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Protect ED patient if a urinary catheter is placed
Prevent life-threatening complications
Have you just placed a urinary catheter in an ED patient? If so, possible complications include urosepsis, septicemia, trauma to the urethra or bladder, and urethral perforation, warns Mark Goldstein, RN, MSN, EMT-P I/C, clinical nurse specialist at the Emergency Center at Beaumont Hospital in Grosse Pointe, MI. Here are tips to avoid complications:
Take the time to provide aseptic technique.
"Take along an extra catheter, just in case the original catheter is misplaced, dropped, or accidentally contaminated," says Amy Mundisev, RN, BSN, CEN, ED clinical educator at Trinity Regional Medical Center in Fort Dodge, IA.
Don't anchor a Foley catheter unless necessary.
"Discuss the option of a clean catch or straight catheter with the physician, if appropriate," says Angel Keene, RN, BSN, ED nurse at Indiana University Health Goshen (IN) Hospital.
Use the smallest size catheter necessary for the patient.
"This is important for preventing injury to the urethra," says Keene. "A catheter that is too large would keep constant pressure on the urethra."
Use the closed system kit that comes with the catheter already attached to the drainage bag.
"This helps to minimize the chances of contamination," says Keene. "If a separate catheter and bag are being used, be sure the connecting ends remain sterile or that they are cleaned with alcohol."
Keep the urine collection bag low.
Urine that sits in the drainage bag over a period of time can grow bacteria, explains Keene, and if the drainage bag is raised over the level of the bladder, the urine can drain from the tubing and bag back into the bladder.
"Always keep the drainage bag lower than the bladder to keep urine flowing out, and never in," she says.
You can stop UTIs
The most likely complication associated with catheter use is a catheter-associated urinary tract infection (CAUTI), says Goldstein. Bacteremia, a serious and potentially life-threatening complication, will develop in approximately 3% of all catheterized patients, he adds.
"Using infection-control measures, an estimated 17% to 69% of CAUTIs may be prevented," Goldstein says.
Urinary tract infections in patients that are elderly or immunocompromised can be very serious, warns Keene, and potentially lead to sepsis and death. Goldstein gives these tips to prevent CAUTIs:
Perform hand hygiene immediately before and after insertion, or any manipulation of the catheter device or site.
Cleanse the perineal area to decrease bacteria in the surrounding area before indwelling catheter insertion. "Avoid vigorous cleansing, which may increase the risk of infection," Goldstein says.
Insert indwelling catheters using aseptic technique and sterile equipment. The equipment needed for insertion includes sterile gloves, drape, sponges, an appropriate antiseptic or sterile solution for periurethral cleansing, and a single-use packet of lubricant jelly, adds Goldstein.
Choose catheter materials appropriate for each patient. The short-term use of silver alloy catheters may reduce the incidence of CAUTI and bacteriuria, says Goldstein, and silicone or hydrogel catheters are recommended for patients using catheters longer than 14 days.
Change indwelling catheters and drainage bags according to clinical indications, such as infection, obstruction, or when the closed system is compromised, rather than at routine, fixed intervals.
Obtain urine samples aseptically, and only from newly placed catheters.
"After cleansing the needleless sampling port with a disinfectant, aspirate the urine with a sterile syringe," says Goldstein. "Avoid irrigation unless needed to prevent or relieve obstructions." (See related stories on sterile technique and discontinuing catheters below, and asking for help, p. 89.)
For more information on preventing complications with urinary catheters, contact:
Don't take shortcuts with sterile technique
Katherine Murczek, RN, clinical practice partner in the ED at Advocate Christ Medical Center in Oak Lawn, IL, says good sterile technique is the single best way to prevent infection. Here are three recommendations:
1. Use all the components of the urinary catheter kit.
"All too frequently, staff take shortcuts and decide not to use the sterile drape, forceps, or all of the cotton balls," says Murczek. Many don't use the sterile drapes because they believe it impairs their vision, she notes.
ED nurses may find the forceps awkward to use, adds Murczek, and may use only their sterile, gloved hand to handle the cotton ball and clean the patient. Countless times, she says, ED nurses have claimed they can clean a patient without the forceps and not break sterile technique. "They want to believe their fingers touch one side of the cotton ball and the other side touches the patient, leaving them sterile," she says. "I believe this to be absolutely false."
2. Start over if necessary.
Anatomy and patient size sometimes make it difficult to insert catheters successfully the first time, especially in females, says Murczek. "Be willing to admit when you break sterile technique, even to the patient," she says. "Get a new kit and start over, because it's in the best interest of the patient."
3. Pretend you're inserting the catheter in a family member.
Murczek asks ED nurses to pretend it's their parent, grandparent, or child that they're performing the procedure on. "We all expect the best for our family," she says. "We must provide that level of care to every patient."
Is catheter use valid? Even if so, discontinue ASAP
A urinary catheter should only be placed when truly necessary, says Katherine Murczek, RN, clinical practice partner in the ED at Advocate Christ Medical Center in Oak Lawn, IL. "It should not be placed for staff convenience," she says.
Determine if your patient has a valid reason for needing the catheter, says Angel Keene, RN, BSN, ED nurse at Indiana University Health Goshen (IN) Hospital. "Being obese and incontinent is not a valid reason for an indwelling Foley catheter," she adds.
Never insert a Foley catheter in a trauma patient if blood is present, says Keene, due to the possibility of internal injury to the genitourinary system.
Remove the catheter when it is no longer necessary for the patient, says Keene. "This can definitely be overlooked in the ED," she says. "Nurses do not want to remove a catheter, only to find later that it needs to be re-inserted, so they tend to leave them in."
The longer a catheter stays in, warns Keene, the more risk there is for infection. For this reason, she says, encourage physicians to discontinue catheters for patients if they are able to use a bedpan or bedside commode.
"This may be less convenient at times, but it will be better for the patient in the long run," Keene says.
Ask for assistance with urinary catheter
Patients may need someone to help calm them during catheterization, says Angel Keene, RN, BSN, ED nurse at Indiana University Health Goshen (IN) Hospital. "A soothing voice to preoccupy the patient may be all that is necessary to help them hold still and avoid tensing up," she says.
Patients who have altered mental status may be combative during catheterization, adds Keene. "Using an extra person to hold the patient's legs in an open position may be necessary to accomplish the task," she says.
An extra staff person can help to position the patient, says Keene, to assist in maintaining sterile technique. "In large patients, an extra person may be necessary to help the primary nurse visualize the urethra due to excessive skin folds," she says.