CONTINUING CARE RESIDENT CARE MANUAL...

CONTINUING CARE RESIDENT CARE MANUAL PROCEDURE

NUMBER II-C-30 DATE April 8, 2010

PAGE 1 OF 12 APPROVED BY: Vice President & Senior Operating Officer, Rehab & Continuing Care

SITE: Edmonton General, Youville Home, St. Joseph’s, Lethbridge

CATEGORY: Resident Care; Care of the Resident

TITLE: Long Term Urinary Catheter Maintenance / Care

1.0 GOALS

• To maintain urinary flow through a drainage system. • To minimize the risk of infection. • To promote comprehensive urinary elimination assessment, nursing

diagnosis, planning, intervention and evaluation appropriate to the resident health status and medical condition.

• To ensure procedural techniques meet acceptable best practice standards and the facility expectations for care.

2.0 RATIONALE

Risks: Catheterization of the urinary tract is the most common cause of hospital-acquired infections. Acquisition of urinary tract infection during indwelling bladder catheterization is associated with significant excess morbidity and costs, and nearly a threefold increase in mortality among hospitalized patients. Risk Management Recommendations: Prevention of UTIs includes adequate hydration, good personal hygiene, and mobilization of patients/residents. Indwelling catheters should be avoided whenever possible, and the use of antimicrobials should be limited to symptomatic infections (pg 35-4 APIC Text of Infection Control and Epidemiology).

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DATE April 8, 2010 PAGE 2 OF 12


Studies indicate that both the intraluminal and extraluminal pathways are important in the development of catheter-associated bacteriuria. This suggests that both strict aseptic adherence to the care of a closed catheter drainage system and good meatal care are fundamental in the prevention of such infections. Catheter irrigations or instillations are outlined in Potter and Perry Canadian Fundamentals of Nursing 4th Ed. Refer to this source for the procedure. A Physician’s/NP order to irrigate should include the type of sterile solution to be used. It is recommended that blockage can be avoided by noting the duration that the catheter remained patent on previous trial. The recommended method of management left to nurses is to try to pre-empt the blockage of a catheter by changing it before it blocks.

3.0 CONTRAINDICATIONS

• Surgical patients where bleeding (i.e. blood clot) would be the first suspected cause of blockage.

• Delicate genito-urinary surgeries where re-introduction of a catheter would disturb the surgical procedure.

• Short term indwelling catheter (less than one week). 4.0 “BEST PRACTICE’ – Management of an Indwelling Catheter

4.1 Size of Catheter • A small diameter catheter (12 Fr or 14 Fr) is recommended because

large sized catheters are associated with more problems such as bypassing.

• Catheters with a small balloon are recommended. Larger balloons (30

cc) were designed to control bleeding following genito-urinary surgery.

• Catheter balloons should be filled to the maximum capacity recommended by the manufacturer. A partially filled balloon fills asymmetrically which increases the potential for erosion of the bladder mucosa.

• Inflate balloon only to manufacturer’s recommendation.

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4.2 Type of Drainage System • A closed system of drainage (not opened except for emptying the bag)

is recommended by the Centre for Disease Control.

4.3 Frequency of Drainage bag changes • Change the entire system only when it functions poorly, is obstructed,

or is the source of odors. Do not change catheter tubing and or the bag routinely. When one part of the system needs to be changed, change the entire system. (Ref: APIC text of Infection Control and Epidemiology, Pg. 46-8, 13.)

4.4 Frequency of Catheter Changes

• Current clinical research does not support a standard routine frequency for catheter changes. Instead, client specific catheter change patterns are recommended as follows:

For individuals who have no problems with sediment, systemic UTI, discomfort or bypassing the recommended frequency is every 8-12 weeks.

For individuals who have problems with sediment, frequent catheter blockage, recurrent UTI, and bypassing the recommended frequency is at least monthly. To avoid crises the goal is to change the catheter before problems occur.

4.5 Treating an Infection

• If a patient develops a urinary infection, REPLACE the existing catheter AND THE ENTIRE SYSTEM. Refer to the UTI protocol, Infection Control regarding culture and treatment recommendations for symptomatic residents.

5.0 “BEST PRACTICE’ - Investigating Catheter Blockage

Is the catheter blocked? YES? ♦ assess the cause of blockage ♦ check for evidence of encrustation ♦ measure the pH of the patient’s urine ♦ if there is evidence of symptoms, send MSU with a physician’s

order for Culture and Sensitivity testing ♦ treat if necessary and if typical symptoms develop according to

the Urinary Tract Infection Protocol Flow Chart

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If cause is infective encrustation, take action: ♦ assess how often the catheter should be changed for that

particular patient (see point 4.4) ♦ consider all-silicone catheters ♦ specialist referral if problem unresolved. NO? ♦ check functional reasons ♦ assess bag position ♦ find out if the patient has constipation ♦ check if tube is kinked or compressed ♦ assess the internal position of the catheter tip ♦ find out if the patient is experiencing bladder spasm

5.1 Blockage

• The most common reason for indwelling catheters failing to drain is blockage of the catheter eye or lumen by encrustation.

• Two populations of bacteria exist in the catheterized urinary tract; those growing within the urine itself and those growing on the surface of the catheter.

• The following strategies are recommended to prevent catheter blockage:

Use a silicone catheter. Silicone catheters have a larger opening in the lumen and cause less encrustation than latex or silicone-coated catheters.

Establish an individual pattern for scheduled catheter change so that the catheter can be changed before it becomes blocked.

5.2 Encrustation

• Encrustation is caused by minerals which separate from alkaline urine (the alkalinity being caused by ammonia produced from the breakdown of urea).

• Avoidable contributing factors to alkalinity in urine include dietary factors and the use of antacids.

• Monitor the pH levels of urine. Encrustation is 10 times greater in individuals with a pH above 6.8.

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5.3 Evidence of Symptoms Signs and symptoms of urinary tract infection (UTI) • cloudy urine • foul-smelling urine • hematuria • fever (not the best indicator of infection in the older adult) • malaise • tenderness over the bladder • flank pain

5.4 Treatment

• Identify contributory factors and so provide proactive care (eg. using litmus paper to monitor urinary pH).

• The use of silicone catheters with small diameters left in situ for as long as possible, less frequent changing of drainage bags and mobilization of patients whenever possible.

6.0 “BEST PRACTICE’ – Catheter Irrigation for the treatment of

blockage

• Catheter maintenance solutions should be used with reservation, and are considered to be a management tactic rather than as first-line treatment, keeping in mind individual variations between patients

• May be performed to maintain or restore the catheter’s patency; eg. remove pus or blood clots that may block the catheter and prevent drainage.

• Requires strict sterile technique to prevent bacteria from entering the bladder • Recurrent introduction of solution into the bladder can damage the bladder

wall • Solutions should be introduced by gravity only • 50 mL is as effective as larger amounts • Twice daily irrigation with any solution is inappropriate and the general rule is

not to irrigate more than every other day • If you encounter resistance during instillation of the irrigating solution, don’t try

to force the solution into the bladder. Stop the procedure and notify the physician.

6.1 The ‘closed method’ of irrigation is preferred

may be intermittent or continuous use a triple lumen; the irrigating solution is infused through the

irrigating port of the catheter and into the bladder and then is drained out through the catheter’s drainage lumen

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6.2 The ‘open method’ of irrigation may be used occasionally for patients who

develop blood clots or mucus plugs that occlude the catheter and when it’s undesirable to change the catheter performed with a double-lumen.

6.3 The problem of blockage is caused by bladder/catheter colonization by

urease secreting bacteria that raise the pH of urine and allow biofilm development and the precipitation of minerals (commonly known as sediment) to occur. The best practice for management of this problem is to try not to irrigate so that the biofilm and sediment are not washed back up into the bladder. Those residents with long term catheters may need more frequent changing of the catheter. If a catheter requires such frequent changing to maintain patency as to be daily, then a solution called Contisol, a catheter washout solution, made up of citric acid, 3.23%, magnesium oxide 0.38%, sodium bicarbonate 0.7% and disodium edtate 0.01% may be tried, though a recent study found no significant effect. Again, this solution requires a Physician’s/NP order.

7.0 PROCEDURE: Refer to Perry & Potter Textbook on unit, entitled

“Clinical Nursing Skills and Techniques”, the Urinary Elimination Chapter. Note that catheter changes are a sterile procedure.

8.0 PATIENT TEACHING

• Encourage catheterized patients, who are not fluid restricted, to increase intake to 3000 mL per day (3.2 qt.)

• Encourage patient to eat foods containing ascorbic acid (eg. citrus fruits and juices, cranberry juice, and dark green and deep yellow vegetables)

• Perineal care • Toileting self-care

Example: If a patient’s catheter blocks q monthly, and you have followed the best practice guidelines, try changing the catheter q3 weekly.

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TITLE: Long Term Urinary Catheter Maintenance / Care 9.0 CATHETER BAG CARE

9.1 Emptying the Drainage Bags

Bags should be emptied when ¾ full to prevent the weight pulling on the tubing. Monitoring output is required at a minimum every eight hours. 1. Identify the resident 2. Provide privacy 3. Wash hands 4. Collect your equipment:

• chlorhexidine swabs • disposable gloves (Aseptic Technique) • drainage container (individual supply; labeled)

5. Put on your gloves

6. Empty the drainage bag (large and leg bag drainage bags to be emptied when ¾ full) in a container or the toilet.

7. Open the drainage spout on the bag carefully while directing it into

the toilet or drainage container used only for this purpose. Allow all of the urine to drain out of the bag. Do not allow the drainage spout to come in contact with contaminated surfaces.

8. Wipe the drainage spout with an alcohol swab applying aseptic

technique, and close it securely. 9. If urine has been emptied in a drainage container, empty it into the

toilet. Rinse the container out thoroughly with hot water and put it away for the next use.

10. Leave the resident in a comfortable position. Remove your gloves,

wash your hands and document actions, observations and tolerance.

9.2 Changing the Drainage Bag

1. Wash hands 2. Identify the resident


PAGE 8 OF 12 TITLE: Long Term Urinary Catheter Maintenance / Care

3. Provide privacy 4. Collect your equipment:

a. Chlorhexidine swabs b. Disposable gloves (Aseptic technique) c. Gauze sponges or sterile caps or plugs d. Clamp or fold catheter over about 3 inches to clamp off.

5. Apply gloves. 6. Empty the catheter into the toilet or in a drainage container. 7. Clamp the catheter. 8. Disconnect the drainage tubing from the foley catheter by using a

pull and twist motion. Be very careful not to pull on the foley catheter.

9. Avoiding contamination, place a sterile plug, cap or sterile gauze

sponges over the exposed end of the drainage tube. 10. To reconnect to a leg bag, or if leg bag to large drainage bag,

cleanse the end of the foley catheter and the end of the tubing on the clean drainage bag with an alcohol swab, then connect the two ends using a push and twist motion.

11. In order to maintain the drainage, the drainage bag must be below

the resident’s bladder. Ensure there are no kinks in the tubing. 12. If you are attaching a leg bag, strap the bag to the lower leg below

the knee so the urine can drain by gravity. The leg straps should be snug but not interfere with circulation. Ensure the anti-reflux valve is at the top closest to the catheter or urine will not drain. The drain valve should be at the bottom of the bag.

13. Leave the resident in a comfortable position. 14. Remove gloves, wash your hands and document actions,

observations and resident tolerance to the procedure.

9.3 Cleaning the Drainage Bag

Clean drainage bags daily to prevent urinary tract infections and to make the bags last longer. This can be done when emptying or switching from one type of bag to another. 1. Wash hands.


PAGE 9 OF 12 TITLE: Long Term Urinary Catheter Maintenance / Care

2. Identify the resident. 3. Provide privacy. 4. Collect your equipment:

a. Liquid soap (general use liquid detergent) b. Acetic Acid Solution (vinegar and water solution 1:3 dilution)

(Ref: APIC Text 46A-4) (can be mixed at the time of use using a peri wash bottle (bottle should be labelled)

c. Peri wash bottle. d. Clean towel to ensure a clean work space e. 60cc syringe

5. Put on gloves 6. Empty the drainage bag into the toilet or drainage container. 7. Disconnect the bag from the foley catheter. Cleanse the ends with

a chlorhexidine swab. Clamp, cap or connect the foley to an alternate bag. Do not let the tip touch a contaminated surface.

8. Put a few drops of liquid soap and 1-2 cups of tap water into the

periwash bottle; shake and pour into the bag. 9. Gently shake the solution around in the bag to loosen any deposits.

Rub the sides of the bag together. Friction is required. Ensure all areas of the bag are clean including the drainage spout and tubing.

10. Drain the soapy water through the spout and tubing and rinse the

bag well with 1-2 cups of clear tap water. Drain the rinse water and run clear tap water through the bag, tubing and spout to be sure no soap is left inside.

11. Rinse the bag to control odor, using the acetic acid solution

(vinegar and water solution 1:3 dilution strength) using a 60 ml syringe or use the periwash bottle, mixing the vinegar solution in the bottle and then pour into the bag.

12. If a strong odor persists from the bag after cleaning and the bag is

getting hard, cracked or discolored, discard it and replace it with a new bag.

13. The clean bag should be allowed to dry with the drainage spout and

tubing open. Ensure the spout, connector and tubing does not touch contaminated surfaces. All ends should be swabbed with chlorhexidine before reconnecting.

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14. Remove gloves, wash your hands, and document actions,

observations and tolerance. 9.4 Equipment:

The unit utility carts are supplied with standard catheterization equipment as follows: 1. Source Med-Rx Urological Catheterization Kit 85-5034 (Foley

Catheterization Tray)

NOTE : Best Practices recommends sterile saline antiseptic rather than Povidone-Iodine antiseptic/ Germicide that is enclosed in the kits.

2. ezflo Urine Drainage Bag Closed system 2000 ml bag with .7

drainage tube by Bard Canada Inc. (Latex) 153561 3. Bardic Dispoz-a-Bag Medium Leg Bag with 11” extension 150180

sterile 000522789 Source Medical 4. BD 2 oz. 60 ml Syringe Catheter Tip 309620 Order # 000198689 5. Solution, Acetic Acid 30% 4L order #000434548 Chief Medical

Supplies 6. Pericare bottle, 240 ml, Order # 000107987, Source Medical 7. Chlorhexidine Swabs, 2% with 70% Alcohol, (Solu IV) Order #

101.06

9.5 Recommend Catheter Holders be used to secure the tubing to the resident’s leg: 1.. FOL0102, StatLock Catheter Stabilization Device: Foley 2-way,

www. Statlock.com (available on the supply cart). 2. Additional Style: 000423343 Holder, Catheter / Drain Adhesive

Large 2703 Trudell Medical

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TITLE: Long Term Urinary Catheter Maintenance / Care 10.0 “BEST PRACTICE” – INTERMITTENT CATHETERIZATIONS

In Continuing Care, single-use (i.e. sterile) catheters are to be utilized, using aseptic technique, The intermittent catheter is disposed of after use. If a resident is catheterized for an in and out collection of a urine specimen, a physician/NP order is required.

11.0 DOCUMENTATION Minimum charting requirements:

• size of catheter used • the amount of sterile water placed in the balloon • insertion time • type of irrigation used (if any) • time of catheter removal • detail of amount voided and time of first voiding post catheter removal • problems encountered Report the following: • no urinary output in 8 hours • pain • fever • changes in urine colour, odour, sediment or bleeding • leakage or dislodging • no hydration taken • behavioural or mental status changes


PAGE 12 OF 12 TITLE: Long Term Urinary Catheter Maintenance / Care 12.0 REFERENCES Best Practice; Evidence Based Practice Information Sheets for Health Professionals. (2000).

Management of short term indwelling urethral catheters to prevent urinary tract infections. Volume 4, Issue 1, ISSN 1329-1874.

Evans, A. & Godfrey, H. (2000). Bladder washouts in the management of long-term catheters.

British Journal of Nursing. 9(14), 900-906. Gantz,N;Tkatch,L.& Makris,A.Geriatric Infections in APIC Text of Infection Control and

Epidemiology Pages 35-1-46-34. (Available in Caritas Infection Control Dept.) Gates, A. (2000). The benefits of irrigation in catheter care. Professional Nurse. 835-838. Getliffe, K. (2003). Managing recurrent urinary catheter blockage: problems, promises, and

practicalities. Journal of Wound, Ostomy and Continence Nursing, 30, 146-151. Lippincott, Williams & Wilkins. (2003). Best practice: a guide to excellence in nursing care. Moore, K.N., Hunter, K. F., McGinnis, R., Puttagunta, L., Chobanak, J., Bascu, C., Fader, M,. &

Voaklander, D. (2009). Do catheter washouts extend patency time in long term urethral catheters? A randomized controlled trial of acidic washout solultions, normal saline washout, or standard care. Journal of Wound, Ostomy, and Continence Nursing, 36, 82-90.

Rubin, M., Berger, S.A., Zodda, E.M., Gruenwald, R. (1980). Effect of catheter replacement on

bacterial counts in urine aspirated from indwelling catheters. The Journal of Infectious Diseases. Vol. 142, No. 2

Tenney, J. (1987). Bacteriuria in women with long-term catheters. The Journal of Infectious

Diseases. 157, 199-202. Wilde, M.H. (1997). Long-term indwelling urinary catheter care: conceptualizing the research

base. Journal of Advanced Nursing. 25, 1252-1261.

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