Clinical Skills Female Catheterisation - Learning Central

Female Catheterisation

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Clinical Skills Female Catheterisation Clinical Skills and Simulation Team

Female Catheterisation Aims and Outcomes

Aims and Outcomes The aim of this module is to facilitate learning regarding the purpose and procedure of Female Urethral Catheterisation. Learning Outcomes At the end of the session the students should be able to:  Define the reasons why urethral catheterisation may be necessary.  State the common risk factors that may arise as a result of the procedure being carried out.  Discuss the reasons why insertion of the urinary catheter may be contraindicated.  Describe the information required for the completion of patient care plan documentation.  Evaluate own learning and recognise how improvements can be made. On completion of both the ‘Male Catheterisation’ and ‘Female Catheterisation’ e-tutorials you will be asked to complete an online assessment. When the answers are all submitted you will receive a certificate. Please print this page out and bring it with you when you attend your scheduled ‘Catheterisation’ session.

Female Catheterisation Introduction

Introduction Short Term Indications PTFE (Polytetrafluoroethylene) coated, Plastic catheters (PVC), (1 – 28 days) Drainage of urine during and post operatively Monitoring output during an acute illness To obtain an uncontaminated specimen of urine To measure post micturition residual urine Various urological investigations i.e. urodynamics, x-ray Relief of acute retention of urine, most likely caused by bladder outflow obstruction.

Continuous bladder irrigation to prevent clot retention post bladder surgery. Pre and post-partum or during labour


Introduction Long Term Indications 100% Silicone catheters, Latex catheters coated with hydrogel, Silicone-elastomer, Latex Catheter coated with Hydrogel and Silver (up to 12 weeks.) Patients with a neurological condition or injury who have difficulty in completely emptying the bladder. Patients with outlet obstruction who may be unfit for surgical repair. Post surgical drainage when ‘stenting’ of the ureter is required. Management of terminally ill patients when micturition may be difficult, painful, frequent or when skin integrity may be compromised.

Intractable incontinence – in dwelling catheters should only be used when all other avenues (eg: sling therapy*) have been explored and failed and skin integrity may be compromised. * During a sling procedure, strips of synthetic mesh, the patients own tissue or sometimes animal or donor tissue are used to create a sling or "hammock" under the urethra.


Introduction

Risks associated with Female Catheterisation Bacteriuria and urinary tract infection-Maintaining an aseptic technique will help minimise the risk. Haematuria (bleeding)- patients taking medication such as aspirin or warfarin will increase the risk of haematuria, recent catheter related trauma, recent urinary tract surgery, and known bladder cancer will also increase this risk. Using the correct procedure and never forcing the catheter will minimise the risk of trauma to the urethra. Urethral Stricture- occurs when a part of the urethra becomes narrowed. The length of the female urethra is 3-4cm. Any section of the urethra may be affected. There is usually some scar tissue around the affected part of the urethra that causes the narrowing. The length of strictures vary from less than 1 cm to the full length of the urethra. Loss of bladder tone - Fitting a flip-flo valve to the catheter in mobile patients will help maintain bladder tone. Sexual function can be compromised in the use of a catheter. Altered body image due to urethral catheterisation may impede the person’s desire to want sexual intercourse. If the patient is currently on antibiotics, there is a high risk of further infection, increased usage leads to resistance.


Introduction Contra Indications Lack of consent Urethral stricture Blood at the meatus-may indicate urethral trauma. Patient will need imaging of UG tract. Seek senior support (a supra pubic catheter may be required to drain urine).


Introduction

Consent The five key principles of the Mental Capacity Act (2005) need to be taken into consideration when consenting a patient to catheterisation. 1. A presumption of capacity – every adult has the right to make their own decisions and must be assumed to have capacity to do so unless it is proved otherwise. 2. Individuals should be supported to make their own decisions – a person must be given all practicable help before anyone treats them as not being able to make their own decisions. 3. Unwise decisions – just because an individual makes what might be seen as an unwise decision, they should not be treated as lacking capacity to make that decision. 4. Best interests – an act done or decision made under the act, for or on behalf of a person who lacks capacity, must be done in their best interests. 5. Least restrictive option – anything done for or on behalf of a person who lacks capacity should be the least restrictive of their basic rights and freedoms. Explain the procedure to the patient, explaining why it is required and indicating potential problems, including possible discomfort both during and following the procedure. Give an indication of how long catheterisation may be required.


Introduction

Patient comfort Catheterisation is not a comfortable procedure. Ensure you maintain patient privacy and dignity throughout. Cover all parts of the body not requiring exposure, and keep checking for any signs of distress throughout the procedure. Stop immediately if any extreme discomfort is expressed and seek the advice of a senior.

Female Catheterisation Equipment

Equipment Clean a stainless steel trolley with hard surface cleansing wipes. Gather all your equipment and store it on the lower shelf of the trolley.


Equipment You will need:

A catheter pack which contains: Sterile drape (fenestrated, disposable) Cotton gauze balls Gallipot (for cleansing solution) Gauze surgical swabs Collecting receiver or kidney bowl


Equipment You will also need:

Two 10ml ampoules of saline (for cleansing) Urine collection bag, or urometer for hourly estimations. Catheter (Start with 12cH, or may require larger eg. 14cH if post surgical in some circumstances). For short term use (under 28 days) use an uncoated latex, PVC, polytetrafluoroethylene (PTFE) or silver alloy catheter. For longer term, use an all silicone, silicone elastomer or hydrogel coated catheter. Check the patient has no latex allergies. Lidocaine (6 ml, 2%) gel (for lubrication, dilatation and analgesia) 10ml ampoule of sterile water for injections to inflate balloon (10ml used for standard catheters, check catheter label for correct volume). 10ml syringe and green needle (to aspirate water for balloon inflation) 2 pairs of sterile gloves

Female Catheterisation Procedure

Procedure

Introduce yourself and any colleagues involved at the contact. Verbally confirm the identity of the patient by asking for their full name and date of birth. If patient unable to confirm, check identity with family/ carer. Explain procedure to patient including risks and benefits and gain informed consent. If patient unable to give consent, act in patients best interests by following Consent Policy. Offer patient a chaperone and document decision in health records. Wash and dry your hands , and put on an apron.


Procedure

Saline Cleaning Solution

Two Packs of Sterile Gloves

Catheter in sterile sheath Water for Injection Anaesthetic Gel/Lubricant

Urine Collection Bag

Check for any allergies e.g. latex or anaesthetic gels. If patient is allergic to latex then a silicone catheter should be utilised. Open the catheter pack carefully onto the top shelf of the trolley using an aseptic technique. Open all your supplementary packs onto the sterile field now stretched out on the trolley.

Collecting Tray

Gauze Balls & Sheets

Drape


Procedure

Ensure the patient has privacy Place the patient in the supine position with the knees flexed and separated and feet flat on the bed, about 60 cm apart Place protective sheet under the patient’s buttocks and adjust lighting as necessary


Procedure

Re -wash and dry your hands. Put on a pair of sterile gloves from the trolley, taking care not to contaminate the sterile field.


Procedure

Hold the labia open, and with your dominant hand cleanse the urinary meatus, using saline soaked gauze balls. Use each gauze for a single downward movement only.


Procedure

Explain to the patient that you are going to insert the lidocaine gel, and it may be a little uncomfortable. Insert the tip of the lidocaine gel into the meatus. Instil 6ml of the gel slowly and evenly into the urethra.

Cover the patient with a sterile drape and explain to the patient you are going to wash your hands. Leave the gel work for 5 minutes. Remove and dispose of PPE to comply with waste management policy.


Procedure

Apply 2nd pair of sterile gloves Open the catheter sheath about 1cm along the perforations, keeping the tip of the catheter covered until insertion. Apply the fenestrated appropriately

sterile

drape

Place receiver or kidney dish between the patients legs


Procedure

Pick up the catheter with your dominant hand. Use the blue sheath to insert the catheter

Insert the lubricated tip of the catheter into the urinary meatus. Advance the catheter about 5 - 6cm, until urine begins to flow then advance the catheter a further 1-2 cms. If at any time the patient experiences any undue pain or there is resistance when passing the catheter, stop and seek advice.


Procedure

Note: If the catheter accidently slips into the vagina, leave it there to assist as a landmark. With another lubricated sterile catheter, insert into the urinary meatus until you get urine back. Remove the catheter left in the vagina at this time.


Procedure

Remove the blue outer sheath. Remove the sterile cap from the urine collecting bag or urometer and connect to the larger port on the catheter, take care not to pull the catheter back when attaching the bag. Measure the amount of urine. To be aware of bladder capacity for patients who have presented with urinary retention. To monitor renal function and fluid balance.


Procedure

Inflate the pilot balloon with the required amount of water. The catheter label indicates the amount needed. Observe for signs of pain, discomfort and urethral bleeding

Following inflation, withdraw gently on the catheter to ensure that the catheter is fixed in the bladder by the inflated balloon.


Procedure

Ensure the patient is dry and made comfortable. If the area is left wet or moist, secondary infection and skin irritation may occur Attach the urine collecting bag to a urine collecting bag stand. If the patient is mobile, use the leg bag straps to secure to the patients leg.


Procedure

If using a Urometer, attach to the bedside with a hook which is supplied within the packaging.


Procedure Dispose of gloves and materials in a ‘tiger’ clinical waste bag Wash hands. Record the procedure in the patient's notes.

Include: 

The date

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Time

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Why the procedure was carried out

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That informed consent was obtained

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That an aseptic technique was used for the procedure

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The type and size of catheter used, expiry date, batch number (the sticky label on the outer packet has this information-stick in the notes)

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The residual volume of urine

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Post procedural investigations or complications

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Your management plan

Female Catheterisation Indwelling Urinary Catheters

Indwelling Urinary Catheters – Troubleshooting Problems During insertion of catheter If the opening of the female urethra is difficult to locate



Place a small amount of lidocaine gel in the area as this should help to dilate the opening

Resistance felt during insertion



DO NOT try to forcefully pass the catheter as this could lead to damage to the urethra and false passages being made

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Insert more lidocaine gel (20 – 30 ml). This will help to dilate the urethra and any mild strictures that may be present.

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Try different sizes of catheter

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Males – ask them to cough

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If resistance persists refer to your senior colleague and/or urology


Indwelling Urinary Catheters – Troubleshooting Problems

Catheter not draining any urine Fluid Balance?

If equal then no immediate action required. However, ensure adequate hydration encourage patient to drink or if necessary prescribe fluid via most appropriate and least invasive route

Positive fluid balance (more in than out)

Abdominal Assessment Bladder Scan Palpable Bladder? If bladder full and/or palpable attempt the actions on the following slide


Indwelling Urinary Catheters – Troubleshooting Problems

Catheter not draining any urine FIRST (to unblock any possible debris build up around drainage holes) 50 ml fluid in and aspirate back out (use 50 ml bladder tip syringe with saline or concertina style prefilled catheter flush device) Ensure that you get back what you put in The flow of urine may resume following the flush

SECOND Deflate Balloon Reposition catheter by pushing further into bladder Re-inflate balloon The flow of urine may resume after repositioning of the catheter

FINALLY If all of this fails to resume the flow of urine then you will need to remove the catheter and insert new one using aseptic technique

Female Catheterisation Checklist

Checklist  Explain procedure to patient and obtain informed consent.  Follow guidelines for aseptic technique.  Position patient comfortably. Maintain privacy.  Wash hands.  Wear first pair of sterile gloves.  Hold the labia open, and with your dominant hand cleanse the urinary meatus, using saline soaked gauze balls. Use each gauze for a single downward movement only.

 Instil 6ml of 2% lidocaine gel into the urethra to achieve surface anaesthesia.  Cover patient with sterile drape for privacy and dignity.  Remove gloves and wash hands.

 Apply second pair of sterile gloves.

Female Catheterisation Checklist

Checklist  Place the fenestrated sterile drape appropriately.  Place a collecting vessel for urine between the patient's legs.  Using the blue sterile sheath to hold the catheter, tear a small hole in the perforations near the tip gently pass it into the urinary meatus.

 Advance the catheter about 5 - 6cm, until urine begins to flow then advance the catheter a further 1-2 cm.  Attach appropriate urine collecting product.  Inflate the pilot balloon with the required amount of water. The catheter label indicates the volume required.  Ensure the patient is dry and made comfortable and attach to either: the thigh of the patient with the straps supplied, or urine collecting bag stand.  Dispose of gloves and materials in appropriate clinical waste bag, and wash hands.

 Record the procedure in the patient's notes.

Quiz

Online Assessment Have you completed both Male and Female Catheterisation E-Tutorials?

Yes Proceed to the online assessment (or type the following into your browser) http://bit.ly/1t2PWWm

No Proceed to the Male Catheterisation E-Tutorial (or type the following into your browser) http://bit.ly/1uL90GY (Flash version) http://bit.ly/1BpbMpr (PDF version)

Female Catheterisation References & Helpful Links

References & Helpful Links

Patel, N. and Knight, D. 2009. Clinical Practical Procedures for Junior Doctors. Churchill Livingstone: Elsevier Dornan, T. and O’Neill, P. 2006. Core Clinical Skills for OSCEs in Medicine. Churchill Livingstone: Elsevier Royal College of Nursing (2012) Catheter Care RCN Guide for Nurses. London: RCN. Stoneham, M. and Westbrook, J. 2007. Invasive Medical Skills: A Multimedia Approach. Blackwell Publishing Athreya, B.H. 2010 Handbook of Clinical Skills: A Practical Manual. World Scientific Thomas, J. Monaghan, T. 2007. Oxford Handbook of Clinical Examination and Practical Skills. Oxford Medicine Online Revised September 2014