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catheter care guidelines 2013 - Canterbury District Health Board

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1. change catheter and record details Record problem actions and outcome in patient notes Acknowledgement ICS Ref 4501 Authorised by Clinical Nurse Specialist Page 39 of 45 July 2013 Canterbury District Health Board Te Poari Hauora 6 Waitaha CDHB Nursing Policies and Procedures Health Catheter Guidelines Appendix 13 URINE BY PASSING FLOW CHART PROBLEM By passing may be caused by the catheter being blocked Is the catheter the right size larger sizes are associated with irritation and leakage Balloon deflated Urinary tract infection Bladder irritation spasm ACTION See Blocking catheter flow chart Change to a smaller size Fg catheter 12 16 Fg is appropriate for most adults with catheters for long term drainage Check balloon is inflated Check for signs and symptoms of systemic infection Treat as required Consider concentrated urine promote increased fluid intake to dilute urine check for bladder calculi by X ray or ultrasound treat as required if persistent urethral leakage occurs with Suprapubic Catheter SPC it may be necessary to consider surgical closure of the urethra Record problem actions and outcome in patient notes Ref 4501 Authorised by Clinical Nurse Specialist Page 40 of 45 July 2013 Catheter Guidelines Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Appendix 14 BAL
2. Are we treating the catheter or the patient Clinical Nurse Specialist 19 4 175 179 Smith J A M 2003 Indwelling catheter management From habit based to evidence based practice Ostomy Wound Manage 49 12 htto www o wm com content indwelling catheter management from habit based evidence based practice page 0 2 Stephen Haynes J amp Hampton S 2011 Achieving effective outcomes in patients with overgranulation Retrieved 17 October 2012 fromhttp www wcauk org downloads booklet_overgranulation padf Tenke P Bjerklund Johansen T E Matsumo T Tambyah P A amp Naber K G 2008 European and Asian guidelines on management and prevention of catheter associated urinary tract infections International Journal of Antimicrobial Agents 31 Suppl 1 S68 S78 Retrieved 13 July 2011 from http www escmid org fileadmin src media PDFs 4ESCMID _Library 2Medical Guideline s otherguidelines Euro Asian UTI Guidelines ISC pdf Ref 4501 Authorised by Clinical Nurse Specialist Page 44 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha The Newcastle Upon Tyne Hospitals NHS 2010 Guideline for adult indwelling urethral catheterisation Retrieved August 10 2011 from http www newcastle hospitals org uk downloads clinical quidelines CrossDirectorate Indewlling201009 pdf The Royal Marsden Hospital NHS 2011 The Royal Marsd
3. balloon size amount of water instilled in balloon batch number and expiry of catheter Any problems with insertion Description of urine colour and volume drained Specimen collected as clinically indicated Expected date of next and or subsequent catheterisation where this will take place and by whom Marsden Manual 2008 INFECTION PREVENTION AND CONTROL PRINCIPLES Catheterisation of the urinary tract should only be performed when there is a specific and adequate clinical indication as catheterisation carries a high risk of infection Adherence to a sterile continuously closed method of urinary drainage has been shown to markedly reduce the risk of acquiring a catheter associated infection Strict aseptic technique is essential Hand hygiene is the primary defense against cross infection Bacteriuria secondary to insertion of a catheter occurs in 20 30 of patients The risk of infection is related to the method of insertion duration of catheterisation quality of catheter care and patient susceptibility Department of Health 2001 Standard Precautions are maintained when in contact with urine and or other body fluids Gloves are changed after each procedure and between patient contact Hand hygiene should be performed in accordance with the 5 Moments for Hand Hygiene Gravity is important for drainage and the prevention of urine backflow Ensure that catheter bags are always draining downwards do not become kinked and are secured
4. frail elderly men to avoid urethritis orchiepididymitis and prostatitis those prone to infection e g diabetes mellitus faecal incontinence CONTRAINDICATIONS FOR SUPRAPUBIC CATHTERISATION Although suitable for a wide variety of patients they are inappropriate with e Obesity or immobility the traditional stoma site may become concealed by an apron of excess anterior abdominal wall fatty tissue making sitting and changing catheters problematic e Haematuria of unknown origin e Bladder tumours e Small contracted or fibrotic bladders which may have resulted from long term urethral catheterisation on free drainage ICS 2009 CARE OF THE SUPRAPUBIC CATHETER Although the principles of care and management of the suprapubic catheter are similar to those of a urethral catheter there are differences e Patients with a spinal injury may be at risk of autonomic dysreflexia secondary to their injury All staff must recognize signs of Autonomic Dysreflexia kept with each patient refer to Burwood Spinal Unit manual for signs and symptoms and intervention e Strategies to support the SPC may be required e g anchoring to the abdominal wall to prevent traction and potential displacement of the catheter or balloon e Urine may still leak via the urethra especially if the catheter is blocked or the drainage tube kinked e Immediately following insertion of a SPC aseptic technique should be employed to clean the insertion site Dressings may be r
5. this hand is now considered contaminated and should maintain a firm grasp until the procedure is completed a using empty 10 ml syringe deflate balloon gently and unhurriedly b note how far in the old catheter was placed and or length of discoloration of old catheter 15 Pick up the pre lubricated catheter with dominant and align catheter alongside old catheter ensuring sterility of catheter is not compromised 16 With non dominant hand gently remove old catheter you may feel some mild resistance and with dominant hand insert new catheter at the same angle and depth in as the old catheter 17 Do not take the catheter out unless it is going to be reinserted immediately 18 Wait for some urine to flow from the catheter may take a few minutes if a routine catheter change 19 Once there is urine draining from the catheter a inflate the balloon using 7 10 mls of sterile water b apply gentle traction the catheter should retract slightly and then remain in situ oor Ref 4501 Authorised by Clinical Nurse Specialist Page 25 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health c if it is immobile the catheter may be in the urethra deflate balloon and withdraw slightly if urine drains re inflate balloon and try retraction test again 20 Secure the catheter to the thigh abdomen with additional leg strap or tape 21 Place
6. Insert sterile syringe directly into sample port and aspirate 3ml urine a minimum of 1 ml is required for satisfactory testing Laker 1995 the port will self seal when the syringe is withdrawn Or if using needle and syringe insert needle at a 45 angle into the catheter above the clamp avoiding the water channel to the balloon 7 Disconnect the needle from the syringe and carefully empty urine filled syringe into specimen container 8 Discard needle and syringe into sharps container 9 Wipe the sample port or access area with alcohol swab 10 Release catheter clamp Ref 4501 Authorised by Clinical Nurse Specialist Page 29 of 45 July 2013 Catheter Guidelines NGE A CDHB Nursing Policies and Procedures Canterbury Wurse Maude District Health Board aane Health Te Poari Hauora 6 Waitaha 11 Remove gloves and dispose of equipment in a yellow biohazard bag 12 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR 13 Label specimen container with patient details soecimen type date and time of collection a place in biohazard bag and seal b complete lab form note in particular patient symptoms and if on antibiotic therapy 14 Arrange for transport to the laboratory or refrigerate sample 15 Document in patient record rationale for collection of urine sample date and time taken Needleless Access Sample port or urine specimens Ref 4501 Authorised by Clinical Nurse Specialist Page 30 o
7. and management of chronic urinary catheters in long term care Much controversy little consensus Journal of American Medical Directors Association 4 Suppl 20 S52 59 Geng V Cobusse Boekhorst H Farrell J Gea Sanchez M Pearce l Schwennesen T et al 2012 Evidence based guidelines for best practice in urological health care Catheterisation Indwelling catheters in adults Retrieved October 16 2010 from http www uroweb org fileadmin EAUN guidelines EAUN_ Paris Guideline_ 2012 LR 0 nline_file pdf Getliffe K A 1994 The characteristics and management of patients with recurrent blockage of long term urinary catheters Journal of Advanced Nursing 20 1 140 9 Gould C V Umscheid C A Agarwal R K Kuntz G Pegues D A Healthcare Infection Control Practices Advisory Committee HIPAC 2009 Guideline for prevention of catheter associated urinary tract infections Retrieved from http Awww cdc gov hicpac cauti 001_cauti htm Health Quality and Safety Commission 2012 The 5 moments of hand hygiene Retrieved December 20 2012 from http Awww handhygiene org nz index php option com_content amp view article amp id 9 amp lte mid 109 Holtom B 2003 Blocked indwelling urethral catheters Evaluating evidence based practice Retrieved September 12 2009 from http www jcn co uk printFriend asp ArticlelD 677 Medical Devices Agency 2001 Problems removing urinary catheters MDA London Miles G amp Sch
8. fluid intake Inability to tolerate catheter e Urethral mucosal irritation e Psychological trauma e Unstable bladder e Radiation cystitis Catheter may need to be removed and seek an alternative means of urine drainage Explain the need and functioning of the catheter Consider anticholinergics Formation of crusts around the urethral meatus e Increased secretions collect at the meatus and form crusts due to the irritation of urothelium by the catheter Encourage daily meatal wash and after bowel movement using soap and water or saline Penile pain on erection e Not allowing enough length of catheter to accommodate erection e Poor technique and inadequate lubrication with intercourse Ensure that an adequate length is available to accommodate erection Give patient education re use of water based lubrication and condoms with sexual activity Dysuria after catheter removal e Inflammation of the urethral mucosa Advise the patient that dysuria is common but will usually be resolved once micturition has occurred at least 3 times Encourage a fluid intake of 2 litres per day Inform medical staff if the problem persists Catheter falling out e Bladder spasm e Balloon deflation e Catheter traction e Reduced bladder neck urethral tone See bladder and or urethral spasm flow chart Check that balloon is still inflated Secure catheter to leg to prevent pull Ensure drainag
9. hospital and described as a night bag in the community e Night bags have longer 120cm length tubing commonly with an outlet port to allow emptying e Bags should be changed when they become damaged contaminated or malodorous and at catheter changes www nhshealthquality org 2004 e Inthe community the night bag is emptied and can be washed with warm water and mild detergent between uses however there is no strong evidence to support the benefits of doing this Disposable 2 litre closed system bag hourly measuring bag with sample port Used when frequent measurement of urine output is indicated Ref 4501 Authorised by Clinical Nurse Specialist Page 11 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Disposable 4 litre plastic bags e Bags with non returnable valves e Used post operatively in urology and for bladder irrigation e Usually short term and only changed if damaged contaminated or malodorous Wong 2001 CATHETER VALVES A catheter valve is a small device connected to the catheter in place of a drainage bag Closing and opening of the valve allows for bladder filling and intermittent bladder emptying rather than continuous drainage into a bag It can be released when the patient wishes to pass urine i e every 3 5 hours The catheter valve can be connected to night drainage bag and opened to allow free drainage overnight Cat
10. intermittent irrigation may be indicated during urological surgery or to manage catheter obstruction Moore et al 2009 Nurses should aim to assess individual patients pattern of catheter life and plan changes accordingly rather than wait until a catheter blocks The Burwood Spinal Unit uses the method of bladder washout to minimize the likelinood of catheter blockage particularly important for those patients at risk of Autonomic Dysreflexia Patients who follow the Spinal Unit catheter protocol perform bladder washouts weekly if the patient is well If a spinal injured patients catheter blocks it must be changed immediately Currently in New Zealand there are no licensed catheter maintenance solutions available for use e g Suby G DOCUMENTATION Details regarding the catheterisation should be recorded in the patient s notes For further information please refer to your healthcare organizational policy and procedure manual e Patient details e Procedure documented in the patient s medical records and signed by the person inserting the catheter e Indication for catheterisation e Time and date of catheterisation e Catheter details and balloon size type e g Hydrogel lubricious coated silicone Ref 4501 Authorised by Clinical Nurse Specialist Page 16 of 45 July 2013 District Health Board Te Poari Hauora OM Catheter Guidelines Vaitaha Canterbury i CDHB Nursing Policies and Procedures Healt size
11. sterile gauze swab around SPC site and tape in place 22 Ensure that the catheter bag is well supported and draining below bladder level 23 Take a urine specimen for laboratory examination if required a if a sterile bag has been used specimen can be taken from the bag on this occasion 24 Ensure the patient is left dry and comfortable 25 Remove gloves and dispose of equipment in a yellow biohazard bag 26 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR 27 Record information pertaining to reason for catheterisation type of catheter expected change date etc into relevant documents Ref 4501 Authorised by Clinical Nurse Specialist Page 26 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Appendix 4 CLEAN INTERMITTENT CATHETERISATION IN THE COMMUNITY These guidelines are for patients performing the procedure themselves Please refer to your healthcare organizational policy and procedure manual Catheterisation should be done when the bladder feels full If there is no sensation of bladder fullness catheterisation should be done on waking 2 3 times during the day and just before going to bed The volumes drained off should be checked to ensure that the bladder is not holding more than 300 400ml If the volumes are more than this then catheterisation may need to be done more frequently Equipment required e Nelaton c
12. this reduces potential contamination of other equipment etc 3 Collect equipment and write bag change date on urinary drainage bag with Vivid marker pen Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on non sterile gloves Place guard or paper towel under catheter drainage bag connection point Wipe end of catheter with alcohol wipe and allow drying for 20 seconds Squeeze catheter outlet to prevent leakage Disconnect catheter from tubing Using non touch technique insert new tubing connection into catheter 10 Place used bag into receiving jug or similar 11 Ensure urine is draining 12 Ensure that the catheter bag is well supported and draining below bladder level 13 Remove gloves and dispose of equipment in a yellow biohazard bag 14 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR gt OONO Ref 4501 Authorised by Clinical Nurse Specialist Page 34 of 45 July 2013 CDHB Nursing Policies and Procedures Canterbury strict Health Board f j District Health Boarc Catheter Guidelines Te Poari Hauora 6 Waitaha ean Y Appendix 9 PROBLEM SOLVING Problem Cause Suggested Action Urinary tract infection e Poor aseptic catheterisation technique e Inadequate urethral cleaning Contamination of catheter tip Poor handling of drainage system Breaking the closed system e Obtain a CSU see procedure on obtaining catheter specimen e Review catheteris
13. 45 July 2013 CDHB Nursing Policies and Procedures Canterbury District Health Board Health Poari Hauora 6 Waitaha Catheter Guidelines Appendix 11 BLADDER AND OR URETHRAL SPASM FLOW CHART PROBLEM ACTION e Confirm size with GP surgeon Balloon Is 30 ml Yes e Change to 10 ml balloon irritating balloon bladder being wall used e Promote fluid intake e Deflate balloon and reinflate with 7 10 mls sterile water No e Promote fluid intake e Consider anticholinergic medication Spasm associated with general pain and discomfort Check size of Is it the smallest recommended gauge 12 Is it being used properly Is a catheter fixin 9 Is patient carer over handling catheter device used Daily perineal wash ls perineal hygiene Use soap and water only appropriate Latex sensitivity Change to 100 Silicone catheter Bladder Is patient Discuss possibility of reducing stopping washouts from BWO with patient Consult with Burwood BWO Burwood Spinal Unit causing Spinal bladder Unit spasm Review rationale for BWO Discuss with Jirritation patient possibility of reducing stopping BWO Bladder washouts have to Use minimal pressure when instilling fluid into bladder and minimal continue pressure when withdrawing fluid during washout Ensure 20 mls buffer of fluid left in bladder between pushes of Do minimum number of flushes Reduce frequency if possible Still a prob
14. A spare Foley and Nelaton catheter of the same size or gauge must be available at all times The Spinal Unit Protocol recommends weekly washout and fortnightly catheter change A bladder washout may be performed after a catheter change EQUIPMENT REQUIRED e Catheter pack e Hydrogel or Silicone Foley catheter of same replacement size 16 18 Ch Fg e Alcohol based hand rub One pair of sterile gloves and one pair clean gloves e 0 9 sodium chloride or antiseptic solution for cleaning e Two 10 ml syringes e Sterile water 10 ml to inflate catheter balloon e Water based soluble lubricant or anaesthetic lubricating gel e Drainage bag or catheter valve e Leg strap or tape to secure the catheter to the leg e Scissors e Disposable waterproof sheet e Receptacle for dirty swabs old catheter e Disposable plastic apron e Urine Specimen jar if required PROCEDURE 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent a ensure patient privacy and keep warm at all times b the patient may require some pain control antispasmodic medication prior to procedure due to discomfort secondary to bladder spasm Ref 4501 Authorised by Clinical Nurse Specialist Page 24 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health c check whether patient is feeling well enough for SPC change if not reschedule SPC change Burwoo
15. Canterbury District Health Board N en Health Awhi te tangala Te Poari Hauora Waitaha A HI Se Maudie Canterbury Continence Forum Health Professionals Working in Partnership CATHETER CARE GUIDELINES 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Contents ACKNOWLEDGEMENTS sssissnntenssnsasnnsiinejacsdanadnpinndaapiannsdedasianbuidsienstnsadnastadatenidenadinve 3 THE CONTINENCE REFERRERS AND PROVIDERS FORUM 3 CATHETER CARE GUIDELINES wiciiccissicisencatsucsvnesssesvatsvncsvnccsuesvatstncienedtnaniadiintsenes 4 RESPONSIBILITY OF HEALTH CARE WORKERS nnaneeenanen ena n nenen e nne ne 4 CONSENT sasabana Pan e Ga a Baka Ba agan aoa a aa Baga 4 DECISION TO GATHETERISE 5555597555 nagane na neg nenangi aana gagana ag anan ag 4 INDICATIONS FOR URINARY CATHETERISATION but are not limited to 5 POSSIBLE COMPLICA TIONG EE 6 TERM OF CATHETERISATION Intermittent Short Term Long Term 6 ASSESSMENT AND CATHETER SELECTION ccccseeeceeeeeeeeeeeeeeesneeeeeesseaes 7 CATHETER TYPES EN 7 CHOICE OF CATHETER MATERIAL 55s segs 6 sen san nega eag gae nag ag a eag agak gag EEN 8 CHOICE OF CATHETER LENGTH stssccsssstsonwonsasravcecssakisevesssnssescevansservesisbsetvensierinnes 9 CHOICE OF CATHETER SIZE DIAMETER ssssinsssassisnssanadessanvedessansdussaenchsntganuiantonse 9 CATHETER BALLOON SIZE genge d
16. LOON DOES NOT DEFLATE FLOW CHART PROBLEM ACTION e Try inserting 0 5 1ml sterile water into inflation Ridge cuff formed lumen to soften balloon ridge cuff with sterile by deflated balloon syringe e Gently twist rotate catheter Blocked deflation lumen channel e Try to remove or dislodge debris blocking the inflation lumen by gently milking the catheter along the length of the catheter e Try a different syringe withdraw water very Faulty inflation slowly or leave syringe in place the water may valve or syringe seep out over a period of time e Insert the needle of a sterile 10 ml syringe into the balloon inflation lumen just above the inflation valve If the valve is faulty the water may be withdrawn gently via the syringe Constipation present may cause pressure on inflation lumen Resolve relieve constipation e Do not cut the catheter it may recoil inside urethra e Do not cut the inflation valve off if the balloon Consult local policy does not deflate it will no longer be possible to try for further advice alternative methods or seek medical e Do not attempt to burst the balloon by over help inflating it a cystoscopy will be required to remove balloon fragments remaining fragments may result in calculi Record problem actions and outcome in patient notes Record catheter details batch number expiry date etc and report to Acknowledgement ICS Ref 4501 Authorised by Clinical Nurse Specialist Pa
17. ROCEDURE 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent 3 Ensure patient privacy and keep warm at all times 4 Assist patient into the supine position with legs extended a place a waterproof sheet under buttocks b do not expose the patient at this stage of procedure Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR Put on plastic apron Prepare equipment if using trolley place all equipment required on bottom shelf a take trolley to patients bedside 8 Open outer cover of catheterisation pack and slide the pack onto top shelf of trolley a open up pack using an aseptic technique b add catheter and other sterile equipment gloves syringe sterile leg bag or catheter valve lubricating gel c pour sterile water for balloon and 0 9 sodium chloride for cleaning into tray compartments 9 Remove bed sheet cuddly cover that is maintaining patient s privacy NO Ref 4501 Authorised by Clinical Nurse Specialist Page 22 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health a assist pt into the supine position with knees bent hips flexed and feet resting about 60 cm apart 10 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on sterile gloves 11 Place sterile drapes across patient s thighs and the fenestrated drape drape with central access hole is plac
18. aitaha Male With one hand grasp the penis at right angles from the body and cleanse using a circular motion moving from the meatus to the base of the penis Retract the penis if uncircumcised Apply lubricant to the insertion end of the catheter Hold the penis perpendicular to the body insert the catheter with firm gentle pressure Some resistance may be felt at the prostatic urethra bladder sphincter If firm gentle pressure does not overcome the resistance wait momentarily until the sphincter muscle relaxes Breathing deeply relaxing and reapplying gentle firm pressure and maintaining the penis in the perpendicular position will help Never force the catheter 5 Let the urine pass into the toilet or container leaving the catheter in place until all the urine has drained 6 When urine stops flowing slowly withdraw the catheter If more urine starts to flow stop withdrawing the catheter until the urine stops Remove catheter 7 Clean the catheter by rinsing it under clean running water tip end upward Shake dry and store in a clean dry sealed container The catheter can be used for one week and then thrown away The container should be changed or cleaned once a week 8 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR Ref 4501 Authorised by Clinical Nurse Specialist Page 28 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health ree Te Poari H
19. anterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha e Onremoval the 100 Silicone catheter balloons may not deflate smoothly or completely thus increasing the risk of urethral or SPC tract trauma Medical Devices Agency 2001 see section on catheter removal re suggestions to minimize this occurrence Metal catheters silver or stainless steel less commonly used e Used for intermittent catheterisation CHOICE OF CATHETER LENGTH Catheters are available in 3 lengths e Paediatric e Female length 20 25cm ashorter length catheter may be more convenient for ambulant women with a long term catheter IDC a female length catheter should NEVER be used with a male patient NPSA 2009 N B Only male length catheters should be used for suprapubic catheterisation unless discussed with a Urologist e Male length 40 45 cm the use of male or standard length catheters is acceptable in all patients if that is their preference CHOICE OF CATHETER SIZE DIAMETER The size or diameter of the catheter is measured in either Charri re Ch or French Fr Catheters range in size from 5 24 French gauge Fr Ideally select the smallest size possible that will drain adequately for its intended use Use of a catheter with a larger Fr Ch size increases the risk of bladder and or urethral spasm leading to pain blockage or by passing of urine If any of these symptoms occur re cathe
20. are anaesthetic gel syringe and lubricate tip of catheter 12 With your non dominant hand wrap a sterile gauze swab around penis and lift the penis this hand is now considered contaminated and should maintain a firm grasp until the procedure is completed a if non circumcised retract the foreskin b using your other hand clean the meatus with gauze swabs and 0 9 sodium chloride or antiseptic solution Use a circular motion moving from the meatus to the base of the penis 13 Insert the nozzle of the anaesthetic lubrication jelly into the urethra Slowly squeeze the gel into the urethra a once instilled hold the distal urethra closed and using the barrel of the syringe massage the gel along the urethra on the underside of the penis b wait 2 5 minutes to give the gel time to work if post urology surgery consider using two syringes 14 Grasp the penis with slight upward tension and perpendicular to the patient s body and maintain the grasp of the penis until the procedure is finished a insert the catheter into meatus with your dominant hand and gently continue insertion of catheter 15 When the first sphincter is reached at level pelvic floor muscle lower the penis 90 degrees facing patient s toes 16 If resistance is felt DO NOT USE FORCE AS YOU MAY DAMAGE THE URETHRA a consider 2nd tube of lubricant b increase the traction on the penis and apply gentle pressure on the catheter c ask the patient to take a deep breath or to cough
21. ately 50 of catheterised patients are prone to developing encrustation leading to catheter blockage some patients blocking within days others after several weeks Getliffe 1994 Catheter changes based on an individualised plan All current best practice evidence strongly advocates the development of an individualised plan of care to determine the choice of catheter and drainage system to be used and the frequency of catheter change Tenke et al 2008 e This plan should aim to prevent the complications associated with long term catheterisation and should incorporate the patients abilities personal preferences and tendency for catheter to block Miles 2009 e Most patients pattern can be established within 3 6 catheter changes and catheter changes should be planned for several days prior to the likely time of blockage Miles 2009 e Review the need for continued use of an indwelling catheter All patients should have an ongoing review in consultation with the GP Consultant patient and family of all aspects of their catheter care especially of the need for continuing with long term catheterisation APIC 2008 to meet their individual needs PERSONAL CARE Daily warm soapy water is sufficient for meatal care or prn if build up of secretions is evident Uncircumcised men should gently ease down foreskin over catheter after cleaning BOWEL CARE Good bowel care involves assessment of normal bowel habit avoiding constipation and
22. atheter Alcohol based hand rub Water based soluble lubricant or anaesthetic lubricating gel Toilet tissue or wet wipes Container for collecting urine if not using the toilet Mirror Torch or lamp A female length catheter is recommended for most women However for those who are bedridden chair bound or obese a longer male length catheter connected to a drainage bag may enhance their ability to perform the procedure Procedure 1 Perform hand hygiene 2 Set up equipment on a clean easily accessible surface a ensure catheter is within reach b open lubricant 3 Assume comfortable position This may be lying on the bed sitting on the toilet or wheelchair or standing over the toilet A mirror can be used initially to aid the localisation of the urinary meatal opening but is recommended that the palpation method be used rather than relying on a mirror 4 Remove the catheter from the clean container or packet taking care not to touch the end that will be inserted Female Separate labia and gently cleanse with downward strokes Apply lubricant to the insertion end of the catheter Part the labia with the non dominant hand hold the catheter in the other hand and gently insert the catheter into the urethra Direct the catheter upward until urine flows Ref 4501 Authorised by Clinical Nurse Specialist Page 27 of 45 July 2013 Canterbury CDHB Nursing Policies and Procedures District Health Board Health Catheter Guidelines Te Poari Hauora 6 W
23. atient into the supine position with legs extended a place a waterproof sheet under buttocks b do not expose the patient at this stage of procedure If unable to lay supine a lateral position with 1 2 pillows between legs is suitable Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR Put on plastic apron Prepare equipment a if using trolley place all equipment required on bottom shelf b take trolley to patient s bedside 8 Open outer cover of catheterisation pack and slide the pack onto top shelf of trolley a open up pack using an aseptic technique a O NO Ref 4501 Authorised by Clinical Nurse Specialist Page 19 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health b add catheter and other sterile equipment gloves syringes sterile leg bag or catheter valve anaesthetic gel c pour sterile water for balloon and 0 9 sodium chloride for cleaning into tray compartments 9 Remove bed sheet cuddly cover that is maintaining patient s privacy 10 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on sterile gloves 11 Place sterile drape across patient s thighs the fenestrated plastic sheet is placed with the hole over the penis a connect sterile catheter to sterile drainage bag or catheter valve whilst on sterile field b fill inflation syringe with 10 ml of sterile water c prep
24. ation and catheter care technique Urethral mucosal trauma and or bleeding after catheterisation e Incorrect catheter size e Poor technique e Movement of the catheter in the urethra e Creation of a false passage as a result of too rapid insertion of catheter eRe catheterise using the correct size of catheter eCheck the catheter support and apply or reapply as necessary eCheck catheter type latex sensitivity replace with 100 silicone catheter e Catheter may need to be removed while the mucosa is healing eEnsure the catheter is still draining and increase oral fluid intake to dilute and flush out the blood elf you suspect the catheter is not draining or if the bleeding has not stopped after 24 hours seek medical attention immediately No drainage after catheterisation e Incorrect identification of external meatus female e Blockage of catheter e Check that catheter has been sited correctly e If the catheter has been inserted in the vagina leave the catheter in position to act as a guide re identify the urethra and catheterise e See blocking catheter Ref 4501 Authorised by Clinical Nurse Specialist Page 35 of 45 July 2013 Canterbury CDHB Nursing Policies and Procedures District Health Board Te Poari Hauora 6 Waitaha Catheter Guidelines ean 9 e Empty bladder flow chart e Check patient s fluid status to discount dehydration increase
25. auora 6 Waitaha Appendix 5 COLLECTION OF CATHETER SPECIMENS This procedure is based on the Royal Marsden Hospital Manual and can be used as a guide only Please refer to your healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Indications Signs and symptoms of a urinary tract infection IDC in situ The patient has an indwelling catheter and at least two of the following signs and symptoms Fever gt 38 C or chills New or increased burning pain dysuria on urination frequency or urgency New flank or supra pubic pain or tenderness Change in character of urine Worsening of mental or functional status McGeer et al 1991 Ideally catheter bags with needless sample access ports should be used and disconnection of the catheter bag is not recommended Equipment required e Isopropyl Alcohol 70 swab Alcohol based hand rub Non sterile gloves Sterile Syringe barrel nozzle and needle if not a needle free system Gate clip or quick clamp Urine Specimen container Procedure 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent 3 Clamp drainage tube just below the catheter drainage bag connection until urine collects 4 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on sterile gloves 5 Clean access point with swab saturated with 70 Isopropyl Alcohol using firm friction and allow to air dry 6
26. balloons may cause drainage and deflation difficulties Testing the balloon by inflating the balloon prior to insertion is not required Bard 2003 CATHETER STORAGE Catheters should be stored flat in original packaging out of direct sunlight and NOT bundled tightly together with rubber bands Check expiry date before use CATHETER DRAINAGE BAG SELECTION Adherence to a sterile continuously closed method of urinary drainage has been shown to markedly reduce the risk of acquiring a Catheter Associated Urinary Tract Infection CAUTI ICS 2009 Selecting a system involves e Indications for catheterisation The intended duration Infection control issues Wishes of the patient Mobility of patient Dexterity of patient e g ease of emptying bag with differing outlets Variety of catheter bag outlet types Acknowledgement International Continence Society 2009 WA y Ref 4501 Authorised by Clinical Nurse Specialist Page 10 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Patients should be made aware of the importance of hand washing both before and after handling the catheter drainage system Leg bags 500 750 mls e Leg bags should be sterile and left in situ to minimise the risk of introducing infection between the catheter and bag connection point e Drainage bags must have either an anti reflux valve or anti refl
27. below thigh level Metal or plastic hangers should be attached to the side of the bed Cloth bags tied to the bed to support the bags are also available Cloudy offensive smelling or unexplained blood stained urine is not normal and needs further intervention A urine specimen for culture is taken only when clinically indicated An aseptic technique is used If cultured most urine from patients with an indwelling urinary catheter would show a degree of bacteria These catheter associated urinary tract infections in otherwise healthy patients are often asymptomatic and likely to resolve spontaneously when the catheter is removed Wong 2001 If a patient is commenced on a course of antibiotics catheter change is mandatory Prophylactic antibiotic cover for indwelling catheters is rarely necessary WHEN A PATIENT IS BEING DISCHARGED The patient and or family whanau should be given the following information e Patient handout You and Your Catheter Ref 4501 Authorised by Clinical Nurse Specialist Page 17 of 45 July 2013 CDHB Nursing Policies and Procedures Canterbury strict Hee DG H al h Lemet hean Goar a DH Catheter Guidelines Te Poari Hauora 6 Waitaha e Copy of documentation required for the health provider responsible for ongoing catheter care outlining the indication for catheterisation type of catheter e g Hydrogel silicone balloon size amount of water instilled in the balloon any problems with insertion expected
28. cient dexterity and cognitive ability is necessary to manage regular drainage ICS 2009 The Australian New Zealand Therapeutic Goods Authority ANZTGA has approved reuse of catheters in the home setting In the community C I C is a clean procedure and each catheter may be used for a week Ref 4501 Authorised by Clinical Nurse Specialist Page 6 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha People who self catheterise should continue to do so if possible during hospitalisation While in a hospital setting a new catheter should be used each time due to an increased risk of infection 2 Short term catheterisation up to 14 days ICS 2009 The Foley catheter is left in situ for up to two weeks e g in a pre operative and immediate post operative period to monitor urinary output or if medically indicated An indwelling catheter IDC should be used for the minimum possible time 3 Long term catheterisation 2 weeks to 3 months The Foley catheter is left in situ for up 3 months The catheter may be placed urethrally IDC or suprapubically SPC depending on the individual patient s circumstances Marsden Manual 2001 An indwelling catheter IDC should be changed on an individual needs basis Tenke et al 2008 This can vary dramatically from individual to individual e g if the catheter regularly blocks a pattern may be identified an
29. d Spinal Unit patients only 3 Position the patient lying on their back with SPC insertion site exposed place waterproof sheeting between nurse and patient Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR Put on plastic apron Prepare equipment if using trolley place all equipment required on bottom shelf a take trolley to patient s bedside 7 Open outer cover of catheterisation pack and slide the pack onto top shelf of trolley 8 Open up pack using an aseptic technique a add catheter and other sterile equipment gloves syringes sterile leg bag or catheter valve anaesthetic gel b pour sterile water for balloon and 0 9 sodium chloride for cleaning into each tray compartment 9 Using clean gloves remove dressing from site 10 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on sterile gloves 11 Place sterile drapes across patient s thighs and the fenestrated drape drape with central access hole is placed over the suprapubic stoma site a connect sterile catheter to sterile drainage bag or catheter valve whilst on sterile field b fill inflation syringe with 10 ml of sterile water c lubricate tip of catheter 12 Clean around catheter site thoroughly using cleaning solution and a new swab each time 13 It is suggested that inserting gel into the tract makes catheterisation easier 14 With your non dominant hand wrap a sterile swab around old catheter inflation lumen port
30. d the catheter should be changed in accordance with that pattern Miles amp Schroeder 2009 In accordance with the manufacturers recommendations for catheter usage it is recommended that catheter changes are based on e Function of the catheter e Degree of catheter encrustation e Frequency of blockage e Patient comfort ASSESSMENT AND CATHETER SELECTION Each patient s individual needs should be considered carefully when selecting a catheter These include e Indication for catheterisation APIC 2008 e Consistency of urine e Anticipated duration of catheterisation e Type of catheterisation i e urethral or suprapubic ICS 2009 CATHETER TYPES Nelaton catheter in out use e g Clean Intermittent Self Catheterisation e Straight tip f a e Specialist tip Straight tip Coude or Tiemann Coude Tiemann tip if SSC N f Acknowledgement Urol Nurses 2011 Society of Urological Nurses and Ref 4501 Authorised by Clinical Nurse Specialist Page 7 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Foley indwelling catheter IDC urethral or suprapubic SPC drainage short term or long term use e A 2 way channel most commonly used Three way eA 3 way channel for bladder irrigation e g urine containing clot or debris e Specialist tips Malecot rounded whistle tip CHOICE OF CATHETER MATERIAL Cathe
31. date of next and or subsequent catheterisation where this will take place and by whom e Who to contact if problems arise acute and non acutely Ref 4501 Authorised by Clinical Nurse Specialist Page 18 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Appendix 1 MALE CATHETERISATION This procedure is based on the Royal Marsden Hospital Manual and can be used as a guide only Please refer to your healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Ensure a good light source is available and ensure patient privacy and keep warm at all times Providing a clean working surface such as a trolley to set up catheterisation equipment is ideal Equipment required e Sterile catheterisation pack Disposable pad Sterile gloves Appropriate size Foley catheter Sterile anaesthetic lubricating jelly Lignocaine gel syringe ideally Chlorhexidine free 0 9 sodium chloride or antiseptic solution for cleaning Alcohol based hand rub Sterile water for the balloon Syringe Disposable plastic apron Leg strap or tape to secure the catheter to the leg Sterile drainage bag or catheter valve Urine bag holder if required Urine Specimen jar if required Procedure 1 Perform hand hygiene Discuss procedure with patient and gain verbal consent Ensure patient privacy and keep warm at all times Assist p
32. e http intraweb cdhb local corp quality documents PolicyHealthcareWaste pdf Chung C Chung M Paoloni R O Brien M J amp Demel T 2007 Comparison of lignocaine and water based lubricating gels for female urethral catheterisation A randomised controlled trial Emergency Medicine Australasia 19 4 315 319 Cottenden A Bliss D Z Buckley B Fader M Getliffe K Paterson J et al 2009 Management using Continence Products In P Abrams L Cardozo S Khoury amp A Wein Eds ncontinence 4 Ed pp 1519 1642 Plymouth Health Publication Department of Health 2001 Guidelines for preventing infections associated with the insertion and maintenance of short term urethral catheters in acute care Journal of Hospital Infection 47 Suppl S39 S46 Dougherty L amp Lister S Eds 2008 The Royal Marsden Hospital manual of clinical nursing procedures 7 Ed Retrieved from http www royalmarsdenmanual com Erickson B Navai N Patil M Chang A amp Gon C 2008 A prospective randomised trial evaluating the use of hydrogel coated latex versus all silicone urethral catheters after urethral reconstructive surgery Journal of Urology 179 1 203 206 Ref 4501 Authorised by Clinical Nurse Specialist Page 42 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Gammock J K 2002 Use
33. e bag is emptied regularly e Teach pelvic floor exercises as appropriate Ref 4501 Authorised by Clinical Nurse Specialist Page 36 of 45 July 2013 Canterbury District Health Board Te Poari Hauora 6 Waitaha Catheter Guidelines CDHB Nursing Policies and Procedures Health Appendix 10 BLOCKING CATHETER FLOW CHART PROBLEM Is catheter draining but slowly or not much Does catheter block occasionally Is catheter completely blocked Ref 4501 Authorised by Clinical Nurse Specialist ACTION e Increase fluid intake e Consider constipation e Consider UTI Eliminate simple mechanical obstruction e g constipation kinked tubing crossed legs restrictive clothing over full drainage bag bladder spasm consider anticholinergic e g Oxybutynin e Any grittiness when catheter gently rolled between fingers els there encrustation seen in eye of the catheter when it is removed e Consider silicone catheter wider lumen e Recommend increasing fluid intake e Consider catheter valve Establish catheters blocking pattern and then plan to change before blockage occurs At least three catheter changes are required to identify a blocking pattern e Consider trial of catheter removal for at least 48 hours e Contact Continence team Spinal Injuries Unit for advice Establish pattern and monitor Record in patient s notes Acknowledgement NMA 2010 Page 37 of
34. e catheter bag is well supported and draining below bladder level 20 Ensure the patient is left dry and comfortable 21 Remove gloves and dispose of equipment in a yellow biohazard bag 22 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR 23 Record information pertaining to reason for catheterisation type of catheter expected change date etc into relevant documents Watch point Post Obstructive Diuresis may require IV replacement of electrolytes Walker 1990 This will occur with patients with renal impairment and they require hospital admission and close observation Ref 4501 Authorised by Clinical Nurse Specialist Page 23 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Appendix 3 SUPRAPUBIC CATHETER SPC CHANGE This is based on the BURWOOD SPINAL UNIT PROTOCOL and can be used as a guide only Please refer to your healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Ensure a good light source is available and ensure patient privacy and keep warm at all times Providing a clean working surface such as a trolley to set up catheterisation equipment is the ideal The catheter must be replaced immediately if it falls out the bladder stoma alignment will become misaligned within 20 minutes and the abdominal stoma opening may close over within 24 hours
35. ed in accordance with that pattern Some patients may have their catheter changed in accordance with Burwood Spinal Unit protocol which is once every two weeks to reduce the likelihood of complication due to potential catheter blockage i e dysreflexia The catheter must be replaced immediately if it falls out because the bladder stoma alignment will become misaligned within 20 minutes and the abdominal stoma opening may close over within 24 hours Patients should have a spare Foley and Nelaton catheter the same size gauge that the patient uses available at all times in case of emergencies Suprapubic catheters must be changed in accordance with the manufacturers recommendations for catheter usage Once efficient urethral drainage has been instituted the catheter can be withdrawn and the fistula will close rapidly Peate 1997 CATHETER CHANGE PROCEDURES AND CATHETER COMFORT Use of local anaesthetic Catheter related pain or discomfort can occur as the catheter is introduced in situ or upon removal Local anaesthetic lubricant gels are commonly used to aid the insertion of indwelling catheters in males and minimize trauma Similar use of anaesthetic gel is generally recommended for females ICS 2009 Anaesthetic gels may be contraindicated in patients with damage or bleeding urethral membranes and used with caution in those with cardiac conditions hepatic insufficiency and epilepsy ISC 2009 Note due to the reports of adverse reac
36. ed over the urethral orifice a connect sterile catheter to sterile drainage bag or catheter valve whilst on sterile field b fill inflation syringe with 10 ml of sterile water c prepare anaesthetic gel syringe and lubricate tip of catheter 12 With your non dominant hand separate the labia minora to expose the urethral meatus this hand is now considered contaminated and should remain in this position until the procedure is completed 13 Using gauze swabs clean both the labia folds and the urethral meatus a move swabs from above the meatus down towards the rectum b discard each swab after each downward stroke 14 With dominant hand insert the catheter into the meatus upward at approx 30 degree angle until urine begins to flow 15 Advance the catheter as far as comfortably possible approx 6 8 cm to avoid inflating the balloon in the urethra 16 Inflate the balloon slowly using sterile water to the volume recommended on the catheter Bard 2001 a always ensure urine is flowing before inflating the balloon checking that no pain is felt by the patient 17 Withdraw the catheter slightly until resistance is felt a if not already attached connect the sterile drainage system to catheter b if specimen of urine is obtained immediately following the insertion of an IDC before the catheter bag is attached the urine can drain directly into the specimen container 18 Secure the catheter to the thigh with additional leg strap or tape 19 Ensure that th
37. eene eegen leterbeeer 10 CATHETER STORAGE aee a E A E E AT E 10 CATHETER DRAINAGE BAG SELECTION ccccesseeceeeeeseeeceeseeseeeeeeseeseees 10 INDICATIONS FOR SUPRAPUBIC CATHETERIGATION a renanen anaa nenen 12 CONTRAINDICATIONS FOR SUPRAPUBIC CATHTERIGATION eee 13 CARE OF THE SUPRAPUBIC CATHETER eaaa aaanee nana nean na nana ene n ae 13 SUPRAPUBIC CATHETER CHANGE AE eege Ee EE de 14 CATHETER CHANGE PROCEDURES AND CATHETER COMFORT 14 Ne 15 BOWEL CARE ee 15 FLUID INTAKE E 16 RRE Je E KEE 16 DOCUMENTATION ME 16 INFECTION PREVENTION AND CONTROL PRINCIPLES 0 rnnneeen nenen 17 WHEN A PATIENT IS BEING DISCHARGED aaa nanen nenen eaaa nane anana nenen 17 Appendix 1 MALE CATHETERISATION eee anane ananem anana nana anana ene 19 Appendix 2 FEMALE CATHETERISATION sanane nenen a anana nane anana n ene 22 Appendix 3 SUPRAPUBIC CATHETER SPC CHANGE lt rnananannne eaaa anae 24 Ref 4501 Authorised by Clinical Nurse Specialist Page 2 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Appendix 4 CLEAN INTERMITTENT CATHETERISATION IN THE COMMUNITY eebe 27 Appendix 5 COLLECTION OF CATHETER SPECIMENS AA 29 Appendix 6 BLADDER WASHOUT aa 31 Appendix 7 EMPTYING CATHETER BAGS AEN 33 Appendix 8 CHANGING CATHETER BAGS IN HOSPITAL oaeee 34 Appendix 9 PROBLEM SOLVING
38. en Hospital Manual of Clinical Procedures 8 Ed Retrieved 18 January 2012 from http www rmmonline co uk rmm8 procedure 1 1 ss104 Urological Society of Australia and New Zealand 2009 Pfizer s development of chlorhexidine free lignocaine 2 gel Published 10 May 2009 Ref 4501 Authorised by Clinical Nurse Specialist Page 45 of 45 July 2013
39. equired if secretions soil clothing but they are not essential e Once the insertion site has healed 7 10 days the site and catheter can be cleaned using soap and water and a clean cloth Royal Marsden Manual 2008 Cleaning should be directed away from the insertion site Talcum powder creams and strongly perfumed soaps should be avoided e Overgranulation of the site may occur A hydrocortisone based steroid cream is the preferred treatment e g Pimafucort for 5 7 days If the overgranulation is quite proud Silver Nitrate can be used on a PRN basis to cauterise the tissue until the tissue has completely sloughed Ref 4501 Authorised by Clinical Nurse Specialist Page 13 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha SUPRAPUBIC CATHETER CHANGE A new suprapubic tract usually takes between 10 days and 4 weeks to become established after which time the catheter may be changed safely The first SPC change must be performed at 4 6 weeks by a doctor or by a specialised urology nurse who is experienced in this procedure Burwood Spinal Unit recommends the first change at four weeks Long term suprapubic catheters should be changed on an individual needs basis once the suprapubic tract has healed This can vary dramatically from individual to individual e g if the catheter regularly blocks a pattern may be identified and the catheter can be chang
40. f 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Appendix 6 BLADDER WASHOUT This procedure is based on the BURWOOD SPINAL UNIT PROTOCOL and can be used as a guide only Please refer to your Healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Equipment required e Sterile bladder washout or dressing pack Isopropyl Alcohol 70 wipes x 2 One pair of sterile gloves and one pair non sterile gloves Alcohol based hand rub Gate clip or quick clamp Drainage bag Disposable waterproof sheet 60 ml syringe Normal Saline 500 ml warmed Sterile kidney dish Procedure 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent a ensure patient privacy and keep warm at all times b the patient may require some pain control antispasmodic medication prior to procedure due to discomfort secondary to bladder spasm Position your patient with catheter and drainage bag connection point exposed a place waterproof sheeting between nurse and patient Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR Put on plastic apron Prepare equipment if using trolley place all equipment required on bottom shelf Open up pack using an aseptic technique a add sterile equipment gloves 60 ml syringe sterile kidney dish container and isopropyl alcohol 70 swab 8 Warm
41. fecting the pelvis Trauma of pelvis or abdomen Inflammation of the genitourinary tract cystitis urethritis vaginal pain Immunocompromised patients Spinal cord injured patients due to risk of autonomic dysreflexia ICS 2009 INDICATIONS FOR URINARY CATHETERISATION but are not limited to Urinary drainage e During surgical procedures and post operative care e Urinary retention bladder outlet obstruction e Management of intractable incontinence where catheterisation will enhance the persons quality of life used as a last resort when alternative non invasive methods are unsatisfactory ICS 2009 e Comfort for the terminally ill Monitoring e Accurate monitoring of urine output in acute care e Urodynamic investigation Treatment e To instill medication into the bladder e Irrigate the bladder when haematuria is a concern RCN 2008 e To keep perineal area dry to assist healing in the presence of skin breakdown and or infection Precautions e Patients with cognitive impairment e Patients with existing heart valve joint replacements may require antibiotic cover e Distortion of the urethra due to recent urethral prostate surgery or trauma urethral strictures Ref 4501 Authorised by Clinical Nurse Specialist Page 5 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health POSSIBLE COMPLICATIONS e Inability to catheterise e Catheter Associated Ur
42. ge 41 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health REFERENCES APIC 2008 An APIC guide to the elimination of catheter associated urinary tract infections CAUTIs Developing and applying facility based prevention interventions in acute and long term care settings Retrieved December 8 2009 from http www apic org Content NavigationMenu PracticeGuidance APICEliminationGuides CAUTI Guide 0609 pdf Australian and New Zealand Urology Nurses 2006 Catheter Care Guidelines AUNS Catheter Care SIG Bard 2003 Indwelling catheters Integrated care pathway package Bard Limited West Sussex U K Bard 2010 Recommendations on the use of silver alloy coated catheters Retrieved from http bardmedical com Resources Products Documents Brochures Urology IC_CDC CG atheterizationRecommendations pdf Canterbury District Health Board 2011 Infection control policy and procedure Retrieved 30 January 2013 Available from the Canterbury District Health Board Policies and Procedures Web site http intraweb cdhb local manuals firstline volume 10 4812 20Volume 2010 20Transmission 20Based 20Precautions 20lsolation 20Guidelines pdf Canterbury District Health Board 2006 Legal and Quality Management of healthcare waste Retrieved 30 January 2013 Available from the Canterbury District Health Board Policies and Procedures Web sit
43. hand rub ABHR 26 Record information pertaining to reason for catheterisation type of catheter expected change date etc into relevant documents Watch point Post Obstructive Diuresis may require IV replacement of electrolytes Walker 1990 This will occur with patients with renal impairment and they require hospital admission and close observation Ref 4501 Authorised by Clinical Nurse Specialist Page 21 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Appendix 2 FEMALE CATHETERISATION This is based on the Royal Marsden Hospital Manual and can be used as a guide only Please refer to your healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Ensure a good light source is available and ensure patient privacy and keep warm at all times Providing a clean working surface such as a trolley to set up catheterisation equipment is the ideal Equipment required e Sterile catheterisation pack Sterile gloves Appropriate size Foley catheter Sterile lubricating or anaesthetic lubricating gel 0 9 sodium chloride or antiseptic solution for cleaning Alcohol based hand rub Sterile water for the balloon Syringe Disposable plastic apron Leg strap or tape to secure the catheter to the leg Sterile drainage bag or catheter valve Urine bag holder if required Urine Specimen jar if required P
44. heter valves must be changed in accordance with the manufacturers recommendations Valves are generally inappropriate after certain types of surgery e g radical prostatectomy and for patients with e Poor mobility Poor bladder capacity Detrusor overactivity Ureteric reflux Renal impairment Cognitive impairment ICS 2009 A spigot is not a suitable alternative to a valve as it has to be removed from the catheter to allow drainage and thereby breaking the closed drainage system N B New drainage bags and valves should be used when a catheter is changed INDICATIONS FOR SUPRAPUBIC CATHETERISATION For some patients the insertion of an indwelling catheter suprapubically into the bladder through the abdominal wall offers advantages over the urethral route Suprapubic catheterisation may be necessary following e Urethral trauma e g urethral stricture e Pelvic trauma In most cases the suprapubic cystotomy is a temporary measure Suprapubic catheterisation also offers advantages in e Acute care Ref 4501 Authorised by Clinical Nurse Specialist Page 12 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health facilitation of post surgical trial of voiding by temporarily clamping the suprapubic drainage tubing e Long term care for those who are sexually active in a wheelchair or have restricted hip mobility or experience urethral pain
45. inary Tract Infection C A U T I e Urethral injury Inflation of balloon before insuring correct catheter placement in the bladder False Passage by injury to the urethral wall during insertion Bladder calculi Bladder cancer ICS 2009 Haemorrhage trauma sustained during insertion or balloon inflation Urethral strictures following damage to the urethra long term problem Paraphimosis due to failure to return foreskin to normal position following catheter insertion Blitz 1995 Allergic reactions to soap catheter materials lubrication gel e Psychological trauma TERM OF CATHETERISATION Intermittent Short Term Long Term Catheterisation can be divided into three groups according to the length of time in use 1 Intermittent The catheter is inserted and removed immediately after emptying the bladder The process of intermittently catheterising is described as Clean Intermittent Catheterisation C I C or Clean Intermittent Self Catheterisation Frequency of C I C is based on individual need Intermittent catheterisation can be used e f post void residual urine volumes are more than 100ml e g acute urinary retention post surgery neurological conditions that result in urinary retention Post surgical intervention e g following Mitrofanoff procedure When medically indicated to obtain a urine specimen to check post void residual bladder volume e Ifthe concept of C I C is acceptable to user or carer e Suffi
46. is vciiscscstucscuantantdunnduasdinnennndatsdnaadsanesantecnencadvanesntia 35 Appendix 10 BLOCKING CATHETER FLOW CHAT 37 Appendix 11 BLADDER AND OR URETHRAL SPASM FLOW CHART 37 Appendix 12 URINE DOES NOT DRAIN FLOW CHAT 38 Appendix 13 URINE BY PASSING FLOW CHAT 40 Appendix 14 BALLOON DOES NOT DEFLATE FLOW CHAT 40 EE 41 This document has been formulated in consultation with Continence Nurses Urology Nurses nurses working in the field of continence management and the medical staff from the department of Urology Christchurch Hospital ACKNOWLEDGEMENTS Andrea Lord Nurse Consultant Anne Murray Urology Unit Clinical Charge Nurse Christchurch Hospital Di Poole Continence Clinical Nurse Specialist The Princess Margaret Hospital Jane Harvey Continence Clinical Nurse Specialist Karen Betony Clinical Nurse Educator Nurse Maude Association Nicky Varcoe Clinical Nurse Specialist Urodynamic Unit Burwood Spinal Unit Ruth Abrams Urology Clinical Nurse Specialist Christchurch Hospital Sharon English Urologist Stephen Mark Urologist Sue Chambers Continence Clinical Nurse Specialist Christchurch Hospital Val Sandston Clinical Manager Middlepark Rest home and Village THE CONTINENCE REFERRERS AND PROVIDERS FORUM Canterbury funders and providers working together to promote continence services for the population of Canterbury The forum provides support and liaison among people and services involved in conti
47. l sterile saline 60 ml into bladder and then gently withdraw 60 ml 19 Continue this process until urine runs clear or patient indicates 20 With final instillation leave 30 ml in bladder 21 Swab connection with Isopropyl Alcohol 70 wipe and attach drainage to catheter 22 Remove gloves and dispose of equipment in a yellow biohazard bag 23 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR 24 Document procedure and any abnormalities in patients notes Ref 4501 Authorised by Clinical Nurse Specialist Page 32 of 45 July 2013 Catheter Guidelines Te Poari Hau 5 Waitaha Caritorbury CDHB Nursing Policies and Procedures District Health Board Health Appendix 7 EMPTYING CATHETER BAGS This procedure is based on the Royal Marsden Hospital Manual and can be used as a guide only Please refer to your healthcare organizational policy and procedure manual Standard precautions and principles of asepsis to be used Catheter bags should be emptied every 3 5 hours or when full Equipment required e Isopropyl Alcohol 70 wipes x 2 e One pair non sterile gloves e Alcohol based hand rub Clean Jug specified for this use and large enough to avoid spillage e g 2 3 litres Procedure 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent a ensure patient privacy and keep warm at all times b when emptying catheter bags avoid interruption until task is completed this reduces potential conta
48. lem Keep catheter movement to a minimum Discuss with GP wars Sege l l Is patient taking anticholinergic medication Discuss with G P Consultant Continence team Ref 4501 Authorised by Clinical Nurse Specialist Page 38 of 45 July 2013 CDHB Nursing Policies and Procedures Canterbury District Health Board Health Poari Hauora 6 Waitaha Catheter Guidelines Appendix 12 URINE DOES NOT DRAIN FLOW CHART PROBLEM ACTION Y Empty Bag Drainage bag gt 2 3 full Check positioning of drainage bag and tubing is the bag below the level of the bladder is the tubing kinked or twisted is the patient sitting on it Adjust position of drainage bag and or tubing Bladder mucosa obstructing Raise the bag above level of bladder catheter eyes suction briefly to relieve suction pressure pressure Recurrent catheter Catheter blockage by Try to relieve blockage and identify cause blockages see mucus cellular or bacterial milk the catheter gently along its length Blocking debris and or mineral change catheter and observe nature of catheter flow deposits blockage cut open eye of catheter to view p men chart Catheter blocked by Treat immediate cause of blockage pressure from faecal loading and reassess management of bowels in lower bowel Catheter blocked by bladder calculi Change catheter and perform ki Cystoscopy and removal of stones Unexplained problem
49. mination of other equipment etc Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on non sterile gloves Clean drainage bag outlet valve with Isopropy Alcohol 70 wipes Place jug under drainage bag out let holding jug at an angle Position a disposable paper towel to protect floor from spills Empty drainage bag directly into jug After emptying the bag wipe the end of the catheter outlet with an alcohol swab Note the amount and colour of drainage record prn 10 Empty jug carefully down the sluice to avoid splashing 11 Place jug straight into sanitizer and store dry 12 Remove gloves and wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR o ONDA Ref 4501 Authorised by Clinical Nurse Specialist Page 33 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health BE Te Poari Hauora 6 Waitaha Appendix 8 CHANGING CATHETER BAGS IN HOSPITAL Standard precautions and principles of asepsis to be used Equipment required e Disposable gloves Alcohol based hand rub Isopropyl Alcohol 70 wipes x 2 Clean guard or paper towel New urinary drainage bag Waterproof vivid pen not biro Container for old catheter bag Procedure 1 Perform hand hygiene 2 Discuss procedure with patient and gain verbal consent a ensure patient privacy and keep warm at all times b when emptying catheter bags avoid interruption until task is completed
50. nence service provision funding research and education in Canterbury Ref 4501 Authorised by Clinical Nurse Specialist Page 3 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health CATHETER CARE GUIDELINES These guidelines are based on current clinical practice in New Zealand and internationally where possible supported by published research articles The information contained in this document is strictly for guidance purposes and does not supersede individual institutions policy and procedure guidelines Adherence to the instructions published by product manufacturers is strongly recommended The authors take no responsibility for any adverse events incurred as a result of using information within this document RESPONSIBILITY OF HEALTH CARE WORKERS e To acquire adequate training to carry out the procedure defined by place of work Self monitoring is required to ensure the skill of catheterisation is up to date e Accurate assessment of specific clinical indication for catheterisation e To minimize the trauma and infection risk associated with inserting and maintaining urinary catheters Risk prevention aseptic technique competent staff and sterile equipment Risk reduction intermittent catheterisation instead of indwelling catheterisation e Tominimize psychological trauma to the patient e Nurses need to know what type of catheter equipmen
51. or to try to pass urine d gently rotate the catheter 17 Continue to advance the catheter to the bifurcation junction observe urine flow e Bifurcation junction Ref 4501 Authorised by Clinical Nurse Specialist Page 20 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health If urine does not flow immediately lignocaine gel may be causing blockage in which case a flush may be required 18 Inflate the balloon slowly using sterile water to the volume recommended on the catheter Bard 2001 a always ensure urine is flowing before inflating the balloon checking that no pain is felt by the patient b if there is pain it could indicate the catheter is not in the bladder 19 Withdraw the catheter slightly until resistance is felt a if not already attached connect the sterile drainage system to the catheter b if a specimen of urine is obtained immediately following the insertion of an IDC before the catheter bag is attached the urine can drain directly into the specimen container 20 Secure the catheter to the thigh with additional leg strap or tape 21 Ensure that the catheter bag is well supported and draining below bladder level 22 Reposition the foreskin if applicable 23 Ensure the patient is left dry and comfortable 24 Remove gloves and dispose of equipment in a yellow biohazard bag 25 Wash hands with antimicrobial liquid soap or alcohol based
52. roeder J 2009 An evidence based approach to urinary catheter changes British Journal of Community Nursing 14 5 182 187 Moore K et al 2009 Do catheter washouts extend patency time in long term indwelling urethral catheters A randomized controlled trial of acidic washout solution normal saline washout or standard care Journal of Wound Ostomy and Continence Nursing 36 1 82 90 National Clinical Guidance Centre 2012 Partial update of NICE clinical guidelines 2 Infection Prevention of healthcare associated infection in primary and community care Retrieved October 16 2012 from http www nice org uk nicemedis live 13684 58654 58654 pdf National Patient Safety Authority NPSA 2009 Female urinary catheters causing trauma to adult males Retrieved May 22 2010 from http www nrls nosa nhs uk resources Entryld45 59897 New Zealand Government Medsafe 2010 New Zealand Data Sheet APO OXYBUTYNIN Retrieved September 2011 from http www medsafe govt nz profs datasheet a apooxybutynintabsyrup pdf Ref 4501 Authorised by Clinical Nurse Specialist Page 43 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health NZNO 2010 Self directed learning package Registered Nurse first assist for the placement of P E G tubes in endoscopy suites in New Zealand Retrieved October 17 2011 from http www nzno org nz LinkClick asp
53. sterile saline 500m and a pour into sterile jug in the community the saline may be drawn directly from the new bottle b keep empty saline bottle beside dressing table for collection of bladder washout fluid 9 Clean catheter and drainage bag connection point with swab saturated with 70 Isopropyl Alcohol using firm friction and allow to air dry 10 Wash hands with antimicrobial liquid soap or alcohol based hand rub ABHR and put on sterile gloves 11 Clamp the outlet end of catheter below bifurcation junction with quick clamp or using sterile swab pinch shut using fingers and thumb a some Foley catheters Releen cannot be used with the quick clamp w pl ar Ref 4501 Authorised by Clinical Nurse Specialist Page 31 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health 12 Disconnect catheter from bag and wipe catheter outlet with Isopropyl Alcohol 70 swab and keep this in place in between instillations 13 Using 60 ml syringe draw up 60 ml of warmed normal saline ejecting any air in syringe 14 Attach syringe to catheter outlet 15 Release clamp of catheter and gently instill 60 mls saline 16 Then gently withdraw 30 ml saline ensuring 30 ml remains in bladder a discard used solution into old saline bottle container 17 Draw up 60 ml of warmed normal saline and attach syringe to catheter outlet 18 Gently instil
54. straining and discussing dietary intervention The use of antispasmodic drugs e g oxybutynin for catheter related bladder irritation may contribute to constipation and decreased gastrointestinal motility Medsafe 2010 Straining in association with Ref 4501 Authorised by Clinical Nurse Specialist Page 15 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health emptying bowels contributes to bladder spasm catheter bypassing and catheter blockage FLUID INTAKE To assist in maintenance of catheter patency a general recommendation is 1 1 5 litres fluid intake daily ICS 2009 However the amount of fluid intake recommended for an individual needs to be considered in the context of that individual s medical status and physiological requirements Getliffe 1994 Drinking orange juice or other fruit juices such as lemon or lime has been shown to increase time to catheter blockage ICS 2009 BLADDER WASHOUT The use of bladder washouts remains controversial Bladder instillations or washouts consist of the instillation of a solution into the bladder via a catheter Holtom 2003 Breaking the closed system to perform a bladder washout will increase the risk of infection If a bladder washout has to be performed an aseptic technique must be followed Whilst evidence fails to demonstrate any beneficial effect from irrigation instillation or washout
55. t is available and know the benefits and disadvantages of the catheter equipment used e Nurses should ensure that all catheter equipment is used according to manufacturers guidelines and only be used for the purpose it was designed for Royal College of Nurses 2008 CONSENT e To obtain consent for the procedure of catheterisation consent is required for all aspects of catheter care including catheter removal Risks are explained in the process of consent including blockage discomfort infection bleeding and in men painful erection e Initial catheterisation should be in consultation with a medical practitioner DECISION TO CATHETERISE Most patients with long term indwelling urinary catheters experience some complications at some time with many experiencing frequent and distressing complications so the decision to use catheters long term should only be taken after all other options have been explored and their use should be regularly reviewed Ref 4501 Authorised by Clinical Nurse Specialist Page 4 of 45 July 2013 Catheter Guidelines Canterbury CDHB Nursing Policies and Procedures District Health Board Health Te Poari Hauora 6 Waitaha Factors to consider prior to catheterisation e ls there an alternative less invasive method of management History of haematuria and or discharge History of urethral obstruction or previous catheterisation History of recent surgery or malignancy to the lower urinary tract Congenital abnormalities af
56. terisation with a smaller size should occur Children require smaller paediatric catheters generally until they reach puberty when they move into the adult sizes General Guide e Adults 12 16 Fr ICS 2009 To assist consistency of practice the Canterbury Urologists have agreed that 16 Fr should be the catheter size of first choice in the community however Nurse Maude staff should adhere to their policy which focuses on individual care Urology Dept 2012 e Suprapubic 16 20 Fr e Haematuria 20 24 Fr Ref 4501 Authorised by Clinical Nurse Specialist Page 9 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health a3way haematuria catheter should be used to allow for the option of continuous bladder irrigation without requiring a further catheter change When not in use the irrigating port should be spigotted CATHETER BALLOON SIZE Foley catheters are retained in the bladder by a balloon filled with sterile water The balloon sizes range from 5 30 mls The smaller 10 ml balloon size is recommended for all adults to minimize the risk of discomfort and bladder irritation ICS 2009 The balloon should be fully inflated to the recommended volume indicated on the packaging and inflation valve of the catheter A 10ml balloon should be filled with between 7 10mls of sterile water The amount of water inserted should be documented Improperly inflated
57. ters are made of non toxic polyvinylchloride latex or silicone and these may have a silicone hydrophilic or silver coating All catheters should be used in accordance with manufacturers instructions and conform to the Australia New Zealand Therapeutic Products Agency ANZTPA standards Nelaton catheter non toxic polyvinylchloride with hydrophilic and or silicone coating e Used for intermittent catheterisation e Coated catheters may reduce urethral trauma and CAUTI ICS 2009 Foley Latex based silicone coated catheter e Short term use up to 6 weeks e May be used for IDC SPC Foley Latex based Hydrogel coated catheter e Long term use up to 12 weeks e May be used for IDC SPC Foley Latex based Silver alloy coated catheter e Short term use up to 2 weeks Bard 2010 e May be considered to reduce the risk of catheter associated infection but further economic evaluations are required to determine cost benefit ICS 2009 e May be used for IDC SPC Foley 100 Silicone based catheter Latex free e Long term use up to 12 weeks e May be used for IDC SPC e Drainage lumen is wider and so may reduce the level of catheter encrustation and blockage e Silicone catheters may be more rigid than latex catheters and less comfortable for the patient e Silicone is semi permeable and the balloon may require re inflating at regular intervals Ref 4501 Authorised by Clinical Nurse Specialist Page 8 of 45 July 2013 Catheter Guidelines C
58. tions the Urological Society of Australia and New Zealand recommend the use of Chlorhexidine free Lignocaine gel wherever possible USANZ 2009 If bladder spasm is the cause of catheter related pain a low dose of an anticholinergic medication can help ICS 2009 Ref 4501 Authorised by Clinical Nurse Specialist Page 14 of 45 July 2013 Catheter Guidelines Te Poari Hauora 6 Waitaha Canterbury CDHB Nursing Policies and Procedures District Health Board Health Catheter change urethral or suprapubic Protocols on indwelling catheter change frequency can vary widely from two weekly to up to 3 months if the catheter is trouble free In the absence of clear supporting evidence this remains an area of controversy There are two differing approaches early change vs a longer change interval More frequent changes reduce incidence of complications but increase risk of infection trauma and long term histological changes as well as use of increased resources Leaving a catheter in place until it blocks has significant impact upon both the patient and family as well as placing unplanned demand upon health care services Catheters should not remain in situ beyond the manufacturers recommended guidelines RCN 2008 up to 12 weeks for silicone and hydrophilic coated Latex Foley catheters The only clinical indications to change a catheter sooner are infection obstruction or when the closed system is compromised Gould et al 2010 Approxim
59. ux chamber to prevent reflux of contaminated urine from the bag into the tubing e tis recommended that drainage bags should have a sample access port for the collection of urine specimens while maintaining a closed system preferably needle free e Most commonly they are disposed and discarded after 1 week however latex based leg bags can be used for longer periods of time e Used during the day and secured to the leg in a variety of ways e g leg straps leggi fix or catheter bag holders strapped from the waist the belly bag may be placed upon the abdomen e Legs bags must be kept below the level of the bladder some people may choose to wear the leg bag on their thigh others prefer to wear the leg bag on their calf e Leg bags can also be used to reduce trauma for the confused or forgetful patient while in hospital e Drainage tubing on leg bags is available in different lengths and can be tailored to individual s requirements e The leg bag should only be disconnected from the catheter when the bag is due to be changed or when the catheter needs changing e Atnight a larger capacity bag is attached to the bottom of the leg bag providing a link system and allowing for greater drainage Stewart 1998 e The general recommendation for changing disposable drainage bags is weekly or when they become damaged odorous or have sediment in the bottom www nhshealthquality org 2004 Disposable 2 litre plastic bags night bag e For general use in
60. x fileticket um_ cYKwZlOw 3D amp tabid 358 NHS Quality Improvement Scotland 2004 Best practice statement urinary catheterisation and catheter care Retrieved from www nhshealthquality org Peate 1997 Patient management following suprapubic catheterisation British Journal of Nursing 6 1 551 562 Practices Advisory Committee HICPAC 2010 HICPAC Guideline for prevention of catheter associated urinary tract infections Infection Control and Hospital Epidemiology 31 4 319 326 Pratt R J Pellowe C M Wilson J A Loveday H P Harper P J Jones S R et al 2007 Epic 2 National evidence based guidelines for preventing healthcare associated infections in the NHS Hospitals in England Journal of Hospital Infection 65 Suppl 1 1 64 Queensland Government Queensland Health 2002 What is a suprapubic catheter SPC Raz R Schiller D amp Nicolle L E 2000 Chronic indwelling catheter replacement before antimicrobial therapy for symptomatic urinary tract infection Journal of Urology 164 1254 1258 Royal College of Nursing 2008 Catheter care guidance for nurses Retrieved January 24 2010 from http www rcn org uk data assets pdf_file 0018 157410 003237 pdf Schamovitz G Z 2012 Urethral catheterisation in women periprocedural care Retrieved October 16 2012 from http emedicine medscape com article 80735 periprocedure aw2aab6b3b2 Simpson C amp Clark A P 2005 Nosocomial UTI

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