Reducing Iatrogenic Urethral Injury and Urinary Tract Infections Colleen Kasa RN BScN CMSN© CNE Urology May 2015 CNE Urology May 2015

Reducing Iatrogenic Reducing Iatrogenic Urethral Injury and Urethral Injury and

Urinary Tract InfectionsUrinary Tract Infections

Colleen Kasa RN BScN Colleen Kasa RN BScN CMSN©CMSN©

CNE Urology May CNE Urology May 20152015

UTI’SUTI’S

► 600,000 patients developed hospital 600,000 patients developed hospital acquired UTI per yearacquired UTI per year

► 80% of these are urinary catheter 80% of these are urinary catheter associated (CAUTI)associated (CAUTI)

► Common pathogens: E. Coli, Klebsiella, Common pathogens: E. Coli, Klebsiella, Proteus, enterococcus, Psuedomonas, Proteus, enterococcus, Psuedomonas, Candida.Candida.

► Every day that catheter remains, risk of Every day that catheter remains, risk of CAUTI increases by 5%; 100% in 30 daysCAUTI increases by 5%; 100% in 30 days

► PROMPTLY REMOVE UNNECESSARY URINARY PROMPTLY REMOVE UNNECESSARY URINARY CATHETERSCATHETERS

Indications for a urinary Indications for a urinary cathetercatheter

► Urinary tract obstructionUrinary tract obstruction►Gross hematuria with clotsGross hematuria with clots►Neurogenic bladder dysfunction or urinary Neurogenic bladder dysfunction or urinary

retentionretention► Urologic or other surgery or studiesUrologic or other surgery or studies► Stage 3 or 4 sacral area decubitus ulcer with Stage 3 or 4 sacral area decubitus ulcer with

incontinenceincontinence► Accurate outputs in critically ill patientsAccurate outputs in critically ill patients►Hospice or palliative (if patient requests)Hospice or palliative (if patient requests)

Migrating BacteriaMigrating Bacteria

► Immunocompromised patientsImmunocompromised patients►Patients on antibiotics – fungus/yeastPatients on antibiotics – fungus/yeast► Introduction of the bacteria with the Introduction of the bacteria with the

insertion, especially if mucosal disruptedinsertion, especially if mucosal disrupted►Migrate up the catheter in the Migrate up the catheter in the

periurethral sheathperiurethral sheath►Migrate up the internal lumen of the Migrate up the internal lumen of the

catheter if break in the closed drainage catheter if break in the closed drainage system – reduce UTI’s to 25%system – reduce UTI’s to 25%

Catheters are NOT for:Catheters are NOT for:

► IncontinenceIncontinence► ImmobilityImmobility►Obtaining specimensObtaining specimens►Monitoring of outputsMonitoring of outputs►Patient request/conveniencePatient request/convenience

Strongly Recommended-CDCStrongly Recommended-CDC

1.1. Educate personnel in correct techniques of Educate personnel in correct techniques of catheter insertion and carecatheter insertion and care

2.2. Catheterize only when necessaryCatheterize only when necessary3.3. Emphasize handwashingEmphasize handwashing4.4. Insert catheter using aseptic technique and sterile Insert catheter using aseptic technique and sterile

equipmentequipment5.5. Secure catheter properlySecure catheter properly6.6. Maintain closed sterile drainageMaintain closed sterile drainage7.7. Obtain Urine samples asepticllyObtain Urine samples asepticlly8.8. Maintain unobstructed urine flowMaintain unobstructed urine flow9.9. Empty drainage system at least every 8 hours, Empty drainage system at least every 8 hours,

using aseptic technique, pt. specific containerusing aseptic technique, pt. specific container

Moderately RecommendedModerately Recommended

1.1. Periodically re-educate personnel in Periodically re-educate personnel in catheter carecatheter care

2.2. Use smallest suitable bore catheter Use smallest suitable bore catheter and balloon possibleand balloon possible

3.3. Avoid irrigation unless needed to Avoid irrigation unless needed to prevent obstructionprevent obstruction

4.4. Refrain from daily meatal careRefrain from daily meatal care5.5. Do not change catheters at regular Do not change catheters at regular

intervalsintervals

Weakly RecommendedWeakly Recommended

1.1. Consider alternative techniques of Consider alternative techniques of urinary drainageurinary drainage

2.2. Replace the collection system when Replace the collection system when sterile closed system has been violatedsterile closed system has been violated

3.3. Spatially separating infected and Spatially separating infected and uninfected patients with indwelling uninfected patients with indwelling catheterscatheters

4.4. Avoid routine bacteriologic monitoringAvoid routine bacteriologic monitoring

Other ComplicationsOther Complications

1.1. Non bacterial urethral inflammationNon bacterial urethral inflammation

2.2. Urethral stricturesUrethral strictures

3.3. Mechanical Trauma (catheter not Mechanical Trauma (catheter not stabilized, confused patients, etc)stabilized, confused patients, etc)

Any traumatic/difficult Any traumatic/difficult catheterization predisposes the male catheterization predisposes the male urethra to future difficulties…urethra to future difficulties…scarring, false passages, fistulas.scarring, false passages, fistulas.

CathetersCatheters

► Clean Intermittent CathetersClean Intermittent Catheters► Foley Catheters Size 14-16 FrenchFoley Catheters Size 14-16 French► Materials: latex, silicone, Materials: latex, silicone, lubriciouslubricious► Balloon Sizes: 5cc to 30ccBalloon Sizes: 5cc to 30cc► 3-Way catheters: balloons 30cc – often 45-3-Way catheters: balloons 30cc – often 45-

50cc in balloon – may actually be tethered 50cc in balloon – may actually be tethered into the prostatic fossa (applies pressure to into the prostatic fossa (applies pressure to the operative site)the operative site)

► Used for continuous bladder irrigation Used for continuous bladder irrigation (TURP`s) Notice the functional diameter of (TURP`s) Notice the functional diameter of the holesthe holes

Female CatheterizationFemale Catheterization

Male AnatomyMale Anatomy

Benign Prostatic HypertrophyBenign Prostatic Hypertrophy

Pressure Points in the Male Pressure Points in the Male UrethraUrethra

Support the troops!Support the troops!

Urethral TearUrethral Tear

Inspect carefully for meatal Inspect carefully for meatal damagedamage

Paraphimosis with Paraphimosis with constrictionconstriction

Edema and DiscolorationEdema and Discoloration

Manual reduction of Manual reduction of ParaphimosisParaphimosis

Catheter in Male BladderCatheter in Male Bladder

Difficult Catheterizations Difficult Catheterizations (Male)(Male)

►ResistanceResistance - not the nurses fault - not the nurses fault►(strictures, false passages, scarring, BPH)(strictures, false passages, scarring, BPH)►Pain During InsertionPain During Insertion►(explanations, pointing toes, Xylocaine (explanations, pointing toes, Xylocaine

gel)gel)►(consider specially shaped catheters-(consider specially shaped catheters-

coude)coude)►PAIN DURING INFLATION OF BALLOONPAIN DURING INFLATION OF BALLOON

►ResistanceResistance - not the nurses fault - not the nurses fault►(strictures, false passages, scarring, (strictures, false passages, scarring,

BPH)BPH)►Pain During InsertionPain During Insertion►(explanations, pointing toes, Xylocaine (explanations, pointing toes, Xylocaine















Problem with Female Problem with Female CatheterizationsCatheterizations

► Difficulty Visualizing UrethraDifficulty Visualizing Urethra► (good lighting, know anatomy, review (good lighting, know anatomy, review

history for bladder repair, female history for bladder repair, female circumcision, have patient bear down as if to circumcision, have patient bear down as if to void..urethra opens)void..urethra opens)

► How many of you have put the catheter into How many of you have put the catheter into the vagina? (leave it there so you know the vagina? (leave it there so you know where not to go!)where not to go!)

► Difficulty with insertion- abuseDifficulty with insertion- abuse► (use smaller catheter, explanations, consider (use smaller catheter, explanations, consider

Xylocaine gel for lubrication of catheter)Xylocaine gel for lubrication of catheter)

Xylocaine GelXylocaine Gel

► Physician’s Order (some programs may have standing Physician’s Order (some programs may have standing order)order)

► Xylocaine must be sterileXylocaine must be sterile► Insert into the urethra for 5 - 15 minutes. Insert into the urethra for 5 - 15 minutes. 1. Opens the posterior urethra (hold penis at 90 degrees to1. Opens the posterior urethra (hold penis at 90 degrees to straighten the path)(TUG)straighten the path)(TUG) 2. Lubricates the path for the catheter2. Lubricates the path for the catheter 3. Desensitizes the urethra during and after the procedure3. Desensitizes the urethra during and after the procedure 4. Psychological benefit – you are acknowledging that this4. Psychological benefit – you are acknowledging that this is unpleasant and you are doing your best to alleviate is unpleasant and you are doing your best to alleviate discomfortdiscomfort

Xylocaine SyringeXylocaine Syringe

Checklist for Proper Placement Checklist for Proper Placement of Catheterof Catheter

►1. Insert Catheter to the hub1. Insert Catheter to the hub►2. Wait for Urine return (? flush)2. Wait for Urine return (? flush)►3. Catheter does not recoil when 3. Catheter does not recoil when

releasedreleased►4. Balloon fills without resistance4. Balloon fills without resistance►5. Patient does not have pain during5. Patient does not have pain during► inflationinflation►6. Balloon can be brought to the wall of 6. Balloon can be brought to the wall of ► the bladderthe bladder

Moving Along

Question 1Question 1

►1. How often does a catheter need to 1. How often does a catheter need to be changed?be changed?

Answer 1Answer 1

► Catheters should not be routinely changed. Catheters should not be routinely changed. ► Always follow manufacturers’ Always follow manufacturers’

recommendationsrecommendations► Change catheter if encrusted, plugged or not Change catheter if encrusted, plugged or not

functioning wellfunctioning well► In general short term catheters are intended In general short term catheters are intended

for 5-10 days (latex foley)for 5-10 days (latex foley)► Long term catheters can remain as long as Long term catheters can remain as long as

functioning well (silicone, silastic)functioning well (silicone, silastic)► NB: catheters should be last resort for urine NB: catheters should be last resort for urine

drainage. drainage.


►Should you ever irrigate a catheter?Should you ever irrigate a catheter?

Answer 2Answer 2

►Generally catheters should not be irrigated, as Generally catheters should not be irrigated, as bacteria and/or debris can be forced back into bacteria and/or debris can be forced back into he bladder and potentially cause infection.he bladder and potentially cause infection.

►However,However, when a catheter is initially when a catheter is initially inserted, the catheter may need to be inserted, the catheter may need to be irrigated to flush out any lubrication that may irrigated to flush out any lubrication that may be obstructing the drainage eye. be obstructing the drainage eye.

► Three way catheters are intended to be Three way catheters are intended to be irrigated to flush out clots and keep the irrigated to flush out clots and keep the catheter patent.catheter patent.

Question 3Question 3►Doesn’t a bigger catheter do a better Doesn’t a bigger catheter do a better

job?job?

Answer 3Answer 3

►No, the smallest catheter that allows No, the smallest catheter that allows free flow of the urine is best. The free flow of the urine is best. The periurethral mucosa is less periurethral mucosa is less compressed and is able to do a better compressed and is able to do a better job of lubricating the urethra and job of lubricating the urethra and deterring bacterial migration up the deterring bacterial migration up the outside of the catheteroutside of the catheter


► Isn’t a bigger balloon better to hold Isn’t a bigger balloon better to hold the catheter in place?the catheter in place?

Answer 4Answer 4

A bigger balloon actually causes stress at the A bigger balloon actually causes stress at the bladder sphincter (1cc of H2O weighs 1 gm)bladder sphincter (1cc of H2O weighs 1 gm)

May cause spasms, significant injury if May cause spasms, significant injury if catheter is removed with the balloon intactcatheter is removed with the balloon intact

► A larger balloon holds the drainage higher A larger balloon holds the drainage higher in the urine at the base of the bladder-in the urine at the base of the bladder-leaves residual of urine at the baseleaves residual of urine at the base

Large Balloon ProblemsLarge Balloon Problems


►How forceful should a nurse be to get How forceful should a nurse be to get a catheter inserted?a catheter inserted?

Answer 5Answer 5

► Steady even pressure should be all that is required Steady even pressure should be all that is required to insert a urinary catheterto insert a urinary catheter

► Knowledge about the anatomy is essential so the Knowledge about the anatomy is essential so the nurse is aware of the locality of spincters, which nurse is aware of the locality of spincters, which might spasm during insertion and require a might spasm during insertion and require a hesitationhesitation

► Explanations, xylocaine gel, breathing techniques Explanations, xylocaine gel, breathing techniques all assist the patient to relax theall assist the patient to relax the

► SphinctersSphincters► If catheter is not inserting easily…STOP and get If catheter is not inserting easily…STOP and get

help! Consider coude catheter, experienced nurse help! Consider coude catheter, experienced nurse or urologist. or urologist.


►What kind of catheter is best for the What kind of catheter is best for the patient?patient?

Answer 6Answer 6

►Often best solution is no catheterOften best solution is no catheter► Consider the purpose for the catheter (ie. Consider the purpose for the catheter (ie.

Draining large clots will require a much larger Draining large clots will require a much larger catheter)catheter)

►Generally the smallest catheter to drain the Generally the smallest catheter to drain the bladder is the bestbladder is the best

► Consider latex allergies…most catheters are Consider latex allergies…most catheters are made of a latex combinationmade of a latex combination

► Latex is generally used for short term (5-10 Latex is generally used for short term (5-10 days) and silicone for long term (>10 days)days) and silicone for long term (>10 days)


►Why should a catheter be tethered?Why should a catheter be tethered?

Answer 7Answer 7

Both make and female catheters should Both make and female catheters should be tethered to maintain the integrity be tethered to maintain the integrity of the urethral mucosa (reduces of the urethral mucosa (reduces pistoning effect) and reduces the pistoning effect) and reduces the pressure on the urinary tract spincters pressure on the urinary tract spincters and stress pointsand stress points


►What if no urine comes out of the What if no urine comes out of the catheter?catheter?

Answer 8Answer 8

►Possible considerations:Possible considerations: ►patient may have just voidedpatient may have just voided►Catheter isn’t in the bladderCatheter isn’t in the bladder►Catheter is plugged – drainage eye, Catheter is plugged – drainage eye,

catheter may be bent, catheter may be catheter may be bent, catheter may be above the bladder…need gravity to flowabove the bladder…need gravity to flow

►Patient may be hypovolemic….may Patient may be hypovolemic….may need bolus to have urineneed bolus to have urine


►What causes a catheter to bypass?What causes a catheter to bypass?

Answer 9Answer 9

►Bypassing is caused by detrusor Bypassing is caused by detrusor instabilityinstability

►Common Causes:Common Causes:►Obstruction: clots, encrustation, kinking Obstruction: clots, encrustation, kinking ► constipationconstipation► infectioninfection► large balloon…5gms vs. large balloon…5gms vs.

30gms30gms


►Why can’t you just fill a 10cc balloon Why can’t you just fill a 10cc balloon with 5 cc.?with 5 cc.?

Answer 10Answer 10

►A balloon should always be spherical A balloon should always be spherical and symmetrical in the bladder. This and symmetrical in the bladder. This prevents potential erosion of the prevents potential erosion of the bladder mucosa andbladder mucosa and

sphincter.sphincter.

It also keeps the drainage eye lower in It also keeps the drainage eye lower in the urine, allowing for better drainage.the urine, allowing for better drainage.

We’re Finished!

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References (continued)References (continued)10)10)Greene Linda, Marx James, et al Guide to the Elimination of Catheter-Greene Linda, Marx James, et al Guide to the Elimination of Catheter-

Associated Urinary Tract Infections (CAUTIs) Developing and Applying Facility-Associated Urinary Tract Infections (CAUTIs) Developing and Applying Facility-Based prevention Interventions in Acute and Long-Term Care Settings Based prevention Interventions in Acute and Long-Term Care Settings Association for Professionals in Infection Control and epidemiology pages 1-Association for Professionals in Infection Control and epidemiology pages 1-4141

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References (continued)References (continued)17)17)Nazarko, Linda Effective evidence based catheter management British Journal Nazarko, Linda Effective evidence based catheter management British Journal

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Prevention of Catheter-associated Urinary Tract Infections CDC Department of Health Prevention of Catheter-associated Urinary Tract Infections CDC Department of Health and Human Services Centers for Disease Control and Prevention Published: February and Human Services Centers for Disease Control and Prevention Published: February 19811981

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Reducing Iatrogenic Urethral Injury and Urinary Tract Infections Colleen Kasa RN BScN CMSN© CNE Urology May 2015 CNE Urology May 2015