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Female catheterisation: what nurses need to know!
Accident and Emergency Nursing (2003) 11, 91–95 0965-2302/03/$ - see front matter ª 2003 Elsevier Science Ltd. All rights reserved. doi:10.1016/S0965-2302(02)00188-1
Female catheterisation: what nurses need to know! Andrea L. Devine
Urinary catheter insertion is a common procedure used in the management of hospitalised and community based patients. Nurses need to be aware of the associated complications of catheterisation in order to practice safely and minimise the risks to the patient. This article is a practical guide for nurses who will be involved in female catheterisation, from decision to catheterise, choosing the type and size of catheter, and tips on catheter care and how to avoid the most common problems associated with catheterisation. c 2003 Elsevier Science Ltd. All rights reserved.
Introduction The insertion of urinary catheters is an intervention often carried out by nurses in the Accident and Emergency Department (A&E). The most common indications for catheterisation in A&E are: • As a monitoring tool for acutely ill or injured patients to assess renal perfusion from urine output. • Relief of acute urinary retention. • Reinsertion of blocked or bypassing long-term catheters. • Management of symptoms for patients with chronic conditions such as incontinence or neurological disorders.
Andrea L. Devine ENP A&E Department, Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, UK Manuscript received: 19 August 2002; accepted : 28 August 2002
De Courcy-Ireland (1993) believes many nurses are inadequately trained and, whilst they are aware of the risks involved in male catheterisation, which may cause significant trauma, female catheterisation is often considered as a simple task. Catheterisation is a skill, which should only be undertaken when the nurse is deemed competent to do so in accordance with the NMC professional code of conduct (Nursing and Midwifery Council, 2002), which states:
ª 2003 Elsevier Science Ltd. All rights reserved.
To practice competently you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision.
Complications of catheterisation Infection One of the most frequently reported complications of catheterisation is urinary tract infection (UTI). In a study of 1497 catheterised patients by Tambayah & Maki (2000), 235 (14.9%) developed catheter associated UTI. Studies carried out by the Public Health Laboratory Service suggest up to 40% of hospital acquired infection is due to UTI and are commonly associated with catheterisation. Catheterised patients (1–4%) with UTI go on to develop bacteraemia with a mortality rate of between 13 and 30% (Ward et al. 1991). With this evidence in mind, catheterisation should only be carried out if essential, and the nurse is aware of how to minimise the risks. Infection may be introduced into the urinary tract of catheterised patients in several different ways:
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
91
Female catheterisation: what nurses need to know!
• Contamination of the catheter upon insertion. • Breaks in the closed drainage system causing contamination of the lumen of the drainage tube allowing organisms to enter the drainage bag and ascend the collection tube and catheter. • Bacterial entry between the external catheter and the urethral surface directly into the bladder (Warren 2001). When inserting a catheter aseptic technique should always be used. To avoid cross infection, effective hand washing prior to application of gloves and wearing of aprons is recommended. Many nurses find it easier to apply two pairs of sterile gloves and remove the first pair after cleansing the external genitals, preceding contact with the catheter as it is being inserted. Once the catheter is in situ a closed drainage system should be maintained and the drainage bag emptied as infrequently as possible. Studies carried out by Wilson & Coates (1996) suggest the cleansing of catheter ports with alcohol to be ineffective. However, using an appropriate catheter stand will prevent contamination of the bag through contact with the floor or hospital trolley. Removal of the catheter as soon as possible is recommended, as the risk of infection increases by 5–8% for each day it is in situ (Mulhall et al. 1988).
inflammation, through careful techniques and the use of appropriate catheters. Anaesthetic gel Catheterisation can cause pain and trauma to the bladder neck and female urethra, which unlike the male urethra, does not have its own lubricating glands. The use of an anaesthetic gel inserted directly into the urethral meatus 5 minutes prior to catheter insertion, dilates the urethral folds and opening making for easier location of the orifice, reducing the risk of trauma and ensuring the procedure is less painful for the patient (Pomfret 2001). Catheter size When selecting the correct catheter size, choose the smallest catheter that will drain adequately and cause least trauma. The smaller the catheter, the more easily the urethral folds can close around it. Catheter diameter is measured in charriere (Ch). Each charriere is equivalent to 0.33 mm, therefore a 12 Ch catheter has a 4.0 mm diameter. For an adult female, a size 12 or 14 Ch should be appropriate (Pomfret 1996). Bigger sizes should be reserved for drainage of urine containing debris or severe haematuria and only in consultation with an urologist, urological nurse practitioner or other expert.
Trauma The female urethra is approximately 4 cm long leading from the bladder to the external urethral orifice. Prior to urination the urethra lies flat in unequal folds and has a delicate lining made up of blood vessels, nerves, and collagen that can be easily damaged during catheterisation (Tortora & Grabowski 1996). Damage to tissue can also occur due to pressure necrosis; if the catheter tip is continuously exerting pressure in one area of the bladder, or in the urethra, from tension exerted on the catheter, such as the weight of a full catheter bag. The catheter itself can cause inflammation of the tissue lining the urethra and bladder, because it is a foreign body (Getliffe 1997). Those inserting or removing a catheter should always aim to minimise tissue damage and
92
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
Balloon size The drainage eyes of a catheter tip lie above the balloon, therefore the greater the balloon size the larger the volume of residual urine in the bladder, providing a reservoir for infection (Getliffe 1993). Catheter balloons should be filled in accordance with manufacturers guidelines. A balloon larger than 10 ml is not necessary to hold the catheter in place and the increased weight of a larger balloon may cause damage to the bladder neck (Roe 1996). Types of catheter All catheters produced in the UK undergo strict testing for cytotoxicity in order to pass
ª 2003 Elsevier Science Ltd. All rights reserved.
Female catheterisation: what nurses need to know!
safety standards for approval by the British Standard Committee. PVC(Polyvinylchloride). Plastic catheters are more rigid than catheters made from other materials and may cause discomfort to some patients (Pomfret 1996). They have a wide lumen allowing rapid flow rate. These may be left in situ for up to 14 days. Latex. Latex is the softest of all catheter materials, however its smoother surface makes it more prone to crust formation and it has been known to cause urethral irritation (Getliffe 1993). The incidence of latex allergy has increased in recent years and patients should always be asked about previous reactions. Latex absorbs water and body fluids, which may cause an increase in the diameter of the tube. These catheters are therefore only suitable for short-term use (Getliffe 1997). Teflon. Teflon coating is used as a covering for latex catheters to prevent irritation and absorption. Teflon has a smooth surface reducing the likelihood of it being rejected, thus causing less trauma and irritation (Seth 1988). These catheters are suitable for up to 28 days. Silicone. Silicone is a soft material that causes minimal irritation. However, these catheters are prone to premature deflation of the balloon and catheter failure (Getliffe 1993). Manufacturers recommend these may be left in situ for up to 12 weeks. Hydrogel coated latex. Cox et al. (1988) suggest the hydrogel coated latex catheters are the most compatible with human tissue making them more comfortable, easier to insert and more resistant to encrustation. These may also be left in situ for up to 12 weeks. Conformable. This catheter is specifically designed to mould and collapse with the folds of the female urethra, making it more comfortable, as it moves naturally with the urethra, and is less likely to block. These are made of latex with a silicone elastomer coating (Brocklehurst et al. 1988). Length of catheter The female urethra is only approximately 4 cm long in comparison to the male urethra, which is 15–20 cm in length. Longer length catheters increase the risk of kinking, leading to blockage and back flow of urine. For this reason, shorter
ª 2003 Elsevier Science Ltd. All rights reserved.
length catheters are available, designed specifically for women. However, not all patients will benefit from the shorter catheter, which may rub on the thighs of obese patients (Wright 1991). Always offer patients a choice of short or long length catheters where appropriate. Anatomy Identifying the urethral orifice can be difficult, as anatomy may vary from person to person and alter with age. Nurses should have a basic knowledge of the landmarks to be identified, when attempting catheterisation, to avoid cross infection of the catheter tip through, for example, accidental catheterisation of the vaginal orifice. The external genitalia of a female, collectively known as the vulva, includes the mons pubis, labia, clitoris, and structures associated with the vestibule. The mons pubis is an area of fatty tissue covered by pubic hair, which cushions the pubic symphisis. The two elongated folds of skin descending from the mons pubis are the labia majora, which enclose and protect the more delicate inner folds of the labia minora. Within the labia minora is the area known as the vestibule containing the openings of the urethra and vagina and the vestibular glands responsible for the production of mucous for lubrication during sexual arousal. At the top of the vestibule is the clitoris, a small protruding structure hooded by a skin fold known as the prepuce of the clitoris, formed by the fusion of the labia minora. The external urethral orifice is above the vaginal orifice and below the clitoris (Tortora & Grabowski 1996). When performing female catheterisation, it is a good idea to use swabs to separate the labia minora, exposing the urethral orifice. This position can be maintained with your nondominant hand throughout the procedure. Adequate lighting should be available to ensure good visibility. Equipment • clean trolley • sterile catheterisation pack
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
93
Female catheterisation: what nurses need to know!
• sterile local anaesthetic gel – Instillagel 2% Lignocaine • disposable plastic apron • two pairs of sterile gloves • sachet of antiseptic solution or saline • two sterile catheters of suitable size and material • sterile universal container • 10 ml sterile syringe • 10 ml sterile water • suitable drainage bag • straps or stand • disposable bag • protective sheeting Insertion 1. Explain the procedure to the patient. 2. Ensure privacy and adequate lighting. 3. Position the patient on her back with knees bent and feet comfortably apart. 4. Place protective sheeting under the patient’s buttocks. 5. Wash hands with a bactericidal soap. 6. Open the catheter pack to act as your sterile field in which to place all other equipment, using an aseptic technique. 7. Uncover the patient ensuring exposure of the vulva. 8. Clean hands with an alcohol rub and apply two pairs of sterile gloves. 9. Arrange sterile towels to cover surrounding areas. 10. Separate the labia majora and cleanse with gauze swabs soaked in cleansing solution; firstly the labia majora, then the labia minora, identifying the urethral meatus. Always swab from front to rear in single strokes, to minimise the risk of infection. 11. Insert the nozzle of the anaesthetic gel gently into the urethra and slowly instill 6– 10 ml of gel. Warn the patient that the gel may cause some stinging. Remove the nozzle and discard the tube. N.B. Allow a minimum of 5 minutes to elapse before catheterisation. 12. Discard first pair of sterile gloves. 13. Place the catheter in the sterile receiver between the patients’ legs. 14. Hold the catheter in the dominant hand. Remove the perforated end of the plastic cover and introduce the catheter tip into the
94
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
15.
16.
17. 18.
19. 20. 21. 22. 23. 24.
urethral orifice in an upward and backward motion for 5–6 cm. Once urine starts to flow, advance the catheter a further 5 cm to ensure the balloon is in the bladder. N.B. If the patient experiences undue pain or there is excessive resistance, stop and seek medical advice. Inflate the balloon with 10 ml of sterile water according to manufacturers guidelines. N.B. If the patient experiences pain while inflating the balloon it may still be in the urethra. Deflate and advance the catheter a further few centimetres. Withdraw the catheter until resistance is felt. A urine specimen may be collected in a sterile container for microbiology at this stage. Connect to an appropriate closed drainage system. Record urinary output on a fluid chart. Make patient comfortable and ensure that she is dry. Dispose of equipment according to local policy. Wash hands. Record the insertion of urinary catheter in the patients’ notes. Include; date and time of catheterisation, catheter type, length, balloon volume, batch number and manufacturer, any problems occurring during the procedure and gel used. (BAUN 2001; Baxter 2001)
Obtaining samples Urine samples should always be obtained from the sample port by needle aspiration and never from a catheter bag or a break in the closed drainage system. This port is specially designed to reseal when the needle is withdrawn, however, it is important to consult the manufacturers guidelines to ascertain how many times this may be punctured safely (Baxter 2001).
Antibiotics All catheterised patients will have developed bacteriuria within two weeks of insertion, however, research suggests treatment with
ª 2003 Elsevier Science Ltd. All rights reserved.
Female catheterisation: what nurses need to know!
antibiotics for asymptomatic bacteriuria, in order to prevent symptoms, is ineffective and increases the incidence of resistant bacteria (Warren 2001).
Conclusion The risks associated with catheterisation can be minimised or eradicated with appropriate training and education of nurses. Nurses should be familiar with local policies surrounding urinary catheter insertion and catheter care. Understanding of up to date research is essential. Catheterisation can be an embarrassing and degrading experience for female patients and we should aim to ensure the procedure is as comfortable as possible, through providing adequate reassurance, explanation and care. When dealing with patients with long-term catheters, A&E nurses should be able to provide them with the knowledge and skills they need to prevent trauma and infection, and promote an independent lifestyle outside hospital. References Baxter A 2001 Urinary catheterisation. In: Mallett J, Dougherty L (eds). Manual of Clinical Nursing Procedures. Blackwell Science, Oxford British Association of Urological Nurses (BAUN) 2001. Guidelines For Female Urethral Cateterisation Using 2% Lignocaine Gel. Clinimed, UK Brocklehurst JC, Hickery DS, Davies L, Kennedy AP, Morris TA 1988 A new urethral catheter. BMJ;296: 1691–1693 Cox AJ, Hukins DUL, Sutton TM 1988 Comparison of invitro encrustation on silicone and hydrogel
ª 2003 Elsevier Science Ltd. All rights reserved.
coated latex catheters during eighteen weeks. British Journal of Urology;61: 156–161 [cited in Pomfret 1996] De Courcey-Ireland 1993 An issue of sensitivity: use of anaesthetic gel in catheterising women. Professional Nurse;8(11): 738–742 Getliffe K 1993 Care of urinary catheters. Nursing Standard;7(44): 31–34 Getliffe K 1997 Catheters and catheterisation. In: Getliffe K, Dolman M (eds). Promoting Continence. Balliere Tindall, London Mulhall AB, Chapman RG, Crow RA 1988 Bacteriuria during indwelling urethral catheterisation. Journal of Hospital Infection;11: 253–262 Nursing and Midwifery Council 2002 Code of Professional Conduct. Paragraph 6, Clause 6.2. NMC, London Pomfret IJ 1996 Catheters: design, selection and management. British Journal of Nursing;5(4) Pomfret I 2001 Urethral catheterisation – is gel needed? Journal of Community Nursing;15(10) Roe B 1996 Catheterisation. In: Norton C (ed). Nursing For Continence. Beaconsfield Publishers, UK Seth 1988 Urinary catheters: selection, maintainence and nursing care. In: Cruickshank JP, Woodward, S., (eds). Continence and Urinary Catheter Care Mark. Allen Publishing, London [cited in Stewart E. (2001)] Tortora GJ, Grabowski SR 1996 Principles of Anatomy and Physiology. 8th edn. Harper Collins College Publishers, New York Tambayah PA, Maki DG 2000. Catheter associated urinary tract infection is rarely symptomatic. Archive of International Medicine 13(March) Ward et al. 1997 Urinary catheters: selection, maintainence and nursing care. In: Cruickshank JP, Woodward S. (eds). Management of Continence and Urinary Catheter Care. Mark Allen Publishing, London [cited in Stewart, E. (2001)] Warren JW 2001 Catheter associated urinary tract infections. International Journal of Antimicrobial Agents;17: 299–303 Wilson M, Coates D 1996 Infection control and urine drainage bag design. Professional Nurse;11(4): 245–255 Wright ES 1991 A choice to help meet womens needs: development in female urethral catheters. Professional Nurse (January)
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
95
Female catheterisation: what nurses need to know! Andrea L. Devine
Urinary catheter insertion is a common procedure used in the management of hospitalised and community based patients. Nurses need to be aware of the associated complications of catheterisation in order to practice safely and minimise the risks to the patient. This article is a practical guide for nurses who will be involved in female catheterisation, from decision to catheterise, choosing the type and size of catheter, and tips on catheter care and how to avoid the most common problems associated with catheterisation. c 2003 Elsevier Science Ltd. All rights reserved.
Introduction The insertion of urinary catheters is an intervention often carried out by nurses in the Accident and Emergency Department (A&E). The most common indications for catheterisation in A&E are: • As a monitoring tool for acutely ill or injured patients to assess renal perfusion from urine output. • Relief of acute urinary retention. • Reinsertion of blocked or bypassing long-term catheters. • Management of symptoms for patients with chronic conditions such as incontinence or neurological disorders.
Andrea L. Devine ENP A&E Department, Stepping Hill Hospital, Poplar Grove, Stockport SK2 7JE, UK Manuscript received: 19 August 2002; accepted : 28 August 2002
De Courcy-Ireland (1993) believes many nurses are inadequately trained and, whilst they are aware of the risks involved in male catheterisation, which may cause significant trauma, female catheterisation is often considered as a simple task. Catheterisation is a skill, which should only be undertaken when the nurse is deemed competent to do so in accordance with the NMC professional code of conduct (Nursing and Midwifery Council, 2002), which states:
ª 2003 Elsevier Science Ltd. All rights reserved.
To practice competently you must possess the knowledge, skills and abilities required for lawful, safe and effective practice without direct supervision.
Complications of catheterisation Infection One of the most frequently reported complications of catheterisation is urinary tract infection (UTI). In a study of 1497 catheterised patients by Tambayah & Maki (2000), 235 (14.9%) developed catheter associated UTI. Studies carried out by the Public Health Laboratory Service suggest up to 40% of hospital acquired infection is due to UTI and are commonly associated with catheterisation. Catheterised patients (1–4%) with UTI go on to develop bacteraemia with a mortality rate of between 13 and 30% (Ward et al. 1991). With this evidence in mind, catheterisation should only be carried out if essential, and the nurse is aware of how to minimise the risks. Infection may be introduced into the urinary tract of catheterised patients in several different ways:
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
91
Female catheterisation: what nurses need to know!
• Contamination of the catheter upon insertion. • Breaks in the closed drainage system causing contamination of the lumen of the drainage tube allowing organisms to enter the drainage bag and ascend the collection tube and catheter. • Bacterial entry between the external catheter and the urethral surface directly into the bladder (Warren 2001). When inserting a catheter aseptic technique should always be used. To avoid cross infection, effective hand washing prior to application of gloves and wearing of aprons is recommended. Many nurses find it easier to apply two pairs of sterile gloves and remove the first pair after cleansing the external genitals, preceding contact with the catheter as it is being inserted. Once the catheter is in situ a closed drainage system should be maintained and the drainage bag emptied as infrequently as possible. Studies carried out by Wilson & Coates (1996) suggest the cleansing of catheter ports with alcohol to be ineffective. However, using an appropriate catheter stand will prevent contamination of the bag through contact with the floor or hospital trolley. Removal of the catheter as soon as possible is recommended, as the risk of infection increases by 5–8% for each day it is in situ (Mulhall et al. 1988).
inflammation, through careful techniques and the use of appropriate catheters. Anaesthetic gel Catheterisation can cause pain and trauma to the bladder neck and female urethra, which unlike the male urethra, does not have its own lubricating glands. The use of an anaesthetic gel inserted directly into the urethral meatus 5 minutes prior to catheter insertion, dilates the urethral folds and opening making for easier location of the orifice, reducing the risk of trauma and ensuring the procedure is less painful for the patient (Pomfret 2001). Catheter size When selecting the correct catheter size, choose the smallest catheter that will drain adequately and cause least trauma. The smaller the catheter, the more easily the urethral folds can close around it. Catheter diameter is measured in charriere (Ch). Each charriere is equivalent to 0.33 mm, therefore a 12 Ch catheter has a 4.0 mm diameter. For an adult female, a size 12 or 14 Ch should be appropriate (Pomfret 1996). Bigger sizes should be reserved for drainage of urine containing debris or severe haematuria and only in consultation with an urologist, urological nurse practitioner or other expert.
Trauma The female urethra is approximately 4 cm long leading from the bladder to the external urethral orifice. Prior to urination the urethra lies flat in unequal folds and has a delicate lining made up of blood vessels, nerves, and collagen that can be easily damaged during catheterisation (Tortora & Grabowski 1996). Damage to tissue can also occur due to pressure necrosis; if the catheter tip is continuously exerting pressure in one area of the bladder, or in the urethra, from tension exerted on the catheter, such as the weight of a full catheter bag. The catheter itself can cause inflammation of the tissue lining the urethra and bladder, because it is a foreign body (Getliffe 1997). Those inserting or removing a catheter should always aim to minimise tissue damage and
92
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
Balloon size The drainage eyes of a catheter tip lie above the balloon, therefore the greater the balloon size the larger the volume of residual urine in the bladder, providing a reservoir for infection (Getliffe 1993). Catheter balloons should be filled in accordance with manufacturers guidelines. A balloon larger than 10 ml is not necessary to hold the catheter in place and the increased weight of a larger balloon may cause damage to the bladder neck (Roe 1996). Types of catheter All catheters produced in the UK undergo strict testing for cytotoxicity in order to pass
ª 2003 Elsevier Science Ltd. All rights reserved.
Female catheterisation: what nurses need to know!
safety standards for approval by the British Standard Committee. PVC(Polyvinylchloride). Plastic catheters are more rigid than catheters made from other materials and may cause discomfort to some patients (Pomfret 1996). They have a wide lumen allowing rapid flow rate. These may be left in situ for up to 14 days. Latex. Latex is the softest of all catheter materials, however its smoother surface makes it more prone to crust formation and it has been known to cause urethral irritation (Getliffe 1993). The incidence of latex allergy has increased in recent years and patients should always be asked about previous reactions. Latex absorbs water and body fluids, which may cause an increase in the diameter of the tube. These catheters are therefore only suitable for short-term use (Getliffe 1997). Teflon. Teflon coating is used as a covering for latex catheters to prevent irritation and absorption. Teflon has a smooth surface reducing the likelihood of it being rejected, thus causing less trauma and irritation (Seth 1988). These catheters are suitable for up to 28 days. Silicone. Silicone is a soft material that causes minimal irritation. However, these catheters are prone to premature deflation of the balloon and catheter failure (Getliffe 1993). Manufacturers recommend these may be left in situ for up to 12 weeks. Hydrogel coated latex. Cox et al. (1988) suggest the hydrogel coated latex catheters are the most compatible with human tissue making them more comfortable, easier to insert and more resistant to encrustation. These may also be left in situ for up to 12 weeks. Conformable. This catheter is specifically designed to mould and collapse with the folds of the female urethra, making it more comfortable, as it moves naturally with the urethra, and is less likely to block. These are made of latex with a silicone elastomer coating (Brocklehurst et al. 1988). Length of catheter The female urethra is only approximately 4 cm long in comparison to the male urethra, which is 15–20 cm in length. Longer length catheters increase the risk of kinking, leading to blockage and back flow of urine. For this reason, shorter
ª 2003 Elsevier Science Ltd. All rights reserved.
length catheters are available, designed specifically for women. However, not all patients will benefit from the shorter catheter, which may rub on the thighs of obese patients (Wright 1991). Always offer patients a choice of short or long length catheters where appropriate. Anatomy Identifying the urethral orifice can be difficult, as anatomy may vary from person to person and alter with age. Nurses should have a basic knowledge of the landmarks to be identified, when attempting catheterisation, to avoid cross infection of the catheter tip through, for example, accidental catheterisation of the vaginal orifice. The external genitalia of a female, collectively known as the vulva, includes the mons pubis, labia, clitoris, and structures associated with the vestibule. The mons pubis is an area of fatty tissue covered by pubic hair, which cushions the pubic symphisis. The two elongated folds of skin descending from the mons pubis are the labia majora, which enclose and protect the more delicate inner folds of the labia minora. Within the labia minora is the area known as the vestibule containing the openings of the urethra and vagina and the vestibular glands responsible for the production of mucous for lubrication during sexual arousal. At the top of the vestibule is the clitoris, a small protruding structure hooded by a skin fold known as the prepuce of the clitoris, formed by the fusion of the labia minora. The external urethral orifice is above the vaginal orifice and below the clitoris (Tortora & Grabowski 1996). When performing female catheterisation, it is a good idea to use swabs to separate the labia minora, exposing the urethral orifice. This position can be maintained with your nondominant hand throughout the procedure. Adequate lighting should be available to ensure good visibility. Equipment • clean trolley • sterile catheterisation pack
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
93
Female catheterisation: what nurses need to know!
• sterile local anaesthetic gel – Instillagel 2% Lignocaine • disposable plastic apron • two pairs of sterile gloves • sachet of antiseptic solution or saline • two sterile catheters of suitable size and material • sterile universal container • 10 ml sterile syringe • 10 ml sterile water • suitable drainage bag • straps or stand • disposable bag • protective sheeting Insertion 1. Explain the procedure to the patient. 2. Ensure privacy and adequate lighting. 3. Position the patient on her back with knees bent and feet comfortably apart. 4. Place protective sheeting under the patient’s buttocks. 5. Wash hands with a bactericidal soap. 6. Open the catheter pack to act as your sterile field in which to place all other equipment, using an aseptic technique. 7. Uncover the patient ensuring exposure of the vulva. 8. Clean hands with an alcohol rub and apply two pairs of sterile gloves. 9. Arrange sterile towels to cover surrounding areas. 10. Separate the labia majora and cleanse with gauze swabs soaked in cleansing solution; firstly the labia majora, then the labia minora, identifying the urethral meatus. Always swab from front to rear in single strokes, to minimise the risk of infection. 11. Insert the nozzle of the anaesthetic gel gently into the urethra and slowly instill 6– 10 ml of gel. Warn the patient that the gel may cause some stinging. Remove the nozzle and discard the tube. N.B. Allow a minimum of 5 minutes to elapse before catheterisation. 12. Discard first pair of sterile gloves. 13. Place the catheter in the sterile receiver between the patients’ legs. 14. Hold the catheter in the dominant hand. Remove the perforated end of the plastic cover and introduce the catheter tip into the
94
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
15.
16.
17. 18.
19. 20. 21. 22. 23. 24.
urethral orifice in an upward and backward motion for 5–6 cm. Once urine starts to flow, advance the catheter a further 5 cm to ensure the balloon is in the bladder. N.B. If the patient experiences undue pain or there is excessive resistance, stop and seek medical advice. Inflate the balloon with 10 ml of sterile water according to manufacturers guidelines. N.B. If the patient experiences pain while inflating the balloon it may still be in the urethra. Deflate and advance the catheter a further few centimetres. Withdraw the catheter until resistance is felt. A urine specimen may be collected in a sterile container for microbiology at this stage. Connect to an appropriate closed drainage system. Record urinary output on a fluid chart. Make patient comfortable and ensure that she is dry. Dispose of equipment according to local policy. Wash hands. Record the insertion of urinary catheter in the patients’ notes. Include; date and time of catheterisation, catheter type, length, balloon volume, batch number and manufacturer, any problems occurring during the procedure and gel used. (BAUN 2001; Baxter 2001)
Obtaining samples Urine samples should always be obtained from the sample port by needle aspiration and never from a catheter bag or a break in the closed drainage system. This port is specially designed to reseal when the needle is withdrawn, however, it is important to consult the manufacturers guidelines to ascertain how many times this may be punctured safely (Baxter 2001).
Antibiotics All catheterised patients will have developed bacteriuria within two weeks of insertion, however, research suggests treatment with
ª 2003 Elsevier Science Ltd. All rights reserved.
Female catheterisation: what nurses need to know!
antibiotics for asymptomatic bacteriuria, in order to prevent symptoms, is ineffective and increases the incidence of resistant bacteria (Warren 2001).
Conclusion The risks associated with catheterisation can be minimised or eradicated with appropriate training and education of nurses. Nurses should be familiar with local policies surrounding urinary catheter insertion and catheter care. Understanding of up to date research is essential. Catheterisation can be an embarrassing and degrading experience for female patients and we should aim to ensure the procedure is as comfortable as possible, through providing adequate reassurance, explanation and care. When dealing with patients with long-term catheters, A&E nurses should be able to provide them with the knowledge and skills they need to prevent trauma and infection, and promote an independent lifestyle outside hospital. References Baxter A 2001 Urinary catheterisation. In: Mallett J, Dougherty L (eds). Manual of Clinical Nursing Procedures. Blackwell Science, Oxford British Association of Urological Nurses (BAUN) 2001. Guidelines For Female Urethral Cateterisation Using 2% Lignocaine Gel. Clinimed, UK Brocklehurst JC, Hickery DS, Davies L, Kennedy AP, Morris TA 1988 A new urethral catheter. BMJ;296: 1691–1693 Cox AJ, Hukins DUL, Sutton TM 1988 Comparison of invitro encrustation on silicone and hydrogel
ª 2003 Elsevier Science Ltd. All rights reserved.
coated latex catheters during eighteen weeks. British Journal of Urology;61: 156–161 [cited in Pomfret 1996] De Courcey-Ireland 1993 An issue of sensitivity: use of anaesthetic gel in catheterising women. Professional Nurse;8(11): 738–742 Getliffe K 1993 Care of urinary catheters. Nursing Standard;7(44): 31–34 Getliffe K 1997 Catheters and catheterisation. In: Getliffe K, Dolman M (eds). Promoting Continence. Balliere Tindall, London Mulhall AB, Chapman RG, Crow RA 1988 Bacteriuria during indwelling urethral catheterisation. Journal of Hospital Infection;11: 253–262 Nursing and Midwifery Council 2002 Code of Professional Conduct. Paragraph 6, Clause 6.2. NMC, London Pomfret IJ 1996 Catheters: design, selection and management. British Journal of Nursing;5(4) Pomfret I 2001 Urethral catheterisation – is gel needed? Journal of Community Nursing;15(10) Roe B 1996 Catheterisation. In: Norton C (ed). Nursing For Continence. Beaconsfield Publishers, UK Seth 1988 Urinary catheters: selection, maintainence and nursing care. In: Cruickshank JP, Woodward, S., (eds). Continence and Urinary Catheter Care Mark. Allen Publishing, London [cited in Stewart E. (2001)] Tortora GJ, Grabowski SR 1996 Principles of Anatomy and Physiology. 8th edn. Harper Collins College Publishers, New York Tambayah PA, Maki DG 2000. Catheter associated urinary tract infection is rarely symptomatic. Archive of International Medicine 13(March) Ward et al. 1997 Urinary catheters: selection, maintainence and nursing care. In: Cruickshank JP, Woodward S. (eds). Management of Continence and Urinary Catheter Care. Mark Allen Publishing, London [cited in Stewart, E. (2001)] Warren JW 2001 Catheter associated urinary tract infections. International Journal of Antimicrobial Agents;17: 299–303 Wilson M, Coates D 1996 Infection control and urine drainage bag design. Professional Nurse;11(4): 245–255 Wright ES 1991 A choice to help meet womens needs: development in female urethral catheters. Professional Nurse (January)
Accident and Emergency Nursing (2 0 0 3 ) 11, 9 1 –9 5
95