GUIDELINES FOR THE SELECTION AND MANAGEMENT OF … · For measurement of urine output in the acutely ill child, e.g. trauma, sepsis, renal failure, urine retention. NOTE - in cases

CAEC Reg. ID. No. 828 Sheffield Children’s (NHS) Foundation Trust

GUIDELINES FOR THE SELECTION AND MANAGEMENT OF URETHRAL CATHETERS IN THE HOSPITAL/COMMUNITY SETTING

Author: Jo Searles Review date: July 2017 © SC(NHS)FT 2017. Not for use outside the Trust. Page 1 of 25

GUIDELINES FOR THE SELECTION AND MANAGEMENT OF URETHRAL CATHETERS IN THE HOSPITAL/COMMUNITY

SETTING

Reference: 828v4 Written by: Jo Searles Peer reviewer: Prasad Godbole Approved: November 2017 Review Due: October 2020

Purpose To provide guidance regarding the selection of appropriate catheters, catheterisation procedure and management of catheters, in order to maximise patient safety and comfort.

Intended audience

These guidelines and procedures are aimed at all staff within the hospital and community who are involved with: Selection of catheters for catheterisation Procedure of catheterisation Care and management of catheters Except where specifically stated, these guidelines refer to urethral catheterisation.




Contents

1. Introduction ............................................................................................................ 3 2. Intended Audience ................................................................................................. 3 3. Guideline Content .................................................................................................. 3

Background .......................................................................................................... 3 Indications For And Methods Of Catheterisation .................................................. 4 Selection Of Appropriate Catheter ........................................................................ 5 Catheterisation Procedure .................................................................................... 8 Drainage Systems ................................................................................................ 8 Catheter Care and Maintenance .......................................................................... 9 Discharge Home ................................................................................................ 11 Summary of Main Points .................................................................................... 11 Appendix 1: Sterile Procedure - Male/Female Urinary Catheterisation and Catheterisation of Mitrofanoff ............................................................................. 13 Appendix 2: Clean Procedure for Intermittent Catheterisation for Patient/Parent/Carer .......................................................................................... 16 Appendix 3: Procedure - Emptying a Catheter Bag ............................................ 17 Appendix 4: Hospital Procedure – Catheter Flush .............................................. 18 Appendix 4A: Home Procedure – Bladder Flush ................................................ 19 Appendix 5: Procedure – Bladder Washout Following Augmentation ................. 20 Appendix 6: Procedure – Installation Of Catheter Maintenance Solutions .......... 21 Appendix 7: Procedure - Collection Of A Catheter Specimen Of Urine ............... 22 Appendix 8: Procedure - Removal Of A Catheter ............................................... 23

4. References ........................................................................................................... 24




GUIDELINES FOR SELECTION AND MANAGEMENT OF URETHRAL CATHETERISATION IN THE HOSPITAL/COMMUNITY SETTING

1. Introduction

To provide guidance in the selection of appropriate catheters, catheterisation procedure and management of catheters, in order to maximise patient safety and comfort.

2. Intended Audience These guidelines and procedures are aimed at all staff within the hospital and community who are involved with: Selection of catheters for catheterisation Procedure of catheterisation Care and management of catheters Except where specifically stated, these guidelines refer to urethral catheterisation. The principles and catheter care once in place are the same for all catheters.

3. Guideline Content

Background In adults urinary tract infections account for approximately 23% of all health care associated infections. Approximately 8% of these are associated with the presence of an indwelling catheter. The risk of developing bacteriuria from urinary indwelling catheterisation increases at a rate of 3-10% per day. Of those who develop bacteriuria 2-6% develop urinary tract infection, of which 1-4% develop bacteraemia with a mortality rate of 15-30%. In the absence of data relating to children it is prudent to assume similar, if not greater risks than with adults. The risk of infection is associated with the method and duration of catheterisation, quality of the catheter care and susceptibility of the host. It is essential therefore, that careful assessment is made of the need for catheterisation and that the most appropriate equipment is selected, used and managed safely, to minimise the risk to patients. The main principles guiding catheterisation and catheter management are therefore associated with minimising infection risk and maximising comfort, dignity and concordance. They are: 1) Catheterise only when all other methods of management are not appropriate 2) Consider purpose of catheterisation and, for long term use, utilise intermittent or supra-pubic catheterisation where possible, in preference to an indwelling urethral catheter 3) The necessity for continuing urethral catheterisation, should be reviewed at least daily and the catheter removed at the earliest opportunity.( Nicolle LE 2014)




4) Catheterisation should be carried out by trained, competent personnel. The professional undertaking the procedure is responsible for selecting the appropriate catheter required for the purpose. 5) Within the hospital setting, catheterisation should always be carried out as a sterile procedure to minimize hospital acquired infections. NOTE - The only exception is when catheterisation is performed in hospital by the child/parent/carer when this can be undertaken as a clean procedure. 6) All staff caring for catheters should minimise the risk of infection by using correct catheter management techniques at all times... Indications For And Methods Of Catheterisation Indications for Catheterisation Acute For measurement of urine output in the acutely ill child, e.g. trauma, sepsis, renal failure, urine retention. NOTE - in cases of suspected urethral trauma an urgent urological opinion should be sought before catheterisation. Planned - Short-term

o Urological/pelvic surgical procedures. o Epidural analgesia (because of high risk of urinary retention) o Major surgery e.g. scoliosis surgery, major laparotomy o Diagnostic procedures eg mcug ,urodynamics

Long-term o management of deteriorating renal function o intractable incontinence (as a last resort where all other methods,

such as voiding programmes, continence aids, behavioural/environmental modification and medication have been tried, and proven ineffective).

o Management of neuropathic bladder Urine Sampling - Intermittent catheterisation may also be used for urine sampling, Methods of Catheterisation There are three methods of catheterisation: Intermittent urethral Indwelling (urethral) Suprapubic Intermittent Self-catheterisation, A catheter is inserted into the bladder to drain urine and is then removed. This may be via the urethra or via a Mitrofanoff stoma. (A Mitrofanoff stoma is a non-refluxing conduit surgically created between the bladder and abdominal wall. Advantages:

o Reduced risk of infection o Minimal risk of catheter blockage o Increased freedom and independence

Disadvantages: o Procedure requires a highly motivated co-operative child and/or parent




o Urethral intermittent catheterisation may be painful or problematic if the child has impaired mobility and/or manual dexterity.

Indwelling (urethral) Catheterisation Advantages

o Allows short-term measurement of urine output in postoperative / critically ill patients

o Short-term relief or prevention of urinary retention Disadvantages

o Risk of urethral damage on insertion (particularly in male patients) o Risk of urinary tract infection

Supra-pubic Catheterisation Advantages:

o No risk of urethral damage o Less risk of acquired urinary infection compared to urethral

catheterisation o Easier to manage if not ambulant

Disadvantages: o Complication of encrustation/over-granulation around supra-pubic

stoma site o Urethral leakage may occur o Catheter has to be inserted under general anaesthesia

Intermittent and supra-pubic catheterisations therefore have benefits over indwelling urethral catheterisation. If long-term catheterisation is necessary and intermittent catheterisation is not appropriate, supra-pubic catheterisation is preferable to indwelling urethral catheterisation and should therefore be the treatment of choice. Selection Of Appropriate Catheter It is the responsibility of the professional undertaking catheterisation to select the appropriate catheter, taking into consideration the age and size of the child, the purpose and duration for which it is required and the comfort and practical management of the system selected. The following should be considered:

o Material o Length o Diameter/circumference o Balloon size o Drainage system to be attached o Suitability for purpose

1) Catheters for intermittent urethral/Mitrofanoff stoma catheterisation are:

o Plastic Nelaton/non-hydrophilic - non-coated so require lubrication prior to insertion

o Gel pre-coated e.g. Hollister Advance o Hydrophilic e.g. Lofric/Easicath/Speedicath




Whichever catheter is selected the procedure of intermittent catheterisation is a clean procedure at home, but must be performed in hospital setting as a sterile procedure. All catheters used in hospital must be single use only, although patients may re-use nelaton/non-hydrophylic catheters at home. Pre-coated catheters i.e. hydrophylic and gel coated, may reduce trauma and potential urethral strictures therefore they should be promoted where possible in preference to Nelaton catheters (MDA 2000 ) unless coated catheters cannot be used. Intermittent catheters are semi-rigid and are not designed for indwelling use. If the catheter has hydrophilic coating it must not be left in-situ for any length of time (more than 10 minutes) as the coating will dry out and removal of the catheter will cause trauma. 2) Catheters available for short-term indwelling use:

-Latex - These are prone to encrustation and there is associated increase in the risk of trauma and discomfort. -94% latex 6% chemicals - These are associated with increased irritation and reactions to chemicals and should therefore, be avoided. -PTFE (Teflon) coated latex – These have a smooth surface, reducing encrustation, discomfort and trauma. Last 4-6weeks.

3) Catheters available for long-term indwelling use:

o Biocath - hydrogel coated. Latex bonded with a hydrogel coating.

Hydrogel surface is more resistant to bacterial colonisation and encrustation. Last 3-12weeks.

o All silicone - A latex-free catheter suitable for patients with latex allergy (actual or potential). Catheter walls are thinner and internal diameter is equal to a higher gauge catheter.

NOTE – With silicone catheters the balloon may deflate over time as silicone allows water to diffuse through the balloon membrane. Clinicians may recommend that the balloon infill is checked and refilled during the lifespan of the catheter to prevent it from falling out especially where small volumes of water are used in the balloon . In view of the increased risk of urethral stricture and latex allergy in children, an 'all silicone' catheter is recommended as first choice (Talja et al 1990). Silicone catheter are less likely to cause urethral inflammation than latex. ( Nicolle 2012) Hydrogel catheters may be used as an alternative to all silicone, if there is no risk of latex allergy. Wherever possible, patient’s personal preference should be considered in order to increase compliance, e.g. with intermittent catheters the slippery nature of a hydrophyllic catheter may be prohibitive for some children with dexterity problems and a Nelaton catheter may therefore be the best choice. NOTE – The duration of use given for all catheters is approximate and depends on the individual patient. Length - Catheters come in three lengths: Paediatric - 30cm Male - 43cm Female - 26cm




It is important to select the correct length to: - ensure effective drainage Minimize risk of inflation in the urethra in males - minimise possibility of kinking - maximise normal activity of the child e.g. a male length indwelling/supra-pubic catheter in a small child will inhibit mobility and is more likely to be pulled or kink. NOTE - A male length catheter is required in Mitrofanoff patients whether male or female, to ensure adequate drainage of the bladder. Diameter - There has to be a compromise regarding catheter diameter. The wider the catheter the better is the drainage, but the greater is the risk of urethral trauma and bladder spasms. In general, the smallest gauge catheter possible for adequate drainage should be used for urethral catheterisation. For Mitrofanoff stomas the largest gauge possible is required for drainage particularly following augmentation, in order to effectively clear resulting debris and mucous. Feeding Tubes - These have sometimes been used as an alternative to a catheter. Caution should be exercised since there are issues of practitioner liability (Medical Advice Agency 2010) and risks of the tube knotting the bladder (Foster et al 1992, McGillvray 2002). Feeding tubes have been used in the absence of small sized catheters, notably for neonates/premature babies. Size 4 and 6 Nelaton (non ballooned) catheters are available for use in small babies and neonates and have the same lumen as the equivalent feeding tube. These are licensed for bladder drainage and can be taped in situ negating the need to use feeding tubes. These catheters should also be used for investigations such as micturating cysto-urethrograms if small Foley catheters are unavailable. Balloon size

o Balloons should be inflated with sterile water using - air/saline/tap water etc. can affect drainage, cause irritation, increase transfer of bacteria and cause crystal formation and therefore should not be used.

o Balloon sizes vary from 3ml-30ml capacity. o In children the balloon capacity selected should be as small as

possible i.e. 3ml or 5ml capacity and the balloon should be filled with between 3ml-5mls depending on the age/bladder capacity of the child of the child (see fig.1).

o The larger the balloon is inflated the larger the residual volume in the bladder and the greater the risk of irritation and bladder spasm.

o Underfilling or overfilling of the balloon can cause balloon distortion, ineffective drainage or bladder spasm and the catheter will beless reliable retained.

o In neonates, if Foley catheters are used, these should be taped in situ and the balloon not inflated.

The size of the catheter selected for both intermittent and indwelling use and the degree of inflation of the balloon depends on the age, size and bladder capacity of the child. (General guidelines are given in fig.1)




Fig.1 Size Guide for Catheter Selection

Age Intermittent catheter

(Non ballooned)

Indwelling catheter Water to balloon

Neonate 4-6 4-6 Nelaton catheter Taped in situ

Infant (< 1year) 6 6 Foley/Nelaton 1.5ml

Infant (1-5 years) 8-10 8-10Fr Foley 2-3ml

Child (5 years to puberty)

12 12Fr Foley 5ml

Adolescent 12-14 12-14Fr Foley 5ml

Catheterisation Procedure Catheterisation can be performed by staff band 3 and above providing they are fully trained. All staff, once trained, can catheterise both male and female patients. Where possible, dignity and patient choice should be considered when identifying staff to catheterisation. Staff undertaking male catheterisation should have completed relevant training and competency package. The full procedures for male and female sterile catheterisation and clean intermittent catheterisation can be found in appendices 1 and 2 respectively. Drainage Systems Once an indwelling catheter is inserted it is important to select the most appropriate drainage system to control or collect the output of urine. This may be in the form of bags, valves or spigots. Wherever possible, a closed, sterile, continuous drainage system should be used. In research carried out in adults, this has been shown to reduce infection rates from 97% to between 8 and 15% (Lo 2014 ,Yates 2016 ). This system minimizes the number of times the system is broken into and therefore reduces the risk of infection. Drainage bags If continuous drainage is required and the patient is ambulant a sterile leg bag correctly secured and supported should be used. The size required will depend on the size of the child. 100ml ,125ml , 350ml and 500ml bags are available t. The length of the tube chosen, should also be dictated by the size of the child (i.e. short tube or long tube). An overnight bag should be connected onto the leg bag at night. This can then be removed the next morning, leaving the leg bag in situ for daytime use. The leg bag and catheter should not be disconnected unnecessarily. Night bags should not be re-used in the hospital setting, but drainable night bags can be rinsed out and re-used at home (EPIC 3 guidelines 2014). Catheter drainage bags should be positioned below the level of the bladder to prevent potential reflux/potential infection. This should be no greater than 30cm below bladder level, as a suction effect can occur which can pull the bladder mucosa into the catheter eye, causing blocking of the catheter and trauma to the bladder mucosa (Getliffe 2007). Night bags should be placed on a stand, avoiding contact with the floor (EPIC 3 Guidelines 2014).




Catheter valves If continuous drainage is not necessary, the use of a catheter valve will: - Allow greater freedom - Encourage the normal activity of the bladder

- Promote usual bladder capacity - Maintain a closed system, minimising infection

The catheter valve should be used in long-term situations in preference to spigots and can be used with urethral, or supra-pubic catheters. Bags and catheter valves should be changed every 5-7 days Night bags should be changed daily in hospital, but can be washed out at home and changed every 5-7 days (EPIC 3 guidelines 2014). Emptying drainage bags Cross infection is most likely to occur during changing and emptying of drainage bags (Getliffe K, Dolman M, 2003 ), therefore bags should be emptied often enough to maintain urine flow to prevent reflux, i.e. no more than 2/3 full, but not unnecessarily (EPIC3 guidelines 2014).

Hands must be washed before bags are emptied, and non-sterile latex free gloves applied.

A clean container should be used for each patient, avoiding contact between drainage tap and container.

The drainage tap should be wiped with tissue/wipes to prevent contamination.

Urine should be disposed of in an appropriate place.

The container should be cleaned or disposed of along with gloves.

Hands must be washed after procedure.

(Procedure for emptying a catheter bag is available in Appendix 3) Catheter Care and Maintenance Cleaning the catheter Daily bathing or showering using soap and water is sufficient to ensure the catheter remains clean. There is no proven benefit to routine urethral/meatal cleansing (catheter toileting), or the routine use of antiseptic/antimicrobial solutions (Classen et al 1991. EPIC3 guidelines 2014). Bladder Flush/Washouts To unblock and reduce encrustation of indwelling catheters, it may be necessary to flush the catheter. This can be done with cooled boiled water in the home situation, or normal saline in hospital. The fluid should be instilled gently and not drawn back in a normal bladder, as this may cause trauma to the bladder mucosa (Getliffe K, Dolman M, 2007). In some instances however, agitation of solutions instilled into the bladder may be appropriate, e.g. following bladder augmentation. Repeated irrigation and agitation to washout the bladder may be necessary following surgery, this can be required several times a day to clear the excessive mucous which may be produced. Washouts should be decreased gradually as the mucous production reduces, but current good practice advocates at least weekly washouts for life where




bladders have been augmented, as this is thought to decrease the risk of stone formation. (Procedures for bladder flush and bladder washout can be found in appendix 5) Catheter Maintenance Solutions There are a number of catheter maintenance solutions available, which can be used to minimise encrustation and maintain catheter life if there are recurrent problems with blockages. NOTE - There is no indication for prophylactic use of catheter maintenance solutions in reduction/prevention of infection (Association for Continence Advice 2007. EPIC 3 guidelines 2014). All other causes of blockage should be eliminated prior to considering use of catheter maintenance solutions i.e. kinking, positioning, constipation, detrusor spasm. The 3 commonly used catheter maintenance solutions available on prescription are: 1) Sodium Chloride 0.9% - Used to irrigate catheters, particularly if there is pus, blood, clots or debris present, however, will not dissolve encrustation. 2) Suby G (3.2% citric acid) - Dissolves crystals formed by urea producing bacteria and contains Magnesium Oxide to prevent irritation caused by citric acid. 3) Solution R (6% citric acid) - Dissolves encrustation but is very acidic. This should only be used after Suby G has been tried. 4) Catheter maintenance solutions should only be used after a full patient assessment had been carried out. Checking the PH of the urine may also be useful to indicate when maintenance solutions are appropriate. Maintenance solutions should not be used routinely. If used, maintenance solutions must be closely monitored, decreased and discontinued as soon as possible. They should not be used without consultation with the urology/continence team. Care must be given that the administration technique of the solution is sterile, as there is potential to increase the risk of infection by breaking the system. The use of a bladder infusion kit when instilling solution prevents the need to break the system and should be used if available .The procedure can sometimes be uncomfortable and therefore instillation must be acceptable to the patient. Weekly washouts should coincide with changes of bags/valves, to minimize infection risks (Association for Continence Advice 2007). (Procedure for administration of maintenance solutions is available in Appendix 6). Taking a catheter specimen of urine All catheter specimens should be taken following an aseptic technique using a syringe and needle or sterile syringe if the system contains a needle free port . Samples should never be taken from the catheter bag. (Procedure for taking a catheter specimen of urine is available in Appendix 7) Removal of a catheter Urethral catheters should be removed using a sterile procedure (Bardsley 2017 ) to minimize risk of infection on removal . It is preferable to remove in the early morning to enable any problems of retention to be resolved during the daytime hours. (Procedure for removal of a catheter is available in Appendix 6)




Treatment of urinary tract infections UTI/bacteria in a patient with a long term catheter is unavoidable and inevitable due to the presence of the foreign body and proximity of the urinary system to the bowel ( Bray 2006 ) The use of antibiotics is only indicated when the patient is symptomatic ( Simpson 2001 It is important to ensure the patient drinks at least 1.5l fluid per day and that constipation is prevented as these factors will further increase risk of UTI ( Bray 2006) Discharge Home Prior to discharge:

Minimising risk of infection should continue when the patient goes home. Patients/parents/carers should therefore undergo training on how to look after the catheter as soon as it is inserted, in readiness for discharge (Getliffe 2003). Drainage systems should be selected in conjunction with child and parents, taking into account the dexterity of the child and the need to promote independence at home and school.

Teaching plans where appropriate should be completed and patients/parents/carers given written information about the management of their catheter and drainage system.

Documentation/information regarding catheter type, size, length and volume in the balloon is vital to ensure continuing care (EPIC 3 DOH). This information should be recorded in patient notes and passed on to the relevant professionals providing ongoing care.

Referral should be made prior to discharge to local community nurses/urology nurses with details of discharge arrangements and equipment documented to ensure continuing support after discharge.

On discharge:

It is the responsibility of the discharging nurse l to provide the patient with enough supplies for I month and to ensure parents/carers have access to appropriate ongoing supplies after this period.

Patient/parent/carer should be given advice regarding the procedure to follow if the catheter falls out or does not drain.

Contact numbers for community or specialist nurse, should be given to parents prior to discharge.

Details of discharge including equipment supplied must be documented in patient notes.

Summary of Main Points For long-term use, indwelling urinary catheters should be a last resort, and used only when alternative methods of management have been considered.




The need for catheterisation should be reviewed regularly and urinary catheter removed as soon as possible. Intermittent catheterisation should be used in preference to an indwelling catheter if clinically appropriate and a practical option for the patient. Catheterisation in hospital should be undertaken by healthcare personnel who are appropriately trained and competent to undertake such procedures or by the patient/parent in certain circumstances. All catheterisation carried out by healthcare personnel should follow an aseptic technique according to Trust guidelines on catheterisation. Healthcare personnel must select the appropriate catheter required, taking into account patient's individual characteristics, suitable material etc. Silicone catheters should be used in children unless specifically contra-indicated. Size of catheter and volume of balloon inflation is dependent on age and bladder capacity of patient. Catheter insertion, care and any changes should be documented. Indwelling catheters should be connected to a closed drainage system or catheter valve and linked to an overnight system if appropriate. The connection between the catheter and drainage system should not be broken except for good clinical reasons e.g. changing bags every 5-7days. Urinary drainage bags should be positioned below the level of the bladder and should not be in contact with the floor. Routine urethral/meatal cleansing (catheter toilet) has no proven benefit and daily bathing/showering is sufficient to clean the catheter. All urine samples should be taken using an aseptic technique, and never from the bag. Catheter maintenance solutions should not be used prophylactically. However, they may be used to minimise catheter blockage, but only following a full patient assessment, preferably carried out by the urology/continence team. Patients/parents/carers should be educated and trained to manage the catheter and drainage system prior to discharge home. 1 months’ supply should be available on discharge and arrangements made for continuing supplies, ongoing support and training for the duration of long-term catheterisation.




Appendix 1: Sterile Procedure - Male/Female Urinary Catheterisation and Catheterisation of Mitrofanoff

Equipment: Sterile pack 1.5-5ml sterile water (if ballooned

catheter) Sterile gloves x2pairs Sterile saline KY jelly if not pre-lubricated catheter

Appropriate catheter Bed protection

Sterile bowl, receiver Alcohol hand rub Sterile drainage bag/valve Specimen pot Stand or leg straps Sterile syringe and needle

Action: Rationale:

1) Discuss the procedure with the patient/parent(s) and explain why necessary.

To ensure co-operation and gain verbal consent.

2) Ensure privacy by using screens or curtains.

To maintain patient dignity and comfort.

3) Wash hands as per hospital policy and apply gloves.

To reduce risk of contaminating sterile equipment.

4) Prepare trolley and take to patient bedside.

To prepare equipment and ensure easily accessible.

5) Ensure appropriate size and type catheter.

To minimise risk of pain and discomfort, or allergic reaction and ensure catheter appropriate for desired duration.

6) Apply bed protection. To prevent urine leakage onto bedclothes.

7) Position patient. To ensure patient is comfortable and access easy.

8) Wash hands as per hospital policy. To reduce risk of infection and contamination.

9) Open packs using aseptic technique.

To reduce risk of introducing infection into the urinary tract.

10) Put on sterile gloves

To reduce infection and contamination

11) Place sterile field across patient, for boys make a hole for the penis.

To create a sterile field.

12) Clean area with saline. Girls - separate labia minora using non-dominant hand. Using gauze swab with sterile saline, clean around urethral orifice using single downward strokes without contaminating gloves. Discard swab after each stroke. Boys – wrap a sterile swab around penis with non-dominant hand and use this to hold the shaft. Retract foreskin

To reduce risk of introducing infection into urinary tract during catheterisation.




as necessary, clean glans penis with sterile saline without contaminating gloves. Mitrofanoff – clean around umbilicus/abdominal stoma using gauze swab and sterile saline.

13) Gloves can become contaminated during the cleaning stage, particularly with girls and un-co-operative children. The individual practitioner should assess the risk of contamination and potential distress to the child and change gloves where appropriate

To reduce risk of infection

14) Lubricate catheter Clinicians should assess in each individual the appropriateness of using lignocaine gel noting that it may sting the child and reduce co-operation with procedure Where appropriate it should be used as per manaufacturers guidelines

Lubrication helps reduce trauma/discomfort

15) Place receiver between legs. To provide a container for urine as it drains.

16) Insert catheter into orifice until urine obtained. Girls – insert in an upward and backward direction. Boys – grasp the penis behind the glans raising it until almost totally extended and maintain this grasp to insert the catheter. If resistance is felt at the external sphincter increase the traction of the penis slightly, apply constant gentle pressure and advance the catheter. Mitrofanoff – insert catheter into umblilicus/abdominal stoma and advance along Mitrofanoff channel.

Direction relates to anatomical structure. Resistance may be experienced due to spasm of the external sphincter.

17) Once urine obtained advance catheter a further 2cm If urine is not obtained no not inflate the balloon .

To ensure fully positioned in the bladder. To prevent catheter falling out easily, particularly if child wriggling or un-co-operative. To prevent inadvertent inflation of balloon in urethra, causing pain and trauma. To ensure bladder is fully drained.




-If Intermittent – once urinary flow ceases, remove catheter slowly, stopping if further urine flows. -If indwelling – gently inflate balloon with sterile water, as appropriate for age of child and type of catheter.

18) Withdraw catheter slightly. To maintain patient comfort and reduce risk of bladder neck trauma

19) Support catheter using suitable anchoring device.

20) Reposition foreskin in males. To prevent paraphimosis.

21) Make patient comfortable and ensure dry

To prevent secondary infection and skin irritation

22) Measure amount of urine, if non routine change of catheter.

To determine bladder capacity. To monitor fluid balance.

23) Send sample for laboratory examination if appropriate.

To determine existing infection and obtain baseline.

24) Dispose of equipment and clinical waste

To prevent environmental contamination.

25) Wash hands as per hospital policy. To prevent cross infection.

26) Record details of catheter type/size/length/ amount of water in balloon/batch number/ manufacturer/date & time of catheterisation.

To provide reference for future catheter changes. To provide information if any queries or faults arise.

.




Appendix 2: Clean Procedure for Intermittent Catheterisation for Patient/Parent/Carer

Equipment: Catheter (appropriate size & type) Lubrication (if not pre-lubricated) Soap and water/wipes Receiver/toilet (to catch urine)

Action: Rationale:

1) Discuss and explain procedure to patient/parent/carer.

To ensure understanding.

2) Ensure privacy. Remove/adjust patients clothing.

To preserve dignity and ensure comfort To obtain ready access and prevent leakage of urine onto patients clothing.

3) Wash hands as per policy. If carer apply non-sterile gloves.

To reduce risk of infection/contamination.

4) Clean around the area to be catheterised as appropriate for patient: Girls – inside labia front to back Boys – retract foreskin Mitrofanoff – clean around abdominal stoma/umbilicus.

5) Lubricate catheter as appropriate. To prevent trauma to Mitrofanoff channel/urethra.

6) Sit child on toilet or place receiver to catch urine.

To prevent urine leakage.

7) Hold catheter as far from tip as able. To prevent introduction of infection into urinary tract.

8) Insert into urethra/Mitrofanoff channel until urine obtained.

To ensure catheter is in the bladder.

9) Advance catheter further. To prevent catheter from falling out.

10) Withdraw catheter slowly when urine flow stops, stopping if urine begins to flow again.

To ensure bladder is completely empty

11) Dispose of catheter, if single use. If re-usable, rinse under running water, dry on clean tissue and store in a clean plastic bag. NOTE – 1. Do not re-use coated or lubricated catheters. This can result in trauma to urethral channel. 2. All catheters used in hospital or school should not be re-used but disposed of after one use only.

To prevent environmental contamination.

12) Wash hands as per policy. Replace/re-adjust patient clothing.




Appendix 3: Procedure - Emptying a Catheter Bag

Equipment: cleaning wipes Disposable gloves (non sterile) - (latex free if indicated) Sterile jug (in hospital to ensure no cross infection)

Action: Rationale:

1) Discuss procedure with the patient/parent(s) and explain why necessary.

To ensure co-operation and consent.

2) Wash and dry hands as per hospital policy and apply disposable gloves.

To reduce risk of cross infection.

3) Ensure drainage bag is positioned below the level of the bladder at all times.

To allow continuous drainage and prevent back-flow of urine.

4) Ensure bag is on a stand on the floor or attached firmly to the leg or bed frame.

To prevent contact with the floor and tension on the catheter.

5) Clean the outlet valve with alcohol swab.

To reduce risk of infection.

6) Allow urine to drain into appropriate jug.

To empty drainage bag and accurately measure volume of urine.

7) Close outlet valve and clean it again with alcohol swab.

To reduce risk of cross contamination.

8) Cover jug and dispose of contents in sluice. (Note amount for the fluid balance record).

To reduce risk of environmental contamination.

9) Wash and dry hands thoroughly. To reduce risk of infection.

10) Document in nursing record. To ensure effective care is maintained.

11) Ensure a review date/arrangement is made for changing catheter.

To ensure catheter is changed on a regular basis and is not left in situ longer than necessary.

12) Ensure drainage bag is changed every 5-7 days and record date in nursing record.

To minimise risk of infection.




Appendix 4: Hospital Procedure – Catheter Flush Aim: To maintain patency and drainage of the catheter. There are several reasons why catheters become blocked:

1) Pressure on the drainage lumen of the catheter caused by constipation. 2) Kinking of catheter tubing. 3) Post surgery blood clots, or bladder trauma/infection. 4) Bladder tissue or mucosa drawn into the eye of the catheter by build up of

suction or pressure (1). 5) Encrustation which occurs in up to 50 % of patients with long-term

catheters in-situ (2). 6) Debris as a result of augmentation, or concentrated urine due to low fluid

intake. (Debris from urothelial shedding or mucous is less likely to be flushed from the bladder)

Flushing may be required due to repeated catheter blockages. If particularly problematic, as with augmented bladder (which produces excessive mucous), it may be necessary to do a bladder washout. There is an increased risk of developing stones in augmented bladder, therefore a regular washout usually once weekly, is advocated as routine management in order to decrease stone formation. Equipment: Bladder syringe Jug/Receiver Gloves Sterile saline Catheter (if not in situ)

Action: Rationale:

1) Wash hands as per hospital policy and apply gloves (sterile if catheterisation required, non-sterile if already catheterised).


2) Draw up saline (between 20-60mls) in a bladder syringe depending on bladder capacity.

Use of a bladder syringe exerts less pressure and therefore, minimises potential trauma to bladder mucosa.

3) Catheterise as per procedure (if not already in situ).

5) Drain the bladder observing drainage, type and volume.

To ensure bladder is not overfilled if not on free drainage.

7) Connect bladder syringe to end of catheter. Gently push in saline.

Instilling gently minimises potential trauma and discomfort.

8) Remove syringe

9) Allow bladder to drain.

10) Remove catheter, or replace with bag/spigot, as appropriate.

11) Dispose of equipment.

12) Wash hands as per hospital policy.

NOTE – All equipment used in hospital should be sterile and disposed of following use.




For patient/parent /carer, cooled, boiled water may be used at home (see appendix 4A Home Procedure for Bladder Flush). If mucous is problematic e.g. following bladder augmentation, patient may require the syringe plunger to be pulled back to remove urine and debris, or agitated (washed out). This should only be performed following bladder training and under direction of medical/nursing staff as it may cause trauma to a normal bladder (see Guidelines for bladder washout).

Appendix 4A: Home Procedure – Bladder Flush

Aim: To maintain patency and drainage of catheter Equipment: Bladder syringe Jug/Receiver Cooled boiled water (body temperature) Catheter (if not in situ)

Action: Rationale:

1) Wash hands To minimise risk of infection.

2) Draw up water (between 20-60mls) as directed by specialist nurse/doctor.

Use of a bladder syringe exerts less pressure and therefore minimises potential trauma to bladder mucosa.

3) Catheterise as per procedure, if not already in situ.

4) Drain the bladder. To ensure bladder is not overfilled, if not on free drainage.

5) Connect bladder syringe to catheter.

6) Gently push the cooled boiled water into the bladder.

Instilling gently minimises trauma and discomfort.

7) Remove syringe.

8) Allow the saline to drain out.

9) Remove catheter, or replace with bag/spigot, as appropriate.


12) Wash hands.

If the catheter often blocks with mucous, your doctor or specialist nurse may advise you to washout the bladder and repeat up to 500mls of cooled, boiled *salt water. You may be taught to pull the syringe plunger backward and forward, this is called agitation and your specialist nurse will show you how to do this. At home, syringes can be re-used for up to 1 month. They can be washed in soapy water and dried well following every use. They can also go into the dishwasher. However, once the markings have begun to wear off, or the rubber has perished, they should be disposed of. Further syringes can be obtained from your nurse specialist, or community nurse. * Salt water is made up using 500mls of tap water boiled, with 1 flat teaspoon of salt dissolved into it. The water should be cooled to body temperature prior to use.




Appendix 5: Procedure – Bladder Washout Following Augmentation

After bladder augmentation there is a tendency for mucous and other particulate matter to collect as sediment. Regular bladder washouts (weekly, or more often) may be advised by medical/nursing staff in order to prevent catheter blockage and minimise the development of stones. Staff will advise on more thorough washouts in these instances. Equipment: Bladder syringe Saline Jug/Receiver Catheter (if not in situ) Gloves

Action: Rationale:

1) Wash hands as per hospital policy and apply gloves (sterile if catheterisation required, non-sterile if already catheterised).


2) Draw up sodium chloride 0.9% (between 20-50mls) in a bladder syringe depending on bladder capacity.

Use of a bladder syringe exerts less pressure and therefore, minimises potential trauma to bladder mucosa.

3) Catheterise as per procedure (if not already in situ).

4) Drain the bladder observing drainage, type and volume.

To ensure bladder is not overfilled if not on free drainage.

5) Connect bladder syringe to end of catheter. Gently push in saline.

Instilling gently minimises potential trauma and discomfort.

6) Disconnect syringe.

7) Draw up further syringe of saline.

8) Gently, but swiftly, instill into the bladder.

9) Draw back syringe until resistance is felt.

10) Push this saline back in and draw back several times to agitate fluid in the bladder.

To mobilise debris in bladder. To encourage removal of debris.

11) Draw back one syringe full of urine/debris.

12) Discard urine/debris.

13) Repeat 6-12 until urine is clear.

14) Disconnect syringe.

15) Remove catheter or attach drainage bag/valve to catheter.


19) Wash hands as per hospital policy.

If discomfort occurs, discontinue the washout and inform medical staff. If required, child/parent/carer should be taught how to do this procedure at home prior to discharge from hospital. At home bladder washouts may be performed with cooled, boiled water with a teaspoon of table salt dissolved into each 500mls of water.




Appendix 6: Procedure – Installation Of Catheter Maintenance Solutions

Equipment: Gloves Warm water Maintenance solution New drainage bag/valve

Action: Rationale:

1) Ensure the solution has been correctly prescribed. NOTE – Amount instilled is dependent on individual bladder capacity and should be directed by medical staff.

To comply with Administration of Medicines guidance

2) Check the solution has not expired and the packaging is intact.

To comply with Administration of Medicines guidance.

3) Discuss procedure with the patient/parent(s) and explain why necessary.

To ensure co-operation and consent.

4) Ensure the patient is covered and comfortable.

To ensure patient’s comfort and privacy.

5) Wash hands as per hospital guidelines.


6) Warm the solution to body temperature by placing in a sink/bowl of warm water.

To promote comfort

7) Put on gloves and prepare the solution bag by fastening the clamp and removing the security ring.

8) If available connect bladder instillation set into inlet port if not available disconnect the drainage bag from the catheter. Attach the maintenance solution pack. If catheter is not on free drainage, ensure bladder is emptied prior to instilling solution.

Instillation into full bladder will cause pain and discomfort due to excessive filling of the bladder.

9) Open the clamp and allow solution to flow into the catheter as per manufacturer’s directions.

Squeezing the bag can cause damage to the bladder mucosa, or bladder spasm.

10) Close clamp and leave solution in the bladder.

11) Ensure the patient is covered and safe.

To maintain comfort, dignity and safety.

12) Leave for 20-30 minutes or as directed.

Observe for signs of discomfort and if these occur prior to directed time, proceed to step 14 immediately and inform medical staff.

13) Lower the bag below the level of the bladder, open the clamp to let the fluid flow out.

To allow contaminated fluid to flow out of the bladder.

14) Remove bladder instillation set and clamp if used or if not remove maintenance pack from catheter.

15) Connect a new drainage bag/catheter valve to the catheter if instillation kit not used ensure catheter





draining effectively.

16) Assist patient with re-dressing.

17) Tidy away and dispose of equipment as per hospital guidelines/policies.

To prevent infection/contamination.

18) Document administration of maintenance solution

To ensure effective communication.

Appendix 7: Procedure - Collection Of A Catheter Specimen Of Urine Collection of a catheter sample of urine should use an aseptic technique

(EPIC 3 Guidelines 2014)

Equipment: Alcohol swab Non-sterile gloves (latex free if indicated) Gate clip Sterile syringe and needle Universal container

Action: Rationale:

1) Explain the procedure to the patient/parent.

To ensure he/she understands the procedure and gives his/her consent.

2) Screen the bed. To ensure patient privacy.

3) Clamp tubing below sample port on drainage bag until urine collects above clamp.

To obtain an adequate amount of urine.

4) Wash hands per hospital guidelines. To reduce risk of infection.

5) Apply gloves. To reduce risk of infection to operator.

6) Clean sample port with alcohol wipe. To reduce risk of contamination of specimen.

7) Using a sterile syringe and needle aspirate required amount (app. 10 ml) of urine from the sample port. Withdraw the needle.

The rubber cuff is designed to occlude the puncture hole once the needle is withdrawn.

8) Place the specimen in sterile container. Label specimen and send to labs as soon as possible. If there is any delay place in a fridge till dispatched.

To prevent contamination. To ensure accuracy of information.

9) Unclamp the catheter if necessary. To allow drainage to resume.

10) Dispose of syringe and needle in sharps bin.

11) Wash hands as per hospital guidelines.

To reduce risk of cross infection.

12) Make the patient comfortable and remove the screen.

13) Document in nursing record. To ensure other staff aware of specimen.

14) Encourage plenty of fluids. To help dilute any solution remaining and help remove it from the bladder.




Appendix 8: Procedure - Removal Of A Catheter Catheters are usually removed early in the morning (e.g. 6 am) to enable any problems of urine retention to be dealt with during the day Equipment: Dressing pack Disposable gloves(latex if indicated) Syringe for deflating balloon Urine specimen container Needle and syringe Saline

Action: Rationale:

1) Explain procedure to patient/parent/carer and possible symptoms e.g. urgency, frequency and discomfort, caused by irritation of the urethra by the catheter. Advise that further investigation may be required if this has not resolved within 24-48 hours. Encourage patient to drink 2-3 litres fluid daily (adjusted for age).

To ensure patient/parent/carer know what to expect and plan daily activity accordingly. To ensure adequate flushing of bladder and dilute and expel any debris and infected urine present.

2) Wash and dry hands as per hospital policy.

3) Apply gloves and clean the catheter site with saline. Always swab away from urethral opening.

To reduce risk of infection. To reduce risk of bacteria/contamination.

4) Change gloves.

5) Take a catheter specimen of urine (as per appendix 7). If no urine in the tubing clamp below the access port until sufficient collects.

To obtain an adequate urine sample and ascertain if post-catheter antibiotics are necessary.

6) Release catheter leg support. For easier removal of catheter.

7) Check volume of water in balloon against patient record. Use syringe to deflate balloon.

To confirm how much water is in balloon and ensure it is completely dilated before removing catheter.

8) Ask patient to breath in and out, on exhalation, gently but quickly remove the catheter. Warn male patients of discomfort as the deflated balloon passes through the prostate gland, if post pubertal.

To relax pelvic floor muscles.

8) Clean meatus. Tidy away equipment and make the patient comfortable.

9) Wash and dry hands as per hospital policy.

10) Encourage plenty of fluids to help relieve dysuria

11) Observe patient for retention of urine, or signs of infection.




4. References Association for Continence Advice. The Use of Catheter Maintenance Solutions: a guide for good practice. May 2007. . Avorn J., Monane M., Gurwitz J.H. et al. Reduction in Bacteriuria and pyuria after ingestion of cranberry juice. Journal of the American Medical Association 1994. 271 (10): 751-754. Bardsley ;A. 2017 Nursing standard Jan4;31(19)42-45 Bray L.,Sanders C., Nursing management of paediatric urethral catheterisation Nursing Standard.2006 20, 24, 51-60. Prevention of Catheter Associated Bacteriuria; Clinical trials of methods to block three known pathways of infection. American Journal of Infection Control 1991. 19: 136-142. Foster H., Ritchley ., Bloom D. Adventitous knots in urethral catheters: report of 5 cases. Journal of Urology 1992. 148 (5) 1496-8. Garibaldi R.A., Burke J.P. 1974. Factors predisposing to bacteriuria during indwelling urethral catheterisation. New England Journal of Medicine 1974. 291: 215-218. Getliffe K., Dolman M. Promoting Continence: a clinical research resource. 3rd Ed. London: Bailliere Tindall 2007. EPIC3: National Evidence-Based Guidelines for Preventing Healthcare-Associated Infections in NHS Hospitals in England Journal of Hospital Infection 86S1 (2014) S1–S70 http://www.his.org.uk/files/3113/8693/4808/epic3_National_Evidence-Based_Guidelines_for_Preventing_HCAI_in_NHSE.pdf Kunin C.M. Urinary Tract Infections: detection, prevention and management. 5th Ed. Baltimore: Williams & Wilkins 1997; 249-250 Lo,E. Strategies to prevent catheter associated urinary tract infections in acute care hospital 2014cambridge university press 35.5 p464-479 . McGillivray D, Dougherty G.CJEM. 2002 Mar;4(2):108-10.Urethral catheter knotting: Be aware and minimize the risk.Arena B1, Nicolle LE urinary catheter associated infection Infecct Dis Clin North Am 2012 ;26 (1):13-27 Nicolle LE catheter associated urinary tract infections Antimicrobial resistance and infection control 2014 3:23




Urethral catheter knotting: an avoidable complication http://web.imu.edu.my/ejournal/approved/9.CaseReport_Ismail_p37-39.pdf Medical Advice Agency 2010. http://www.mhra.gov.uk/home/groups/dts-bs/documents/medicaldevicealert/con068160.pdf Talja et al. Comparison of urethral reaction to full silicone, hydrogel-coated and siliconised latex catheters. British Journal of Urology 1990. 66: 652-657 Yates ,A.Indwelling urinary catheterisation ;whatis best practice ? British Journal of Nursing 2016 9 p54-

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GUIDELINES FOR THE SELECTION AND MANAGEMENT OF … · For measurement of urine output in the acutely ill child, e.g. trauma, sepsis, renal failure, urine retention. NOTE - in cases