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

Section 6 – Catheter Flushing for Adult Community based patient

Considerations

Catheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter. Manual bladder irrigation or washout involves instilling large amounts of fluid into the bladder, withdrawing fluid for the purpose of removing debris and mucus from the bladder. This procedure should be done under medical supervision and is not suitable to be done in the community

Catheter flushing:

• 
  May be indicated if a patient has a history of blocked catheter
  
• 
  Is an aseptic procedure as the closed urinary drainage system is being broken which is a high risk factor in the development of a UTI.
  
• 
  Is prescribed by a medical practitioner; a treatment order is required stating:
  
  • 
    Normal Saline 9% (is the preferred solution)
    
  • 
    Maximum of two x consecutive flushes of 20mls each (no more than 40mls)
    
  • 
    Management of catheter if unable to flush
    
  • 
    Review date of treatment practice is a short term management option only and the cause of the blockage should be investigated.
    
  • 
    A Urology review must be in place
    
• 
  If a catheter is blocked and has been insitu for >2 weeks it may be replaced without flushing
  
• 
  Catheters that remain obstructed after second flush and catheters that remain patent only with repeated flushing should be replaced and Urology team informed
  

Nursing Alert: Catheter flush is not considered safe practice following renal transplant, or open bladder surgery: Patients with long term catheters are prone to develop decreased bladder capacity. Caution should be practiced when performing catheter flush in these patients with only the prescribed amount of fluid used and if a second flush is needed, adequate care must be taken to ensure previous fluid volume has been drained out
Equipment:

Personal Protective Equipment (PPE) and sterile gloves

Disposable catheter pack

50ml catheter tip syringe (to ensure low pressure on the catheter

Blue under sheet

One pair sterile gloves

One alcohol wipe

Normal Saline 9% (N/S) solution at body temperature (never use cold solution to flush catheter as it can induce a bladder spasm

Procedure:

1. 
   Treatment orders are required for a catheter flush
   
2. 
   Explain the procedure to patient
   
3. 
   Gain verbal consent and document in the nursing notes
   
4. 
   Prepare sterile setup, place N/S in catheter tray and draw up the required amount using a sterile 50 ml catheter tip syringe
   
5. 
   Place blue sheet under the catheter and drainage bag connection
   
6. 
   Don PPE and sterile gloves
   
7. 
   Place sterile towel under site where urinary catheter and drainage bag are attached
   
8. 
   Clean catheter and drainage bag connection with alcohol wipe (allow to air dry)
   
9. 
   Disconnect and wrap the drainage bag end in a sterile gauze swab, if possible give to the patient to hold. Keep connection end sterile.
   
10. 
    Pinch the end of the tubing about an inch from the end of the catheter, and carefully insert catheter tip syringe
    
11. 
    Using up to 20mls of N/S flush the catheter to evacuate any debris. Do not withdraw fluid. If resistance is encountered allow syringe to refill by gravity, discard fluid and repeat flush. (If resistance remains the catheter should be replaced as per catheter management policy)
    
12. 
    Pinch the end of the tubing about an inch from the end of the catheter, and carefully pull to remove the catheter tip syringe
    
13. 
    Reconnect catheter to drainage bag without contaminating either connection
    
14. 
    Secure catheter to the abdomen/thigh
    
15. 
    Evaluate outcome and document in the nursing notes
    

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Section 7 – Trial of Void: Community based patient

A trial of void (TOV) assesses the emptying ability of the bladder by recording voided volumes and measuring the post void residual (See CHHS Continence Assessment and Management Procedure for information on Bladder Scan)

TOV with IDC Pathway:

• 
  Plan procedure with patient
  
• 
  Removal of the catheter is normally between 6:00am (LINK Team) or community nurse 8:00am to 8.30am
  
• 
  Drain the bladder and remove catheter
  
• 
  Document time of catheter removal and urine volume
  
• 
  Advise patient to maintain fluid intake of 200mls/hour capped at 1000mls over four to five hours (unless contraindicated)
  
• 
  Advise the patient to void urethrally when they have the desire to void, measure and record all voided volumes on the bladder diary
  

If anytime the patient becomes uncomfortable and is unable to void it is recommended the patient contact the RN (through the Team Leader) and be re-catheterised (as per medical orders) as soon as possible.

1. 
   The attending nurse to contact the patient for progress call within three hours. (e.g. if catheter is removed by LINK team at 6am call at 9.00am)
   
2. 
   After the four to five hours from catheter removal , the attending nurse returns - request the patient to void
   
3. 
   Measure residual bladder volume by bladder scanner
   
4. 
   Interpretation of TVO: successful or unsuccessful
   
5. 
   Document outcome Inpatients’ records and inform Medical Officer at Urology Out Patients Unit
   

The Medical Officers TVO order is only valid for 24 hrs post removal of catheter. If the patient has a new episode of retention or other related urinary symptoms they should be referred back to the Urologist or treating hospital.

TOV with SPC Pathway:

1. 
   Explain the procedure to patient (nurse contact details should be provided)
   
2. 
   If catheter is on free drainage – disconnect drainage bag and insert catheter valve into catheter
   
3. 
   Advice the patient to maintain fluid intake of 250mls hour during the day (unless contraindicated) and record on chart provided
   
4. 
   Measure and record each urethrally voided urine. Immediately following urethral voiding release the valve and drain the bladder
   
5. 
   Measure and record any residual
   
6. 
   If the client is unable to void advice the client to release the valve, drain the bladder, measure and record volume of urine. Resume timed emptying of the bladder via the valve
   
7. 
   Advise the client to void urethrally:
   
   1. 
      if they experience a strong desire to void
      
   2. 
      if they feel uncomfortable
      
8. 
   Void volumes and post void catheter residuals are compared to parameters set by medical officer’s guidelines
   
9. 
   Document outcome in client notes and follow medical instructions for either repeat TOV or removal of catheter
   

Educational Notes:

Bladder emptying occurs as a result of a complex interaction between the sympathetic and parasympathetic nervous system and physical structures of the bladder and urethra. Bladder dysfunction can result from a wide range of conditions, e.g.:

• 
  Bladder outlet obstruction
  
• 
  Neurogenic dysfunction
  
• 
  Following childbirth
  
• 
  Following some surgical procedures
  
• 
  Medications e.g. anticholinergic can contribute to urinary retention
  
• 
  Chronic constipation. Rectal examination may be required to assess for constipation
  

Ensure that the client is not constipated at time of catheter removal as constipation can contribute to urinary retention and this may result in failed trial of void

Medical authorisation is required prior to TOV:

• 
  Knowledge of client’s medical history is crucial
  
• 
  Knowledge of the client’s usual urine production is recommended to facilitate correct
  
• 
  Timing of the TVO e.g. day time urine production maybe significantly reduced in the elderly
  
• 
  A maximum total bladder capacity should not exceed 600mls (void volume + residual)
  
• 
  An assessment prior TOV will anticipate the expected 24 hours urine production, e.g. some elderly clients will have low urine volume throughout the day and large volumes diuresis overnight
  

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