Educational material for nurses and other health care worker.

1. URINARY CATHETERIZATIONS
PREPARED BY MOUNIR HATHROUBI
CRN RCMC CBSPD INTERNATIONALY CERTIFIED

2. BACKGROND

3. CASE STUDY
Results
 65 patients and 81 insertions were observed
 In only 11% of cases was no one else present
(buddy system in use)
 Mean insertion time 6 minutes (range 2 – 22)
 No hand hygiene prior to 74% of insertions
 No hand hygiene in 91% post insertion
 59% of insertion attempts were associated with a
major break in sterile technique
Methods
 2 teams of nursing students
 0630 – 2100, in 4 or 8 hour
blocks of time
 January 29 – June 30, 2014
 Observation, checklists, field
notes

4. CATEGORIES AND FREQUENCIES OF MAJOR BREAKS IN STERILITY
Category Frequency Examples
Contamination of sterile field 22 (27%) •Nurse touched items on
sterile field with bare non-
sterile hands.
•Stethoscope/garment/torso
touched sterile field.
Contamination of the
catheter
25 (31%) •Patient’s labia closed over
the catheter during insertion
and contaminated the
catheter; nurse did not get a
new one.
•Catheter tip touched
genitalia before being
introduced into urethra.
Breach of sterile barrier 31 (38%) •Sterile gloved hand used to
swab genitalia (without
tongs); same hand used to
insert catheter.
•Nurse inserting catheter
ripped her sterile gloves, did
not get new ones.
Barriers to Aseptic Insertion Technique
 Inconsistent or inconvenient locations for hand
gel
 Little room in cubicles to set up sterile field
 Cotton wisps clung to tongs in kits
 Common practice to don sterile gloves over
clean gloves

5. INDICATIONS
Intermittent
 Measurement of bladder residual volume.
 Obtaining uncontaminated urine for microscopy and culture (especially in females or young children).
 Facilitating adequate bladder emptying (e.g. in conditions associated with atonic bladder).
 Intravesical installation of drugs (e.g. contrast media in suspected bladder trauma or for micturating cysto-urethrography, instillation
of local cytotoxic agents).
 Urodynamic assessment.
 Exclusion of urethral or prostatic obstruction in acute renal failure/ anuria
Continuous
 Acute or chronic urinary retention.
 Accurate measurement of urine output and to aid fluid balance (e.g. postoperatively).
 Long term (e.g. when TURP is medically contraindicated).

6. WHERE TO BE INCERTED ?

7. MECHANISM

8. CONTRAINDICATIONS:
 Trauma patient with suspected urethral injury as evidenced by:
 Blood at the urethral meatus
 High-riding prostate on rectal examination
 Penile, scrotal, perineal hematoma
 Radiographic evidence of urethral/bladder trauma (in many centers a gentle attempt at urethral
catherisation by an experienced doctor is accepted practice)
 Postoperative urological patients. Always consult the urologist first if the patient has had bladder neck or
prostate surgery.
 Known stricture or ‘impossible insertion‘ last time.

9. CHOOSE THE CORRECT CATHETER
Lumen
 Single lumen—these catheters have no balloon and are used for in/out catheterization
 Double lumen—two-way catheters have a draining lumen and a balloon inflation lumen and are used for
continuous catheterization
 Triple lumen (or three-way catheters)—have a draining lumen, a balloon inflation lumen and an irrigation
lumen. Insert when blood, clots or debris are to be washed out of the bladder (e.g. post TURP).
Size
 Catheter size refers to the circumference of the catheter, not the luminal diameter and is recorded in French
sizes (1 French (F) = 1 Charrière = 0.33 mm).
 Choose the smallest catheter that will allow adequate urinary drainage. Size 12–14F is usually adequate for
males and females. Use size 16–20F if the patient has urine with debris, mucous, blood clots or haematuria,
which may occlude smaller lumens. A 22F triple lumen is the standard size for bladder irrigation and ‘washout’.
Smaller sizes (6–10F) are available for children.

10. HANDY HINTS:
 In female adults the normal position of the urethra is 2.5cm inferior to the glans clitoris. It may be difficult to
find in infants or postmenopausal elderly females. Occasionally the urethral opening recedes superiorly into
the vagina and can be found by palpation.
 Female urethra is 4cm long. The male urethra is 20 cm long – always advance the catheter to the hilt prior to
balloon inflation.
 Do not over- or under fill the catheter balloon, as this will lead to balloon distortion, causing the catheter tip to
deviate within the bladder, and can potentially result in bladder wall necrosis.
 Urine must flow from an inserted catheter before the balloon can be inflated. Urine may not flow initially
because of obstruction by lubricating gel. You may be able to expedite flow by gently suctioning the catheter
with a syringe, or applying suprapubic pressure to the patient.
 If the patient is immunosuppressed, or has prosthetic heart valves, catheter insertion may cause a serious
bacteraemia and bacterial seeding. Senior advice should be sought with regard to prophylactic antibiotics
prior to catheter insertion

11. URINARY CATHETERS TYPES

13. ONE WAY / HYDROPHILIC URINARY CATHETER ( SILICONE)

14. 2 WAY CHANEL CATHETER / TIP / SIZE / AGE CATEGORIES

15. COMPONANTS OF FOLEY CATHETER

16. 3 WAY CATHETER CHANELS

17. WHY USE SILICONE STRAIGHT TIP FOLEY CATHETER?
The bleu line
is Xry
detectable
Two-Way 100% Select Silicone Straight Tip Foley
Catheter With 10cc Balloon Capacity features large,
smooth eyes for maximum comfort and drainage and
symmetrical balloon for added reliability. The clear silicone
color makes it easy for visualization of clots, mucus and
urine flow through the catheter while the silicone material
causes less tissue irritation and encrustation during
extended periods of indwelling use.
Why use Silicone Straight Tip Foley
Catheter?
•Unisex
•Maximize safety and comfort
•Straight tip
•Uncoated Catheters

18. 100% SILICONE STRAIGHT TIP FOLEY CATHETER

19. URINARY CATHERIZATION KIT

20. URINARY BAG COMPONANTS

21. COMPONENTS OF ASEPTIC INSERTION
 Set up a sterile field.
 Perform hand hygiene immediately before and after insertion.
 Use sterile gloves, drapes, sponges.
 Use appropriate antiseptic or sterile solution for peri-urethral cleaning, and a single-use packet of
lubricant jelly for catheter tip.
 If catheter is accidentally contaminated, it is discarded, and a new sterile catheter is obtained.

22. EVALUATION
 CAUTI rates, catheter days, costs of UTIs
 Compliance with catheter insertion guidelines
 Compliance with catheter maintenance and care
 Hand hygiene rates

23. ALTERNATIVES
 Consider alternatives to indwelling urinary catheters first:
 Bladder scanner to assess volume of urine in bladder
 Straight catheter for one-time or intermittent needs
 Condom catheter for men without urinary retention or obstruction

24. INFECTION CONTROL STUDY

25. RISK MANAGEMENT

26. QUALITY IMPROVEMET

27. URINE COLOR
olour Causes
Green •Drugs: Cimetidine, Promethazine, Amitriptyline, Flutamide, Indomethacin, Methocarbamol, Methylene blue, Mitoxantrone, Propofol,
Phenylbutazone, Triamterene
•Condition: Hartnup Disease, Indicanemia, Indicanuria
•Infection: Pseudomonas Infection
•Dyes: Carbolic Acid, Flavine derivatives, Indigo Blue, Methylene Blue, Resorcinol
•Other: Clorets, Listerine, Magnesium Salicylate, Asparagus
•Cases: Verdant waste - How Green is my urine
Orange •Drugs: Idarubicin, Ferrioxamine, Oxamniquine, Phenazopyridine, Rifampicin, Sulfasalazine, Warfarin
•Food/supplements: Carotenes, B-complex vitamins, Senna, Rhubarb, Beets and blackberries
•Condition (hypercarotenemia): Diabetes mellitus, hyperlipidemia, hypothyroidism, porphyria
•Case: Where are the lemons?
Red •Stones: (calculi in the renal pelvis, ureter or bladder)
•Malignancy— TCC, RCC, Wilms
•Trauma—blunt or penetrating trauma to the abdomen or pelvis; a catheter will commonly cause haematuria. BPH is a common cause of
of intermittent gross haematuria
•Renal: Primary renal disease (e.g. glomerulonephritis; including IgA-related, membranous, mesangiocapillary, focal and minimal change).
change). Renal disease associated with / due to / secondary to systemic vasculitis (e.g. SLE, polyarteritis nodosa), Papillary necrosis
secondary to analgesic nephropathy or diabetic nephrosclerosis. Hereditary (e.g. Alport’s syndrome).
•Infection: Pyelonephritis, UTI, pyonephrosis, cystitis, prostatitis, TB, schistosomiasis
•Coagulopathy: Anticoagulation, Inherited defect (e.g. haemophilia, Von Willebrand’s), Acquired defect (e.g. DIC, thrombocytopenia).

28. URINE COLOR SIGNIFICATION
Red-Brown •Drugs: Levadopa, nitrofurantoin, metronidazole
•Condition: Rhabdomyolosis (myoglobinuria), bile pigment
•Other: Fava beans
•Case: Mahogany Myoglobinuria
Purple •Infection: Bacteria such as Providencia stuartii, Klebsiella pneumoniae, P. aeruginosa, Escherichia coli, and enterococcus species.
•Condition: Hartnup Disease, Indicanemia, Indicanuria
•Case: Tyrian Rage
Black •Drugs: Stimulant laxatives (e.g. cascara, senna)
•Condition: Alkaptonuria, methemoglobinuria
•Other: Melanin
•Case: Black Urine Case - Brown/Black urine
Milky
•Pyuria
•Case: Pyuria

29. LABORATORY URINALYSIS
Laboratory urine analysis
 Microscopy
 Un-centrifuged specimen
 Examine for red cells, white sells and epithelial cells
 Pyuria (>10 x 106 /L) indicative of the presence of inflammation
 Pyuria is usually, but not always associated with significant bacteruria
 White cells can be associated with non-infectious conditions such as calculus, renal disease, trauma and neoplasia

30. LABORATORY URINALYSIS
 Casts
 Plugs of High MW mucoprotein form in the renal tubules and collecting ducts by agglutination of protein cells
or cellular debris and flushed loose by urine flow
 Hyaline
 Normal if present in small amounts
 Inflammation, trauma to glomerular capillary, renal parenchymal disease
 Epithelial
 Eclampsia, amyloidosis, heavy metal poisons
 Renal tubular damage and nephrosis
 Granular
 Coarse or fine
 Lead poisoning, ARF, CRF, PN

31. LABORATORY URINALYSIS
 Fatty/waxy
 Nephrotic, diabetes, CRF
 RCC
 GN, SLE, SBE, renal infarction
 Malignant HT, collagen disease, sickle cell
 WCC
 Acute PN and GN
 Lupus nephritis
 Drugs
 Contrast, amphotericin, isoniazid, frusemide, penicillin, sulphonamides, gentamicin, Bactrim

32. CULTURE
 Urine in the bladder is normally sterile
 In process of specimen collection contamination from urethra and periurethral areas is common
 Count significance (Significant bacteruria)
 Must take age, sex, clinical history into account
 Generally accepted that >108 bacteria per litre is indicative of significant bacteruria
 PPV >98%
 NPV < 65%
 33% of acutely symptomatic females have bacterial counts below this (significant bacteruria taken as 105 in
these people)
 Sensitivity and specificity of microbiology tests


33. CONCLUSION
 Urinary catheters should only be inserted if there is an appropriate indication.
 Aseptic insertion technique is strongly recommended, but multiple barriers can arise.
 An approach that blends “The 4 E’s” with mindfulness may be successful at overcoming barriers.

34. THANK YOU

35. REFERENCES
 https://litfl.com/urinary-catheterisation/
 https://www.sciencedirect.com/science/article/abs/pii/S174270611930217X
 https://www.ahrq.gov/hai/cauti-tools/archived-webinars/breaking-down-barriers-slides.html
Other Resources
 www.Catheterout.org External Link Disclaimer
 Strategies to Prevent CAUTI in Acute Care Hospitals, 2014 Update from SHEA:
 http External Link Disclaimer://www.jstor.org/stable/10.1086/675718 External Link Disclaimer