Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (turp)

The purpose of this section is to introduce a catheter into the bladder to completely empty the bladder or to measure residual urine volume

Equipment:

• 
  Disposable catheter pack
  
• 
  Short term Nelaton catheter of correct size (female 12-14 Fg/male 14-16Fg) i.e., smallest size suitable
  
• 
  0.9% Sodium Chloride 60ml
  
• 
  Lubricant sachet
  
• 
  Measuring jug
  
• 
  Procedural under pad
  
• 
  Clean gown
  
• 
  Sterile gloves
  
• 
  Safety glasses or goggles
  
• 
  Sterile specimen jar, if required.
  

Procedure:

1. 
   Follow the insertion procedure as noted for either female or male catheterisation, however, you do not require anchoring device, urinary drainage bag or syringe and water for injection
   
2. 
   Once the catheter is inserted and urine starts to drain, hold the catheter in place digitally until the urine ceases to flow. Withdraw the catheter gently until urine recommences flowing. Once urine flow ceases gently withdraw catheter completely.
   
3. 
   Leave the patient comfortable
   
4. 
   Lower the patient’s bed
   
5. 
   Discard equipment.
   
6. 
   Record the procedure in the patient's clinical record:
   
   1. 
      Date and time of procedure
      
   2. 
      Type and catheter size
      
   3. 
      Reason for insertion
      
7. 
   Record output, clarity, colour and odour on the patient's FBC
   
8. 
   Perform urinalysis
   
9. 
   Record if a specimen is sent to pathology
   

Alert: Specific Spinal Cord Considerations. Do not clamp the catheter in spinal cord injured patients above T6. Ascertain if patient is on anticoagulants prior to procedure. Seek expert advice for patients with artificial heart values who grow Enterococcus species in the urine prior to the procedure. Potential risk of creating a false passage associated with forced instrumentation. Balloon inflated in urethra/ tract resulting in haematoma, haemorrhage, rupture or necrosis
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Section 6 – Catheter Intermittent: Patient Education

The purpose of this section is to provide procedural information for nurses to assist in supporting and educating patients in the procedure of clean intermittent catheterisation.

Registered Nurses who educate clients in the procedure for Clean Intermittent Catheterisation (CIC) must have current theoretical knowledge and be clinically competent in the procedure. A student nurse may undertake the procedure under the direct supervision of a competent clinician.

This applies to all nurses and contains information on

• 
  Documentation and patient education requirements
  
• 
  Self catheterisation procedure and equipment
  
• 
  Catheter equipment
  

Procedure:

• 
  A Medical or Nurse Practitioner must order intermittent catheterisation
  
• 
  The patient’s ability to perform catheterisation and adhere to a schedule is essential to the success of the CIC program. They must have adequate hand dexterity, mobility and cognition to learn the procedure and understand the principles of management. Age is not a barrier to learning self-catheterisation where the above points are noted
  
• 
  The aim of the technique is to achieve bladder emptying at regular intervals, to reduce urinary tract infections, to promote bladder function and maintain continence
  
• 
  Nurses must utilise a clean technique when teaching and performing intermittent catheterisation
  
• 
  Utilise clean working surfaces for the procedure
  
• 
  Urinary volumes, both voided and residual (where appropriate) should be recorded until a pattern has been established. If large amounts urine (more than 500mls) is drained consider more frequent catheterisation
  
• 
  Patient Accountability and care plans will document a personalised timetable of self-catheterisation
  
• 
  Patient education will include anatomy and function of the urinary system, infection control, fluid balance, bowel management and the management of complications.
  
• 
  Once the technique is mastered, the patient may work towards performing the procedure without a mirror and in any position that suits the client. Assistance in determining this routine may be obtained from Continence Advisors, Continence CNC, Medical Officer or Urologist
  

Equipment:

• 
  Intermittent (nelaton) catheter, recommended sizes 8 to 10Fg children, 12 to 14Fg adults. Male 400mm length and female 160mm length
  
• 
  Warm water and a clean face washer (or moist towelettes)
  
• 
  Water soluble lubricant or anaesthetic gel
  
• 
  Container to collect and measure urine (e.g. measuring jug, kidney dish, slipper pan)
  
• 
  Appropriate light source
  
• 
  Hand held mirror for females (initial use only)
  
• 
  Cotton tip (initial use only)
  
• 
  Protective sheet (initial use only)
  

Female

Procedure:

1. 
   Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and lubricate catheter
   
2. 
   Place patient in a comfortable sitting position, back supported, knees apart and legs bent so that the perineum is visible in a mirror
   
3. 
   Instruct patient to separate the labia majora with the non-dominant hand to expose the urethral opening, and with the dominant hand, wash this area with warm water or moist towelettes. Start at the top and work downwards
   
4. 
   With the labia still separated by the non-dominant hand, using the first and third fingers, the nurse uses the cotton bud and mirror to point out the anatomy of the clitoris, urethral opening and the vagina
   
5. 
   Patient then palpates the urethra with the second finger (feels like a small hole or donut) and leaves it over the urethral meatus. The client then takes the catheter in the dominant hand, holding it two to three cm away from the tip, and gently inserts into the urethra, sliding it under the palpating finger in a gentle upwards and backwards motion
   
6. 
   Allow urine to drain into container and apply gentle pressure over the suprapubic area when flow ceases. This will ensure the bladder is empty
   
7. 
   Withdraw catheter slowly, stopping if urine begins to flow again
   
8. 
   Measure and record amount of urine
   
9. 
   Nurse and patient to wash hands thoroughly and clean up
   
10. 
    Document Inpatient file
    
11. 
    Once the patient is efficient and confident, the procedure may be carried out on the toilet
    

Note: it is not harmful should menstrual blood be introduced into the bladder during this procedure
Male

Procedure:

1. 
   Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and thoroughly lubricate the first 15cm of the catheter tip
   
2. 
   Patient sits in a comfortable position with legs separated
   
3. 
   Instruct patient to grasp the penis at the sides (so as not to compress the urethra) with the non-dominant hand
   
4. 
   If the patient is not circumcised, instruct to gently retract foreskin
   
5. 
   Wash the end of the penis gently with a clean sponge or moist towelettes
   
6. 
   Instruct the patient to hold the penis upwards and outwards from the body at a 90º angle with thumb and finger on either side of the penis. Instruct patient to grasp catheter about seven cm from tip
   
7. 
   Identify the urethral meatus and insert well-lubricated catheter and gently advance until urine flow is observed
   
8. 
   Resistance may be felt when catheter reaches the bladder neck. This may be overcome by encouraging the client to take a deep breath, exhale slowly and relax. Encourage the client to void and at the same time applying firm pressure to the catheter (this helps open up the bladder neck)
   
9. 
   Once the catheter is inserted, hold in place whilst urine flows. The penis and catheter are now in a dependent position. Toward the end, ask the client to cough or strain or apply gentle suprapubic pressure to assist with complete emptying. Gently withdraw the catheter, stopping whenever urine begins to flow again
   
10. 
    Measure and record amount of urine
    
11. 
    Nurse and patient to wash hands thoroughly and clean up
    
12. 
    Document Inpatient file
    
13. 
    Once the patient is efficient and confident, the procedure may be carried out on the toilet
    

Catheter types:

• 
  Catheters for self-catheterisation do not require a retention balloon and comprise of a plastic (PVC) tube with two eyes at the tip and a funnel at the other end
  
• 
  Generally, the types of PVC catheters used are either coated or non-coated catheters
  
• 
  Uncoated catheters require separate lubrication to enter the urethra easily and prevent soreness and discomfort. Most of these catheters are single use only, though the ‘CLINY’ brand can be cleaned and reused
  
• 
  Coated catheters feature a special coating that means lubrication is not required for insertion, check manufacturers’ instructions as may need water to activate lubricant They are generally well tolerated and more comfortable than non-coated catheters, but also more expensive and single use only
  
• 
  Catheters are available in paediatric, female and male lengths
  

Catheter supplies:

Catheters can be obtained via:

• 
  Continence Aids Payment Scheme (CAPS) -
  

• 
  ACT Equipment Scheme
  

• 
  Department of Veteran Affairs Rehabilitation Appliance Program (RAP)
  
• 
  Medical and Surgical wholesalers
  
• 
  Some pharmacies
  

Catheter care:

• 
  Catheters should be used according to manufacturer’s instructions, as many catheters are labelled for ‘single use only’. The symbol for single use only is
  
• 
  Where catheters are labelled single use only, ACT Health is obliged to recommend that a new sterile catheter, in a sealed package within the use by date, be used for each catheterisation
  
• 
  Catheters that are not labelled ‘single use only’ see manufacturers’ guidelines for instructions regarding cleaning and reuse
  

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