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The smallest gauge catheter that will drain the bladder should always be chosen. It should be inserted gently to avoid trauma, and under sterile conditions to avoid introducing microorganisms into the urinary system. Once an indwelling catheter has been inserted an absolutely closed drainage system must be maintained. Special care must be taken to guard against tension on the catheter and kinking of the tubing, which can obstruct the flow of urine. Catheters should never be pinned to the bedclothing as this can result in accidental removal of the catheter or unnecessary pulling when the patient moves about in bed. The catheter is taped securely to the patient's body. Male, bedridden patients can have the catheter taped to the abdomen to avoid pressure at the junction of the penis and scrotum.
The tubing and collection bag should be arranged so that there is continuous gravity flow of urine. The bag must always be kept below the level of the bladder to avoid backflow of urine into the bladder. It also should never be inverted, for the same reason. This is especially important when the patient is being positioned, helped out of bed, or transported on a stretcher. The catheter should not be clamped nor should it be routinely irrigated and changed. Most authorities agree that catheters need changing only if they are obstructed, if contamination is suspected, or if there is a malfunction of the apparatus. When the collecting bag is being emptied, care must be taken to avoid contamination of the spout.
Patient care must also include attention to the area surrounding the urinary meatus. At least twice daily, or more often if necessary, the genital area should be washed gently with soap and water and dried thoroughly. Crusts and secretions around the catheter may be removed by gentle wiping with a gauze or cotton square saturated with a mild antiseptic. These measures will reduce the possibility of infection and ensure the comfort of the patient by eliminating unpleasant odors and irritation.
Because of the ever-present danger of urinary tract infection, routine orders for catheterization to relieve bladder distention should be avoided and alternatives to an indwelling catheter should be considered. One-time catheterization following surgery may not be necessary if other measures to induce voiding are tried. Patients who require continuous care because of incontinence or an inability to void normally may respond favorably to measures other than indwelling catheterization, such as condom drainage, suprapubic catheter drainage, and, for some carefully selected patients, self-catheterization.
catheterizationThe placement of a catheter in a lumen. See Right heart catheterization, Subclavian vein catheterization, Swan-Ganz catheterization.
catheterization(kăth″ĕ-tĕr-ĭ-zā′shŭn) [Gr. katheterismos]
Precatheterization: The nurse prepares the patient physically and emotionally by explaining the procedure and expected sensations. The patient's vital signs, including the presence and intensity of peripheral pulses, are assessed to establish a baseline measure. Cardiac monitoring leads are applied and an intravenous infusion initiated. Anxiety and activity levels are documented, as well as the presence and pattern of any chest pain. Any known allergies, particularly to shellfish or iodine (suggestive of sensitivity to radiopaque dye), are also documented, and the cardiologist is alerted to these allergies or any changes in the patient's condition. The groin is cleansed and hair is removed locally, and the patient is informed that an oral or intravenous mild sedative (rather than general anesthesia) will probably be given before or during the procedure, so that he or she is able to cough and breathe deeply as instructed during testing. A radiopaque contrast medium is injected into the arteries and nitroglycerin may be administered to aid visualization. After the injection, the patient may feel light-headed, warm, or nauseated for a few moments. The patient will have to lie on the back for several hours after the procedure and should report chest pain immediately both during and after the procedure.
During catheterization: Support personnel assist with the procedure according to protocol by monitoring cardiac pressures and rhythm and the results of hemodynamic studies. Patient comfort and safety are assured; and changes in emotional status, level of consciousness, and verbal and nonverbal responses are assessed to determine the patient's response to the procedure and need for reassurance or medication to prevent vasovagal reactions or coronary artery spasm. Any complications, such as cardiac arrhythmias or allergic reaction to the contrast medium, are also evaluated and reported.
Postcatheterization: The nurse provides emotional support to the patient and answers questions. Cardiac rhythm and vital signs (including apical pulse and temperature) are monitored until stable according to protocol (usually every 15 min for the first 1 to 2 hr) or more frequently as the patient's condition requires. The blood pressure should not be checked in any limb used for catheter insertion. The dressing is inspected frequently for signs of bleeding, and the patient is instructed to report any increase in dressing tightness (which may indicate hematoma formation). Pressure is applied over the entry site and the extremity is maintained in extension according to protocol. The patient is cautioned to avoid flexion or hyperextension of the affected limb for 12 to 24 hr depending on protocol.
Neurovascular status of the involved extremity distal to the insertion site is monitored for changes, which may indicate arterial thrombosis (the most frequent complication), embolus, or another complication requiring immediate attention. The head of the bed is elevated no more than 30 degrees, and the patient is confined to bedrest. The patient may complain of urinary urgency immediately after the procedure. Fluids are given to flush out the dense radiopaque contrast medium, and urine output is monitored, esp. in patients with impaired renal function. The patient is assessed for complications such as pericardial tamponade, myocardial infarction, pulmonary embolism, stroke, congestive heart failure, cardiac dysrhythmia, infection, and thrombophlebitis. The patient's preoperative medication regimen is resumed as prescribed (or revised).
The patient will need to be driven home, and a responsible adult should be in attendance until the next morning. Both patient and family are provided with written discharge instructions explaining the need to report any of the following symptoms to the physician: bleeding or swelling at the entry site; increased tenderness; redness; drainage or pain at the entry site; fever; and any changes in color, temperature, or sensation in the involved extremity. The patient may take acetaminophen or other nonaspirin analgesic every 3 to 4 hr as needed for pain. The entry site should be covered with an adhesive bandage for 24 hr or until sutures, if present, are removed (usually within 6 days). The patient usually is permitted to shower the day after the procedure and to take a tub bath 48 hr after the procedure (if no sutures are present). Strenuous activity should be avoided for 24 hr after the procedure.
urinary bladder catheterization
Patients with chronic difficulty urinating sometimes are given indwelling urinary catheters; as an alternative, they may be given bladder training instruction, or assistance with toileting. When this is ineffective they may be instructed in the technique of clean, intermittent self-catheterization. To do this, they need to learn about their urethral anatomy and about methods they can use to avoid introducing microorganisms into the urinary bladder (handwashing, periurethral and catheter cleansing, and catheter storage). Most patients need to catheterize themselves four or five times daily. Carefully performed intermittent catheterization is less likely to cause urinary tract infection than is chronic indwelling urinary catheterization. Individuals who have difficulty retaining urine (urinary incontinence) should receive bladder training and assistance in toileting at specific intervals rather than having an indwelling urinary catheter. See: illustration
After the procedure and expected sensations are explained to the patient, the proper equipment is assembled, sterile gloves are donned, a sterile field created, and the indwelling catheter is connected to a closed drainage bag, if not preconnected. The balloon at the tip of this catheter is inflated (and deflated) before its insertion to make sure that it will stay in place after entering the bladder. The patient is properly positioned and draped (see instructions for female and male patients); the urethral orifice is prepared with antiseptic solution and the catheter is gently inserted. Sterile technique is maintained throughout these procedures. The indwelling catheter is advanced beyond the point where urinary flow begins, and the balloon inflated with the specified amount of sterile water, then the catheter is permitted to slip back slightly. The drainage tube is secured to the patient's leg, then looped on the bed, and the tubing leading to the collection bag is straightened to facilitate gravity drainage. The collection bag is suspended above the floor. The drainage tube is prevented from touching a surface when the collection bag is emptied; the spout is wiped with an alcohol swab before being refastened to the bag. The meatal area should be cleansed daily and inspected for inflammation. The patient's ability to void and remain continent is periodically evaluated and catheterization is discontinued when possible. Results of the procedure, including the character and volume of urine drained and the patient's response, are observed and documented. The patient should be draped to limit embarrassment and provided warmth and privacy, exposing only the genitalia area.
Female: The patient should be in the dorsal recumbent position on a firm mattress or examining table to enhance visualization of the urinary meatus. Alternately, the lithotomy position, with buttocks at the edge of the examining table and feet in stirrups, may be used. For female patients with difficulties involving hip and knee movements, the Sims' or left lateral position may be more comfortable and allow for better visualization. Pillows may be placed under the head and shoulders to relax the abdominal muscles.
Male: The patient should be in a supine position with legs extended. Lubricant is applied to the catheter or may be instilled directly into the urethra with a prefilled syringe to facilitate passage of the tube. After the procedure, care should be taken to return the male patient’s prepuce to its normal position to prevent any subsequent swelling.
Unless otherwise restricted, oral intake should be encouraged to maintain adequate urine output, and urine inspected for cloudiness and changes in color or odor, any of which indicate the need for urine culture to test for infection. When removing the indwelling catheter, the patient should be draped, the genitalia cleansed, and the balloon fully deflated using a syringe. The catheter is then gently rotated to ensure that it is not adhering to urogenital tissue, and should easily slip out into the gloved hand. Pulling the glove off over the catheter tip, then wrapping glove and catheter in a waterproof wrapper or bag, provides “double bagging” for disposal.
A high rate of morbidity and mortality is associated with long-term use of indwelling urinary catheters (7 days or longer). Indwelling urinary catheters should be used only for very brief periods or specific concerns, such as urinary retention that cannot be managed with other methods, or palliative care. Most indwelling catheters are made of latex. Silicone catheters should be used in patients with latex allergies. Silver-coated urinary catheters may result in fewer infections than silicone, silicone-coated, or the common hydrogel-coated latex catheters. Experts advocate using the smallest size catheter effective for the patient – usually 14 or 16 French, with a 5-ml balloon. Catheters 18 French or larger create discomfort, increase the risk of blocking the periurethral glands, and can lead to urinary tract infection and urethral irritation and erosion. For long-term use, inflate a 5-ml balloon with 10 ml of water, as underinflation can lead to balloon distortion and catheter deflection. The 30-ml balloon is useful for a short time following genitourinary surgery to decrease bleeding and prevent dislodgement. Urethral catheter tubing should be secured to prevent tension on the bladder neck and accidental dislodgement. For males, securing the tubing restraint on the abdomen works best; for females, the anterior medial thigh. The common practice of changing catheters monthly is based on Medicare and Medicaid reimbursement structures; however, data on the frequency for change are lacking. Thus change is probably best individualized to the patients or carried out following manufacturer’s recommendations for the various types of catheters. Drainage bags should be emptied every 4 to 6 hr (minimum) to avoid migration of bacteria to the catheter lumen. If a patient develops symptoms of a urinary tract infection (fever, chills, malodorous or cloudy urine, hematuria, and/or suprapubic pain), antibiotic therapy should be instituted and a sample of urine sent for culture. Prophylactic antibiotics are not recommended with indwelling urinary catheterization, as they lead to drug-resistant infectious agents.