What is a critical step when inserting an indwelling catheter into a male patient?
Chapter 10. Tubes and Devices Show
Urinary elimination is a basic human function that can be compromised by illness, surgery, and other conditions. Urinary catheterization may be used to support urinary elimination in patients who are unable to void naturally. Urinary catheterization may be required:
Catheter-Associated Urinary Tract InfectionsCatheter-associated urinary tract infections (CAUTI) are a common complication of indwelling urinary catheters and have been associated with increased morbidity, mortality, hospital cost, and length of stay (Gould et al., 2009). Urinary drainage systems are often reservoirs for multidrug-resistant organisms (MDROs) and a source of the transmission of microorganisms to other patients (Gould et al., 2009). The most important risk factor for developing a CAUTI, a healthcare-associated infection (HAI), is the prolonged use of a urinary catheter (Centers for Disease Control and Prevention [CDC], 2015). Urinary tract infections (UTIs) are the most commonly reported HAIs in acute care hospitals and account for more than 30% of all reported infections (Gould et al., 2009). Catheters in place for more than a few days place the patient at risk for a CAUTI. A healthcare provider must assess patients for signs and symptoms of CAUTIs and report immediately to the primary healthcare provider. Signs and symptoms of a CAUTI include:
The following are practices for preventing CAUTIs (Perry et al., 2018):
Urinary CatheterizationUrinary catheterization refers to the insertion of a catheter tube through the urethra and into the bladder to drain urine. Although not a particularly complex skill, urethral catheterization can be difficult to master. Both male and female catheterizations present unique challenges. Having adequate lighting and visualization is helpful, but does not ensure entrance of the catheter into the female urethra. It is not uncommon for the catheter to enter the vagina. Leaving the catheter in the vagina can assist in the correct insertion of a new catheter into the urethra, but you must remember to remove the one in the vagina. For some women, the supine lithotomy position can be very uncomfortable or even dangerous. For example, patients in the last trimester of pregnancy may faint with decreased blood supply to the fetus in this position. Patients with arthritis of the knees and hips may also find this position extremely uncomfortable. Catheterization may also be accomplished with the patient in the lateral to Sims position (three-quarters prone). The male urinary sphincter may create resistance when passing a urinary catheter, particularly for older men with prostatic hypertrophy. Urethral catheterization might be intermittent indwelling. Intermittent catheterization (single-lumen catheter) is used for:
Indwelling catheterization (double- or triple-lumen catheter) is used for:
The steps for inserting an intermittent or an indwelling catheter are the same, except that the indwelling catheter requires a closed drainage system and inflation of a balloon to keep the catheter in place. Indwelling catheters may have two or three lumens (double or triple lumens). Double-lumen catheters comprise one lumen for draining the urine and a second lumen for inflating a balloon that keeps the catheter in place. Triple-lumen catheters are used for continuous bladder irrigation and for instilling medications into the bladder; the additional lumen delivers the irrigation fluid into the bladder. Indwelling urinary catheters are made of latex or silicone. Intermittent catheters may be made of rubber or polyvinyl chloride (PVC), making them softer and more flexible than indwelling catheters (Perry et al., 2018). The size of a urinary catheter is based on the French (Fr) scale, which reflects the internal diameter of the tube. Recommended catheter size is 12 to 16 Fr for females, and 14 to 16 Fr for males. Smaller sizes are used for infants and children. The balloon size also varies with catheters: smaller for children (3 ml) and larger for continuous bladder irrigation (30 to 60 ml). The size of the catheter is usually printed on the side of the catheter port. Insertion of a Foley catheter is within the RN scope of practice, and as such an RN can insert a catheter within their independent scope of practice if the agency policy is supportive and the RN is competent to do so (BCCNP, 2018). An indwelling catheter is attached to a drainage bag to allow for unrestricted flow of urine. Make sure that the urinary bag hangs below the level of the patient’s bladder so that urine flows out of the bladder. The bag should not touch the floor, and the patient should carry the bag below the level of the bladder when ambulating. To review how to insert an indwelling catheter, see Checklist 82.
Watch the videos Urinary Catheterization (Male) AND Urinary Catheterization (Female) developed by Renée Anderson and Wendy McKenzie of Thompson Rivers University, 2018. Removing a Urinary CatheterRemoving an indwelling Foley catheter is within the RN’s scope of practice. As such the RN can choose to remove an indwelling catheter within their independent scope of practice if agency policy is supportive and the RN is competent to do so (BCCNP, 2018). Even with an order to remove an indwelling catheter, it remains the responsibility of the healthcare provider to evaluate if the indwelling catheter is necessary for the patient’s recovery. A urinary catheter should be removed as soon as possible when it is no longer needed. For post-operative patients who require an indwelling catheter, the catheter should be removed preferably within 24 hours. The following are appropriate uses of an indwelling catheter (Gould et al., 2009):
When a urinary catheter is removed, the healthcare provider must assess if normal bladder function has returned. The healthcare provider should report any hematuria, inability or difficulty voiding, or any new incontinence after catheter removal. Prior to removing a urinary catheter, the patient requires education on the process of removal, and on expected and unexpected outcomes (e.g., a mild burning sensation with the first void) (VCH Professional Practice, 2014). The healthcare provider should instruct patients to:
Review the steps in Checklist 83 on how to remove an indwelling catheter.
Watch the video Foley Catheter Removaldeveloped by Renée Anderson and Wendy McKenzie of Thompson Rivers University, 2018. If a patient is unable to void after six to eight hours of removing a urinary catheter, or has the sensation of not emptying the bladder, or is experiencing small voiding amounts with increased frequency, a bladder scan may be performed. A bladder scan can assess if excessive urine is being retained. Notify the healthcare provider if patient is unable to void within six to eight hours of removal of a urinary catheter. If a patient is found to have retained urine in the bladder and is unable to void, an intermittent/straight catheterization should be performed (Perry et al., 2018). Read the To Scan or Not To Scan journal article by Davis, Chrisman, and Walden (2012) for more information on bladder scanning. Critical Thinking Exercises
What is the critical step in inserting an indwelling catheter into a male patient?Male patient: Hold penis perpendicular to body and pull up slightly on shaft. Ask patient to bear down gently (as if to void) and slowly insert catheter through urethral meatus. Advance catheter 17 to 22.5 cm or until urine flows from catheter.
What is the best position for a male in inserting a urinary catheter?Place the patient in the supine position with legs extended and flat on the bed. Prepare the catheterization tray and catheter and drape the patient appropriately using the sterile drapes provided. Place a sterile drape under the patient's buttocks and the fenestrated (drape with hole) drape over the penis.
What is a common cause for difficulty inserting a catheter in a man?Strictures are the most common cause of difficult catheterization. They create narrowing in the lumen, leading to resistance during catheterization that can be anxiety-provoking to both the health care provider and the patient.
What are the steps of insertion of urinary catheterization?Lubricate tip of catheter with sterile lubricant jelly. Holding the coiled catheter in dominant hand, gently introduce the catheter tip into the urethral meatus. Slowly advance the catheter through the urethra into the bladder. If substantial resistance is met, do not force the catheter!
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