Casualty Care

Unless there is a specific indication for a catheter change, such as suspected catheter associated infection or catheter blockage, they should not need to be changed in the deployed environment. A catheter should routinely be changed every 10-12 weeks.

Patient education regarding cleanliness and hygiene, as well as regular urine and catheter monitoring as outlined above will form the mainstay of appropriate prolonged casualty care in the catheterised patient.

The ongoing need for a catheter should be assessed – if the patient no longer requires one it should be removed. The patient will need to be able to pass urine independently when they have the urge to pass urine or within 6 hours of catheter removal; if unable to do so they will need another catheter to be inserted to address acute urinary retention.