Urology – Catheter Insertion and Management, … · Web viewAttend to all documentation including...

CHHS16/008

Canberra Hospital and Health ServicesClinical ProcedureUrology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (TURP)Contents

Contents...................................................................................................................................1

Purpose.................................................................................................................................... 3

Alerts........................................................................................................................................3

Scope........................................................................................................................................3

Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients)....4

Section 2 – Insertion of Female Indwelling Catheter (IDC).......................................................6

Section 3 – Insertion of Male Indwelling Catheter (IDC)..........................................................8

Section 4 – Suprapubic Catheter (SPC) Procedures for Inpatients and Community Based Patients.................................................................................................................................. 10

4.1 Insertion of Suprapubic Catheter.............................................................................11

4.2 Changing Suprapubic Catheter: Inpatient................................................................14

4.3 Removal Suprapubic Catheter.................................................................................16

4.4 Management of Supra Pubic Catheter: Community Based Patient.........................17

Section 5 – Catheterisation Intermittent in the adult Inpatient.............................................19

Section 6 – Catheter Intermittent: Patient Education............................................................20

Section 6 – Catheter Flushing for Adult Community based patient........................................24

Section 7 – Trial of Void: Community based patient..............................................................25

Section 8 – Indwelling Urinary Catheter Management: Inpatient and Community...............27

8.1 Emptying a Urinary Drainage Bag: Inpatient specific...............................................28

8.2 Urinary Drainage Bag Management: Community Specific.......................................29

8.3 Removal of Indwelling Urinary Catheter..................................................................30

Section 9 – Trans Urethral Prostatectomy (TURP)..................................................................31

Section 10 – Bladder Irrigation...............................................................................................35

10.1 Continuous Bladder Irrigation..............................................................................35

10.2 Manual Bladder Irrigation....................................................................................37

Section 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy.39

Doc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 1 of 69

Do not refer to a paper based copy of this policy document. The most current version can be found on the ACT Health Policy Register

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Section 12 – Management of patients undergoing a Percutaneous Nephrolithotomy..........44

Section 13 – Management of patients admitted with Pre-Existing Continent Urinary Reservoirs/Neobladder during routine hospital admissions..................................................50

Implementation......................................................................................................................50

Related Policies, Procedures, Guidelines and Legislation.......................................................51

Search Terms..........................................................................................................................51

References..............................................................................................................................51

Attachments...........................................................................................................................53

Attachment A: Stat Lock – Foley Stabilisation Device.........................................................54

Attachment B: Insertion of Urinary Catheter Sticker..........................................................55

Attachment C: How to care for your Urinary Catheter.......................................................56

Attachment D: Troubleshooting guide for urinary catheters.............................................58

Attachment E: Source of information and/or suppliers for urinary catheter equipment...67

Attachment F: Catheter selection.......................................................................................68



CHHS16/008

Purpose

The Urology Assessment and Management Procedures describe practice which will be performed by registered nurses, medical staff and allied health. New nursing or medical staff, or students (within their defined scope of practice) will be required to perform these skills under the direct supervision of a competent practitioner.

Clinicians providing assessment, education and clinical procedures must have current theoretical and clinical knowledge in continence management.

To provide best practice in managing, educating and supporting patients requiring short/ long term management of urinary catheters.

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Alerts

Strict hand hygiene should be adhered to at all times when performing all clinical procedures as per Healthcare Associated Infections Procedure-Section 2 Infection Prevention & Control Strategies

Consent must be gained for all interactions with patients and care provided consistent with Intimate Body Care and Examinations by Health Care workers Standard Operating Procedure

All staff to adhere to Patient Identification and Procedure Matching Clinical Policy

Scope

This document applies to: Medical Officers (MO) Nurses and Midwives who are working within their scope of practice Students under direct supervision of a registered nurse.

Note: A medical officer/ nurse/ midwife is assessed as competent when they have:

Observed the procedure Performed the procedure at least once under the supervision of a competent medical

officer/ registered nurse/ midwife Been assessed as competent by another competent registered nurse/midwife, medical

officer nominated by the Clinical Nurse Consultant (CNC) or CDN.


Section 1 – Catheter Management for Adults (Inpatients and Community Based Patients)



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General Information: It is recommended that nursing staff who are inserting urinary catheters and/or caring

for and/or removing urinary catheters from patients complete the eLearning course Indwelling Urinary Catheter and the competency assessment form, accessible via Capabiliti.

To introduce a urinary catheter to drain urine from the bladder. If a latex catheter is to be inserted determine the patient’s latex allergy status.

Patient assessment prior to catheterisation should include the exploration of possible patient’s cultural values and beliefs that may influence healthcare practices and consistent with ‘Intimate Body Care and Examinations by Health Care Worker SOP’ . Verbal consent should be obtained especially where catheterisation of males by a female nurse or female catheterisation by a male nurse is required.

For patients with large capacity bladders, indwelling catheters and slow bladder decompression are recommended. No more than 600mls is to be withdrawn from the bladder at any one time unless otherwise indicated by the medical officer as this may induce a syncopic episode.

Community Based Patients:Contraindications for Catheterisation in the Community Acute prostatitis. Suspicion of urethral trauma.

1. ‘Medical Officer’s Orders for Urinary Catheter Management’ clinical record form (form no. 40950) must be completed for all urinary management in the community setting. Medical Officers orders for Catheters should be reviewed every three (3) years.

2. Catheters should be appropriate, comfortable, easy to insert and remove and must minimize secondary complications such as tissue inflammation, encrustation and colonisation by micro- organisms (See Attachment F)

3. The smallest gauge catheter suitable for the patient needs should be used and balloons should generally be 5 to 10ml in size. Patients with a lesion above T6 should use a size 18 to 20Frg to avoid blockage and complications of autonomic dysreflexia.

4. Community Nurses will identify patients with spinal lesions at or above T6 and monitor for autonomic dysreflexia during catheterisation. Where applicable first line emergency management should be provided to those patients. Care provided should be consistent with ‘Autonomic Dysreflexia SOP’

5. All catheters become colonised with bacteria after a few days. If a catheter specimen of urine (CSU) is required this should only be obtained on change of the catheter not the bag.

6. Community nurses will document the management of a patients ‘Urinary Catheter Management Chart’ clinical record form (form no.60535)

7. Patients and/ or carers should be educated on how to care for their catheters and also be provided with the pamphlet ‘How to care for your urinary catheter’, which can be found on the Policy Register (see sample at Attachment C)

8. Catheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter



http://inhealth/PPR/default.aspx

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9. Manual bladder irrigation or washout involves instilling large amounts of fluid into the bladder withdrawing fluids for the purpose of removing debris and mucus from the bladder. This procedure should be done under medical supervision and is not suitable to be done in the community.

10. Patients with long - term catheter requirements are responsible for the provision of ongoing equipment (catheters, leg bags, overnight bags, catheter straps, catheter valves. Consider funding sources such as:o Continence Aids Scheme (CAPS)o ACT Equipment Subsidy Scheme (ACTES) o Rehabilitation Appliances Program (RAP) of Department of Veterans Affairs (DVA)

11. If the patient is not eligible for any of these schemes, they may source equipment from supplies either locally or interstate (see Attachment E)

12. Where possible, liaison should occur with the medical practitioner or management team who inserted the catheter if there are any concerns regarding catheter management in the community

13. Where possible patients should be encouraged to access one of the Community Health Centres ambulatory clinics for their routine catheter change.

14. Where difficulties are experienced or anticipated, contact the continence CNC or GP; if the matter is urgent call an ambulance.

15. If a catheter requires permanent removal, medical orders should be obtained from the treating doctor and documented in client’s file (refer to Removal of Catheter) attached.

Alerts: Seek expert advice for patients with artificial heart values who grow Enterococcus

species in the urine prior to the procedure Patients with spinal lesions at or above T6 require monitoring for Autonomic

Dysreflexia: refer to ‘Autonomic Dysreflexia SOP’ for management pathway Do not clamp catheter prior to change The following conditions do not preclude catheterisation but extra care should be taken

when:o The Patient is taking high dose anticoagulants increasing the risk of haemorrhage.o If there is a history of recent surgery, cancer or radiotherapy to the lower urinary

tract, as there is increased risk of damageo Consult with Medical officer or CNC if in doubt




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Section 2 – Insertion of Female Indwelling Catheter (IDC)

Equipment: Disposable catheter pack (includes extra gloves) 0.9% Sodium Chloride 60ml Lubricant sachet Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or

16F Sterile urinary drainage bag to meet patients needs One x 10ml syringe One x 10ml Sterile Water for Injection Securement device

Inpatient specific: Foleys Statlock device pack including skin prepCommunity specific: Urinary Retaining Strap

Measuring jug if required Procedural under pad Clean gown Sterile gloves Community specific: Sterile gloves x two Community specific: non sterile gloves Safety glasses or goggles Sterile specimen jar, if required

Procedure:1. The medical officer must document the order for catheter insertion and removal in

clinical record2. Community Specific: Medical Officers Catheter Management3. Explain procedure to patient and ensure privacy4. Patient identification and allergy band are checked against clinical notes and stickers.5. Prepare equipment6. Don safety goggles7. Inpatient specific: Raise bed to the appropriate height 8. Position the patient supine with knees flexed drawn up soles of feet together, or knees

wide apart9. Place procedural under pad beneath the buttocks10. Don clean gown11. Don sterile gloves (separate) then gloves from catheter pack12. Remove the protective cover from the tip of the catheter ONLY. Lubricate, leaving the

catheter cover in place13. Place the catheter in the dish14. Using a clean swab each time, cleanse the labia majora with 0.9% Sodium Chloride using

downward strokes15. Separate the labia with free hand, using gloved hand16. Cleanse the labia minora and urethral meatus17. Discard forceps and first pair of gloves. Drape patient with fenestrated sheet to

establish sterile area



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18. Separate the labia with free hand19. Maintain the separation until the catheterisation is complete20. Place the dish containing the catheter between the patient's thighs21. Identify the urethra22. Ask the patient to take a deep breath to relax the sphincter23. Gently insert the catheter until urine flows, then advance 2.5cm further into the orifice

using the sterile catheter sleeve.

Note: Do not use force

24. Remove the sterile catheter sleeve and drain urine into the dish25. Collect sterile urine specimen if required 26. Inflate the balloon with the required amount of sterile water (see balloon hub) 27. Remove the protective cap from the urinary drainage bag, seal outlet tube and attach to

the catheter 28. Inpatient specific: Attach statlock (dated) to the leg to anchor urinary catheter bag

(Attachment A)Community specific: Catheter Retention Strap

29. Drain 600ml only then clamp for one (1) hour30. Leave the patient comfortable31. Lower the patient’s bed32. Discard equipment 33. Inpatient specific: Record the procedure in the patient's clinical record (Attachment B):

a. Date and time of procedureb. Type and catheter size c. Amount of water in the balloon d. Indication and scheduled date for removal or change

34. Community specific: Record the procedure using the ‘Urinary Catheter Management Chart’ clinical record form (form no.60535)

35. Record output, clarity, colour and odour on the patient's FBC and clinical record 36. Perform urinalysis and document on General Observation Chart and clinical record37. Record if a specimen is sent to pathology 38. Watch for haematuria and diuresis in patients with chronic urinary retention 39. Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated

perineal toilets required for hygiene needs

Alert: Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weekly.

Stabilisation of Urinary Catheters: Prepare skin with protectant and allow to dry Align anchor pad over securement site (arrow towards body) Press catheter into anchor and close lid Position on anterior thigh or abdomen



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Peel away paper backing and place on skin (See Attachment A)


Section 3 – Insertion of Male Indwelling Catheter (IDC)

Equipment: Disposable catheter pack (contains extra gloves)

Community specific: sterile gloves x twoInpatient specific: Betadine (check for Iodine allergy)

0.9% Sodium Chloride 60ml 10ml Lignocaine gel syringe Latex (short-term) or Silicone (long-term) catheters x two, usually 14 or 16F Sterile

urinary drainage bag 1 x 10ml syringe Community specific: two x 10ml syringe 1 x 10mls Sterile Water for Injection Securement devices

Inpatient specific: Foleys Statlock deviceCommunity specific: Catheter Retention Strap

Inpatient specific: Measuring jug Procedural under pads (one large & one small) Clean gown

Community specific: non sterile gloves Sterile gloves

Community specific: two x sterile gloves Safety glasses or goggles Sterile specimen jar, if required Sterile catheter introducer, if required (to be used by Medical Officer only).

Alert: A catheter introducer for the introduction of a catheter for male catheterisation is only to be used by a medical officer

Procedure:1. Inpatient specific: The medical officer must document the order for catheter insertion

and removal in clinical recordCommunity specific: Medical Officers Catheter Management

2. Explain procedure to patient and ensure privacy3. Remove the protective cover from the tip of the catheter only. Lubricate, leaving the

catheter cover in place4. Place the catheter in the dish5. Drape the genital area around the penis6. Don safety eyewear and gown7. Inpatient specific: Raise bed to appropriate height8. Wash hands and don sterile gloves x two9. Position fenestrated drape to provide sterile field



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10. Use non dominant hand to hold the penis. Where present retract the foreskin and swab head of the penis paying particular attention to the urethral meatus and glans

11. Hold penis at a right angle (90 degree) to the body and gently instil Xylocaine lubricant into the urethra: Gentle pressure underneath the head of the penis will minimise lubricant leaking out. Allow sufficient time for anaesthetic to work (three to five minutes).

Note: Do not proceed if patient has an erection, wait until this subsides

After this time you may:12. Remove outer pair of sterile gloves if contaminated during the procedure13. Holding penis at 90 degree angle, gently insert and advance catheter to the Y hub. 14. If resistance is felt at the bladder neck, lower the penis slightly and suggest that the

patient breathe slowly whilst pretending to pass urine. The catheter should never be forced

15. If resistance continues, withdraw catheter and insert more anaesthetic gel. Re-insert sterile catheter after a further three to five minutes. If further resistance is encountered, seek advice from CNC, Continence CNC or Medical Officer

16. When urine begins to flow,(at least 15-20mls ) re-check the position of the catheter to ensure it is still in the bladder, then inflate balloon with required volume of sterile water (according to manufacturer’s instructions)

Alert: If resistance is felt at the external sphincter, slightly increase the traction on the penis and apply steady, gentle pressure on the catheter. Ask the patient to attempt to void in order to relax sphincter

17. Attach sterile drainage bag18. Where present, replace foreskin to natural position 19. Secure bag to patients requirements

Inpatient specific: Attach statlock to the leg to anchor urinary catheter bag (See Attachment A)Community specific: Attach Catheter Retaining Strap

20. Drain 600ml only then clamp for one hour21. Leave the patient comfortable22. Documentation:

Inpatient specific: Record the procedure in the patient's clinical record using the Urinary Catheter Label: (See Attachment B): a. Date and time of procedureb. Type and catheter sizec. Amount of water in the balloon d. Indication and scheduled date for removal or change

16. Community specific: Record the procedure using the ‘Urinary Catheter Management Chart’ clinical record form (form no.60535)

23. Record output, clarity, colour and odour on the patient's FBC and clinical notes24. Perform urinalysis and document on General Observation Chart and clinical notes



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25. Inpatient specific: Record if a specimen is sent to pathology Community specific: Contact GP if signs of infection present

26. Observe for haematuria and diuresis in patients with chronic urinary retention. Inpatient specific: Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated penile toilets required for hygiene needs

27. Perform hand hygiene when leaving the patients environment as per the 5 moments of hand hygiene

Alert: Companies who manufacture latex catheters recommend that the catheter be changed every seven days. Silicone catheters as per manufacturers’ recommendations to be changed 6 to 12 weekly


Section 4 – Suprapubic Catheter (SPC) Procedures for Inpatients and Community Based Patients

Background:An SPC may be used for: The management of long-term urinary incontinence or retention of urine The drainage of urine post operatively in urological or gynaecological patients Patients with urethral and/ or pelvic trauma where the utilisation of a urethral catheter

is not possible Patients with ongoing problems associated with urethral catheters such as irritation or

continued blockage

The purpose of this is to provide guidelines for the management of a Suprapubic Catheter (SPC) including: Insertion Catheter Change

o Inpatiento Community based patient

Dressing Changes Removal Management in the Community

This document pertains to adult patients requiring management of a SPC at the Canberra Hospital and Community based patients

4.1 Insertion of Suprapubic CatheterInitial insertion of a SPC may only be performed by a Medical Officer. Further catheter changes may be attended in the community by nursing staff.

Equipment: Alcohol based hand rub (ABHR) Basic dressing packDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 10 of 69


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Sterile dressing towels x two Sterile gown and gloves Sterile water x 20 ml 10ml syringes x three 21g needle 1% Lignocaine x10ml Drain sponge dressing Foleys Statlock device Suture material (as per medical officer’s preference) Suture set Suprapubic catheter introduction kit available from the operating rooms Sterile urinary drainage bag 50ml bladder syringe 500mls bottle 0.9 Sodium Chloride at room temperature Chlorhexidine skin preparation Adhesive tape of choice Safety goggles or shields Procedure underpad Clean gown

Alert: The patient will be required to have a full bladder for initial insertion to assist in the palpation of the bladder and to prevent perforation of the bowel. A full bladder is not required for routine subsequent changes.

Procedure: 1. Inpatient: The medical officer must document the order for the SPC insertion and

removal in the clinical record2. Community specific: Medical Officers Catheter Management3. Obtain the verbal consent4. Explain to the patient the process and purpose of the procedure5. Ask the patient if they have any allergies to dressings or tapes.6. Ensure the patient has adequate analgesic cover prior to procedure if required or

requested 7. Assist patient to the supine position, placing procedure underpad beneath the buttocks8. Don PPE9. Clean trolley with detergent impregnated wipes and disposable towel, wipe dry10. Set up equipment on trolley at the patient’s bedside11. Don clean gown prior to opening sterile equipment12. Open the procedure pack 13. Assist the medical officer with gowning after performing a procedural wash 14. Don clean gloves15. Expose the suprapubic area16. Attend hand hygiene by either hand washing or using ABHR17. Open further equipment required, such as the catheter pack, local anaesthetic, water

for balloon, suture material



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18. Pour chlorhexidine skin preparation into sterile tray19. The medical officer will insert the SPC, provide assistance if required20. Reassure patient throughout the procedure whilst maintaining privacy21. Once SPC inserted, attach urinary drainage bag, ensuring drainage system is closed22. Place drainage bag below the patient’s waist height23. A leg bag may be utilised, however is not advised at initial insertion time24. Ensure Foleys Statlock device is securely attached to the patient’s skin and secure the

catheter25. Apply drain sponge around SPC and secure with tape 26. Discard equipment and gloves into clinical waste receptacle27. Clean trolley with detergent impregnated wipes 28. Ensure patient is comfortable with new dressing change and understands when the

next dressing change will be attended29. Document in the patient’s clinical record using the Urinary Catheter Label:

o Date of SPC insertiono Type and size of cathetero Amount of water in the balloono Amount of urine drainedo Patient’s response to the procedure

30. Change dressing as frequently as required

Note: The insertion of a SPC for gynaecology patients on the ward may be performed under ultrasound.

Dressing ChangeEquipment: Alcohol based hand rub (ABHR) Basic dressing pack Sterile drain dressing 0.9% Sodium Chloride (30ml) Adhesive tape of choice Personal protective equipment (PPE) including clean gloves and safety goggles or shield General waste receptacle Clinical waste receptacle Stat lock (optional)

Procedure:1. Attend steps 1 to 14 of Insertion of SPC2. Don PPE prior to opening sterile equipment3. Open the basic pack and position equipment using the setting up forceps4. Pour normal saline to tray5. Don clean gloves6. Expose the SPC site7. Remove the soiled dressing with setting-up forceps



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8. Discard the dressing and forceps and gloves into the clinical waste receptacle9. Inspect the SPC site for clinical signs of infection and healing 10. If signs of infection notify the Medical Officer and consider swab

Note: Once the SPC insertion site is healed, it does not require a dressing. The site may be cleaned with warm soapy water during daily hygiene routines. Statlock device must remain insitu to anchor the SPC to the body to avoid dislodgement.

11. Don clean gloves12. Use wound cleansing solutions at body temperature .Irrigate with normal saline solution

to remove debris and contaminants13. Swab gently and in one direction only14. Ensure the site is dry before applying new dressing15. Apply new dressing and secure with adhesive tape or bandages16. Statlock device must remain insitu to anchor the SPC to the body to avoid dislodgement17. Discard equipment and gloves into clinical waste receptacle18. Clean trolley with detergent impregnated wipes19. Ensure patient is comfortable with new dressing change and understands when the next

dressing change will be attended20. Change dressing or appliances as frequently as required to effectively remove excessive

exudate or infected material21. Document in the patient’s clinical record and wound care chart:

o A description of the woundo Type of dressing appliedo Any change of dressingo The reason for the change

22. Urinary bags are to be emptied and cared for as per Urinary Bladder Management23. Ensure the patient is involved in the care and management of the SPC in preparation for

discharge

Alert: Maintain a closed drainage system as much as possible so as to prevent infection. Do not use talcum powder, creams or strongly scented soaps near the catheter site to avoid irritation.



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4.2 Changing Suprapubic Catheter: InpatientFirst SPC change following initial insertion must be attended four to six weeks post insertion.Medical Officers or Registered nurses may perform the first and subsequent suprapubic catheter changes, where the catheter is a balloon catheter (Foley) or a Bonanno (Pigtail) utilising aseptic technique unless otherwise specified by the Urologist.

If symptomatic urinary tract infection is suspected and patient is not on antimicrobial therapy then reconsider need for change of SPC prior to clarification of infection status. If change is still required then consult the medical team for consideration of treatment immediately after change ensuring a mid-stream urine is obtained once the new catheter is inserted.

Alert: Size 16 and above catheters are recommended for Suprapubic catheterisations: Latex SPC’s must be changed every two weeks Silastic SPC’s must be changed every six weeks Hydrogel coated and 100% silicone catheters can remain insitu for up to 12 weeks It is recommended that Catheter changes are based on clinical indications such as

infection, obstruction, or when the closed system is compromised within the manufacturers recommend time frame.

Equipment: ABHR Sterile dressing towels x two Sterile gown and gloves Clean gown Catheter of choice – preferably silastic Basic dressing pack Gauze swabs x two packs 0.9% Sodium Chloride 30 to 60mls Sterile water 20ml Syringe 10ml Syringe 20ml Sterile urinary drainage bag Drainage tube dressing Foleys Statlock device Sterile kidney dish Clean clamp Procedure underpad Safety glasses or goggles Adhesive tape of choice (if required) General waster receptacle Clinical waste receptacle



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Alert: The patient’s SPC is to be clamped for 30 to 60 minutes prior to the procedure so as to allow the bladder to fill for easier palpation

Community specific: Patient to consume oral liquids 30- 60 minutes prior to SPC change to ensure bladder volume. Clamping of SPC not required in community setting. Clamping of SPC not recommended in patients with spinal cord injury at T6 level or above or patients with a diagnosis of Autonomic Dysreflexia

An assistant is required to assist gowning and to open further equipment such as the catheter, sterile water and drainage bag

Procedure:1. Attend steps 1 to 14 of SPC Dressing2. Don Sterile gloves3. Sterile catheter is placed in the sterile kidney dish4. Swab around catheter site with 0.9% Sodium Chloride and gauze swab5. Place sterile towels around SPC site6. Second person to withdraw fluid using 20ml syringe from catheter balloon insitu7. Catheter is then gently withdrawn; gentle rotation of the catheter may assist in removal8. Discarded into clinical waste receptacle9. Swab fistula site with 0.9% Sodium Chloride and gauze swab10. Sterile dish containing catheter is placed on the sterile field11. Catheter is inserted through the fistula at a 90 degree angle to the abdominal wall12. Insert the catheter approximately 8 to 10cm or until urine is returned13. Urine specimen may be collected if required 14. Inflate the balloon with the sterile water and 10ml syringe following manufacturer’s

instructions (5 to 10mls)15. Connect the drainage bag to the catheter ensuring closed system16. Apply drainage tube dressing if required17. Secure the catheter to the abdomen with Foleys Statlock device18. Discard equipment and gloves into clinical waste receptacle19. Clean trolley with detergent impregnated wipes 20. Ensure patient is comfortable with new SPC and dressing change and understands when

the next SPC and dressing change will be attended. Advise patient of signs and symptoms of infection and to notify to the medical officer in charge of their case and notify of any changes in the patients clinical condition post procedure.

21. Document in the patient’s clinical record using the Urinary Catheter Label:o Date of SPC changeo Type of catheter and sizeo The amount of water in the balloono The condition of the fistulao The patient’s response to the procedure.



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4.3 Removal Suprapubic CatheterPrior to the removal of the SPC ascertain if the patient is able to void by clamping the catheter for two hours prior to the removal procedure. Check the urine residual using a bladder scanner. The tip of the SPC is sent to pathology for analysis following removal where ordered by a Medical Officer.

Equipment: Basic dressing pack Sterile gloves Stitch cutter or fine suture removal set, if required Syringe one x 20ml 0.9% Sodium Chloride 30 to 60mls Sterile specimen jar Dry absorbent dressing Adhesive tape of choice Safety glasses or goggles (need to ensure this included in the steps) Procedure underpad Bladder scanner

Procedure:1. Attend steps 1-13 of SPC Dressing Change2. Collect catheter specimen of urine (if required) 3. Don sterile gloves4. Remove the suture (if present) holding the catheter insitu5. If the SPC has a balloon, deflate using the relevant size syringe6. Gently withdraw the catheter in a steady continuous motion7. Using sterile scissors cut the tip off into a sterile specimen jar and send to pathology for

analysis if required 8. Use wound cleansing solutions at body temperature irrigate with normal saline

solution, to remove debris and contaminates9. Swab gently and in one direction only10. Ensure the site is dry before applying new dressing11. Apply new dressing and secure with adhesive tape or bandage12. Discard equipment and gloves into clinical waste receptacle13. Clean trolley with detergent impregnated wipes 14. Ensure patient is comfortable with new dressing change and understands when the

next dressing change will be attended15. Document Inpatient’s clinical record using the Urinary Catheter Label:

o Date and time of the SPC removedo Condition of fistulao If the catheter tip is sent for MC&So Patient’s reaction to the procedure.



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Note: It is not unusual for a small amount of leakage at the fistula site on removal of SPC. Regularly change the dry dressing and reassure the patient that this may continue for a few days, however, no medical intervention is required

4.4 Management of Supra Pubic Catheter: Community Based Patient

Alert: If the Supra pubic catheter becomes dislodged it should be replaced within 30 - 45 minutes to prevent the stoma closing over.

Following initial insertion, the tract will take 10 days to four weeks to become established. If the catheter becomes blocked or dislodged within this initial phase, expert medical advice should be sought as soon as possible. The patient should return to the treating hospital for management.

Prior to first change of a suprapubic catheter the ‘Medical Officer’s Orders for Urinary Catheter Management’ clinical record form (form no. 40950) must be completed and signed by the referring medical officer.

Community nurses may perform the first and subsequent suprapubic catheter changes, where the catheter is a balloon catheter (Foley) and NOT a Bonanno (Pigtail)

First change of suprapubic catheters can be performed in the ambulatory clinic or in the client’s own home unless otherwise documented by specialist or General Practitioner (GP)

The size of the catheter should be no smaller than 16Fg in adults with a 10ml balloon Ensure patient has had adequate fluid intake prior to procedure Catheters should not be clamped prior removal Always endeavour to re-insert same size catheter where possible If unable to re-insert a catheter, insert a nelaton catheter to keep stoma open and

arrange prompt transport to treating hospital for catheter reinsertion Urinary Catheters need to be changed at intervals that meet each client’s specific needs

and comply with manufacturers’ recommendations (usually 6 to 12 weeks). Careful evaluation of each catheter change will enable the nurse to establish each patient’s individual catheter change routine. Use a ‘Urinary Catheter Management Chart’ to assist with this process

Stabilising the catheter to the abdomen as well as to the upper thigh with a securement device is vital to reduce adverse events such as dislodgement, tissue trauma, hyper-granulation, inflammation and infection

SPC stoma sites do not routinely require a dressing after the first 24 hours of initial insertion. If the site is discharging a temporary sterile gauze dressing should be applied

Ensure the patient is informed of the procedure should the catheter become dislodged and that contact numbers are in place for Community Nursing team leader, the LINK after hours service and the treating hospital

Where difficulties are experienced or anticipated seek medical assistance Where a catheter is required to be removed permanently, medical orders should be

obtained from the treating doctor and documented Inpatient’s file Medical Officer’s Orders for Urinary Catheter Management should be reviewed every 3

years



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Patients with spinal lesions above T6 require monitoring for Autonomic Dysreflexia (do not clamp catheter prior to change). The following conditions do not preclude catheterisation but extra care should be taken when: The client is taking high dose anticoagulants as these increases the risk of haemorrhage. There is a history of recent surgery, cancer or radiotherapy to the lower urinary tract.Consult with medical officer if in doubt.

Equipment: Sterile catheter pack Urinary catheter to meet patient’s specific needs (size 16 or above) Sterile Normal Saline (cleansing solution) Sterile gloves Non-sterile gloves Water soluble lubricating gel. (Lignocaine 2% gel for patient with SCI and/ or bladder

spasms) 10 ml syringe Drainage equipment to meet patient’s specific needs Safety goggles Disposable Gown Antimicrobial hand gel Small sterile dry dressing may be required

Procedure:1. Read medical order, identify correct client for catheter removal and re-insertion,

explain procedure and obtain consent from patient2. Position patient appropriately for their comfort, condition and delivery of care:

clinic/home3. Don safety eyewear and gown.4. Deflate balloon, do not remove catheter (allow balloon to deflate without drawing back

on syringe to prevent balloon distortion)5. Hand hygiene and don sterile gloves. Drape with sterile towel.6. Lubricate tip of catheter. (Lignocaine 2% gel for patient with SCI and/ or history of

bladder spasms)7. Clean around catheter insitu with normal saline8. Place sterile fenestrated drape over area9. Grasp the catheter with non dominant hand under the drape and remove catheter from

bladder.

Note: position, angle and length of the catheter from the stoma exit to the catheter hub

10. Insert new catheter immediately using your dominant hand at the angle and length of catheter previously removed



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11. Advance the catheter into the tract a further 3 cm (not more) to prevent the catheter tip irritating the bladder wall and to ensure the catheter passes into the urethra. If no urine drains gently apply pressure over the symphysis pubis area

12. Once urine drains, insert the catheter approximately 3 cm further to ensure the catheter is in the bladder and not the suprapubic tract

13. Slowly inflate balloon with required volume of sterile water (according to manufacturer’s instructions), check patient for any ongoing discomfort or pain

14. Withdraw the catheter slightly and attach sterile drainage bag15. Secure catheter to patient’s abdomen and the top of the thigh with securement device

then secure the drainage bag to the leg with leg straps. Discard equipment and attend hand hygiene

16. Document the procedure in the client’s clinical and on Urinary Catheter Management Form

Care of the Suprapubic Catheter: See Suprapubic Trouble shooting guide (Attachment D) The suprapubic catheter emerges at a right angle to the abdomen and needs to be

supported in this position It is not necessary to rotate the catheter at the insertion site between catheter changes Observe the SPC site for signs of infection and/ or over granulation Dressings should not be routinely used. If a dressing is required it must be sterile and

applied using an aseptic technique Hygiene is important and once healed the site should be washed with warm soapy

water, preferably twice daily. Cleaning should be directed away from the insertion site Talcum powder, creams and strongly perfumed soaps should be avoided. Patients should be made aware of the importance of hand washing both before and

after handling the catheter drainage system

Supply of catheter equipment: The treating nurse will educate the client on how to access the necessary supplies. (See

Urinary Drainage System Management for Community Based Patient)


Section 5 – Catheterisation Intermittent in the adult Inpatient

The purpose of this section is to introduce a catheter into the bladder to completely empty the bladder or to measure residual urine volume

Equipment: Disposable catheter pack Short term Nelaton catheter of correct size (female 12-14 Fg/male 14-16Fg) i.e., smallest

size suitable 0.9% Sodium Chloride 60ml Lubricant sachet Measuring jug



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Procedural under pad Clean gown Sterile gloves Safety glasses or goggles Sterile specimen jar, if required.

Procedure:1. Follow the insertion procedure as noted for either female or male catheterisation,

however, you do not require anchoring device, urinary drainage bag or syringe and water for injection

2. Once the catheter is inserted and urine starts to drain, hold the catheter in place digitally until the urine ceases to flow. Withdraw the catheter gently until urine recommences flowing. Once urine flow ceases gently withdraw catheter completely.

3. Leave the patient comfortable 4. Lower the patient’s bed 5. Discard equipment. 6. Record the procedure in the patient's clinical record:

a. Date and time of procedureb. Type and catheter size c. Reason for insertion

7. Record output, clarity, colour and odour on the patient's FBC 8. Perform urinalysis9. Record if a specimen is sent to pathology

Alert: Specific Spinal Cord Considerations. Do not clamp the catheter in spinal cord injured patients above T6. Ascertain if patient is on anticoagulants prior to procedure. Seek expert advice for patients with artificial heart values who grow Enterococcus species in the urine prior to the procedure. Potential risk of creating a false passage associated with forced instrumentation. Balloon inflated in urethra/ tract resulting in haematoma, haemorrhage, rupture or necrosis


Section 6 – Catheter Intermittent: Patient Education

The purpose of this section is to provide procedural information for nurses to assist in supporting and educating patients in the procedure of clean intermittent catheterisation.

Registered Nurses who educate clients in the procedure for Clean Intermittent Catheterisation (CIC) must have current theoretical knowledge and be clinically competent in the procedure. A student nurse may undertake the procedure under the direct supervision of a competent clinician.This applies to all nurses and contains information on Documentation and patient education requirements Self catheterisation procedure and equipment Catheter equipment



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Procedure: A Medical or Nurse Practitioner must order intermittent catheterisation The patient’s ability to perform catheterisation and adhere to a schedule is essential to

the success of the CIC program. They must have adequate hand dexterity, mobility and cognition to learn the procedure and understand the principles of management. Age is not a barrier to learning self-catheterisation where the above points are noted

The aim of the technique is to achieve bladder emptying at regular intervals, to reduce urinary tract infections, to promote bladder function and maintain continence

Nurses must utilise a clean technique when teaching and performing intermittent catheterisation

Utilise clean working surfaces for the procedure Urinary volumes, both voided and residual (where appropriate) should be recorded

until a pattern has been established. If large amounts urine (more than 500mls) is drained consider more frequent catheterisation

Patient Accountability and care plans will document a personalised timetable of self-catheterisation

Patient education will include anatomy and function of the urinary system, infection control, fluid balance, bowel management and the management of complications.

Once the technique is mastered, the patient may work towards performing the procedure without a mirror and in any position that suits the client. Assistance in determining this routine may be obtained from Continence Advisors, Continence CNC, Medical Officer or Urologist

Equipment: Intermittent (nelaton) catheter, recommended sizes 8 to 10Fg children, 12 to 14Fg

adults. Male 400mm length and female 160mm length Warm water and a clean face washer (or moist towelettes) Water soluble lubricant or anaesthetic gel Container to collect and measure urine (e.g. measuring jug, kidney dish, slipper pan) Appropriate light source Hand held mirror for females (initial use only) Cotton tip (initial use only) Protective sheet (initial use only)



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Female Procedure:1. Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and

lubricate catheter2. Place patient in a comfortable sitting position, back supported, knees apart and legs

bent so that the perineum is visible in a mirror3. Instruct patient to separate the labia majora with the non-dominant hand to expose the

urethral opening, and with the dominant hand, wash this area with warm water or moist towelettes. Start at the top and work downwards

4. With the labia still separated by the non-dominant hand, using the first and third fingers, the nurse uses the cotton bud and mirror to point out the anatomy of the clitoris, urethral opening and the vagina

5. Patient then palpates the urethra with the second finger (feels like a small hole or donut) and leaves it over the urethral meatus. The client then takes the catheter in the dominant hand, holding it two to three cm away from the tip, and gently inserts into the urethra, sliding it under the palpating finger in a gentle upwards and backwards motion

6. Allow urine to drain into container and apply gentle pressure over the suprapubic area when flow ceases. This will ensure the bladder is empty

7. Withdraw catheter slowly, stopping if urine begins to flow again8. Measure and record amount of urine9. Nurse and patient to wash hands thoroughly and clean up10. Document Inpatient file11. Once the patient is efficient and confident, the procedure may be carried out on the

toilet

Note: it is not harmful should menstrual blood be introduced into the bladder during this procedure

MaleProcedure:1. Nurse and patient to wash hands thoroughly. Nurse to apply non sterile gloves and

thoroughly lubricate the first 15cm of the catheter tip2. Patient sits in a comfortable position with legs separated3. Instruct patient to grasp the penis at the sides (so as not to compress the urethra) with

the non-dominant hand4. If the patient is not circumcised, instruct to gently retract foreskin5. Wash the end of the penis gently with a clean sponge or moist towelettes6. Instruct the patient to hold the penis upwards and outwards from the body at a 90º

angle with thumb and finger on either side of the penis. Instruct patient to grasp catheter about seven cm from tip

7. Identify the urethral meatus and insert well-lubricated catheter and gently advance until urine flow is observed

8. Resistance may be felt when catheter reaches the bladder neck. This may be overcome by encouraging the client to take a deep breath, exhale slowly and relax. Encourage the



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client to void and at the same time applying firm pressure to the catheter (this helps open up the bladder neck)

9. Once the catheter is inserted, hold in place whilst urine flows. The penis and catheter are now in a dependent position. Toward the end, ask the client to cough or strain or apply gentle suprapubic pressure to assist with complete emptying. Gently withdraw the catheter, stopping whenever urine begins to flow again

10. Measure and record amount of urine11. Nurse and patient to wash hands thoroughly and clean up12. Document Inpatient file13. Once the patient is efficient and confident, the procedure may be carried out on the

toilet

Catheter types: Catheters for self-catheterisation do not require a retention balloon and comprise of a

plastic (PVC) tube with two eyes at the tip and a funnel at the other end Generally, the types of PVC catheters used are either coated or non-coated catheters Uncoated catheters require separate lubrication to enter the urethra easily and prevent

soreness and discomfort. Most of these catheters are single use only, though the ‘CLINY’ brand can be cleaned and reused

Coated catheters feature a special coating that means lubrication is not required for insertion, check manufacturers’ instructions as may need water to activate lubricant They are generally well tolerated and more comfortable than non-coated catheters, but also more expensive and single use only

Catheters are available in paediatric, female and male lengths

Catheter supplies:Catheters can be obtained via: Continence Aids Payment Scheme (CAPS) -

o ACT Equipment Scheme Department of Veteran Affairs Rehabilitation Appliance Program (RAP) Medical and Surgical wholesalers Some pharmacies

Catheter care: Catheters should be used according to manufacturer’s instructions, as many catheters

are labelled for ‘single use only’. The symbol for single use only is Where catheters are labelled single use only, ACT Health is obliged to recommend that

a new sterile catheter, in a sealed package within the use by date, be used for each catheterisation

Catheters that are not labelled ‘single use only’ see manufacturers’ guidelines for instructions regarding cleaning and reuse




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Section 6 – Catheter Flushing for Adult Community based patient

ConsiderationsCatheter flushing is a prescribed procedure using a small amount of fluid to maintain patency of a catheter. Manual bladder irrigation or washout involves instilling large amounts of fluid into the bladder, withdrawing fluid for the purpose of removing debris and mucus from the bladder. This procedure should be done under medical supervision and is not suitable to be done in the community

Catheter flushing: May be indicated if a patient has a history of blocked catheter Is an aseptic procedure as the closed urinary drainage system is being broken which is a

high risk factor in the development of a UTI. Is prescribed by a medical practitioner; a treatment order is required stating:

o Normal Saline 9% (is the preferred solution)o Maximum of two x consecutive flushes of 20mls each (no more than 40mls)o Management of catheter if unable to flush o Review date of treatment practice is a short term management option only and the

cause of the blockage should be investigated.o A Urology review must be in place

If a catheter is blocked and has been insitu for >2 weeks it may be replaced without flushing

Catheters that remain obstructed after second flush and catheters that remain patent only with repeated flushing should be replaced and Urology team informed

Nursing Alert: Catheter flush is not considered safe practice following renal transplant, or open bladder surgery: Patients with long term catheters are prone to develop decreased bladder capacity. Caution should be practiced when performing catheter flush in these patients with only the prescribed amount of fluid used and if a second flush is needed, adequate care must be taken to ensure previous fluid volume has been drained out

Equipment: Personal Protective Equipment (PPE) and sterile gloves Disposable catheter pack 50ml catheter tip syringe (to ensure low pressure on the catheter Blue under sheet One pair sterile gloves One alcohol wipe Normal Saline 9% (N/S) solution at body temperature (never use cold

solution to flush catheter as it can induce a bladder spasm



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Procedure:1. Treatment orders are required for a catheter flush 2. Explain the procedure to patient3. Gain verbal consent and document in the nursing notes4. Prepare sterile setup, place N/S in catheter tray and draw up the required amount using

a sterile 50 ml catheter tip syringe5. Place blue sheet under the catheter and drainage bag connection6. Don PPE and sterile gloves7. Place sterile towel under site where urinary catheter and drainage bag are attached8. Clean catheter and drainage bag connection with alcohol wipe (allow to air dry) 9. Disconnect and wrap the drainage bag end in a sterile gauze swab, if possible give to

the patient to hold. Keep connection end sterile.10. Pinch the end of the tubing about an inch from the end of the catheter, and carefully

insert catheter tip syringe 11. Using up to 20mls of N/S flush the catheter to evacuate any debris. Do not withdraw

fluid. If resistance is encountered allow syringe to refill by gravity, discard fluid and repeat flush. (If resistance remains the catheter should be replaced as per catheter management policy)

12. Pinch the end of the tubing about an inch from the end of the catheter, and carefully pull to remove the catheter tip syringe

13. Reconnect catheter to drainage bag without contaminating either connection14. Secure catheter to the abdomen/thigh 15. Evaluate outcome and document in the nursing notes


Section 7 – Trial of Void: Community based patient

A trial of void (TOV) assesses the emptying ability of the bladder by recording voided volumes and measuring the post void residual (See CHHS Continence Assessment and Management Procedure for information on Bladder Scan)

TOV with IDC Pathway: Plan procedure with patient Removal of the catheter is normally between 6:00am (LINK Team) or community nurse

8:00am to 8.30am Drain the bladder and remove catheter Document time of catheter removal and urine volume Advise patient to maintain fluid intake of 200mls/hour capped at 1000mls over four to

five hours (unless contraindicated) Advise the patient to void urethrally when they have the desire to void, measure and

record all voided volumes on the bladder diary

If anytime the patient becomes uncomfortable and is unable to void it is recommended the patient contact the RN (through the Team Leader) and be re-catheterised (as per medical orders) as soon as possible.



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1. The attending nurse to contact the patient for progress call within three hours. (e.g. if catheter is removed by LINK team at 6am call at 9.00am)

2. After the four to five hours from catheter removal , the attending nurse returns - request the patient to void

3. Measure residual bladder volume by bladder scanner 4. Interpretation of TVO: successful or unsuccessful 5. Document outcome Inpatients’ records and inform Medical Officer at Urology Out

Patients Unit

The Medical Officers TVO order is only valid for 24 hrs post removal of catheter. If the patient has a new episode of retention or other related urinary symptoms they should be referred back to the Urologist or treating hospital.

TOV with SPC Pathway:1. Explain the procedure to patient (nurse contact details should be provided)2. If catheter is on free drainage – disconnect drainage bag and insert catheter valve into

catheter3. Advice the patient to maintain fluid intake of 250mls hour during the day (unless

contraindicated) and record on chart provided4. Measure and record each urethrally voided urine. Immediately following urethral

voiding release the valve and drain the bladder5. Measure and record any residual6. If the client is unable to void advice the client to release the valve, drain the bladder,

measure and record volume of urine. Resume timed emptying of the bladder via the valve

7. Advise the client to void urethrally:a. if they experience a strong desire to voidb. if they feel uncomfortable

8. Void volumes and post void catheter residuals are compared to parameters set by medical officer’s guidelines

9. Document outcome in client notes and follow medical instructions for either repeat TOV or removal of catheter

Educational Notes:Bladder emptying occurs as a result of a complex interaction between the sympathetic and parasympathetic nervous system and physical structures of the bladder and urethra. Bladder dysfunction can result from a wide range of conditions, e.g.: Bladder outlet obstruction Neurogenic dysfunction Following childbirth Following some surgical procedures Medications e.g. anticholinergic can contribute to urinary retention Chronic constipation. Rectal examination may be required to assess for constipation



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Ensure that the client is not constipated at time of catheter removal as constipation can contribute to urinary retention and this may result in failed trial of void

Medical authorisation is required prior to TOV: Knowledge of client’s medical history is crucial Knowledge of the client’s usual urine production is recommended to facilitate correct Timing of the TVO e.g. day time urine production maybe significantly reduced in the

elderly A maximum total bladder capacity should not exceed 600mls (void volume + residual) An assessment prior TOV will anticipate the expected 24 hours urine production, e.g.

some elderly clients will have low urine volume throughout the day and large volumes diuresis overnight


Section 8 – Indwelling Urinary Catheter Management: Inpatient and Community

Alert: In patients with an Indwelling Urinary Catheter, it is important to remove any obvious signs of encrustations from around the urethral meatus. To achieve this, the catheter must be washed gently with warm soapy water at the start of the procedure and during the patient’s daily wash/shower. Avoid back and forth movement of the catheter at the urethral meatus as this may cause unnecessary trauma or irritation and may increase the risk of infection or pressure injury. Observe for any signs of pressure areas or trauma at the urethral meatus. Document findings in appropriate patient records

The purpose of this section is to provide clinical care so as to: Maintain a patent urinary drainage system Prevent urinary tract infections Promote patient comfort Provide education for self management of urinary drainage systems

Perineal/ penile care: Inpatient specific procedure:1. Explain procedure to patient and ensure privacy2. Ensure catheter is securely anchored at all times (See Attachment A)3. Routine daily perineal/ penile care is performed Drainage bag must be kept below the

patient’s waist to prevent reflux of urine back up the IDC4. Encourage a two to three litre fluid intake unless contraindicated5. Record output, clarity, colour and odour6. Perform and record urinalysis where indicated7. Observe for Haematuria8. Watch for Haematuria and diuresis in patients with chronic urinary retention9. Adjust the Patient Accountability and Care Plan to indicate IDC insitu and associated

peri-toilets required for hygiene needs



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8.1 Emptying a Urinary Drainage Bag: Inpatient specificA closed urinary drainage system should be maintained. The catheter and tubing should not be disconnected unless absolutely necessary. This applies to: Urinary Drainage Systems Closed Drainage Systems Catheter Valve Drainage Systems

During urinary drainage bag changes, strict aseptic technique is essential to prevent infection. Ensure that there are no dependent loops in the tubing, where possible, to prevent stasis of the urine in the tubing.

Urinary Drainage Bag Change: Inpatient specific: To change a urinary drainage bag in order to maintain a patent urinary drainage system To prevent contamination of the urinary drainage system Promote patient comfort

Equipment: Sterile urinary drainage bag Alcohol swab Clamp Foleys Statlock device Safety glasses or goggles Clean gown and gloves

Procedure:1. Explain procedure to patient and ensure privacy is maintained2. Prepare equipment and the patient3. Don safety glasses 4. Attend hand hygiene before touching patient by either hand washing or using ABHR 5. Don gloves 6. Ensure the drainage system is closed, clamp off all clamps 7. Remove the protective cap from the drainage tube 8. Clamp the catheter above the tubing connector, and clean the catheter tubing junction

with an alcohol swab 9. Disconnect the catheter from the old tubing, being careful not to contaminate the end

of the catheter, and connect the catheter to the new tubing 10. Unclamp the catheter, and establish drainage by securing the tube and drainage bag to

the bed at the appropriate level 11. Leave patient comfortable and dispose of equipment12. Remove gloves and perform hand hygiene after a procedure or body fluid exposure risk

as per the five moments of hand hygiene13. Document the urinary bag change in the patient’s clinical record, FBC and Patient

Accountability and Care Plan



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8.2 Urinary Drainage Bag Management: Community SpecificProcedure:Types: Leg bags are available in a range of capacities: 350ml, 500ml, and 750mI. Tubing on leg bags is available in different lengths, (5cm to 40cm) and can be tailored to

individual patient's requirements (adjustments can be made with extension tubing and connecting pieces).

Management: Urinary drainage bags should be positioned below the level of the bladder to prevent

harmful reflux of urine. Leg bags can be placed on the thigh or calf and secured to the leg using straps

provided, to prevent urethral trauma and damage to the bladder wall. Aseptic technique should be used when attaching urine drainage bags directly to the

catheter. Urinary drainage bags should be emptied when half to two thirds full. Urinary drainage bags should be replaced as per manufacturer's recommendations;

every seven days for regular bags or at the time of catheter change for long life leg bags

Closed Drainage SystemTypes: Closed link system is used to facilitate overnight drainage and is appropriate for use

with indwelling urethral and supra-pubic catheter drainage systems. Closed drainage systems are available in drainage bags with a two litre capacity and

drainage bottles with a four litre capacity. Closed drainage systems are supplemented by the linking of a larger two litre capacity

bag or urinary drainage bottle with a four litre capacity to the outlet of the sterile leg The linked overnight drainage system need not be sterile but must be cleaned daily to

minimise the bacterial growth and extend the life of the bag. Manufacturer's instructions for cleaning should be observed (outlined below)

Catheter Valve SystemA catheter valve may be used in place of a urinary drainage bag, allowing bladder filling and intermittent drainage. Catheter valves are recommended as single use only items and should not be reused. Manufacturer's instruction regarding frequency of change should be observed. Bard catheter valves are changed weekly, Coloplast Simpla catheter valves are changed at the time of catheter change. For clients/ carers to use this system, they need to have: The cognitive ability to learn strategies to prevent infection and/or urinary

complications An understanding of the principles associated with catheter management The ability to independently manage their catheter care, or a carer who is willing to

ensure safe management The awareness of bladder sensation and recognition of bladder fullness, and manual

dexterity to manipulate the outlet tap



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Alert: Catheter valves are inappropriate for clients with detrusor instability, lack of bladder sensation or clients who are confused.

Instructions for patient/ carer regarding changing of drainage bags/valves: Wash hands Disconnect bag/valve from catheter Connect new bag/valve to catheter - avoid touching clean/sterile connections Wiping connection with alcohol wipe is not necessary

Instructions for patient/ carer regarding cleaning of overnight drainage: Rinse with cold water to prevent agglutination of urinary proteins Wash with warm soapy water (dishwashing liquid) Rinse with clean water Allow to drain and dry (by hooking bags onto a wire coat hanger from a bathroom

rail) Night drainage bottles may be left to dry in an upturned position on a clean towel ‘Urosol’, a deodorant and detergent cleansing agent, may be used to dissolve urinary

crystals. Vinegar or bicarbonate of soda may be used as a substitute Use of bleach should be avoided as it may damage rubber and plastic

8.3 Removal of Indwelling Urinary CatheterTo remove an indwelling urinary catheter

Equipment: Clean gloves Safety glasses or goggles Procedural under pad Syringe (10 or 20ml) Clean kidney dish

Procedure:1. Inform the patient and ensure privacy is maintained2. Explain procedure to patient and ensure privacy3. Consent must be gained for all interactions with patients4. Patient identification and allergy band are checked against clinical notes and stickers 5. Prepare equipment 6. Place patient in supine position 7. Check balloon capacity Inpatient’s clinical records 8. Don safety glasses9. Don gloves10. Detach catheter from Foleys Statlock device 11. Attach syringe to catheter balloon lumen and aspirate fluid slowly to deflate 12. Gently pull catheter to check balloon is deflated



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13. Inform patient to breathe slow deep breaths then withdraw the catheter gently 14. Check catheter tip is intact, if not inform medical officer immediately 15. Place catheter in kidney dish16. Remove Foleys Statlock device from patient’s body with Alcohol swabs and clean skin

area as required (See Attachment A)17. Discard equipment and ensure patient is comfortable 18. Document procedure including patient response Inpatient’s clinical record 19. Remove gloves and perform hand hygiene after a procedure or body fluid exposure risk

as per the 5 moments of hand hygiene20. Document the time and date of removal in the patient’s clinical record, Patient

Accountability and Care Plan and FBC.

Alert: Do not cut the balloon lumen, as the balloon may not be fully deflated

Alert: Patients undergoing a trial of void (TOV) must be provided with either a pan or urinal and inform nursing staff once they have voided. Nursing staff must check for residual urine with Bladder scanner, record on fluid balance chart and inform medical officer of results prior to discharge


Section 9 – Trans Urethral Prostatectomy (TURP)

Surgical procedure performed via the urethra to debulk the prostatic adenoma and relieve obstruction. A transurethral resection removes only enlarged prostatic tissue, as in benign Prostatic Hypertrophy (BPH). Normal prostatic tissue and its outer capsule are left intact.

Background: Patient usually attends preadmission clinic (PAC) and is admitted on the day of surgery

(DOSA). Investigations attended in the PAC are as follows:o Baseline observations, including usual Systolic BPo Height, weight and urinalysiso Bloods – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s ECG, CXR, as per hospital

policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeleton

o Micro culture & sensitivity of urine (MSU) one week prior to surgery Ensure UTI therapy has been completed prior to surgery as per recommendations in the

latest version of the Therapeutic Guidelines: Antibiotic, Prophylaxis: urological surgery Consent completed reflecting the Consent to Treatment Procedure Check reason for admission Inpatient’s clinical record and length of stay as per Request

for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge Planning

Alert: Patients on anticoagulation therapy require further medical investigation, advice and support and nursing observation



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Admission Explain the process and purpose of the Patient Care and Accountability Plan Patient identification and allergy band are checked against clinical notes/ stickers Document findings from Patient Care and Accountability Plan (PCAP) including Risk

Assessments and management plans in clinical records, provide education and CHHS information booklet to patient and family regarding Patient’s Pressure Injury, fall and VTE Risks and management. Measure and fit patient with short leg TED stockings

Attend to height, weight and ward urinalysis and document in clinical records, Patient Care and Accountability Plan and Observation Chart

Obtain baseline observations, usual systolic BP and MEWS Score Provide patient with verbal and inform Pharmacist of patient’s admission and request

Medication Reconciliation is completed Ensure that patient is informed and educated in relation to fasting guidelines as per

guidelines or specific medical orders. Document care provided in clinical record. Inform Food Services via DIETPas

Commence discharge planning Educate patient in deep breathing and coughing exercises, and leg exercises Check consent form completed Bowel preparation if ordered

Preoperative: Attend to all documentation including Pre-op Checklist Measure and fit knee length Anti-embolic stockings and ensure documentation on

Medication Chart Ensure patient has early morning shower and dressed in theatre gown Usual medications are given at 0600

Receiving the patient from PACU: Don PPE as required Patient identification and allergy band are checked against clinical notes/ stickers.

Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct Procedure

Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)

If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review

Ensure the oxygen is attached to wall oxygen outlet Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by

ward staff to ensure correct flow rate) Ensure equipment has been plugged in and cords are positioned safely under bed or off

the floor Clarify the operative procedure performed. All actions to reflect Correct Patient,

Correct Site, Correct Procedure



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Discussion of patient medical history and impacting co morbidities should occur whilst ensuring privacy

The PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of Handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:

Review of post operative vital signs, including any interventions required for stabilisation

Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on Fluid Balance Chart)

Ensure that continuous bladder irrigation (CBI) and indwelling urethral catheter (IDC) are patent – only 0.9% Sodium Chloride 2000ml solution to be used as irrigant for CBI

Ensure Bladder Irrigation Chart is maintained- balances to be recorded on FBC Maintain accurate fluid balance chart for input and output, ensuring CBI fluid included,

and describe the type of output, for example, claret, rose or straw). IDC to be anchored with Statlock unless the surgeon specifically documents request for

Statlock not to used as per Urinary Catheter Management Procedure Ensure Indwelling Catheter is secured with appropriate device, e.g., Statlock Ensure traction is maintained on IDC to provide maximum pressure on the prostatic bed

following surgery. This traction helps to control bleeding and decreases the risk of bladder neck damage. Check post-operative orders regarding the use of traction and the length of time traction is to be applied, usually only for the first 24 hours

If clotting occurs, nurse to initiate manual irrigation using aseptic technique Urine output is to be recorded hourly for 48 hours postoperatively Ensure all output is documented on Fluid Balance Chart Medications administered and documented on medication chart review Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive) Observe the Catheter site for ooze or blood loss. Perform and document a full set of Vital signs and Modified Early Warning Score

(MEWS) including:o Respiratory Rate (RR)o Oxygen Saturationso Temperatureo Blood Pressure (BP)o Pulse (P)o Level of Consciousness (LOC)o Urine Output (UOP)

All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. Continuous Bladder Irrigation etc). Ensure all of the above interventions are completed prior to PACU nurse leaving ward area and patient care is accepted.

Complete Patient Care and Accountability Plan and action appropriately



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Record in the patient's clinical record all post-operative nursing care provided and the patients response

Administer analgesia as per Medical Practitioner’s orders for pain and/ or spasms Administer IV antiemetic for nausea as per Medical Practitioner’s orders Offer and attend to post-operative bed bath Dress in personal nightwear if desired Offer and attend to mouth care, replacing dentures if applicable Position the patient in accordance to post operative instructions Ensure that the call bell is within reach and Lower bed and bed rails to maintain patient safety if required. Note: where patients are

disorientated consider hi low bed Educate and encourage deep breathing and leg exercises Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed

(off affected side) Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in

the patient’s clinical record and escalate if required according to MEWS and MET criteria

Record in the patient's clinical record all post-operative nursing care provided

Post operative Day 1: Attend to general observations fourth hourly Review by Medical Officer Medical Officer will cease CBI depending on consistency and type of urine output General post-operative diet Cease IV fluids if oral intake is adequate Continue oral analgesia as required Patient may shower if stable, or assist sponge Encourage patient to sit out of bed for a few hours Continue discharge planning – contact Discharge Liaison Nurse (DLN) if appropriate Continue patient education Commence ambulation (ensure patient has a functioning IV pole with tongue depressor

taped to the pole for hanging the urinary bag) Continue deep breathing and coughing, and leg exercises Attend to blood specimens – FBC and UEC’s as ordered by Medical Officer Ensure anti embolic stockings are in situ, correctly measured and fitted with no creases Request Medical Officer to commence Discharge summary document in preparation for

discharge

Post operative Day 2: Continue fourth hourly observations IDC removed at 2400 or 0600 hours or otherwise ordered by Medical Officer CBI ceased if not attended to during day one Trial of void (TOV) – document when patient voids – amount, consistency, pain, colour

etc., and attend bladder scan post void Review by Medical Officer after three consecutive bladder scans Patient to attend to self careDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 34 of 69


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Complete patient education prior to discharge and provide written instructions (Prostatectomy package)

Ensure patient has received adequate education, and is self caring with leg bag should discharge occurs with IDC insitu

Discharge: Advise patient to organise own follow-up appointment with Visiting Medical Officer

(VMO) if seeing Urologist privately Follow up in Outpatient Department Clinic (OPD) is usually in 4 weeks. Notification to

OPD of patient’s details is completed by RMO completing the Discharge summary Resident Medical Officer (RMO) to provide patient with Cystogram appointment details

prior to discharge Discharge with analgesia if deemed necessary by Medical Officer Educate the patient regarding the VMO’s post-operative instructions – no driving, heavy

lifting or sexual intercourse etc, until reviewed at follow-up appointment


Section 10 – Bladder Irrigation

10.1 Continuous Bladder IrrigationContinuous Bladder Irrigation (CBI) is the continuous flushing and draining of the bladder designed to prevent the formation and retention of blood clots following transurethral resection of the prostate or where blood clot retention of the bladder occurs

To instil continuous bladder irrigation via a three-way IDC for the purpose of: Providing bladder washout to remove any residual urine and/or bladder sediment to

ensure IDC patency Removing blood clots that may develop post bladder, kidney or prostate surgery Ensuring debris removal from an infected or diseased bladder Introducing medicated irrigation to soothe an irritated bladder so as to promote

healing, and/ or to treat disease

A medical officer must prescribe continuous bladder irrigation (CBI) and a silicone three way-indwelling catheter (22F or 24F) must be inserted prior to the commencement of continuous bladder irrigation (CBI)

Equipment: Dressing Trolley Sterile dish x two Plain stickers to label consecutive irrigation bags Foleys Statlock Device-Not for Dr Chan’s patients Jugs x two 50ml Bladder Syringes x two Y-type CBI tubing (closed system where available) Three-way indwelling catheter



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Gloves: two pairs x sterile, one box clean gloves 500ml bottle of 0.9% Sodium Chloride (at room temperature) 2000mls 0.9% Sodium Chloride irrigation fluid bags x four or five bags (at room

temperature) Procedure under pads (small and large) e.g. Smart Barrier Touch Dry absorbent pad Safety goggles or shield and gown Portable, adjustable IV pole Cytotoxic Spill Kit where EPIRUBICIN or where patient is receiving Cytotoxic treatment Cytotoxic Bin where Cytotoxic precautions are required

Procedure: Check patients clinical record for any medical orders Maintain privacy and explain the procedure to the patient Place patient supine and ensure comfort and dignity Where Chemotherapy precautions are actioned, don non-permeable gown, and

gloves. Please refer to Chemotherapy Care of the Adult Patient eviQ Clinical Procedure

Don safety goggles or eye shield and gown Place procedure under pad beneath patient Place small procedure under pad across patients thighs to prevent fluid leaks whilst

connecting the irrigation fluid Commence irrigation and maintain a steady flow rate

Alert: Ensure that the irrigation is not running to fast or too slow. The irrigation rate is dependent on the urine colour/ opacity. Refer to medical orders for any contraindications

Hang irrigating fluid bags on portable IV pole, 60cms above the level of the bladder Label and number each bag when commencing Maintain strict Bladder Irrigation Chart and Urine Output records. Prior to commencing next irrigation fluid bag, completely empty the current IV irrigation

fluid bag into the urinary drainage bag so as to calculate and record the urine output. Empty the urinary drainage bag. Subtract two litre irrigation fluids from amount of fluid in the urinary drainage bag to calculate urine output

Do not rest urinary drainage bag on the floor at any time Record the number of irrigation bags used and urine output on the bladder irrigation

chart and urine output on fluid balance chart at each bag change Ensure that the patient’s fluid input and urine output is measured and documented

accurately Adjust the Patient Accountability and Care Plan to indicate Bladder Irrigation Monitor the patient with fourth hourly general observations by nursing staff whilst the

indwelling catheter is insitu for signs of sepsis Regular and frequent Perineal toilets must attended whilst indwelling catheter is in situ-

the frequency of which will be documented in the Patient Accountability and Care Plan In the event of a genitourinary tract infection, infection control will collate and present

data for reporting purposes



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Alert: All patients with an Indwelling Catheter insitu are required to have a CHHS Insertion of Urinary Catheter in their clinical records (See Attachment B). If the input and output balance is negative notify the CNC/TL and medical officer to review the patient immediately

Epirubicin Alert: Clinical Handovers must reflect that Chemotherapy has been administered and cytotoxic precautions will subsequently be required for seven days post administration. Where Chemotherapy precautions are actioned, dispose of urinary catheter bags with urinary output directly into the Cytotoxic bin.

10.2 Manual Bladder IrrigationTo instil manual bladder irrigation via a three-way IDC for the purpose of: Removing blood clots or blockage that may develop to maintain patency of an IDC

Equipment: Dressing Trolley Sterile dish x two Jugs x two 50ml Bladder Syringes x two Gloves: two pairs of sterile, one box clean gloves 500ml bottle of 0.9% Sodium Chloride (at room temperature) Procedure under pads (small and large) e.g. Kylie Where Chemotherapy precautions are actioned, don appropriate PPE Safety glasses, goggles or shield General waste receptacle Clinical waste receptacle

Procedure: Maintain privacy and explain the procedure to the patient Provide adequate and appropriate analgesia Place patient supine and ensure comfort Where Chemotherapy precautions are actioned, don appropriate PPE Don personal protective equipment (PPE) includes safety goggles or shield and gown Place procedure under pad beneath patient Place small procedure under pad across patients thighs to prevent fluid leaks whilst

connecting the irrigation fluid Prepare Sterile dish with approx 200mls 0.9% Sodium Chloride or open 500ml bottle of

0.9% Sodium Chloride Have jug ready at the IDC site Open syringe Turn off irrigation Disconnect tubing from Statlock device if present Attend hand hygiene by either washing or using ABHR and don sterile gloves Using aseptic technique, detach the drainage bag from the IDC and attach syringe filled

with 0.9% Sodium Chloride and flush into bladderDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 37 of 69


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Apply suction to the IDC to clear clots from the IDC Disconnect syringe and fill with a further 40mls of 0.9% Sodium Chloride, reconnect to

IDC and flush bladder Continue this procedure until return is clear and free of clots and/ or debris Where closed system is in use, do not disconnect indwelling catheter to manually

irrigate Clamp the tubing below the bulb Firmly squeeze the bulb to commence manual irrigation Repeat process until clear urine is flowing at a steady rate If no urine return after manually irrigating IDC, contact medical officer Repeat the above steps until urine is flowing at a steady rate Reconnect the IDC to the drainage bag and reset the irrigation fluid Secure tubing with appropriately placed Statlock device (Attachment A) to prevent

movement and urethral traction unless contraindicated (as per Dr Chan’s orders) Attend Perineal toilet-The patient will have regular and frequent Perineal toilets

attended whilst indwelling catheter is in situ, the frequency of which will be documented in the Nursing Care Plan

Discard equipment Where Chemotherapy precautions are actioned, dispose of urinary output directly

into the Cytotoxic bin Leave the patient comfortable with call bell within reach

Document in patients clinical record: The patient's response to the procedure The urine output on the Bladder Irrigation Chart & fluid balance chart The amount, size and frequency of irrigated clot The patient's indwelling catheter is patent with no complication during and following

irrigation The urinary drainage system is maintained as a sterile drainage system The patient's indwelling catheter is irrigated as prescribed by the medical officer

according to the patient's clinical management needs with minimal discomfort and no complications

Intake and output are balanced The patient is to be monitored with fourth hourly general observations by nursing staff

whilst the indwelling catheter is insitu for signs of sepsis The patient is to be monitored for signs of suprapubic distension or discomfort

indicating fluid retention The patient’s fluid input and urine output is measured and documented accurately Adjust the Patient Accountability and Care Plan to indicate Bladder Irrigation In the event of a genitourinary tract infection, infection control will collate and present

data for reporting purposes


Section 11 – Pre and Post Operative Management of patients undergoing a Nephrectomy



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To provide guidelines for the pre and post operative management of patients undergoing a Nephrectomy, i.e., surgical removal of a kidney

Alerts: On transfer to ward, all observations should be attended in the presence of the PACU

nurse to ensure any abnormalities may be identified and managed as soon as possible. If the patient meets the MET criteria, activation of MET should occur.

A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post transfer from ICU (Refer to ‘Adult Vital Signs and Early Warning Scores’).

If respirations are twelve (12) or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record.

Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.

Determine if the patient is currently on medication and enquire if the patient has brought any medication to the hospital. If possible, family members must take all personal medications home after the sighting by the medical officer. If this is not possible, place the medications in a patient’s own medication green plastic bag, label and retain in the patient’s own medication cupboard until the patient is discharged- Patients Own Medication- Management Procedure



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On admission:Equipment: Alcohol based hand rub (ABHR) Patient clinical notes and observation charts Personal protective equipment (PPE) including safety goggles or shield and clean gloves Stethoscope Watch with a second hand Sphygmomanometer (blood pressure cuff) Oxygen saturation monitor Thermometer Intravenous (IV) pole – mobile Emesis bag Bedside emergency equipment

Procedure: Patient usually attends preadmission clinic (PAC) and is admitted the day before surgery

or at times, on the day of surgery (DOSA). Investigations attended in the PAC are as follows

Bloods – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s, and serum ferreting assessment.

ECG, CXR, as per hospital policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeleton. Micro urine (MSU)

Consent completed reflecting the Consent to Treatment Procedure Check reason for admission Inpatient’s clinical record and length of stay as per Request

for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge Planning.

Obtain verbal consent Explain the process and purpose of the Patient Accountability and Care Plan Patient identification and allergy band are checked against clinical notes/ stickers Document findings from patient Admission including Risk Assessments and

management plans in clinical records, provide education and pamphlets to patient and family

Attend to height, weight and ward urinalysis and document in clinical records, care plan and Observation Chart

Obtain baseline observations, Usual systolic BP and MEWS Score Provide patient with verbal and CHHS information booklet regarding Patient’s Pressure

Injury, Falls and VTE Risks and management. Document Inpatient Progress notes findings and actions

Inform Pharmacist of patient’s admission and request Medication Reconciliation is completed

Day before surgery, clear fluids until mid-night. Fast from midnight. Inform Food Services via DIETPas

Bowel preparation if ordered

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Measure and fit knee length Anti-embolic stockings and ensure documentation on Medication Chart

Ensure patient has early morning shower and dressed in theatre gown Usual medications are given at 0600Hrs

Before the patient is transferred from PACU/ICU to the ward: PACU/ICU Nursing staff to ensure: Receiving ward is aware of and has accepted patients admission Patient oxygen delivery system has the patients identification label on it Ward Nursing Staff to ensure:

o All emergency equipment is functioning and available, including oxygen and suction

Receiving patient from PACU/ICUEquipment: Don PPE as required Patient identification and allergy band are checked against clinical notes/stickers.

Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct Procedure

Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)

If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review

Ensure the oxygen is attached to wall oxygen outlet Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by

ward staff to ensure correct flow rate) Ensure equipment has been plugged in and cords are positioned safely under bed or off

the floor Transfer of care must reflect Clinical Handover Procedure Clarify the operative procedure performed. All actions to reflect Correct Patient,

Correct Site, Correct Procedure Discussion of patient medical history and impacting co morbidities should occur whilst

ensuring privacy The PACU nurse hands over verbally to the ward nurse at the patient bed side. At the

completion of handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:

Review of post operative vital signs, including any interventions required for stabilisation

Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on fluid balance chart)

Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, etc (ensure hand hygiene is attended after contact with these devices)

IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management Procedure

Urine output is to be recorded hourly for 48 hours postoperatively Doc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 41 of 69


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Check any drains insitu e.g. wound drains and output (ensure hand hygiene is attended after contact with these devices). Drainage bags to be changed and output documented on FBC and Inpatient progress notes daily at midnight

Check output of nasogastric tube for drainage or feeding. Ensure orders are clearly documented in the notes as to purpose, use and position of tube (ensure hand hygiene is attended when in contact with these devices)

Ensure all output is documented on Fluid Balance Chart Medications administered and documented on medication chart review Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive) Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if

any), reinforce wound if required. Do not remove theatre dressing Any pain management devices including Patient Controlled Analgesia (PCA), Epidurals,

Pain Busters, Continuous Opioid infusions, regional local anaesthetic infusions, etc and single shot analgesia technique without pain management device i.e. single shot local anaesthetic block or intrathecal/epidural morphine single dose administration for post operative pain relief (refer to appropriate Pain Management Unit procedures)

Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS)

All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ epidural morphine etc)

Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted

Complete Patient Care and Accountability Plan and action appropriately Record in the patient's clinical record all post-operative nursing care provided and the

patients response Offer and attend to bed bath Dress in personal nightwear if desired Offer and attend to mouth care, replacing dentures if applicable Position the patient in accordance to post operative instructions Ensure that the call bell is within reach and Lower bed and bed rails to maintain patient safety if required. Note: where patients are

disorientated consider hi low bed Educate and encourage deep breathing and leg exercises Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed

(off affected side) Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in

the Patient clinical record and escalate if required according to MEWS and MET criteria Record in the patient's clinical record all post-operative nursing care provided and the

patients response

Ward management:Ward Nursing Staff: Check patients clinical record for any medical orders Ensure Privacy Explain the process and purpose of the dressing changeDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 42 of 69


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Obtain verbal consent for any interventions

General/ Epidural/ Spinal Anaesthetic: Perform and document a Full set of Vital Signs and Modified Early Warning Score (MEWS): On return to ward, then Half hourly for two hours (30mins x two hours), if MEWS ≥ 4 continue half hourly (See

‘Adult Vital Signs and Early Warning Score SOP’) (excluding Day Surgery Unit) When MEWS <4, hourly for four (4) hours (60 mins x four hours), then Fourth hourly for a minimum of 48 hours Where an Epidural is in situ patient assessment is performed Following the guidelines of

the Epidural (Adult and Paediatric ) Chart and Insert Documents and Procedure The Patient Accountability and Care Plan must be commenced within the postoperative

period Risk Assessments for Pressure Injury, Falls, VTE, Mobility/Manual Handling and

Discharge must be completed, actioned and documented in the patient progress notes within the postoperative period as reflected in the Patient Accountability and Care Planning Procedure

Ward Management Day 1: Check patient clinical records for medical orders Remains NBM until reviewed by medical team, if dietary status changed, inform Food

Services via DIETpas and update bed card Commence diet and fluids as ordered (continue to monitor tolerance of diet) Maintain IV Fluids Maintain hourly urine output measures Document drain output and change drainage bag at midnight Maintain strict Fluid Balance Chart Ensure second hourly pressure area care and skin integrity checks are offered and

performed Maintain fourth hourly vital signs Maintain observations as required with Epidural/ PCA Assist patient with sponge in bed Attend perineal/ penile care Observe the wound dressing for ooze or blood loss fourth hourly Sit patient out of bed Reapply TEDs Notify physiotherapist Continue discharge planning with Discharge Liaison Nurse (DLN) and allied health team

as appropriate

Ward Management Day 2: Check patient clinical records for medical orders May progress to Free Fluids to Light Diet if passed flatus and approved by medical staff Inform Food Services of changes via DIETpas and update Bed Card Maintain fourth hourly vital signs



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Maintain observations as required with Epidural/PCA- may be removed if tolerating fluids at the discretion of the APS. Motor Block observations maintained for 24 hours post removal of Epidural

Assist patient with shower Attend Perineal/ penile care Observe the wound for swelling, ooze and/ or redness fourth hourly. Dress as per

medical orders Encourage patient mobilisation with stand by assistance Continue discharge planning Document drain output and change drainage bag at midnight Consecutive post operative days continue as Day 2, drains will be shortened and/ or

removed at the discretion of medical officer. Patient usually discharged on day six to eight depending on progress

Discharge planning: Ensure Medical Officer (MO) has documented discharge Inpatient clinical record Ensure discharge medications are scanned to pharmacy Inform patient of usual discharge procedure, i.e., transfer to Discharge Lounge by 1000

on the day of discharge CNC to refer to the Discharge Liaison Nurse for wound care and/or staple removal at

daily MDT meeting


Section 12 – Management of patients undergoing a Percutaneous Nephrolithotomy

To provide guidelines for the pre and post operative management of patients undergoing a Nephrolithotomy, i.e., surgical removal of a kidney stones via a percutaneous tract using laparoscopic equipment

On transfer to ward, all observations should be attended in the presence of the PACU nurse to ensure any abnormalities may be identified and managed as soon as possible. If the patient meets the MET criteria, activation of MET should occur.

A full set of Vital signs includes Respiratory Rate, Oxygen Saturations, Temperature, Blood Pressure, Pulse, Level of Consciousness and Urine Output. A full set of Vital Signs must be performed every time vital signs are taken in the post transfer from ICU (Refer to ‘Adult Vital Signs and Early Warning Scores’).

If respirations are twelve or less per minute or if the patient complains of headache following spinal or epidural anaesthetic within the first 24 hours, notify the Anaesthetist or Anaesthetic Registrar immediately and document in the patient’s clinical record. Please check surgeon’s preference regarding placement of Statlock, securement of drains and post operative pain management.



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Nephrostomy drainage catheter Do not instil more than 10 ml of Sodium Chloride 0.9% at one time (See NSW Agency for

Clinical Innovation. ACI Urology Network 2012, p. 8). Flush the tube very slowly. Do not apply force as over distension of the renal pelvis

could cause renal tissue damage.

On admission:Equipment: Alcohol based hand rub (ABHR) Patient clinical notes and observation charts Personal protective equipment (PPE) including safety goggles or shield and clean gloves Stethoscope Watch with a second hand Sphygmomanometer (blood pressure cuff) Oxygen saturation monitor Thermometer Intravenous (IV) pole – mobile Emesis bag Bedside emergency equipment

Procedure: 1. Patient usually attends preadmission clinic (PAC) and is admitted the on the day of

surgery (DOSA). Investigations attended in the PAC are as follows2. Bloods – UEC, FBC, COAG’s, X – MATCH (two to four units) 3. ECG, CXR, KUB (kidneys, Ureters and Bladder-confirm position of calculi) X-ray as

required4. Additional bloods, CT, MRI as required5. Micro urine (MSU)6. Consent completed reflecting the Consent to Treatment Procedure7. Check reason for admission Inpatient’s clinical record and length of stay as per Request

for Admission form to predict estimated date of discharge (EDD/PDD), i.e., commencement of Discharge Planning.

8. Explain the process and purpose of the Patient Accountability and Care Plan9. Patient identification and allergy band are checked against clinical notes/ stickers10. Document findings from patient Admission including Risk Assessments and

management plans in clinical records, provide education and pamphlets to patient and family

11. Attend to height, weight and ward urinalysis and document in clinical records, care plan and Observation Chart

12. Obtain baseline observations, Usual systolic BP and MEWS Score13. Provide patient with verbal and CHHS information booklet regarding Patient’s Pressure

Injury, Falls and VTE Risks and management. Document Inpatient Progress notes findings and actions

14. Inform Pharmacist of patient’s admission and request Medication Reconciliation is completed

15. Day before surgery, Nil by Mouth from Midnight or as per Urologist’s ordersDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 45 of 69


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Preoperative: Attend to all documentation including Pre-op Checklist Measure and fit knee length Anti-embolic stockings and ensure documentation on

Medication Chart Ensure patient has early morning shower and dressed in theatre gown Usual medications are given at 0600

Before the patient is transferred from PACU to the ward:PACU Nursing staff to ensure: Receiving ward is aware of and has accepted patients admission Patient oxygen delivery system has the patients identification label on it

Ward Nursing Staff to ensure: Patient bed area has been cleaned All emergency equipment is functioning and available, including oxygen and suction

Receiving patient from PACU:1. Don PPE as required2. Patient identification and allergy band are checked against clinical notes/stickers.

Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Patient Identification and Procedure Matching Policy and Procedure

3. Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)

4. If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review

5. Ensure the oxygen is attached to wall oxygen outlet6. Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by

ward staff to ensure correct flow rate)7. Ensure equipment has been plugged in and cords are positioned safely under bed or off

the floor8. Transfer of care must reflect Clinical Handover Procedure9. Clarify the operative procedure performed. All actions to reflect Procedure Matching

Policy and Procedure 10. Discussion of patient medical history and impacting co morbidities should occur whilst

ensuring privacy11. The PACU nurse hands over verbally to the ward nurse at the patient bed side. At the

completion of Handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:

12. Review of post operative vital signs, including any interventions required for stabilisation

13. Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on fluid balance chart)



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14. Urinary drainage devices e.g. Indwelling Catheters (IDC), Urostomies, Nephrostomy tubes etc (ensure hand hygiene is attended after contact with these devices)

15. IDC to be anchored with Statlock unless the surgeon specifically requests Statlock not to used as per Urinary Catheter Management Procedure

16. Maintain Nephrostomy tube patency as per Drain Management Procedure17. Nephrostomy to be anchored with Statlock device18. Urine output is to be recorded hourly for 48 hours postoperatively 19. Check flank for swelling, bruising or ooze and ensure adequate pain relief20. Check any drains insitu e.g. wound drains and output (ensure hand hygiene is attended

after contact with these devices). Drainage bags to be changed and output documented on FBC and Inpatient progress notes daily at midnight

21. Check output of nasogastric tube for drainage or feeding. Ensure orders are clearly documented in the notes as to purpose, use and position of tube

22. Ensure all output is documented on Fluid Balance Chart 23. Medications administered and documented on medication chart review24. Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive)25. Observe the wound dressing for ooze or blood loss. Note colour, amount and odour (if

any), reinforce wound if required. Do not remove theatre dressing26. Pain management devices such as Patient Controlled Analgesia (PCA), to be managed as

per appropriate PCA procedures 27. All observations are to be recorded on the Modified Early Warning Score (MEWS) charts

and appropriate adjunct charts (i.e. neurovascular, neurological, PCA, Epidural, Intrathecal/ epidural morphine etc)Ensure all of the above are completed prior to PACU nurse leaving ward area and patient care is accepted

28. Complete Patient Care and Accountability Plan and action appropriately 29. Record in the patient's clinical record all post-operative nursing care provided and the

patients response30. Offer and attend to bed bath 31. Dress in personal nightwear if desired32. Offer and attend to mouth care, replacing dentures if applicable33. Position the patient in accordance to post operative instructions34. Ensure that the call bell is within reach and 35. Lower bed and bed rails to maintain patient safety if required. Note: where patients are

disorientated consider hi low bed36. Educate and encourage deep breathing and leg exercises37. Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed

(off affected side)38. Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in

the patient clinical record and escalate if required according to MEWS and MET criteria39. Record in the patient's clinical record all post-operative nursing care provided and the

patients response

Ward Nursing Staff: Check patients clinical record for any medical orders Explain the process and purpose of the dressing change Obtain verbal consent for any interventionsDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 47 of 69


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General/Epidural/Spinal AnaestheticPerform and document a Full set of Vital Signs and Modified Early Warning Score (MEWS): On return to ward, then Half hourly for two hours (30mins x two hours), if MEWS ≥4 continue half hourly (Refer

to Vital Signs and Early Warning Score Procedure) When MEWS <4, hourly for four hours (60 mins x four hours), then Fourth hourly for a minimum of 48 hours The Patient Accountability and Care Plan must be commenced within the postoperative

period Risk Assessments for Pressure Injury, Falls, VTE, Mobility/Manual Handling and

Discharge must be completed, actioned and documented in the patient progress notes within the postoperative period as reflected in the Patient Accountability and Care Planning Procedure

Ward Management Day 1: Check patient clinical records for medical orders Update diet when reviewed by medical team, if dietary status changed, inform Food

Services via DIETpas and update Bed card Monitor tolerance of diet Maintain IV Fluids Maintain hourly urine output measures Document drain output and change drainage bag at midnight Maintain strict Fluid Balance Chart Ensure second hourly pressure area care and skin integrity checks are offered and

performed Maintain fourth hourly vital signs Maintain observations as required with PCA Assist patient with shower Attend perineal/ penile care Observe the wound dressing for ooze or blood loss fourth hourly Sit patient out of bed Reapply TEDs Notify physiotherapist Continue discharge planning with Discharge Liaison Nurse (DLN) and allied health team

as appropriate

Ward Management Day 2: Check patient clinical records for medical orders Monitor tolerance to diet and progression to full diet Inform Food Services of changes via DIETpas and update Bed Card Maintain fourth hourly vital signs Maintain observations as required with PCA- may be removed if tolerating fluids at the

discretion of the APS. Assist patient with shower Attend Perineal/ penile careDoc Number Version Issued Review Date Area Responsible PageCHHS16/008 1 01/02/2016 01/02/2021 SOH 48 of 69


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Observe the wound for swelling, ooze and/ or redness fourth hourly. Dress as per medical orders and as per Drain Management Procedure

Encourage patient mobilisation with stand by assistance Continue discharge planning Document drain output-amount, consistency, colour, odour etc Change drainage bag at midnight Medical Officer may order a Nephrostogram to confirm the patency of the urinary tract

post-operatively Depending on Nephrostogram results the Medical Officer may request the

Nephrostomy tube to be clamped for six to eight hours prior to removal When Nephrostomy tube clamped-observe patient for pyrexia and flank pain Contact the Medical Officer if either occur

Consecutive post operative days continue as Day 2, drains will be removed at the discretion of medical officer

Discharge planning: Ensure MO has documented discharge Inpatient clinical record Ensure discharge medications are scanned to pharmacy Inform patient of usual discharge procedure, i.e. transfer to Discharge Lounge by 1000

on the day of discharge CNC to refer to the Discharge Liaison Nurse for wound care of Nephrostomy tube site

care post removal of Nephrostomy tube at daily MDT meeting Follow-up appointment is usually four to six weeks in the Outpatient Urology Clinic or in

the VMO’s private rooms, please clarify this before patient is discharged Educate the patient regarding the VMO’s post-operative instructions – no strenuous

activity for four to six weeks until reviewed. Ensure adequate fluid intake i.e. two litres per day


Section 13 – Management of patients admitted with Pre-Existing Continent Urinary Reservoirs/Neobladder during routine hospital admissions

PurposeTo provide information on the clinical management of patients who are admitted into Canberra Hospital with a pre existing Continent Urinary Reservoir / Neobladder, to ensure care is consistent for each individual patient.

A Continent Urinary Reservoir, also known as a Neobladder, is a procedure in which a false bladder has been developed from a section of the patients’ bowel. The bladder is continent due to the positioning of the opening in the abdominal wall. The patient is required to self catheterise several times each day in order to release the stored urine. Continent Urinary Reservoirs / Neobladder can also be known as Studor, Kock’s, Indianan or a Charleston Pouch.



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Procedures:Patients who are admitted to Canberra Hospital with a pre-existing Continent Urinary Reservoir require individualised management of the reservoir for the duration of the inpatient admission.

On admission of the patient it will be necessary to: Obtain a review by the Surgical Urology Registrar to initiate and formalise the treatment

plan of the individual reservoir Inform the Stomal Therapist of the patients admission

Senior nursing staff from the Urology Ward are available 24 hours per day to provide further advice and guidance relating to Continent Urinary Reservoirs if required.


Implementation

All staff working in the Urology ward to read and sign Procedure Register. CNC and CDN to monitor Register to ensure all staff are aware of appropriate care for patients undergoing Urology procedures every 12 months.

Staff will be told where to access this Procedure as part of their Ward Orientation




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Related Policies, Procedures, Guidelines and Legislation

Policies and ProceduresPerineal/ Penile Care SOPHealthcare Associated Infections Procedure Health Waste Management PolicyHealth Nursing and Midwifery Continuing Competence PolicyPatient Identification-Surgical Safety Checklist SOPPatient Identification and Procedure Matching procedureHealth Consent and Treatment Policy Health Consent and Treatment ProcedureWound Management ProcedurePost-operative Handover and Observations-Adult Patients (first 24 hours) SOPEpirubicin Chemotherapy use in Urological Surgery SOPChemotherapy Care of the Adult Patient eviQ

LegislationHealth Practitioner Regulation National Law (ACT) Act 2010Health Records (Privacy and Access) Act 1997Health Regulation (Maternal Health Information) Act 1998 Human Rights Act 2004Privacy Act 1988Guardianship and Management of Property Act 1991 Medical Treatment (Health Directions) Act 2006 Powers of Attorney Act 2006

Back to Table of ContentsSearch Terms

Urology, catheter, urine, urinary reservoirs, neo-bladder, Percutaneous nephrolithotomy, nephrectomy, indwelling catheter, suprapubic, catheterisation, void, Urinary drainage bag, TURP, transurethral prostatectomy, bladder irrigation, IDC, SPC,


References

The Joanna Briggs Institute, 2008, Canberra Hospital Procedure Manual 2008, 27 July 2006, pp 207-208

GMCT Urology Network-Nursing, Catheters (Male and SPC), September 2008, p 20Prevention of Indwelling Catheter Associated Urinary Tract Infections, Dailly, Sue, Nursing Older People 23.2, March 2011



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Bard StatLock® Universal Plus Stabilization Device. https://www.bardaccess.com/statlock-other-universal-plus.php Accessed 13 November 2013.

NSW Agency for Clinical Innovation. ACI Urology Network – Nursing. Nursing Management of Patients with Nephrostomy Tubes. Guidelines and Patient Information Templates. 2012.Siddiq M and Darouiche R. Infectious complications associated with percutaneousnephrostomy catheters: Do we know enough? International Journal of Artificial Organs. 2012;35(10):898-907.

The Australian Council on Healthcare Standards (ACHS). [Homepage of ACHS] [Online] – last updated 19 April 2011. Available: www.achs.org.au/ [6 July 2011].

NS485 Madeo M, Roodhouse AJ (2009) Reducing the risks associated with urinary catheters.Nursing Standard. 23, 29, 47-55. Date of acceptance: February 11 2009.

Tucker, S.M., Canobbio, M.M., Paquette, E.V. and Wells M.J. (2000) Patient Care Standards: Collaborative Planning and Nursing Interventions, 7th Edition

Monahan, Mosby (2010) Manual of Medical-Surgical Nursing, 7th Edition

Le, V. The Joanna Briggs Institute (2011) Bladder Irrigation Post Transurethral Resection of the Prostate

Mikel L. Gray, PhD, Securing the Indwelling Catheter- American Journal of Nursing, December 2008Australian Infection Control Association-Position Statement, “Preventing Catheter Associated Infections Inpatients”, November 2010

Timby, B. Fundamentals of Nursing: Nursing Skills and Concepts. 9th ed Lippincott, Williams and Wilkins. 2008

Jones, S. et al Care of urinary catheters and drainage systems. Nursing Times; 103:42. 2007Getliffe K & Dolman M, Promoting Continence, A Clinical Research Resource, Bailliere.2006

NHS Quality Improvement Scotland, Best Practice Statement June, Urinary Catheterisation & Catheter Care.2007

National Institute for Clinical Excellence June 2003, "Infectious Control: Prevention of healthcare-associated infection in primary and community care" Standard 1.2.5.1, 1.2.5.7, 1.2.5.3, Clinical guideline 2,

Guidelines for prevention of Catheter –Associated Urinary Tract Infections. CAUTI Guidelines. 2009



http://www.achs.org.au/

https://www.bardaccess.com/statlock-other-universal-plus.php

https://www.bardaccess.com/statlock-other-universal-plus.php

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Wasson, D., (1998-2002), Perspectives–Transurethral Resection of the Prostate, http: 11perspectivesinnursing.org/vin3/wasson.html

Tucker, S.M., Canobbio, M., Paquette, E. V., & Wells, M. F., (2000), Patient Care Standards – Collaborative Planning and Nursing Interventions, pp633–635.

Bladk, J., & Matassarin–Jacobs, E., (1997), Medical–Surgical Nursing – Clinical Management for Continuity of Care, 5th edition, pp 2350–2363.

The Joanna Briggs Institute, Canberra Hospital – Acute Care Practice Manual 2008, supra-pubic catheter site dressing, 5.2.2007, p195-197

‘World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare.

Farrell, M., Smeltzer, S & Bare, B., (2005) Smeltzer & Bare’s Textbook of Medical-Surgical Nursing, Lippincott Williams & Wilkins Pty. Ltd, Australian & New Zealand Edition, pp 1360-1361


Attachments

Attachment A: Stat Lock – Foley Stabilisation DeviceAttachment B: Insertion of Urinary Catheter StickerAttachment C: How to care for your Urinary CatheterAttachment D: Troubleshooting guide for urinary cathetersAttachment E: Source of information and/ or suppliers for urinary catheter equipmentAttachment F: Catheter selection

Disclaimer: This document has been developed by ACT Health, <Name of Division/ Branch/Unit> specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.

Date Amended Section Amended Approved ByEg: 17 August 2014 Section 1 ED/CHHSPC Chair



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Attachment A: Stat Lock – Foley Stabilisation Device



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Attachment B: Insertion of Urinary Catheter Sticker

Sticker available on order through Corporate ExpressID 18838521ACT Hth Ins of Urinary Cath Lbls Roll 500



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Attachment C: How to care for your Urinary Catheter



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Attachment D: Troubleshooting guide for urinary catheters

TROUBLESHOOTING GUIDE FOR URINARY CATHETERSPROBLEM POSSIBLE CAUSE WHAT TO DO

CATHETER LEAKAGE

(Bypassing)

Check Plumbing Is the catheter or tubing kinking - check bag and/or valve connections, check line and connection of tubing. Use catheter securing device.

Faecal Impaction / Constipation

Assess, alleviate and prevent by review of bowel management.

Catheter too large A urethral catheter that is greater than 18Fg may need to be gradually downsized.o Women IDC: 12 -14Fg/10ml balloono Men IDC: 14- 16Fg /10ml balloono SPC: 16 -18

Balloon too large A 5-10ml balloon is advised. Authorisation from an Urologist is required for long-term use of a catheter with a 30 ml balloon, given it may contribute to bladder neck erosion.

Catheter blockage If a catheter is blocked and has been insitu for >2 weeks it may be replaced and documented on Urinary Catheter Management Chart. Determine the blocking agent and consult with Medical Officer re indications for antibiotic therapy or refer for a urological review.

Bladder spasm See BLADDER SPASM

BLADDER PAIN Bladder spasm Consider concentrated urine – increase fluidsBladder Distension Assess and action as per NO URINE

DRAININGTraction on Catheter Secure with tape or strapBladder infection - Symptomatic

See INFECTION

Balloon too large or Catheter too large

5-10 ml balloon advised (as per manufacturer’s recommendationsIDC – less than 18Fg advised

BLADDER SPASM (Cramps)

Traction on catheter with movement

Ensure catheter is not under tension. Recommend use of catheter strap.


Alleviate and prevent. Review bowel management.

Bladder infection See INFECTION



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Overactive bladder Discuss use of anticholinergic medication with Medical Officer. Consider use of topical oestrogen for urethritis in females

New Catheter in situ

Spasms should settle within 24-48 hours, Reassure patient they should resolve.

BLEEDING Trauma Ensure catheter is not under tension, check securement devices. Some clients may experience a small amount of bleeding following SPC change.

Infection See INFECTIONPersistent Haematuria

Urgent referral to medical officer / Urological consult

NO URINE DRAINING +/- urinary leakage

Kinked tubing Check for correct lie and connection of tubing

Low fluid intake Recommend fluid intake of between 2-3 litres daily unless otherwise stated by Medical Officer.



Drainage bag above bladder level

Lower bag, ensure bag is below bladder level to assist gravity.

Catheter is blocked with mucous or debris

If a catheter is blocked and has been insitu for >2 weeks it may be changed.Catheter Flush:o may be indicated if a client has a history

of blocked cathetero is prescribed by a medical practitioner

and requires a treatment ordero is a short term management option only

and the cause of the blockage should be investigated. A Urology review must be in place. (See Catheter Flushing SOP)

NO DRAINAGE OF URINE AFTER SEVERAL HOURS

Check as above. o Check for palpable bladder i.e. blocked catheter. Check the catheter position in the bladder by deflating the balloon and slightly rotate and push catheter in.

o Check for sediment and document characteristics.

o Replace catheter.o If anuria is identified (urinary output of

less than 100-250mls in 24 hours), immediately refer client to nearest local



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hospital emergency department.INFECTION o Review catheter management; ensure

closed link system is being maintained. Clients with symptomatic catheter related infection should be treated as per local prescribing procedure or the latest version of the Therapeutic Guidelines: Antibiotic if not availableo Concerns regarding persistent infective

symptoms should be referred to a Medical Officer.

PAIN AND DISCOMFORT AROUND THE CATHETER, BLEEDING, ITCHING AND SORENESS

Bladder and/or urethral irritation

o Alleviate urethral traction trauma and potential for pressure necrosis; secure catheter with catheter retaining strap.o Liaise with Medical Officer.o See INFECTIONo Discuss with medical officer possible use of

topical oestrogen for urethritis (in post-menopausal women) with Medical Officer.

Allergy to catheter material

Change catheter type

Hyper granulation of supra pubic site due to pulling or tension.

o Prevent catheter traction and alternate the side the catheter is taped to on a weekly basis.o Keep stoma clean and dry.o Silver nitrate treatment may be required

(See Wound Care Manual).

Infection of stoma Arrange for wound swab, treat as required (See Wound Care Manual)

CATHETER FALLS OUT

Catheter balloon deflates prematurely Balloon faulty

Balloon intact

o Insert new catheter. Nelaton catheter to keep site open until Foleys availableo Check balloon of dislodged catheter for

faults.o Anchor inadequate, or trauma at transfer

URINE IS CLOUDY, OFFENSIVE SMELLING

Infection See INFECTION

Low fluid intake Recommend fluid intake: 2-3 litres daily unless otherwise stated by Medical Officer.



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Difficult removal Ridging of deflated balloon or hysteresis’

o Allow balloon to spontaneous deflateo Select appropriate catheter materials: all- silicone catheters have a tendency to cuff, consider all-silicone catheter with integrated balloon (Releen In-Line Foley catheter or hydrogel coated catheter (Bard Biocath). Consider latex allergy status of clients.o Where cuffing is suspected, consider instilling 1ml of sterile water back into the balloon (after complete deflation). Consider the use of anaesthetic gel prior

to the removal of the catheter.

Difficult removal Bladder Spasm

Anxiety

o Apply lubricate to stoma site.o A fair degree of pull may be required, holding the catheter close to stoma, apply consistent firm pressure whilst supporting the abdomen with the non-dominant hand until the catheter releases.o Encourage relaxation, allay anxiety

UNABLE TO INSERT SPC

Spasm of tract/bladder

o Apply anaesthetic gel (Lignocaine 2%) to stoma site.o Place catheter in stoma, apply firm constant pressure to catheter whilst waiting release of spasm.o Insert Nelaton intermittent catheter to

maintain tract, then remove and quickly insert usual catheter, or try smaller size Foley catheter.

o Report to medical practitioner, antispasmodic/muscle relaxant therapy may be required.o Where unsuccessful, send patient to hospital

within 30 to 45 minutes for management.

Not following tracto Re-attempt at correct angle. Always observe the angle of tract during catheter removal.

NO DRAINAGE AFTER CATHETER INSERTION

Catheter /balloon not in bladder

o Advance catheter a little further. Once in the bladder SPC should not be advanced more than 10 cm in total.o Check/consider the tip of catheter is not

located in the urethra.



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No urine in bladder Dehydration o Give extra fluids.o Ensure drainage before inflating balloon.o Advise increased fluids prior to plannedo catheterisation.


CATHETER LEAKAGE

(Bypassing)

Check Plumbing Is the catheter or tubing kinking - check bag and/or valve connections, check line and connection of tubing. Use catheter securing device.



Catheter too large A urethral catheter that is greater than 18Fg may need to be gradually downsized.o Women IDC: 12 -14Fg/10ml balloono Men IDC: 14- 16Fg /10ml balloono SPC: 16 -18

Balloon too large A 5-10ml balloon is advised. Authorisation from an Urologist is required for long-term use of a catheter with a 30 ml balloon, given it may contribute to bladder neck erosion.

Catheter blockage If a catheter is blocked and has been insitu for >2 weeks it may be replaced and documented on Urinary Catheter Management Chart. Determine the blocking agent and consult with Medical Officer re indications for antibiotic therapy or refer for a urological review.

Bladder spasm See BLADDER SPASM

BLADDER PAIN Bladder spasm Consider concentrated urine – increase fluidsBladder Distension Assess and action as per NO URINE

DRAININGTraction on Catheter Secure with tape or strapBladder infection - Symptomatic

See INFECTION

Balloon too large or Catheter too large

5-10 ml balloon advised (as per manufacturer’s recommendationsIDC – less than 18Fg advised



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BLADDER SPASM (Cramps)

Traction on catheter with movement

Ensure catheter is not under tension. Recommend use of catheter strap.


Alleviate and prevent. Review bowel management.

Bladder infection See INFECTIONOveractive bladder Discuss use of anticholinergic medication

with Medical Officer. Consider use of topical oestrogen for urethritis in females

New Catheter in situ

Spasms should settle within 24-48 hours, Reassure patient they should resolve.

BLEEDING Trauma Ensure catheter is not under tension, check securement devices. Some clients may experience a small amount of bleeding following SPC change.

Infection See INFECTIONPersistent Haematuria

Urgent referral to medical officer / Urological consult

NO URINE DRAINING +/- urinary leakage

Kinked tubing Check for correct lie and connection of tubingLow fluid intake Recommend fluid intake of between 2-3

litres daily unless otherwise stated by Medical Officer.



Drainage bag above bladder level

Lower bag, ensure bag is below bladder level to assist gravity.

Catheter is blocked with mucous or debris

If a catheter is blocked and has been insitu for >2 weeks it may be changed. Determine the blocking agent and consult with Medical Officer re indications for antibiotic therapy or a urological review.Catheter Flush:o may be indicated if a client has a history

of blocked cathetero is prescribed by a medical practitioner

and requires a treatment ordero is a short term management option only

and the cause of the blockage should be investigated. A Urology review must be in place. (See Catheter Flushing SOP)

NO DRAINAGE OF Check as above. o Check for palpable bladder i.e. blocked



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URINE AFTER SEVERAL HOURS

catheter. Check the catheter position in the bladder by deflating the balloon and slightly rotate and push catheter in.

o Check for sediment and document characteristics.

o Replace catheter.o If anuria is identified (urinary output of

less than 100-250mls in 24 hours), immediately refer client to nearest local hospital emergency department.

INFECTION o Review catheter management; ensure closed link system is being maintained.

Clients with symptomatic catheter related infection should be treated as per local prescribing procedure or the latest version of the Therapeutic Guidelines: Antibiotic if not availableo Concerns regarding persistent infective

symptoms should be referred to a Medical Officer.

PAIN AND DISCOMFORT AROUND THE CATHETER, BLEEDING, ITCHING AND SORENESS

Bladder and/or urethral irritation

o Alleviate urethral traction trauma and potential for pressure necrosis; secure catheter with catheter retaining strap.o Liaise with Medical Officer.o See INFECTIONo Discuss with medical officer possible use of

topical oestrogen for urethritis (in post-menopausal women) with Medical Officer.

Allergy to catheter material

Change catheter type

Hyper granulation of supra pubic site due to pulling or tension.

o Prevent catheter traction and alternate the side the catheter is taped to on a weekly basis.o Keep stoma clean and dry.o Silver nitrate treatment may be required

(See Wound Care Manual).

Infection of stoma Arrange for wound swab, treat as required (See Wound Care Manual)



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CATHETER FALLS OUT

Catheter balloon deflates prematurely Balloon faulty

Balloon intact

o Insert new catheter. Nelaton catheter to keep site open until Foleys availableo Check balloon of dislodged catheter for

faults.o Anchor inadequate, or trauma at transfer

URINE IS CLOUDY, OFFENSIVE SMELLING

Infection See INFECTION

Low fluid intake Recommend fluid intake: 2-3 litres daily unless otherwise stated by Medical Officer.

Difficult removal Ridging of deflated balloon or hysteresis’

o Allow balloon to spontaneous deflateo Select appropriate catheter materials: all- silicone catheters have a tendency to cuff, consider all-silicone catheter with integrated balloon (Releen In-Line Foley catheter or hydrogel coated catheter (Bard Biocath). Consider latex allergy status of clients.o Where cuffing is suspected, consider instilling 1ml of sterile water back into the balloon (after complete deflation). Consider the use of anaesthetic gel prior

to the removal of the catheter.

Difficult removal Bladder Spasm

Anxiety

o Apply lubricate to stoma site.o A fair degree of pull may be required, holding the catheter close to stoma, apply consistent firm pressure whilst supporting the abdomen with the non-dominant hand until the catheter releases.o Encourage relaxation, allay anxiety



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UNABLE TO INSERT SPC

Spasm of tract/bladder

o Apply anaesthetic gel (Lignocaine 2%) to stoma site.o Place catheter in stoma, apply firm

constant pressure to catheter whilst waiting release of spasm.o Insert Nelaton intermittent catheter to

maintain tract, then remove and quickly insert usual catheter, or try smaller size Foley catheter.

o Report to medical practitioner, antispasmodic/muscle relaxant therapy may be required.o Where unsuccessful, send patient to

hospital within 30 to 45 minutes for management.

Not following tracto Re-attempt at correct angle. Always

observe the angle of tract during catheter removal.

NO DRAINAGE AFTER CATHETER INSERTION

Catheter /balloon not in bladder

o Advance catheter a little further. Once in the

bladder SPC should not be advanced more than 10 cm in total.o Check/consider the tip of catheter is not

located in the urethra.No urine in bladder Dehydration o Give extra fluids.

o Ensure drainage before inflating balloon.o Advise increased fluids prior to plannedo catheterisation.



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Attachment E: Source of information and/or suppliers for urinary catheter equipment

Continence Aids Payment Scheme (eligibility criteria applies)

ACTES ACT Equipment Scheme

If client is eligible for CAPS and has used their allowance they may be eligible for assistance

G.P. MEDICAL

30 Colbee Court, Phillip, 2606 ACT Ph. 6282 0059INDEPENDENT LIVING CENTRE

24 Parkinson St. Weston, 2600, ACT

Ph. 6205 1900

Fax (02) 62051906

Provides information and advice about products.

INDEPENDENCE SOLUTIONS

6 Holker St. Newington, NSW, 2127

Customer service number: 1300 788 855

Fax: 1300 788 811

BRIGHT SKY ( proceeds support ParaQuad NSW programs)

6 Holker St (corner of Avenue of Africa)

Newington NSW 2127

Phone 1300 88 66 01 Fax 1300 88 66 02

Email: [email protected]

Webstore: www.brightsky.com.au

LOCAL PHARMACIES may order relevant equipment for clients

MOBILITY MATTERS PTY LTD

33-35 Townsville St. Fyshwick

Ph. 6239 1381



http://www.brightsky.com.au/

mailto:[email protected]

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Attachment F: Catheter selection

Catheter Materials Recommended Usage

Advantages Disadvantages

Polyvinyl Chloride (PVC)

PVC non balloon

Short term use only, maximum 7 days

Intermittent catheterisation

Large internal diameter allows good drainage postoperatively

Uncomfortable for long-term use

Rigid and inflexible

Polytetrafluoroethylene (PTFE) or Teflon coated with latex core

Short term, up to 28 days

Smoother on external surfaces for insertion – reduces tissue damage

More resistant to encrustation

If left in situ for too long Teflon coating may wear thin

Unsuitable for clients allergic to latex

Silver-alloy coated Catheter expected to be in situ for up to 14 days

Protective against bacteriuria when used for 5days

Not so effective at 14 days - not proven for long term effectiveness

Silicone

All silicone BARD

All silicone CLINY

Long term up to 12 weeks

Wide lumen for drainage. Suitable for clients with latex allergy

‘Cuffing’ of balloon can occur on deflation and can be more difficult to remove suprapubically

Releen 100% Silicone Long term up to 12 weeks

Reduced urethritis/inflammation of urethra.

Wide lumen – reduced encrustation. Integrated balloon – less ridging

Hydrogel coated latex

Biocath® Foley CatheterLong term use up to 12 weeks

More compatible with body tissue, less trauma. May resist colonisation of bacteria and reduce infection

Does contain latex – unsuitable for clients allergic to latex



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Silicone elastomer-coated latex (silicone bonding to outer and inner surfaces)

Long term use up to 12 weeks

May help to reduce potential for encrustation

Unsuitable for clients allergic to latex

Hydrogel coated silicone

Lubri-sil™ (BARD)

Long term use up to 12 weeks

Suitable for clients with latex allergy

Rigid; may be uncomfortable for clients



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