Dr.T.V.Rao MD

URINARY CATHETER CARE SKILLS IN ASEPSIS

DR.T.V.RAO MD 1

• Urinary catheter

is any tube

placed in the

body to drain

and collect urine

from the bladder

WHAT IS A URINARY CATHETER

DR.T.V.RAO MD 2

• Developed in the 1920s by Dr. Frederick Foley

• The urinary catheter was originally an open system with the urethral tube draining into an open container.

• In the 1950s, a closed system was developed in which the urine flowed through a catheter into a closed bag.

URINARY CATHETER

DR. FREDERICK FOLEY

3

• About 15-25% of patients

during their hospitalization

will have an urinary

catheter placed

• Many are placed either in

the intensive care or

Emergency Department

• 40% - 50% of these

patients do not have a valid

indication for urinary

catheter placement

URINARY CATHETER UTILIZATION

4

WHAT IS A FOLEY'S CATHETER

DR.T.V.RAO MD 5

PURPOSE OF CATHETERIZATION

Catheterization is carried out for a number of

reasons and can either be a temporary or

permanent solution to a number of problems.

Problems include physical disease and damage,

psychological issues and a way to help to improve

the quality of life to someone who is bed ridden.

Good regular catheter care involves good hygiene,

observation, monitoring well-being and prevention

of problems associated with catheterization.

DR.T.V.RAO MD 6

URINARY CATHETER-RELATED INFECTION:

BACKGROUND

• Urinary tract infection (UTI) causes over 40% of

hospital-acquired infections

• Most infections due to urinary catheters

• 25% of inpatients are catheterized

• Leads to increased morbidity and costs

• The ability to insert a urinary

catheter is an essential skill in

medicine.

• Catheters are sized in units called

French, where one French equals

1/3 of 1 mm. Catheters vary from 12

(small) FR to 48 (large) FR (3-

16mm) in size.

They also come in different varieties

including ones without a bladder

balloon, and ones with different

sized balloons - you should check

how much the balloon is made to

hold when inflating the balloon with

water!

CATHETERIZATION IS A SKILL IN

MEDICINE

DR.T.V.RAO MD 8

• The potential for contact with a

patient's blood/body fluids while

starting a catheter is present and

increases with the inexperience

of the operator. Gloves must be

worn while starting the Foley, not

only to protect the user, but also

to prevent infection in the patient.

Trauma protocol calls for all team

members to wear gloves, face

and eye protection and gowns.

CAUTION ON CATHETERIZATION

DR.T.V.RAO MD 9

• Povidone-iodine (PI) is

currently the most widely

used agent for site

disinfection

• Chlorhexidine gluconate

(CHG) has been compared

to PI with mixed results

• We performed a formal

meta-analysis of published

and unpublished studies to

clarify relative efficacy

WHICH DISINFECTANT SHOULD BE

USED FOR CATHETER SITE CARE?

CHLORHEXIDINE FOR SITE DISINFECTION:

CR-BSI

Risk ratio.1 .2 .5 1 2 5 10

Study Risk ratio (95% CI)

0.18 (0.02,1.46) Maki et al,7 1991

1.05 (0.07,16.61) Sheehan et al,8 1993

0.97 (0.20,4.77) Meffre et al,9 1995

0.64 (0.15,2.81)

Mimoz et al,10

1996

0.13 (0.01,2.45) Legras et al,11

1997

0.75 (0.20,2.75) Humar et al,13

2000

0.36 (0.14,0.95) Knasinski et al,

14 2000

0.49 (0.28,0.88) Overall (95% CI)

Favors CHG Favors P-I

(Chaiyanupruk et al. Ann Intern Med 2002)

WHAT IS INDWELLING CATHETER • In indwelling urinary catheter is one that is left in place

in the bladder. Indwelling catheters may be needed for

only a short time, or for a long time. These catheters

attach to a drainage bag to collect urine. A newer type

of catheter has a valve that can be opened to allow

urine to flow out, when needed. An indwelling catheter

may be inserted into the bladder in two ways:

• Sometimes, one may insert a tube, called a suprapubic

catheter, into your bladder from a small hole in your

belly. This is done as an outpatient surgery or office

procedure.

DR.T.V.RAO MD 12

• Condom catheters are most

frequently used in elderly

men with dementia. There

is no tube placed inside the

penis. Instead, a condom-

like device is placed over

the penis. A tube leads from

this device to a drainage

bag. The condom catheter

must be changed every

day.

CONDOM CATHETERS

DR.T.V.RAO MD 13

• Some people only need

to use a catheter on

occasion. Short-term, or

intermittent, catheters

are removed after the

flow of urine has

stopped. For more

information on this type

of catheter, see: Clean

intermittent self-

catheterization.

INTERMITTENT (SHORT-TERM) CATHETERS

DR.T.V.RAO MD 14

EXPLAIN THE PATIENT BEFORE DOING THE

CATHERITIZATION

• Before you start tell the person what you are going to

do and why. This is important for everyone, but

especially if the person is confused, has memory

problems as in Alzheimer's disease or dementia. If you

can, assist the catheterized person with their hygiene,

rather than doing it yourself. It is important to try to help

the person / patient keep their skills rather than just

take over for them. There are so many advantages but

it can just take that bit longer.

DR.T.V.RAO MD 15

• Wash your hands

before and after

handling the drainage

device. Do not allow the

outlet valve to touch

anything. If the outlet

becomes obviously

dirty, clean it with soap

and water.

HAND WASHING THE MOST IMPORTANT

PREPARATION BEFORE CATHETERIZATION

DR.T.V.RAO MD 16

ANTISEPTIC HAND RINSES

MANY USING ALCOHOLS

• 60-70% alcohol

solutions

• Effective against most

bacteria, viruses, fungi

• Protective against hand

drying

• Faster, increased

compliance

• Wash around the

catheter entry site with

soap and water twice

each day. Clean the top

several inches of the

catheter too.

Always wash the site

after a bowel

movement.

CARING BEFORE THE INSERTION OF

CATHETER

DR.T.V.RAO MD 18

• Introduction Female

urethral catheterization, the

insertion of a catheter

through the urethra into the

urinary bladder to permit

drainage of urine, is a

fundamental skill Insert the

catheter completely into

the urethra, and do not

inflate the balloon until

there is return of urine, to

avoid trauma …

HEALTH CARE WORKERS SHOULD DEVELOP

SKILLS IN INTRODUCTION OF CATHETER

DR.T.V.RAO MD 19

PRINCIPLES OF PLACEMENT OF

CATHETER AND COLLECTING BAG

DR.T.V.RAO MD 20

THE URINE COLLECTING BAG SHOULD BE AT A

LOWER LEVEL TO THE PATIENT

TO PREVENT RETROGRADE FLOW

DR.T.V.RAO MD 21

• Criteria for insertion and continuation of a F/C includes:

a. Retention

b. Critical I&O

c. Comatose

d. Paralyzed

e. Neurogenic Bladder

f. Pre-op placement

g. Wound with incontinence

h. Bladder Irrigation

i. Physical trauma/pain with bedpan/incontinence brief

j. Terminal illness/comfort measures

DR.T.V.RAO MD 22

COMPLICATIONS OF CATHETERIZATION

DR.T.V.RAO MD 23

• The main complications are tissue trauma and infection. After 48

hours of catheterization, most catheters are colonized with

bacteria, thus leading to possible Bacteriuria and its

complications. Catheters can also cause renal inflammation,

nephro-cysto-lithiasis, and pyelonephritis if left in for prolonged

periods.

• The most common short term complications are inability to

insert catheter, and causation of tissue trauma during the

insertion.

• The alternatives to urethral catheterization include suprapubic

catheterization and external condom catheters for longer

durations.

RISKS / CONSEQUENCES OF

CATHETERIZATION

• UTI

• PYELONEPHRITIS

• DEATH R/T BACTEREMIA

• DAMAGE TO URETHRA (SCARRING AND

STRICTURES)

• Prostatitis and epididymitis

DR.T.V.RAO MD 24

• Indwelling Foley catheters are a major source of UTI’S.

• Direct relationship between duration a f/c is in the patient and incidence of infection.

• Risk factors:

Female

Advanced age

Duration

Diabetes

Renal insufficiency

DR.T.V.RAO MD 25

26

Staphylococcus aureus biofilm on

an indwelling catheter. CDC Public Health Image Library

BIOFILM: EXTRACELLULAR POLYMERS (DONLAN, CID 2001; 33:1387–92, LIEDL, CURR OPINION UROL 2001;11: 75-9)

• Organisms attach to and grow on a surface and produce extracellular polymers

• Intraluminal ascent (48hours) of bacteria faster than extraluminal (72-168 hours)

• Most catheters used >1 week have biofilms

• Extraluminal more important in women

WHAT WE ARE DOING NOW, IS IT RIGHT

RIGHT THINGS TO DO.

FOLEY CATHETER BUNDLE

What is the Foley Catheter Bundle?

Insert using sterile technique

Hand hygiene before and after any contact with the F/C system

Secure catheter to thigh at ALL times

Keep catheter bag below the level of the bladder at ALL times

Maintain a sterile, continuously closed system

Specified criteria for insertion and continuation of a Foley catheter

Peri care daily and after all incontinent stool

What is “Peri Care” for a patient with a f/c? Daily wash with warm soap &

water then dry.

DR.T.V.RAO MD 27

COLLECTION OF URINE FROM

CATHETERISED PATIENTS

• The process of obtaining a sample of urine from a patient with an indwelling urinary catheter must be obtained from a sampling port. The sample must be obtained using an aseptic technique.

• This port is usually situated in the drainage tubing, proximal to the collection bag which ensures the freshest sample possible. The use of drainage systems without a sampling port should be avoided (Gilbert, 2006).

• Specimens should not be collected from the tap from the main collecting chamber of the catheter bag as colonisation and multiplication of bacteria within the stagnant urine or around the drainage tap may have occurred.

DR.T.V.RAO MD 28

• Aspirating urine from a

sampling port has

traditionally been

performed using a

syringe and needle.

However, needle-free

systems are

commercially available,

which may reduce the

risk of inoculation injury.

ASPIRATING THE URINE WITH SYRINGE

AND NEEDLE

DR.T.V.RAO MD 29

CONTRAINDICATIONS FOR

CATHETERIZATION

DR.T.V.RAO MD 30

• Foley catheters are contraindicated in the

presence of urethral trauma. Urethral injuries

may occur in patients with multisystem injuries

and pelvic factures, as well as straddle impacts.

If this is suspected, one must perform a genital

and rectal exam first. If one finds blood at the

meatus of the urethra, a scrotal hematoma, a

pelvic fracture, or a high riding prostate then a

high suspicion of urethral tear is present.

EPIDEMIOLOGY OF URINARY

CATHETERIZATION • Up to 25% of hospitalized patients

• urinary catheterization

• Catheter associated nosocomial UTI

• 5% per day !

• Nosocomial UTI

• 40% of nosocomial infection

• Bacteria ascend intraluminally into the bladder

• within 24 to 72 hours (from Harrison’s 16th)

• > 1 month of catheterization

• Nearly all will be bacteriuic

• Long-term (>30 days) and short-term (<30 days) catheterization

• 80% of patients with nosocomial UTI

• have an indwelling urinary catheter

• Avoid urinary catheter use if not

indicated

• Try to discontinue the catheter

promptly when not needed

• The longer the catheter is

present, the higher the risk of

infection!

• The urinary drainage system

should always remain a closed

system

REMINDER FOR APPROPRIATE URINARY

CATHETER USE

32

• Both nurses and physicians

should evaluate the

indications for urinary

catheter utilization.

• Physicians should promptly

discontinue catheters that

are no longer needed.

• Nurses evaluating

catheters and finding no

indication should contact

physician to promptly

discontinue catheter.

CONSTANT EVALUATION TO CONTINUE TO

USE CATHETER …….

33

IMPORTANT QUESTION WHEN TO

REMOVE

• Should we need to remove the urinary catheter in 48~72 hours of smoothly post op patients to reduce the rate of catheter associated UTI? What’s the rate of catheter associated UTI in 48~ 72 hours?

• Remove urinary catheter as soon as possible!

• Rate of Bacteriuria in indwelling catheter patient in 48 hours post-OP: average 24%

DR.T.V.RAO MD 35

• Programme Created by Dr.T.V.Rao MD

for Medical and Health care Workers in

the Developing World

• Email

• doctortvrao@gmail.com