Indwelling Catheter Management: From Habit-based to Evidence-based Practice
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Coude-tipped catheters should be inserted with the tip pointed upward towards the patient’s umbilicus.
Confusion exists among nurses regarding selecting and filling catheter balloons for routine catheterization; many use 5-cc and 30-cc balloons interchangeably. Either a 1.5-cc or 3-cc (pediatric) or 5-cc (adult) balloon should be used for routine catheterization, filled per manufacturer directions. Catheter balloons are designed to secure the catheter in the bladder, not occlude the urethra or prevent leakage. When filled, the 30-cc balloon weighs approximately 48.2 g and sits high in the bladder.20 The added pressure on the bladder neck and pelvic floor can lead to bladder spasms and leakage. Over time, this can damage the bladder neck, resulting in inability to retain a catheter. In addition, the large balloon results in stasis because the drainage eyes sit above the balloon and, therefore, above the urine.21
Patients with long-term catheters are at significant risk for bladder stones that can puncture the retention balloon. Any patient who experiences repetitive, spontaneous balloon deflation should be evaluated by the urologist for the presence of bladder calculi.
Guidelines for Insertion
Handwashing is considered the single most important action to prevent infections.22 Patients and caregivers alike should be taught to wash their hands with antibacterial soap or alcohol-based hand cleaners before and after catheter insertion, changing drainage systems, or manipulating the catheter.
Male catheterization can be particularly difficult due to the greater urethral length and the prostatic curve. Copious lubrication is essential. Injecting 10 cc of water-soluble lubricant directly into the urethra distends the urethra and places the lubricant high in the urethra where it is needed.23 Using lidocaine jelly 2% reduces discomfort and can prevent urethral spasm; catheter insertion should be delayed for 2 to 5 minutes in order for the anesthetic to take effect.24 The catheter should be advanced almost to the bifurcation to avoid inflation of the balloon in the urethra. Placement should be confirmed by urine return before the balloon is inflated. Lubricating jelly in the drainage eyes may delay urine return; gentle aspiration of urine can confirm placement.
Identification of the female urethra may be difficult, as landmarks vary with each woman. In older women, the urethra may prolapse into the upper vaginal wall. The catheter should be inserted with the patient in the supine position. Insertion of a catheter from the rear, as recommended in nursing procedure manuals, may introduce fecal bacteria into the bladder and should be avoided unless the patient has limited mobility or restricted range of motion, preventing a supine position. In female patients, it is important to identify the urethra before beginning the sterile procedure. If the catheter is inadvertently placed into the vagina, it should be left temporarily as a landmark and a new catheter obtained for insertion into the bladder. Good lighting is essential, and an assistant may be needed to maintain sterile technique, especially with elderly or combative patients.
Pretesting catheter balloons is commonly recommended as a way to prevent insertion of a defective catheter. Some catheter manufacturers no longer recommend pretesting because their balloons are pretested during the manufacturing process.
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