Shirley Budd1
(1)
SEQOL Wiltshire, Continence Advisory Service, Swindon, UK
Shirley Budd
Email: SABudd56@hotmail.co.uk
Catheters are a common method of bladder drainage for obstructive voiding or incomplete bladder emptying. Presuming that a clinical rationale has been proven identifying that a Foley catheter has been assessed as the best method for bladder drainage, this chapter will identify evidence-based practical ideas to support management of the problematic indwelling catheter. This includes explanations and solutions to catheter-associated UTI (CAUTI), bypassing and expelled catheters, the non-draining catheter including catheter encrustation, pain associated with catheters and general problems associated with catheter insertion and removal. Practice that is advised and not advised is detailed.
Assess the patient for potential problems to provide proactive care.
A risk assessment should include an assessment to identify bladder and bowel dysfunction. Assess the patient’s medical conditions, the medication they are taking and the effect these may have on catheter function. A health and social assessment to include fluid intake, types of fluid, diet, and bowel function, abilities of self-care, cognition, mobility, dexterity, eyesight and environment enables proactive care and treatment. Poor fluid intake, constipation and neuropathy will cause problems for catheter management before you have even decided they need a catheter.
Catheter management should involve a multidisciplinary team. It is usually the jurisdiction of a nurse to provide catheter insertion, daily care, assessment and patient education.
Remove the catheter as early as possible. Assessing for catheter removal is identified as an effective nurse-led protocol to reduce CAUTI.
Reasons for catheterisation: use the acronym HOUDINI (make the catheter disappear) to empower nurses to remove catheters:
· Haematuria visible
· Obstruction/inability to empty bladder
· Urological surgery or gynae procedures
· Decubitus ulcer/open sacral wound
· Input/output fluid monitoring haemodynamic instability
· Nursing care only/end of life care to promote comfort
· Immobility
CAUTI
Catheter-associated UTI is the most prevalent nosocomial infection. The design of a Foley catheter results in a number of challenges. The balloon causes a sump of urine collecting below the eyelets. The catheter is a foreign body onto which bacteria adhere and create a self-protecting biofilm as a cause of bacteriuria and symptomatic CAUTI.
Wherever possible assess for using a catheter valve negating the need for a drainage bag to promote bladder filling and emptying and increase flushing of bacteria out with urine.
Assess for suprapubic catheterisation if CAUTI is recurrent and/or a cause of bacteraemia.
Apply aseptic non-touch technique (ANTT) at catheter insertion and change by maintaining sterility and not touching key areas of the catheter.
Effective hand washing and application of clean gloves have been proven to reduce CAUTI. Ensure hands are washed before and after any contact with the patient or provision of catheter care. Alternatively apply alcohol hand rub using the same hand washing technique to cover all areas of the hands when appropriate, e.g. lack of facilities in a patient’s home and hands visibly clean.
Teach patients and carers hand hygiene requirements and skills.
Give fluid and dietary advice including required fluid volume; patient should aim to drink 2.5–3 l or until urine looks clearer and paler. Avoid caffeinated drinks if sensitive to caffeine.
Maintain the closed drainage system by adhering to manufacturers guidelines of 5–7 days to reduce CAUTI.
Only if the patient is unwell as a result of CAUTI should urine samples be taken to ascertain the appropriate antibiotic. Take samples aseptically from the sample port on the drainage bag. Do not use antibiotics to treat bacteriuria. The biofilm on the catheter protecting the bacteria prevents antibiotic effectiveness. Do not use antiseptic bladder washouts. This promotes resistant bacteria.
If antibiotics are required to treat symptomatic CAUTI, the patient should take 24/48 hours of antibiotics then the catheter should be changed depending on length of time catheter has been in-situ. This allows time for antibiotics to start to work and helps to prevent bacteraemia.
Consider antibiotic prophylaxis for patients who have a history of symptomatic urinary tract infection after catheter change or for patients who experience trauma.
Urine Is Bypassing Around the Outside of the Catheter or the Catheter Is Expelled with the Balloon Inflated or Deflated
Proactively assess risks to predict and resolve bypassing of urine around the outside of the catheter and urethral leakage when there is a suprapubic catheter as well as catheter expulsion with the balloon inflated. This is a common occurrence for any patient with neuropathic and idiopathic overactive bladder symptoms (OAB).
Proactively assess and treat OAB symptoms and bowel management. If not resolved, plan for insertion of suprapubic catheter.
Drainage bags should remain at a level below the patient’s bladder to prevent backflow of urine within the drainage bag tubing. Avoid traction and a piston effect with the catheter moving up and down the urethra by appropriate drainage system fixation and regularly emptying the urine drainage bag when the bag is about one half to two thirds full. Use of supportive thigh straps, leg sleeves, bag stands and hangers reduces potential risks from traction and the piston effect of the catheter.
Manage the challenge of balloon deflation of silicone catheters. Some manufacturers provide a syringe of sterile water with 5 % glycerine such as the L.IN.C medical Uniball catheter.
Do not use a 30 ml balloon to promote catheter retention. Large heavy balloons may cause tissue necrosis in the bladder and increase irritation and CAUTI risk. A larger balloon is also noted to cause bladder irritation and bypassing of urine and may still be expelled resulting in damage to the bladder neck and urethra.
Do not over- or underinflate catheter balloons as this is in breach of manufacturer licence and is likely to cause the balloon to fall onto one side, resulting in irritation, bypassing and expulsion.
The Catheter Has Stopped Draining
One of the main problems associated with catheterisation is the non-draining catheter. Before making a decision about treatment, it is essential to identify the cause. If the catheter has blocked for the first time and the fault is not with the drainage system or constipation, then the catheter should be changed and the non-draining catheter examined by cutting it open. On examination the clinician may identify that there are three options identified about the catheter. There may be nothing in the catheter, mucous or a gritty-/toothpaste-type blockage within the catheter lumen which may be visible around the outside of the catheter.
Option 1: There is mucous or debris in the catheter lumen. This is likely to occur where the patient is elderly and/or immobile.
There is little evidence identified to treat this problem identifying an area for research. To support catheter maintenance, ensure patient understands how much fluid they need to drink, at least 30ml/kg or 2.5–3 l or until urine looks clearer and paler. If the catheter continues to block, try saline bladder washout inserted as a sterile solution. Assess for suprapubic catheter as this allows for a larger catheter charrière gauge.
Option 2: There is nothing in the catheter. Assess the urine quality and fluid intake. Can the patient feel the vacuum is released when the drainage bag is detached? The problem is likely to be caused by hydrostatic pressure related to the drainage bag being more than 30 cm from the bladder. This causes the catheter eyelets to be drawn into the delicate bladder mucosa which may cause damage to the bladder walls. Bring the catheter bag closer to the bladder. Try a shorter tube leg bag or possibly a Teleflex Medical belly bag (note, manufacture guide use is up to 28 days).
Option 3: There is crystallisation/encrustation in the catheter lumen and possibly around the eyelets. Evidence identifies that about 50 % of patients will be “blockers”. There is little evidence to say that any of the Foley catheters available on prescription are better at resisting encrustation. However, patients are unique individuals and so it is worth trying a different type of catheter including a hydrogel-coated catheter, silicone or silver alloy catheter. The main point is to manage and map the catheter life span and frequency of catheter blockage using a catheter diary. Then change the catheter routinely more frequently prior to the anticipated blockage date.
If this is not feasible based on patient assessment, then it is appropriate to use catheter maintenance solutions. Getliffe identified that two sequential 50 ml citric acid solutions to treat the catheter are more effective. Using the Optiflo system by Bard with a bellows design promotes treating the catheter, minimising the contact with the bladder mucosal lining. However, evidence identified in a Cochrane review is not robust and use of citric acid solutions should be monitored and minimised whenever possible.
Managing encrustation requires catheter maintenance, not bladder washout. Routinely assess the appearance externally and internally of the catheter. If the catheter continues to be unmanageable, assess for bladder stones. If the catheter is long term and the patient is a “blocker”, then the patient should be assessed for a suprapubic catheter which allows for a larger charrière gauge catheter.
Assess catheter for external signs of encrustation on the outside of the catheter following catheter removal. Possibly use Solution R, 6 % citric acid to dissolve encrustation prior to removal of catheter. Also note encrustation developing around the balloon may result in a stone cast of the balloon falling off when balloon is deflated.
Pain Associated with Catheters
There are many reasons for pain affecting the catheterised patient including difficulty inserting the catheter. The following are management options:
Ascertain where the discomfort is. Is the correct size of catheter used? Always insert the smallest catheter possible, 12 to 14Ch for men and 12Ch for women. A catheter where the gauge is too large is a risk for men potentially developing infection and strictures due to compression of the urethra and paraurethral gland.
Ensure adequate volume of lubrication used during the catheterisation procedure: 11 ml for male catheterisation and 6 ml for female catheterisation. If using anaesthetic antiseptic gel ensure gel remains in urethra for 3 to 5 minutes to allow time for the anaesthetic and antiseptic to work. Warn patients there might be a transitory period where anaesthetic lubricant may cause stinging. Check patient allergies and medical conditions.
Be aware of available catheter materials as a patient may experience allergic reaction to latex or discomfort depending on material used.
When inserting the catheter into the urethra, ensure it is well advanced into the bladder, preferably up to the bifurcation of the valve and drainage bag point for male catheterisation. Wait until urine is draining before balloon inflation. Inflate the balloon slowly, checking all the time that the patient is comfortable.
Following male catheterisation ensure foreskin, if present, is drawn back down over glans penis. If this is not done, paraphimosis may occur where the prepuce creates a tight band around the penis, resulting in oedema, pain and trauma. Ease the foreskin back. A cold compress may help.
Vaginal atrophy results in loss of elasticity and moisture of the mucosa, increasing trigone sensitivity potentially resulting in catheter-related problems such as trauma, bypassing and discomfort. Consider topical oestrogen.
If the discomfort is at the urethral meatus, try anaesthetic gel and nonsteroidal anti-inflammatory drug pain relief.
· Assess for catheter valve.
· Consider suprapubic catheterisation.
· Constipation can cause discomfort pressing on the catheter and bladder.
Points of Interest
Loss of suprapubic catheter tract at catheter change is potentially a risk for people with neuropathy conditions and symptoms. This risk assessment identifies patients who will need prompt catheter insertion following catheter removal.
To reduce the risk of losing the cystostomy site, be organised: applying aseptic non-touch technique (ANNT), prepare a catheter removal field and a catheter insertion field layout, all equipment maintaining sterility. This enables prompt catheter replacement.
If you are not able to insert a Foley catheter, insert an ISC/nelaton catheter, which is firmer, and tape into place to keep the tract open whilst waiting for reinsertion of a foley catheter rather than suprapubic catheter.
Not able to see the female urethra? Dilate female urethral meatus with lubricating gel. Open labia and pull up gently to reveal urethral meatus. Try placing a pillow under the buttocks to tilt the pelvis forward. If the patient is unable to adopt supine position, with feet flat on couch, try side lying. Another health-care professional is likely to be required to support the upper leg.
Catheter balloon does not deflate. If equipment is thought to be faulty, try another syringe. Do not pull on the syringe; this might collapse the deflation channel. Apply slight tension to start the deflation process then allow the balloon to deflate itself. Avoid use of creams and talcum powder as these can block the deflation channel. Never cut any part of the catheter whilst in situ. The catheter may slide up into the bladder.
Balloon cuffing may occur with silicone catheters and is likely to be worse the longer the catheter remains in situ. This causes difficulty in removing the catheter as the balloon forms a doughnut ring. In urethral catheterisation, this may be a problem for men and may be a problem when removing a suprapubic catheter. Try removing the catheter proactively between 6 and 8 weeks. Possibly use L.IN.C Medical silicone suprapubic catheter which has an integral balloon and so should deflate flat. If there is not any latex allergy, try hydrogel-coated latex catheter.
If silicone catheter is resisting removal, allow time for silicone to relax into a softer shape. If this does not work, instil small-volume sterile water for injection: 0.5–1 ml to soften the shape of the cuffing. If it is a suprapubic catheter, tape the catheter to the abdomen, to ensure catheter does not just fall out, and leave for 1–2 h. This allows more time for the silicone cuff to relax. You are likely to need to pull firmly. Alleviate patient anxiety by education, support and encouraging relaxation.
Further Reading
Getliffe K, Dolman M, editors. Promoting continence a clinical research resource. 2nd ed. London: Baillière Tindall; 2003.
Loveday HP, Wilson JA, Pratt RJ. Epic3National evidence-based guidelines for preventing healthcare-associated infections in NHS hospitals in England. London: Richard Wells Research Centre, University of West London; 2013.
NICE. Infection control: prevention of health care associated infection in primary and community care. Clinical guideline ref. CG2, London: NICE; 2012. guidance.nice.org.uk/cg139.
Royal College of Nursing. RCN – catheter care – a guide for nurses, London: RCN; 2012. Available at www.rcn.org.uk.
Stickler D, Feneley R. The encrustation and blockage of long-term indwelling catheters: a way forward in prevention and control. Spinal Cord. 2010;48:784–90.CrossRefPubMed