Comprehensive Nursing Guide to Urinary Catheterization

Introduction to Urinary Catheterization

• Definition and Purpose: A urinary catheter is a tube-like structure inserted through the urethra into the urinary bladder. Its primary functions include:
  • Draining urine from the bladder.
  • Collecting urine for samples.
  • Instilling solutions into the bladder for treatment or diagnosis.
• Key Risks: Catheterization risks introducing external microorganisms into the bladder, necessitating the use of strict sterile technique to prevent healthcare-associated infections (HAIs).
• The Sterile System: Catheters are generally considered a closed system, meaning the tubing and bladder are contained away from external exposure to minimize pathogen entry.

Clinical Terminology and Urinary Alterations

• Polyuria: An increased frequency of urination or an abnormally large amount of urine output. (Etymology: Poly meaning many; Urea referring to urine contents).
• Oliguria: Abnormally low amounts of urine output.
• Anuria: The absence of urine production ($0$ output).
• Urinary Retention: The inability to empty the bladder, often caused by obstructions such as an enlarged prostate or fetal positioning in pregnancy. Use a bladder scanner (ultrasound) to assess for depth/volume of retention.
• Urinary Incontinence: The involuntary leakage of urine.
  • Stress Incontinence: Leakage occurring during physical exertion, sneezing, or coughing, often seen post-pregnancy.
• Bladder Distension: Physical swelling of the abdomen due to trapped urine. It can be painful, cause restlessness, and lead to extreme discomfort.
• Nocturia: Waking up at night to void, which may be associated with aging, an overactive bladder, circulatory problems, or prostate enlargement.

Anatomy and Physiological Considerations

• Baseline Assessment: Nurses must know a patient's normal urinary patterns. Sudden changes, such as only "dribbling" for two days, indicate retention.
• Factors Affecting Voiding:
  • Food and fluid intake (including IV fluids).
  • Medications (may irritate the bladder or cause the sphincter to close).
  • Muscle tone and physical activity.
• Length of Urethra:
  • Females: The urethra is shorter, requiring approximately $7\,\text{cm}$ of catheter insertion. Due to the proximity of the anal cavity to the urethra, females are more prone to UTIs. Peri care should always be performed from "top to bottom" (urethra toward rectum).
  • Males: The urethra is significantly longer, requiring approximately $17\,\text{cm}$ of insertion. The prostate may obstruct the path, especially in men over age $60$.

Types of Catheters and Sizing

• Straight (Intermittent) Catheter: A single-lumen tube designed for one-time use (e.g., to collect a clean urine specimen or check residual urine). It is removed immediately after the bladder is drained.
• Indwelling (Foley) Catheter: Remains in the bladder for a longer duration.
  • Double Lumen: One lumen drains urine; the second is used to inflate an anchoring balloon.
  • Three-Way Catheter: Includes a third lumen for Continuous Bladder Irrigation (CBI), infusing normal saline to prevent clots while the second lumen drains urine/fluid.
• Coude Catheter: Features a slightly curved, tapered tip. It is specifically used for male patients with enlarged prostates to maneuver around the obstruction rather than poking it.
• Condom (External) Catheter: A non-invasive sheath that fits over the penis. It is used for bedbound patients without retention to prevent skin breakdown from moisture. It is secured with internal tape on the shaft; it can be uncomfortable if too snug.
• French Scale ($\text{Fr}$): Measures the catheter diameter; smaller numbers indicate smaller sizes.
  • Females: Typically $12\,\text{Fr}$ to $14\,\text{Fr}$.
  • Males: Typically $14\,\text{Fr}$ to $16\,\text{Fr}$.
  • Children: Typically $5\,\text{Fr}$ to $8\,\text{Fr}$.

Balloon Inflation and Sterile Water

• Inflation Fluid: ALWAYS use sterile water to inflate the catheter balloon.
• Saline Warning: Never use normal saline ($NS$) to inflate the balloon. Saline can calcify over time, causing the balloon to break or become impossible to deflate.
• Balloon Integrity: The kit typically provides a pre-filled $10\,\text{cc}$ syringe of sterile water. Always verify the volume required by checking the catheter bag or the size of the French used (e.g., pediatric patients would not receive $10\,\text{cc}$).

Indications for Catheterization

• Short-Term Indications (< 30 days):
  • Acute urinary retention or obstruction (e.g., prostate, pregnancy).
  • Surgical repair of the bladder or urethra.
  • Prevention of obstruction from blood clots (post-tumor removal).
  • Monitoring output in critically ill patients.
• Long-Term Indications:
  • Chronic retention unmanageable by intermittent methods.
  • Prevention of Stage 3 or Stage 4 pressure ulcers caused by urinary moisture.
  • Comfort for terminally ill patients for whom linen changes are painful.
• Intermittent Indications:
  • Collecting specimens (e.g., from neonates or non-potty-trained infants).
  • Assessing residual urine.
  • Spinal cord injury management (self-catheterization).

Nursing Interventions and Maintenance

• Infection Prevention (CAUTI):
  • Perform frequent perineal care (soap and water).
  • Use an alcohol swab to clean the tubing if it becomes contaminated (e.g., after a bowel movement).
  • Keep the drainage bag below the level of the bladder at all times.
  • Ensure the tubing remains free from kinks.
  • Secure (anchor) the catheter to the patient's leg to prevent traction.
• Bag Placement: Attach the drainage bag to the bed frame, never the side rail, to prevent accidental yanking when the rail is moved.
• Intake and Output (I&O): Empty the drainage bag at the end of every shift or when full using a graduated cylinder. Do not let the drainage spout touch the container.
• Urethral Gel: Use Lidocaine jelly (Instilla gel/Urojet) for lubrication and local freezing. It should be injected into the urethra and left for approximately $5\,\text{minutes}$ prior to insertion to maximize efficacy.

Troubleshooting and Complications

• Accidental Removal: If a patient yanks a catheter out with the balloon inflated, assess for bleeding, notify the doctor for a new order, and check for urethral trauma/pain.
• Pain During Inflation: If the patient says "ow" while you are inflating the balloon, the catheter is likely in the urethra, not the bladder. Stop, deflate the balloon, insert the catheter an extra $1$ to $2\,\text{inches}$, and try again.
• No Urine Present: Check for kinks in the tubing or ensure the patient is not sitting on the tube. If no kinks, perform a bladder scan; the tip may be resting against the bladder wall.
• Cloudy/Smelly Urine: This indicates a possible UTI; notify the physician for potential antibiotic orders.
• High Output Warning: If output exceeds $1\,\text{L}$ in $15\,\text{minutes}$, notify the doctor immediately due to the risk of electrolyte imbalance.
• Vaginal Insertion (Female): If the catheter accidentally enters the vagina, leave it there as a landmark and get a new, sterile catheter to find the urethra. Removing it and reusing it introduces vaginal flora into the sterile bladder.

Removal and Bladder Training

• Removal Process: Use a $10\,\text{cc}$ syringe to withdraw all sterile water. Remove the tube slowly and monitor for urethral swelling.
• Bladder Training: For long-term catheterized patients, the bladder (a muscle) may lose tone. Clamping the catheter for $2$ to $4\,\text{hours}$ allows the bladder to stretch and fill with urine, simulating normal function before the catheter is permanently removed.
• Post-Removal Monitoring: If the patient fails to void within $4\,\text{hours}$ of removal, notify the doctor.

Questions & Discussion

• Question: Does it bleed during insertion?
• Response: Usually, there is no bleeding, but if the prostate is very enlarged, some blood might be seen. This should be monitored to ensure it isn't hemorrhaging.
• Question: How does a condom catheter stay on?
• Response: It uses a specific tape wrapped around the shaft, and the condom fits snugly over it. It is less invasive than an indwelling catheter but can be uncomfortable for the patient.
• Question: Why do we use alcohol swabs on the tube during brief changes?
• Response: Best practice is to clean with soap and water (peri care) and then use an alcohol swab on the external tube to minimize bacterial travel into the urethra, especially if the patient is bedbound and incontinent.
• Question: Why massage the bladder during insertion?
• Response: It helps relax the core muscles and the diaphragm, which in turn helps relax the sphincter to allow the tube to pass more easily.