Indwelling Catheter Management: From Habit-based to Evidence-based Practice
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Drainage bags should be hung on the end of the bed with the tubing in a straight line, avoiding looping or kinking to promote unobstructed urine flow.8 Transporting patients with drainage bags positioned on the patients abdomens or between their legs should be avoided. Stainless steel drainage bag holders are available from medical supply companies, or the patient can be taught to use a new plastic trashcan or tub to hang the bag properly.
Patients and caregivers should receive instructions regarding the following points:
• Keep drainage bags off the floor below the level of the bladder
• Do not allow the outlet tube to touch the collection container or floor when emptying
• Disinfect the urine collection containers after use
• Empty the drainage bag when 1/2 to 2/3 full to avoid traction on the catheter from the weight of the drainage bag.
Nurses should be aware that patients might have strong preferences regarding the type of outlet device that works best for them. Patients with disabilities or limited mobility may require a special type of outlet device.
Common Catheter-associated Complications
Catheter-associated UTI. Much of the recent research on indwelling catheters has focused on the role of biofilms in the development of CAUTI, NUTI, antibiotic resistance, and catheter encrustation leading to blockage. With an understanding of biofilms, nurses can better understand how CAUTIs and catheter encrustations develop.
Biofilms develop on urinary catheters when bacteria adhere to and multiply on catheter surfaces, forming mushroom-like colonies protected in a polysaccharide matrix.33 Once these bacteria attach, they multiply quickly, swarm over the inner-luminal and extra-luminal surfaces of the catheter, and advance in a retrograde fashion.3 Bacteria frequently come from the hands of healthcare workers, cross contamination from other patients, or from the patient’s own colonic or perineal flora.19 Biofilms are of particular concern in the medical community because they can develop on any indwelling device, including intravenous catheters, needleless connectors, endotracheal tubes, pacemakers, mechanical heart valves, and urinary catheters, and they are highly resistant to traditional antimicrobial treatment.34 The longer a urinary catheter is left in place, the higher the risk of biofilm formation leading to infection. For this reason, urinary catheters should be removed as soon as possible.3,8 Studies have shown that all traditional catheter materials are subject to biofilm development.35
Risk factors for CAUTI. Risk factors for catheter-related infection include prolonged catheterization (>6 days), female gender, inserting the catheter outside the operating room, diabetes, malnutrition, renal insufficiency, monitoring of urine output, and positioning the drainage tubing below the drainage bag outlet.3 Other contributing factors are contamination during insertion, fecal incontinence (contamination by Escherichia coli in women), and interruption of the closed-catheter system.3 The most important, potentially modifiable, risk factor is prolonged catheterization (>6 days) — by day 30 of catheterization, essentially all patients are infected.3
Identification and treatment of CAUTI. Catheter-associated urinary tract infection is the most frequently reported complication of urinary catheterization.
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