Question

1. After attempting to insert an indwelling urinary in a female, no urine appears. What would be the recommended action and explain the rationale.

2.After inserting an indwelling urinary catheter, what are three essential components of your documentation?

Answer 1

1-

Troubleshooting

• Catheter not draining/ blocked/patient oliguric
• Check catheter/tubing not kinked
• Check catheter is still secured to patient leg and that it hasn't migrated out of bladder
• Assess patient’s hydration status to ensure they are not dehydrated. Consider the need to perform a bladder scan to assess bladder volume. Escalate to medical team if concerned.
• The patency of a catheter can be checked via the sampling port or catheter tubing. A blocked catheter should be flushed via the catheter tubing, this is of particular importance in case of blood clots or mucus (for example after a bladder augment).  

The following techniques to check for patency and/or flush a catheter should be completed following the Aseptic Technique Procedure.

Checking catheter patency via Needleless Sampling Port		Checking catheter patency and flushing via Catheter Tubing
Clamp  catheter below the sampling point. Scrub sampling point vigorously with 70% alcohol and chlorhexidine (0.5% or 2%) soaked gauze or swabs for at least 15 seconds and allow to air dry prior to accessing port Attach luer lock syringe and gently flush 10mls of normal saline into the catheter. Pull back on the syringe to withdraw saline/urine. If saline is not coming back on suction, gently reinject 10mls of normal saline and let urine drain by itself without sucking back on the syringe. It may be that the catheter tip is stuck to the bladder wall. So ensure the saline is flushing easily and urine is subsequently flowing back by itself, without any suction. At no time should force be used to instil fluid when checking for patency or flushing a catheter.		Clamp catheter and disconnect the catheter bag. Attach a catheter tipped syringe (Toomey Syringe) to the catheter tubing (where the catheter bag has been disconnected) and gently flush 10mls of normal saline into the catheter. Pull back on the syringe to withdraw saline/urine. If saline is not coming back on suction, gently reinject 10mls of normal saline and let urine drain by itself without sucking back on the syringe. It may be that the catheter tip is stuck to the bladder wall. So ensure the saline is flushing easily and urine is subsequently flowing back by itself, without any suction. At no time should force be used to instil fluid when checking for patency or flushing a catheter. Consider attaching a new/clean drainage bag to the catheter.

Catheter leaking

• Ensure the catheter is still draining and that the urine is not overflowing around a blocked catheter. See above for tips regarding catheters not draining.
• If the catheter is a balloon catheter, make sure the balloon is still inflated. Hold the catheter tubing securely in the same position and empty the balloon to make sure the amount that has been placed initially in the balloon is still present. If not, reinflate the balloon to its initial volume with water. Deflation of the balloon happens easily with a 6Fr catheter.
• Check catheter size is correct for age/size of the child. Use of a balloon catheter in neonates should only be with consultation with the treating medical team.
• Consider the need to remove and reinsert a new catheter in consultation with the treating medical team.

Removal of urinary catheter

Equipment required for removal:

• Standard precaution PPE
• 5ml/10ml Syringe – as stated on catheter packaging
• Waterproof sheet
• Kidney dish / receiving container

Procedure:

• Explain procedure to child and family and gain consent.
• Check amount of water used to inflate IDC balloon.
• Gather equipment required for removal
• Ensure patient privacy and have patient in supine position.
• Place waterproof sheet and/or kidney dish between patient legs.
• Perform hand hygiene & don gloves.
• Deflate balloon completely and remove any straps/tapes
• Gently withdraw catheter on exhale if possible, with rotation movements if necessary.
  • Bear in mind that once inflated, the balloon won’t deflate to its total initial flat state and the balloon portion of the catheter will remain larger than the catheter itself.
    • If resistance felt and catheter cannot be easily removed do not force, leave catheter in situ and consult medical team.
    • Consider cutting the catheter at the balloon inflation point to ensure the balloon is deflated.
    • Once removed inspect catheter for intactness. Report if not intact.
• Perform hand hygiene.
• Document catheter removal in the LDA activity.
• Observe for urine output post catheter removal.
• If the patient has not passed urine 6 – 8hours post catheter removal assess the patient’s hydration status and consider the need to perform a bladder scan. Discuss findings with the treating medical team.

Complications

• Inability to catheterise: ensure appropriate catheter size has been selected based on the age/size of the child. Ensure adequate procedural pain relief and distraction is in place during the procedure.
  • Escalate to the treating medical team and consider the need for a referral to the urology team.
  • In young girls, the urethra can be difficult to localise and the catheter can go directly . In this case, leave the first catheter and use another one to place immediately above, which will be more likely to go in the urethra.
• Urethral injury may occur from trauma sustained during insertion or balloon inflation in incorrect position: it is very important to ensure the catheter is in the bladder before inflating the balloon, this can be confirmed by visualising the stream of urine prior to balloon inflation.
• Haemorrhage
• False passage (catheter pushed through urethral wall): The risk of false passage is actually higher when using a smaller catheters, ensure catheter size utilised is appropriate for child’s age and size.
• Urethral strictures following damage to urethra. This may be a long term problem
• Infection

2-Secure the drainage bag on the bed frame below her bladder level. Provide perineal care, then remove your gloves and wash your hands. Document the date and time, the catheter size and type, and the patient's response. Record the amount, odor, color, and consistency of urine and whether you obtained a specimen.

Preventing Infections

1. Keep the drainage bag below the level of your bladder and off the floor at all times.
2. Keep the catheter secured to your thigh to prevent it from moving.
3. Don't lie on your catheter or block the flow of urine in the tubing.
4. Shower daily to keep the catheter clean.