emergency nursing education 1. an 85 year old male with dementia… brought to the ed from his...
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Emergency Nursing Education
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An 85 year old male with dementia…Brought to the ED from his skilled nursing facility
with a complaint of nonfunctioning PEG tube. In the initial assessment, the nurse notes the
patient was incontinent and placed a urinary catheter
The patient is admitted for a PEG change. Overnight the patient becomes more confused and pulls on his catheter leading to severe hematuria and requiring a urology evaluation.
Within 36 hours was febrile, with positive blood cultures, treated for CAUTI and requires a prolonged hospital stay.
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ObjectivesDescribe urinary catheter use with focus on
the emergency department (ED)Identify current evidence on prevention of
CAUTIsOutline nursing assessment of the ED patient
who may require urinary catheterizationList criteria for catheter placementReview communication necessary between
nurses and providers to facilitate appropriate clinical decision-making
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Urinary Catheter UtilizationAbout 15 - 25% of patients will have a
urinary catheter placed during their hospitalization.
Many are placed inED
ICU
OR
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Reducing CAUTIDetermine appropriate indicationAvoid use if no indicationSeek alternatives when possibleUse sterile technique for placementRemove as soon as possible
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Why we think putting in a catheter is a good idea – but it’s notPerception FactsFacilitates I/O measurement
Alternatives are available with less risk (e.g., urinals, daily weights)
Prevents falls from getting up to urinate
Increases risk to fall, especially in the confused patient
Protects skin in the incontinent patient
Increases risk of skin breakdown from immobility, muscle loss, and catheter-related trauma
Saves time for the bedside nurse
Extended LOS, infection complications, and other risks, it does not
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Indications for catheterizationPatient is critically ill and will require
accurate output measurementUrinary retention/obstruction
Bladder scanner or bedside ultrasound firstImmobilization needed for trauma or surgeryIncontinent with open sacral/perineal woundsEnd of life/hospiceChronic or existing catheter use
Re-evaluate need and discuss with provider
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“Not” indications for catheterizationSubstitute for frequent toiletingTo obtain a specimen if the patient can void
freelyPatient preferenceDementiaObesity
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Patients at high risk for inappropriate catheterization
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Reducing inappropriate placements reducesInfection ratesCostAntibiotics useLength of stayMorbidityPatient discomfort
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Communication with providersClear understanding of indicationsCommitment to nonmaleficence (doing no
harm)Patient focused care
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So, how does this affect the care of this patient?Brought to the ED from his SNF with a
complaint of nonfunctioning PEG tube. In the initial assessment, the nurse noted the patient being incontinent and placed a urinary catheterIncontinence is not an indication by itself for
catheter placement
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So, how does this affect the care of this patient?The patient was admitted for a PEG change.
Overnight the patient became more confused and pulled on his catheter leading to severe hematuria and requiring a urology evaluation.The agitated patient (possibly due to dementia)
is not a good candidate for catheter placement
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So, how does this affect the care of this patient?Within 36 hours was febrile, with positive
blood cultures, treated for CAUTI and required a prolonged hospital stay.This patient had no indications to place a
catheter; the suggestion is that placement of the catheter in the ED was a potential cause of infection. Patient stay is prolonged, patient develops a clinical problem he did not present with initially. This infection is potentially preventable.
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Another example…A 76-year-old woman admitted for
congestive heart failure…Urinary catheter placed and started on diuretics Condition improved; ready for discharge on 3rd dayNo urinary output for 5 hours after catheter
removalBladder scan showed 500 mL of urineStraight catheterization Observed overnight for symptom resolution
CAUTI ED slides, Fakih, 2012
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So, how does this affect the care of this patient?Urinary catheter placed and started on
diureticsAccurate I & O measurement can be a valid
indication for catheter placement for critically ill patients
Evaluate for need before placement
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So, how does this affect the care of this patient?Condition improved; ready for discharge on 3rd dayNo urinary output for 5 hours after catheter removalBladder scan showed 500 mL of urine
Not all patients with congestive heart failure require catheterization
Early removal may have prompted evaluation of urinary retention
Additional day of hospitalizationRisk for urosepsis
Explore alternatives for measuring I & ORemoval after initial diuresis to shorten exposureFrequent toiletingCommunicate with inpatient staff indication for
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Another example…
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So, how does this affect the care of this patient?Team felt the catheter would make her
more comfortableComfort is a myth
It may be convenient for the staff and the patient, but does not promote comfort, nor is it a safe indication
Some patients may request a catheter to avoid the need to get up. It is still an inappropriate reason
ConsequencesProlonged, unexpected hospitalization from
hospital-acquired CAUTIRisk for urosepsis
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The take homeReview indications for urinary catheter
placementDiscuss placement with providerCommunicate indications for placement with
inpatient staff for timely removalDo no harm
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Other indications for urinary catheter:Urinary retention/obstruction?
o Use bladder scanner firstImmobilization needed for trauma or surgery?Incontinent with open sacral/perineal wounds?End of life/hospice?Chronic or existing catheter use?
o Re-evaluate need and discuss with provider
Insert catheter and treat signs of shock:HypotensionDecreased cardiac output/functionDecreased renal functionHypovolemiaHemorrhage
Re-assess after intervention
Do NOT insert
Explore alternatives
Still critically ill, requiring accurate output measurement?
Insert or maintain catheter Remove catheter
prior to admission
Is the patient critically ill and will require accurate output measurement?
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