SYNOPSIS FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

DISSERTATION PROPOSAL

A COMPARATIVE STUDY TO EVALUATE THE EFFECTIVENESS OF STERILE VERSUS CLEAN TECHNIQUE OF URINARY CATHETER CARE IN PREVENTION OF CATHETER RELATED UTI AMONG FEMALE CLIENTS IN RAJARAJESWARI HOSPITAL AT BANGALORE.

SUBMITTED BY,

ANJU KUNJUMON

IST YEAR, MSC. NURSING

(MEDICAL SURGICAL NURSING)

RAJARAJESWARI COLLEGE OF NURSING

MYSORE ROAD,

BANGALORE 74.

1

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE : MS. ANJU KUNJUMON FIRST YEAR M.SC NURSING, RAJARAJESWARI COLLEGE OF NURSING, MYSORE ROAD, KAMBIPURA BANGALORE- 560074.

2. NAME OF THE INSTITUTION : RAJARAJESWARI COLLEGE OF NURSING, BANGALORE 74.

3. COURSE OF STUDY AND SUBJECT : M.SC NURSING

MEDICAL-SURGICAL NURSING

4. DATE OF ADMISSION TO THE COURSE: 16 -7- 2012

5. TITLE OF THE TOPIC : A COMPARATIVE STUDY TO EVALUATE THE EFFECTIVENESS OF STERILE VERSUS CLEAN TECHNIQUE OF URINARY CATHETER CARE INPREVENTION OF CATHETER RELATED UTI

AMONG FEMALE CLIENTS IN RAJARAJESWARI HOSPITAL, BANGALORE.

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6. BRIEF RESUME OF THE INTENTED WORK

6.1INTRODUCTION

“Prevention is better than cure”

One the most common infections especially among women is an infection of the urinary tract. About

40% of women develop a urinary tract infection (UTI) at some point in their life. The condition is

uncommon in boys and young men. Serious consequences can occur if a urinary tract infection affects the

kidneys. Infections of the urinary tract are usually treated with antibiotics1.

Women are especially prone to urinary tract infection. This is due to the shortness of the female

urethra. A count of 100,000 bacteria per milliliter in a woman without symptoms indicates asymptomatic

bacteriuria. In addition, women are at particular risk of recurrent UTIs after menopause because of decreased

levels of oestrogen, which reduces the number of lactobacilli. Lactobacilli are 'friendly' bacteria that inhibit

the vagina of fertile women and prevent other bacteria from invading the urethra. Also, after menopause, the

mucous lining of the urinary tract 'thins out' and its ability to resist bacteria invasion is reduced2.

An infection of the urinary tract usually occurs when bacteria from the digestive tract attaches to the

outer opening of the urethra and begins to multiply. Most infections originate from a type of bacteria called

Escherichia coli (E. coli), which normally lives in the colon. However, other types of bacteria such as

Chlamydia and Mycoplasma can cause UTIs in both men and women, although these infections tend to

remain limited to the urethra and the reproductive system. The primary risk factor for developing a UTI is

gender. Simply, many women suffer from frequent UTIs. Women tend to get urinary tract infections more

often than men because bacteria can reach the bladder more easily in women. The urethra is shorter in

women than in men, so bacteria have a shorter distance to travel. The outer opening of the urethra is also

located near the rectum in women. Bacteria from the rectum can easily travel up the urethra and cause

infection3.

The sooner UTI symptoms are treated the better. Nearly 20 per cent of people who have a UTI will

have another, and 30 per cent of those will have yet another. Usually, the latest infection stems from a strain

or type of bacteria that is different from the infection before it, indicating a separate infection. It's impossible

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to predict whether a urinary tract infection will strike again, however knowing what symptoms to be aware

of can help4.

Catheter-induced urinary tract infections are very common, and preventive measures are extremely

important. Catheters should not be used unless absolutely necessary and they should be removed as soon as

possible. Reducing the risk for infections during long-term catheter use, however, remains problematic. If a

catheter is required for long periods, it is best to use it intermittently if possible (as opposed to an indwelling

catheter). Doctors recommend replacing it every 2 weeks to reduce the risk of infection and irrigating the

bladder with antibiotics between replacements5.

The most important prevention measures of UTI are adequate education, patient compliance, the use

of appropriate catheter type and material, consistent catheterization technique and proper catheter care. Daily

hygiene is very important. A typical catheter is one that has been pre connected and sealed and uses a

drainage bag system. To prevent infection, advise the client to drink plenty of fluids, including 3 glasses of

cranberry juice a day. The catheter tube should be free of any knots or kinks. Clean the catheter and the area

around the urethra with soap and water daily and after each bowel movement. (Women should be sure to

clean front to back.).Wash hands before touching the catheter or surrounding area. Never disconnect the

catheter from the drainage bag without careful instructions from a health professional on strict methods for

preventing infection. Keep the drainage bag off the floor. Stabilize the bag against the leg using tape or some

other system. Since UTI is caused mostly by E. coli organisms, the various predisposing/associated factors

responsible for UTI, if present, have to be simultaneously investigated and treated6.

The long-term indwelling urethral catheter continues to be a major cause of morbidity in patients in

hospitals, nursing homes and home care. These hospital-acquired infections can increase hospital costs,

length of stay, and mortality rates. Many authorities have recommended that wherever possible, alternative

techniques should be considered for the management of patients with urinary retention or incontinence7.

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6.2 NEED FOR THE STUDY

Women are significantly more likely to experience UTI than men because of the length of their

urethra - the longer the urethra, the more protection you have. In women the urethra is fairly short and

straight making it easier for germs to travel into the bladder. Nearly 1 in 3 women will have had at least 1

episode of UTI requiring antimicrobial therapy by the age of 24 years. Almost half of all women will

experience 1 UTI during their lifetime. Specific subpopulations at increased risk of UTI include infants,

pregnant women, the elderly, patients with spinal cord injuries and/or catheters, patients with diabetes or

multiple sclerosis, patients with acquired immunodeficiency disease syndrome/human immunodeficiency

virus, and patients with underlying urologic abnormalities8.

Catheter-associated UTI is the most common nosocomial infection, accounting for >1 million cases

in hospitals and nursing homes. The risk of UTI increases with increasing duration of catheterization. In no

institutionalized elderly populations, UTIs are the second most common form of infection, accounting for

nearly 25% of all infections9.

Urinary tract infections account for approximately 40 percent of all hospital-acquired

infections annually, with fully 80 percent of these hospital-acquired urinary tract infections attributable to

indwelling urethral catheters. It is well established that the duration of catheterization is directly related to

risk for developing a urinary tract infection (UTI). With a catheter in place, the daily risk of developing a

UTI ranges from 3 percent to 7 percent10.

Urinary tract infection is the most common non-intestinal infection in women worldwide. The

pathogens causing UTI are consistent across the globe. The pathogenesis of urinary tract infection involves

ascending infection with coliform bacteria colonizing the perineum in susceptible women (80–

90% Escherichia coli, 5–10% Staphylococcus saprophyticus with the remainder caused by Proteus and other

Gram negative rods).Lower urinary tract symptoms which accompany UTI include bothersome sensations

such as urinary urgency, frequency, painful urination, hesitancy, and the sense of incomplete bladder

emptying.

Most of these UTI are uncomplicated and managed on an outpatient basis with simple antibiotic

regimens. In low and middle income countries with reduced access to medical care, UTI may be expected to

cause more morbidity and incur greater risk of adverse outcomes when women are unable to get appropriate

treatments early in the course of disease. A total of 100 urine samples were collected and analyzed for the

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presence of bacteria. 75 (75.0%) were found to be positive for bacterial UTI. The distribution of infection on

the basis of age revealed prevalence rates of 100.0%, 94.4% and 64.0% for age groups 30-39, 20-29 and 40-

49 respectively. The prevalence rates for the groups were found to be significantly high (P> 0.05). One

hundred and ten bacterial agents were isolated, characterized and identified. . Klebsiella spp showed the

highest frequency of occurrence of 43 (39.1%) and followed in descending order by Escherichia coli,

Staphylococcus aureus, Proetus vulgaris, Pseudomonas aeruginosa and Salmonella spp with 31 (28.2%), 23

(20.9%), 11(10.0%) 1 (0.9%) and 1 (0.9%) respectively. The study revealed a high prevalence of bacterial

UTI in the study area for all the age groups investigated. The result underscores the need for the

implementation of a control program in the area11.

The purpose of this study was to compare the incidence of urinary infection using clean intermittent

catheterization with the incidence of infection using sterile intermittent catheterization in patients

hospitalized with spinal cord injury who were not receiving prophylactic antibiotics. Forty-six patients were

assigned randomly to a clean (n = 23) or sterile (n = 23) study group. Catheterizations were done at least

every six hours. Infection was defined as bacteriuria greater than or equal to 100,000 organisms/mL or

greater than or equal to 10,000 organisms per mL with fever of 100 degrees F or greater. Results of urinary

dipslides were recorded daily. Twenty-eight subjects (60.9%) converted to greater than or equal to 100,000

organisms per mL. Method of catheterization was neither associated significantly with development of

greater than or equal to 100,000 organisms per mL. (X2[1,46] = .36, p = .55) nor with symptomatic

infections (X2[1,46] = .15, p = .70). Data support the use of clean intermittent catheterization under the

conditions used in this study, including the use of a sterile catheter each day and careful monitoring of

infection and technique12.

If the patient have any signs and symptoms of urinary tract infection that definitely is the

responsibility of the nurses to take all measures to prevent urinary tract infection. Hence, owing to the

detailed background mentioned above, it is in the interest of the investigator to compare the effect of sterile

versus clean catheter care technique for preventing catheter associated urinary tract infection and the risk of

its complications.

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6.3 REVIEW OF LITERATURE

According to Polit and Hunglar, “Review Of Literature” is considered as an essential step of research

process. It involves systematic identification, location, scrutiny and summary of written materials that

contain information in a research problem13. The review is described as follows.

Literature related to the effectiveness of sterile and clean technique to prevent catheter related

UTI.

A comparative study was conducted in Nehru hospital, PIGMER, Chandigarh, on the effectiveness of

sterile versus clean technique for indwelling catheter care. A total of 53 subjects were studied, 27 subjects

were in group I (sterile technique) and 26 were included in group II (clean technique). A quasi-experimental

design was adopted and the tools for data collection comprised of identification data sheet, nursing

assessment tool to detect urinary tract infection (questionnaire, observational checklist, patient’s record sheet

and laboratory investigation proforma and indwelling catheter care procedures for sterile and clean

technique). Simple random sampling technique was used for assigning the subjects in intervention group I

and group II. Data analysis was done using independent t test and chi square tests. The findings of the study

are both the techniques were effective in preventing catheter associated bacteriuria was observed evidence by

X2 =1.17 d.f. 1p>0.05. It was concluded that both the techniques are equally effective if carried out

correctly14.

A comparative study on Povodine-Iodine versus savlon for precatheterization cleansing and association

of bacteriuria with duration of catheterization was analyzed in surgical ward at Kasturba Medical College

Hospital, Manipal. The study includes age groups of 19 years to 60 years were included in the period from

November 2005 to July 2006.The study group was divided into group “A” and “B”. Group “A” consists of

50 patients with 25 females and 25 males and Group “B” consists of 50 patients with 24 females and 26

males. Group “A” patients were directed to use Povodine-Iodine IP5% W/V (available Iodine 0.5% W/V)

(Wockhard limited, Aurangabad, India) and Group “B” was directed to savlon 1% (chlorhexidine IP 0.75%

and cotrimide IP 0.15%, Isopropile alcohol IP 0.04%, purified water QS) for precatheterization cleansing.

Urine cultures and urine analysis were carried out immediately after catheterization in the third day and fifth

day of insertion of the catheter, with a total of 3 samples from each patient. Findings showed that the females

in group “A” had higher rate of bacteriuria than males and 16% in group “B” using savlon as disinfectant for

precatheterization cleansing, developed bacteriuria15.

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A comparative study was conducted in Yazd in Iran, rates of bacteriuria and UTIs when water and

povidone-iodine solution were used for periurethral cleaning prior to catheterization in women who had

indwelling catheters inserted prior to gynecologic surgery. A single-blinded prospective randomized trial

was performed. The sample for this study was 60 women undergoing inpatient gynecology surgery who

required urinary catheterization as part of their routine care and were expected to have their catheter in place

for 24 to 48 hours. Overall, 18.3% of the 60 subjects had bacteriuria at the time of catheter removal, but the

rates were not statistically significantly different in the water (20%) and povidone - iodine (16.7%) groups.

None of the subjects met the criteria (colony count greater than 105) for a UTI. The findings of the current

study, suggest that compared to water, the use of topical antiseptics for cleaning the peri-urethral area prior

to catheter insertion does not significantly reduce the incidence of bacteriuria and UTIs16.

A comparative study on sterile and nonsterile urethral catheterization in patients with spinal cord injury

was designed in Ortho-Rehab-Neuro Hospital Center, Jackson Memorial Hospital, Miami , FL 33136-1094,

USA to determine the effect of sterile and nonsterile intermittent catheterization on the incidence of urinary

tract infection (UTI) in patients after spinal cord injury. The study included 29 patients with neurogenic

bladder dysfunction treated with intermittent catheterization. One group of 14 patients was on sterile

catheterization; another group of 15 patients was on nonsterile catheterization. Prospective single centre

randomized controlled trial. The mean ages of patients in the non-sterile and sterile catheterization groups

respectively were 38 (SD +/- 22) and 34 (SD +/- 14). In the non sterile group 60% were men and 60% of

patients were tetraplegic with the remainder being paraplegic. In the sterile group 50% of patients were men

and 64% were tetraplegic with the remainder being paraplegic. 66 urinary cultures were taken from the non

sterile group and 56 from the sterile group. On a weekly basis, urine samples were obtained and analyzed. A

total of 122 urine samples were analyzed. The patients on sterile catheterization had a 28.6% UTI incidence;

the group using a nonsterile catheterization technique had a UTI incidence of 42.4%. 17

A comparative study of sterile versus non-sterile urethral catheterization in Kent and Sussex Hospital,

Tunbridge Wells, Kent. In a prospective study, 156 patients underwent preoperative urethral catheterization,

randomly allocated to 'sterile' or 'clean/non-sterile' technique groups. There was no statistical difference

between the two groups with respect to the incidence of UTI. There was a considerable cost difference

between the two groups, the 'sterile' method being over twice as expensive as the 'clean' method. Strict

sterility is not necessary in preoperative short-term urethral catheterization and is more expensive and time

consuming18.

A four-group experimental study was done with 97 adult patients who had urinary catheters over 2 days

in three ICUs between April and July 2008.The purpose of this study was to compare the catheter –

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associated urinary tract infection (CAUTI) rates resulting from the use of four perineal care agents (soap-and

–water, skin cleansing foam, 10% povidone-iodine, and normal saline) among patients in intensive care units

(TCUs). The patients received one of the four perineal cares. Data collected included the incidence of

CAUTI at baseline (prior to perineal care) and 1 week , 2 weeks, and 4 weeks after beginning perineal care

the patients were divided into UTI and non UTI groups. The hazard ratio (HR) and 95% confidence intervals

were calculated by Cox’s proportional hazard analysis. The results shows that the cumulative incidence of

CAUTIs per 100 urinary catheter days were 3.18 episodes during 1 week with urinary catheter, 3.31 episodes

during 2 weeks, and 3.04 episodes during 4 weeks after beginning perineal care. Interval incidence of

CAUTIs per 100 urinary catheter days for soap-and-water was 3.15, 4.39, and 3.62 episodes during week

1,2, and 4 after beginning perineal care respectively.Interval incidence of CAUIs per 100 urinary catheter

days for skin cleansing foam was 1.92, 4.44, and 5.26 episodes during week 1, 2, and 2-4, respectively.

Interval incidence of CAUTIs per urinary catheter days for 10% povidone-iodine solution was 5.3, 1.54, and

0 episodes during week 1, 2, and 2-4, respectively. Interval incidence of CAUTI per 100 urinary catheter

days for normal saline was 2.36, 0, and 2.13 episodes during week 1, 2, and 2-4 , respectively and the

cumulative incidence of CAUTI per 100 urinary catheter days for soap-and-water was 2.36, 1.72, and 1.81

episodes during week 1, 2, and 4 after beginning perineal care, respectively. Kaplan Meier analyses showed

no statistical difference in the cumulative incidences of CAUTI by agents at 1 week (X2 by log-rank = 1.617,

p = .655), 2 weeks (X2 by log-rank = 2.238, p = .525), and 4 weeks (X2 by log-rank = 2.046, p = .563). There

were no statistical differences among the agents after controlling for age, antibiotic use, fecal incontinence,

consciousness, fever and diabetes, which are known risk factors of CAUTI in patients with indwelling

urinary catheters19.

An experimental study on two techniques for cleansing the periurethral area immediately prior to

catheterization in a randomized clinical trial of 436 women undergoing obstetric care. Both groups were

catheterized using what the authors described as clean technique. Specifically, nurses washed their hands

using a detergent-based hand cleanser, opened a sterile pack for catheterization, donned sterile gloves, and

inserted the catheter using a “no-touch” technique. (These techniques qualify as “sterile” based on CDC

criteria.) However, subjects were randomly assigned to undergo periurethral cleansing, using a chlorhexidine

solution or tap water. The main outcome measure of the study was bacteriuria, dichotomized as high

bacterial colony counts (>=10 6 CFU/ mL) versus low colony counts (<10 6 CFU/mL). Urine specimens

were obtained within 24 hours of catheterization or immediately before removal if the catheter remained in

place for less than 24 hours. Data were analyzed on an intention-to-treat basis. Seventy subjects (14%) did

not have complete data because a urine specimen was not obtained when the catheter was removed. No

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statistically significant differences were found when the frequency of bacteriuria was compared between

subjects cleansed with chlorhexidine versus tap water20.

A comparative study on the effect of water vs. povidone-iodine solution for periurethral cleaning in

women requiring an indwelling catheter prior to gynecologic surgery. This study compared rates of

bacteriuria and urinary tract infections in 60 women randomized to periurethral area cleansing with water or

povidone-iodine solution prior to insertion of an indwelling urinary catheter. A urine specimen was collected

immediately before and 24 hours after catheter insertion. There were no significant differences in the rate of

bacteriuria or urinary tract infections in the water and povidone-iodine groups.21

A comparative study of sterile versus non-sterile urethral catheterization. In a prospective study, 156

patients underwent preoperative urethral catheterization, randomly allocated to 'sterile' or 'clean/non-

sterile' technique groups. There was no statistical difference between the two groups with respect to the

incidence of UTI. There was a considerable cost difference between the two groups, the 'sterile' method

being over twice as expensive as the 'clean' method. Strict sterility is not necessary in preoperative short-term

urethral catheterization and is more expensive and time consuming22.

A comparative study of clean and sterile technique in intermittent catheterization in the spinal cord

rehabilitation units in western Canada. Thirty-six patients with cervical spinal cord injuries requiring

intermittent catheterization by nursing staff were recruited. None had a previous history of voiding

dysfunction or urinary tract infections. They used randomized controlled design and the subjects were

randomized to either clean or sterile intermittent catheterization technique. Protocols for both clean and

sterile techniques were standardized and followed by nursing staff and caregivers. Primary outcome measure

was symptomatic urinary tract infection as diagnosed by urine culture > or = 10(5) colony-forming units/mL,

pyuria (> or =10 leukocytes on high-power field), and accompanying symptoms. A total of 189 urine

specimens from 36 subjects were cultured. Of the 36 subjects, 15 (43%) developed a symptomatic urinary

tract infection: 6/16 (37%) from the clean group; 9/20 (45%) from the sterile group (P> 0.05). Mean time to

onset for symptomatic urinary tract infection for the clean group was 3.0 (standard deviation (SD) 2.4) weeks

and for the sterile group, 3.6 (SD 1.3) weeks (P> 0.05). The most common urinary organisms at onset of

symptomatic urinary tract infection were Enterococcus species followed by Klebsiella. Clean intermittent

catheterization in the rehabilitation setting does not appear to place the patient with spinal cord injury at

increased risk for developing symptomatic urinary tract infection, and has significant cost and time saving

benefits for the health care system, as well as enhancing the transition for the patient from rehabilitation to

community23.

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A comparative study on sterile water versus 10% povidone-iodine in periurethral cleaning prior to

urinary catheterization in children Objective is to compare urinary infection rate in children cleaned with

sterile water versus a 10% povidone-iodine before bladder catheterization. Prospective randomized

controlled study of children requiring bladder catheterization in the emergency department whose parents

consented to the study were randomly assigned to either of 2 groups, in which sterile water (the “sterile

water” group) or 10% povidone-iodine (the “10% povidone-iodine” group) was to be used for peri-urethral

cleansing prior to catheterization. Result shows the sterile water group had 92 patients and the povidone-

iodine group had 94. Most children (87%) were under 12 months of age. Urine cultures were positive in 16%

of children in the povidone-iodine group and in 18% in the water group. There was no significant difference

in signs and symptoms between the 2 groups. There was no significant association between solution

preparation and cultures on univariate regression analysis. The conclusion shows cleaning the periurethral

area of children with sterile water prior to catheterization is not inferior to cleaning with povidone-iodine24.

A comparative study on water versus antiseptic periurethral cleansing before catheterization among

home care patients. The purpose of this study was to compare the risk of acquiring symptomatic urinary tract

infections through the conventional practice of using 0.05% chlorhexidine gluconate (CHG) versus sterile

water for periurethral cleansing before insertion of an indwelling urinary catheter. A randomized controlled

trial was used, and subjects were randomly allocated to either the sterile water group or the 0.05% CHG

group. Urine specimens for culture were collected 4 times for each subject within 2 weeks. Seventy-four

urine samples were collected in 20 subjects (sterile water group, 8; 0.05% CHG group, 12). There was no

significant difference in colonization count between the 2 groups. In addition, none of the subjects in the 2

groups developed symptomatic bacteriuria. Using sterile water to clean the periurethral area before

catheterization among home care patients will not increase the risk for urinary tract infections25.

A comparative study on the effect of sterile versus clean reused catheters in intermittent

catheterization for bacteriuria. Monthly urine cultures were analyzed at the University of Alberta Department

of Medical Microbiology and Infectious Diseases to determine whether single-use sterile catheters and clean

technique reduced the incidence of bacterial colonization in those using long-term intermittent self-

catheterization. Thirty subjects with spina bifida, ages 3 years to 16 years, entered a crossover study with

random assignment to 6 months of sterile single-use catheters or clean reused catheters. Seventeen subjects

were catheterized by a parent or caregiver; 13 were responsible for self-catheterization and cleaning of the

catheters. Six months of descriptive data were also collected at Alberta Children's Hospital from a similar

group of subjects with spina bifida who used sterile catheters only. In the crossover group, 38% of all urine

cultures were positive regardless of whether sterile single-use or clean reused catheters were employed. The

other group using only sterile catheters had a 36% positive culture rate. No difference in positive cultures 11

was found between males and females or between children who catheterized themselves and children whose

parents catheterized them. The authors concluded that plastic urethral catheters may be reused26.

An experimental study on clean intermittent self-catheterization (CISC) for quadriplegic patients--a

five year follow-up in Royal Brisbane Hospital, Australia. The findings of clean intermittent self-

catheterization as a long term method of bladder management for 36 quadriplegic spinal cord injured

patients, primarily at C6/C7 level, who were taught CISC between 1983 and 1987.Success in CISC was

assessed by a mail survey, a telephone interview, and current sterile urine status. Twenty nine (81%) of 36

patients continued to use CISC after a mean discharge period of 2.9 years (p less than 0.001) with high levels

of acceptance. Rao's V discriminant analysis showed success in CISC was affected by the interval between

injury and initial self-catheterization (Canonical Correlation Co-efficient = 1.34). Results of urinalysis for

patients continuing CISC were obtained for 18 (62%) patients, 16 (88%) of whom had sterile urine.

Implications of these and other findings along with reasons for cessation of CISC are discussed27.

A prospective comparison of urinary tract infections a one-year prospective study was carried out

comparing short-term patient morbidity, infection rates, and bacterial organisms in 33 children with

meningomyelocele. Twenty-four of the children were treated with clean intermittent catheterization (CIC)

whereas nine children had an interstitial lung disease (ILD). A minimum of four cultures per year were

obtained on each patient. Patients maintained on CIC had 36.8% of their cultures positive for bacteriuria

whereas children with (ILD) had 61.8% of their cultures positive (P less than .001). The incidence of

bacteriuria associated with clinical signs and symptoms was similar in both groups. Four of 24 children

treated with CIC had sterile urine whereas none of the children with ILD were persistently free from

bacteriuria. Only five of 24 children receiving CIC had 50% or more of their cultures positive as contrasted

with seven of nine children with an ILD (P less than .01). Escherichia coli accounted for approximately one

third of organisms recovered from infected urine in both groups. Although the short-term morbidity

associated with both treatment modalities is similar, the incidence of asymptomatic bacteriuria in children

maintained on CIC is significantly less than in children with ILD. Whether this factor plays a role in

determining long-term morbidity is a subject for further studying patients treated with either clean

intermittent catheterization or urinary diversion28.

6.4 STATEMENT OF THE STUDY

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A Comparative Study To Evaluate The Effectiveness Of Sterile Versus Clean Technique Of Urinary

Catheter Care In Prevention Of Catheter Related UTI Among Female Clients In RajaRajeswari Hospital At

Bangalore.

6.5 OBJETIVES OF THE STUDY

1. To find the effectiveness of sterile technique in prevention of catheter related UTI among female clients.

2. To determine the effectiveness of clean technique in prevention of catheter related UTI among female clients.

3. To compare the effectiveness between sterile and clean technique in prevention of catheter related UTI among female clients.

4. To find out the association between sterile technique in prevention of catheter related UTI with selected variables among female clients.

5. To find out the association between clean technique in prevention of catheter related UTI with selected variables among female clients.

6.6 HYPOTHESIS

H1: There is a significant difference between the effectiveness of sterile and clean technique in

prevention of catheter related UTI.

H2: There is a significant association between the effectiveness of sterile technique in prevention of

catheter related UTI with the selected demographic variables.

H3: There is a significant association between the effectiveness of clean technique in prevention of

catheter related UTI with the selected demographic variables.

6.7 ASSUMPTION

Female clients are more prone to develop UTI.

Clean technique of urinary catheter is also as effective as like sterile technique in prevention of catheter related UTI.

6.8 DELIMITATIONS

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Study is delimited to female clients aged between 20-45 years of selected hospitals in

Bangalore.

Data will be collected in 4 weeks.

6.9 VARIABLES

Independent variable :

Group I: Sterile urinary catheter care technique.

Group II: Clean urinary catheter care technique.

Dependent variable :

Prevention of catheter related UTI.

6.10 OPERATIONAL DEFINITIONS

a) EVALUATE: It refers to find out the effectiveness of sterile and clean technique to prevent catheter

related UTI among female clients.

b) EFFECTIVENESS: It refers to the extent to which the sterile and clean technique to prevent

catheter related UTI.

c) STERILE CATHETER CARE TECHNIQUE: In this study, sterile catheter care technique refers to the use of povidone-iodine solution and sterile articles for cleaning the catheter and insertion site to minimize the risk of UTI.

d) CLEAN CATHETER CARE TECHNIQUE: In this study, clean catheter care refers to clean the

catheter and insertion site with normal saline solution.

e) URINARY CATHETER CARE: In this study, it refers to a 14 F size Foley’s catheter tube which is made up of silicone rubber or natural rubber inserted through the urethra to the bladder to drain and collect urine and it should be hygienically cleaned by normal saline or povidone-iodine solution to prevent catheter related UTI.

f) FEMALE CLIENTS: In this study, it refers to the clients who are females with urinary catheter for more

than 3 days.

g) PREVENTION OF URINARY TRACT INFECTION: In this study, this refers to the care rendered to minimize the infection by bacteria anywhere along the urinary tract which includes kidney, ureter, bladder and urethra with symptoms of abnormal urine colour (cloudy), hematuria, foul smell, urge to urinate, pain in suprapubic region, and other associated symptoms like fever, fatigue and flank pain.

14

6.11PILOT STUDY

1) The investigator will obtain permission from the concerned authority and from samples prior to the pilot study.

2) Pilot study will be conducted with 10 samples in group I using normal saline and 10 samples in group II using povidone-iodine solution by purposive sampling technique. The sample will be collected and effect will be evaluated by using with nursing assessment tool.

3) The purpose of pilot study is to identify the feasibility of conducting study by using the prepared methodology and statistical analysis.

7 MATERIALS AND METHODS :

7.1Source of Data: Female clients with urinary catheter are selected from hospitals

Bangalore.

7.2METHOD OF COLLECTION OF DATA

1. Definition of the study subject: The female client who is on indwelling urinary catheter for

minimum 3 days.

2. Research Approach: Evaluative approach.

3. Research Design: Quasi- Experimental-Post test only design.

4. Setting: The study will be conducted at RajaRajeswari Medical college and hospital, Bangalore.

5. Sampling technique: Purposive sampling.

6. Sample size: 60 samples, [30 in sterile group and 30 in clean group]

7. Inclusion and exclusion criteria

A. INCLUSION CRITERIA

a) Female clients with urinary catheter and free from UTI.b) Female clients who are willing to participate in the study.

c) Female clients who can follow the instructions.

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B. EXCLUSION CRITERIA

a) Study excludes male clients.

b) Clients who are already affected with urinary tract infection.

8. Duration of the study:4 weeks

9. Tools for Data Collection :

The data will be collected in the following:

Part 1)

a) Demographic variables.

b) Identification data.

Part 2) Nursing assessment tool to detect UTI.

a. Questionnaire.b. Observational checklist.c. Patient’s record sheet.

10. Collection of data:

The investigator personally will collect data after obtaining formal administrative approval from

concerning authorities and informed consent from the samples. Purposive sampling technique will be used

and patients will be selected based on the inclusion criteria. The purpose of the study will be explained by

the investigator to the clients. All the subjects were taken within 24 hours of catheterization and before

starting the catheter care urine for culture and sensitivity as well as for microscopic examination will be

sent. The sample free from UTI will be selected. The researcher will obtain the data from the patient and

their records. Urine analysis will be done on the 5th day of catheter care.

11. Method of Data Analysis and Interpretation:

The investigator will use a technique such as Mean, Median, Standard deviation and

inferential statistics like Chi-square test to determine the association between selected

variables. Paired‘t’ test will be used to analyze difference between the pre test and post test

score regarding urinary tract infection among female clients. The analyzed data will be

presented in the form of tables, diagrams, and graphs.

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7.3Does the study require any investigation or intervention to be conducted on patient or other

human or animals?

Yes, study will be conducted on female clients with urinary catheter by sterile and clean technique

of catheter care.

7.4 Has ethical clearance been obtained from your institution?

Yes, informed consent will be obtained from concerned authority and subject to study.

Privacy, confidentiality, and anonymity will be guarded.

Scientific objectivity of the study will be maintained with honesty and impartiality.

LIST OF REFERENCES :

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1. “Urinary Tract Infection” [cited on 2012 April 03] Health promotion Board.Internet: Available

from URLhttp://www.hpb.gov

2. “Urinary Tract Infection” , American Accreditation Health Care Commission [A.D.A.M] [cited on

2011] https://client.myoptumhealth.com

3. Dr. Goce Aleksovski , MD Medical Encyclopedia “Urinary Tract Infection Causes and Risk

Factors” eHealthpedia [cited on 2010]http://ehealthforum.com

4. “Urinary Tract Infection” https://docs.google.com

5. “Urinary Tract Infections-Health-The New York Times”January 10, 2013

6. Diane K. Newman, Margaret M. Willson, “Review of Intermittent Catheterisation and Current best

Practices” UROLOGIC NURSING/ January-February 2011 / volume 31 Number 1

7. D.J. Stickler , J. Zimakoff “Complications of urinary tract infections associated with devices used

for long-term bladder management”, Journal of Hospital Infection, Volume 28, Issue 3, November

1994, pages 177-194.

8. Harvey Simon, M.D, “Urinary Tract Infection” Milton S.Hershey Medical Center, 2012 Sept 17

http://pennstatehershey.adam.com

9. Foxman B. “Epidemiology of urinary tract infections: incidence, morbidity, and economic

costs.”2003 Feb; 49(2):53-70.

10. “Catheter-Associated Urinary Tract Infection” [cited on2012]http://www.ihi.org/explore/CAUTI

11. Sten H. Vermund, Vanderbilt University, United States of America, Published: October 19, 2012

August SL, De Rosa MJ (2012) Evaluation of the Prevalence of Urinary Tract Infection in Rural

Panamanian Women. PLoS ONE 7(10): e47752. doi:10.1371/journal.pone.0047752

12. King RB, Carlson CE, Mervine J, Wu Y, Yarkony GM.“Clean and sterile intermittent catheterization methods in hospitalized patients with spinal cord injury”.Rehabilitation Institute of

Chicago, IL 60611. 1992 Sep;73(9):798-802.

13. Denise F. Polit, Cheryl Tatano Beck, Lippincott Williams and Wilkins “Nursing Research:

Generating and Assessing Evidence for Nursing Practice” seventh edition pages 88-111.

14. Prem .V and Monika. D, ”Sterile Vs Clean technique for indwelling catheter care in preventing

UTI,” Nightingale Nursing Times .2010.Jan;5[10]: 30-32,44.

15. Shobha K.L, Ramachandra L , Rao S.P. ”comparison of povidone-iodine versus savlon for pre-

catheterisation cleansing and the association of bacteriuria with its antibiotic susceptibility in

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catheterized patients in surgical ward”. Journal of clinical and Diagnostic Research 2008 August

[cited: 2008 August 14]; 2: 991-996

16. Khadijeh Nasiriani, Zohre Kalani, Farahnaz Farnia, Monire Motavasslian, Fateme Nasiriani,

SandraEngberg, “Comparison of the effect of Water Vs.Povidone-Iodine Solution for periurethral

cleansing in women requiring an Indwelling catheter prior to Gynecologic Surgery”. UROLOGIC

NURSING/ March-April 2009 / volume 29 Number 2

17. Prieto-Fingerhut T, Banovac k, Lynne CM.”A study comparing sterile and nonsterile urethral

catheterization in patients with spinal cord injury”.Ortho-Rehab-Neuro Hospital Center, Jackson

Memorial Hospital, Miami, FL 33136-1094, USA. 1997 Nov-Dec; 22(6):299- 302

18. E.A. Carapeti, S.M.Andrews, P.G. Bentley, “Randomised study of sterile versus non-sterile

urethral catheterization”.Ann R Coll Surg Engl. 1996 January; 78(1): 59–60.

19. Ihnsook Jeong, Soonmi Park, Jae Sim Jeong, Duck Sun Kim, Young Soon Lee, Young Mi Park.”

Comparison of catheter associated Urinary Tract Infection rates by perineal care agents in Intensive

care units.” Asian Nursing Research, September 2010, Vol 4,No 3.

20. Mikel Gray PhD, FNP, PNP, CUNP, CCCN Department of Urology, “Reducing Catheter –

Associate Urinary Tract Infection in the critical care Unit.https://docs.google.com

21. Nasiriani K, Kalani Z, Farnia, Motavasslian M, Nasiriani F, Engberg S,”Comparison of the effect

of water vs. povidone-iodine solution for periurethral cleaning in women requiring an indwelling

catheter prior to gynecologic surgery”. 2009 Mar-Apr; 29 (2):118-21, 131.

22. Carapeti EA, Andrews SM, Bentley PG, Ann R Coll Surg Engl “Randomised study of sterile

versus non-sterile urethral catheterization”. 1996 Jan; 78 (1):59-60.

23. Moore, Katherine N, Burt, Jean; voaklander, Donald C, “Intermittent catheterization in the

rehabilitation setting: a comparison of   clean and   sterile   technique ” Volume 20, Issue 6,Pages 461-468.

24.” Periurethral Cleaning Prior to   Urinary   Catheterization in Children:   Sterile Water versus 10%

Povidone-Iodine” Journal Article. Web minister publications Inc.Volume 48, Issue 6, pages 656 - 660.

25. “Water versus antiseptic periurethral cleansing before catheterization among home   care   patients: a

randomized controlled trial ”American journal of infection control

Publisher, Mosby,[cited on 2008 June] https://docs.google.com

26. Moore KN, Kelm M, Sinclair O, Cadrain G, Bacteriuria in intermittent catheterization users: the

effect of sterile versus clean reused catheters. Rehabil Nurs. 1993 Sep-Oct; 18(5):306-9.

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27. Sutton G, Shah S, Hill V.Royal Brisbane Hospital, Australia.”Clean intermittent self

catheterization for quadriplegic patients--a five year follow-up”. Paraplegia. 1991 Oct; 29(8):542-9.

28. Ehrlich O, Brem AS. “A prospective comparison of urinary tract infections in patients treated with

either clean intermittent catheterization or urinary diversion”.1982 Nov; 70(5):665-9.

9. Signature of the candidate :

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10. Remarks of the guide : This study will help to prevent the UTI and related

complications.

11. Name and designation of

11.1 Guide : Mrs .P .Parvathi .MSc .(N) Associate professor and HOD Dept. of Medical Surgical Nursing Rajarajeswari College Of Nursing.

11.2 Signature :

11.3 Co-Guide : Mrs.Muneeswari MSc(N) Assistant professor and HOD Dept. of Paediatric Nursing Rajarajeswari College Of Nursing.

11.4 Signature :

11.5 Head of department : Mrs .P .Parvathi .MSc .(N) Associate professor and HOD Dept. of Medical Surgical Nursing Rajarajeswari College Of Nursing.

11.6 Signature :

12.1Remarks of the Principal : The topic selected for the study is relevant and forwarded for needful action.

12.2Signature of the Principal :

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ETHICAL COMMITTEE CLEARANCE

6. 1. Title of the dissertation : A Comparative Study To Evaluate The Effectiveness Between Sterile And Clean Technique Of Catheter Care Among Female Clients In Selected Hospitals At Bangalore.

2. Name of the candidate and Address : Ms ANJU KUNJUMON 1st Year MSc. Nursing Rajarajeswari College Of Nursing.

3. Subject : Medical Surgical Nursing.

4.Name of the Guide : Mrs P .PARVATHI .MSC .(N) Associate professor and HOD Dept. of Medical Surgical Nursing Rajarajeswari College Of Nursing.

5. APPROVED/NOT APPROVED (if not approved ,suggestions)

Head of Department of Head of Department ofCommunity Health Nursing Medical Surgical NursingRajarajeswari College OF Nursing Rajarajeswari College OF Nursing

Head of Department of Head of Department ofChild Health Nursing OBG NursingRajarajeswari College OF Nursing Rajarajeswari College OF Nursing

Head of Department of Mental Health Nursing Rajarajeswari College OF Nursing

LAW EXPERT

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