Indwelling Catheter Management: From Habit-based to Evidence-based Practice
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Several studies have shown a direct correlation between increased bladder spasms, leakage, and infection.40
Stool in the rectal vault or colon can occlude the catheter lumen or increase pressure in the bladder, leading to bladder spasm and leakage. In a study by Ziemann et al,39 81% of all patients with leakage had constipation or fecal impaction. This finding underscores the importance of bowel management programs designed to eliminate or promptly correct constipation.
Over time, large-sized catheters stretch the urethra. Urethral dilation should be suspected in a patient with a long-term catheter who has a history of large catheters or large balloons and who has persistent leakage with no apparent cause. These patients should be referred to a urologist and evaluated for other management options.
Blood clots, sediment, mucus, and crystal precipitate are commonly seen in catheterized patients and can lead to occlusion of the drainage eyes or catheter lumen. Irrigation with normal saline can remove clots or debris, but saline is ineffective at removing occlusions caused by catheter encrustations.27 If sediment or blood clots are causing frequent occlusion, a larger catheter and catheter irrigations may be necessary.
Catheter encrustation. Catheter encrustation occurs in up to 50% of long-term catheterized patients and can lead to emergency room visits and frequent catheter changes.27 Encrustation is caused by infection of the urinary tract by Proteus mirabilis or other urease-producing bacteria. The activity of the urease raises the urinary pH (>7), causing precipitation of calcium and magnesium phosphates that attach to biofilm on the catheter inner and outer surfaces.33 Studies have shown that antibiotics or antiseptic solutions are ineffective at eradicating biofilms.42 Patients are classified as either “blockers”(patients who consistently and repeatedly develop encrustations, resulting in decrease urine flow) or “non-blockers.”27,35 Acidifying the urine with cranberry juice or pills or vitamin C has not been shown to delay or decrease encrustation and blockage; however, a recent study found that increasing fluids decreased time until blockage.43 In addition, studies have shown that acidic irrigant solutions instilled into the bladder can dissolve encrustations, although further studies are needed regarding optimal volume and frequency and the effects on bladder mucosa.27 In patients with frequent blockage due to encrustations, a prescription citric acid bladder irrigant solution (Renacidin®, Guardian Laboratories, Hauppauge, NY) may be instilled into the bladder to dissolve encrustation.
Current recommendations or management of encrustation and blockage include the following:
• Inspect and palpate the catheter for signs of encrustation
• Schedule catheter changes based on blockage history (ie, usual time to blockage)
• Increase fluid intake
• Keep extra catheter kits available
• Perform two sequential bladder washouts with <50 cc acidic bladder irrigant solution instilled by gravity no more than every other day.27
In caring for patients with indwelling catheters, nurses should aim for consistent and standardized practices based on current research. Nursing measures should include identifying patients who no longer need indwelling catheters and providing suggestions for appropriate alternatives. Many catheter-associated problems can be avoided by selecting a small size catheter with a 5-cc balloon, following manufacturer’s recommendations for insertion/removal, maintaining a closed system, securing the catheter, and properly positioning drainage bags.
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