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In men, the catheter is introduced into the urinary tract through the penis. A sheath catheter can also be used that resembles a condom which is placed over the penis so the urine is caught and goes into the catheter bag. In female patient’s, the catheter is introduced into the urethral meatus. The process can be complex in women due to the fact that the layout of the genitals can differ (due to age, obesity, Female, childbirth, etc), but a superior clinician must therefore depend on physical pointers and patience when taking care of this kind of patient.
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An important issue that I picked up on whilst on placement in the community is the importance of appropriate catheterisation. We took care of a patient who was bed bound incontinent and her carers asked if we could catheterise her so that they wouldn’t have to keep changing pads and bedding. We explained that research and NHS policy state that catheters should not be just inserted for incontinence or convenience as a reason by itself. This is because there are risks associated with catheters that patients should not be exposed to lightly. The most effective means of preventing Catheter Associated Urinary tract Infections CAUTI is not to catheterise and to use catheters only when absolutely necessary (Tenke et al, 2004).
The UKCC (1996) states that clinicians should always make certain that no action is undertaken that is damaging to the wellbeing or safety of patients. However, urinary incontinence can lead to an excessive use of urinary catheters in elderly patients and 90% of indwelling catheters may be used for the ease of patients or staff (McLaughlin and Sciuto, 1996). This implies that those who cannot reach the toilet ‘in time’ and are as a result considered incontinent.
Catheterisation must only be considered after a complete assessment of the possible benefits and risks has been agreed. The assessment should take account of the reason for proposed motivation for catheterisation; the medical history; existing physical condition and any underlying condition (Parker, 1999).
Brennan (2006) carried out an audit which showed that catheterisation was carried out in 13.9% of patients for retention and in 37.5% for incontinence. Of patients catheterised for incontinence, 55.5% had been incontinent of urine at home and had managed their incontinence using sheaths and pads; but were catheterised during their stay in hospital.
It is vital that the proper catheters should be chosen for comfort and simplicity of insertion and removal. To reduce complications such as tissue damage and colonisation by micro-organisms should be considered (Getliffe, 1996). There are three lengths of catheter currently available, female (23-26 cm), paediatric (30 cm) and standard (40-44 cm)
The standard length catheter is known as the male length catheter. The standard length catheter should be used in male patients. Some women also prefer the male length catheter, for example obese female patients.
Whilst the catheter is insitue there are recommended daily tasks that should be performed by staff of the patient themselves. The meatal area must be cleaned every day with soap and water (Pratt et al, 2007), remembering that if this is part of a bed bath or sponge down at the bedside, the water must be refreshed and a hygienic cloth used. Preferably, nursing staff should encourage the patient to do it themselves, nevertheless, as Leaver (2007) remarks; many competent patients may be unwilling to handle the catheter for anxiety that they will dislodge it. Leaver (2007) also highlights a several important points to bear in mind when carrying out care of a catheter.
Always cleanse the entry site of the catheter first and use strokes away from the position for women this means washing towards the anus. To steer clear of irritation always make certain that the region is well rinsed and dried gently. For men, the foreskin should be retracted and the region beneath cleansed as this is a reservoir for micro-organisms, mainly in the mature patient. Do not rub the region as this may enhance the risk of infection also, bladder irrigation is not recommended on a routine basis because of the toxic effects on the bladder (Parker, 1999).
In the UK it is normally acknowledged that maintenance of the area surrounding the urethral meatus with 0.9% sodium chloride solution is sufficient for both male and female patients as there is no reliable evidence to suggest that the use of antiseptic agents reduces the risk of urinary tract infection.
The responsibility to prevent hospital-acquired infection is the duty of medical and nursing staff (Bridger, 1997). The main complications associated with catheterisation are Urinary Tract Infections, which are the most frequent hospital-acquired infection, maybe accountable for up to 45% of all hospital-acquired illness (Winn, 1996). The danger of developing a UTI amplifies by 5-8% per day of catheterisation (Mulhall et al, 1988). Approximately 80% of UTIs are linked with long term catheters (Pinkerman, 1994). UTIs related to catheterisation as well as making people feel ill, but also are to blame for mortality (Kunin et al, 1992). The results of the Public Health Laboratory Service (2002) survey of English acute hospitals indicated that Catheter Acquired Urinary Tract Infections (CAUTI’s) lead to between 487-1,116 deaths per year. Platt et al (1982) recognised a threefold growth in deaths connected with catheter associated UTI. This is also significant to cost as UTIs are a costly single-site infection and cost the NHS £124 million per year (Plowman et al, 2000).
Most hospital-acquired urinary tract infections develop because the patient has been catheterised. The urinary tract is usually protected from infection because it fills with acidic urine – urine acidity and the flushing mechanism stop microbes adhering to the urinary tract (Nazarko, 2008). Nevertheless, inserting a urinary catheter provides a portal of entry for micro-organisms. Bacteria can penetrate the bladder through the catheter lumen and along the catheter Urethral interface (Salgado et al, 2003).
An estimated 2-6% of people with catheters will develop a urinary tract infection and infection rates are related to the number of days the catheter remains in place (Nicolle, 2005). Catheter-associated urinary tract infections often resolve when the catheter is removed (Tambyah and Maki, 2000). However, if bacteria are permitted to colonize the surface of the catheter and drainage equipment, a bio film is formed, which makes infections more difficult to treat as it protects any bacteria from antibiotics.
The EPIC Project Guidelines recommend four interventions related to reducing urinary catheter-associated infection (Pratt et al, 2001). It recommends assessing the need for catheterisation, selecting the catheter type, aseptic catheter insertion and regular catheter maintenance.
Brennan’s (2006) performed research recognised that education on continence and catheter management for medical staff necessary to guarantee that catheters are not used as a habitual method of managing urinary incontinence but only as a final alternative.
There are several difficulties and considerations that require assessment in respect to catheter management and catheterisation.
Catheters are frequently insitue long term and whilst on my placement on the community I found that these people often have a number of problems such as infections, blockages and recurring pain. There are in the region of 4% of community patients that have urethral catheters (Crow et al, 1986) which shows how many more people could be suffering from these problems and that they seriously need to be considered by clinicians.
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For a number of patients the introduction and removal of a catheter causes severe pain, so a topical analgesic is used. Catheterisation must be performed as a sterile medical process and should only be done by educated, competent staff, using apparatus designed for this purpose, apart from in the case of intermittent self catheterisation where the patient has been taught to carry out the process themselves. If accurate method is not used there may be trauma to the urethra or prostate with men, urinary tract infection, or a paraphimosis in the uncircumcised patient (Mulhall et al, 1988).
Management of long-term indwelling catheters is largely the responsibility of community nurses and recurrent blockage is a commonly experienced problem, which occurs in around 40-50% of long-term catheterised patients, Kunin et al, (1987) stated that catheter management should aim to relieve and manage urinary dysfunction, recognize and minimize risks of secondary complications, to promote patient dignity and comfort and to assist patients to reach their own potential in terms of self-care and independence and to provide a cost-effective service.
It is important to cleanse the urethral meatus (the site of entry of the catheter). This should be done with plain soap and water (Burkitt and Randall, 1987) There is no need to use antiseptic agents as trials of meatal cleansing have failed to demonstrate any reduction in the amount of bacteria in the urine (Mulhall et al, 1988). The purpose of meatal hygiene is to remove the ‘smegma’ ring caused by mucopus, which can form around the catheter at the point of entry into the urethra. If this is not removed, it may cause irritation to the meatus and result in ulceration. In the community we were asked to look at a male patient’s catheter and we found that there was a lot of ‘smegma’ around the catheter site. On further investigation it was found that the patient’s family had been washing the patient but had obviously not been washing the catheter site. This is often neglected through embarrassment or fear that the catheter will become dislodged. This is where education for the patient and family would come in useful before they were allowed to assist in maintaining the patient’s hygiene Billington, (2007).
Traditionally, bladder washouts have been performed to actively flush the bladder and disturb debris, or to reduce or prevent catheter obstruction. This is achieved using a 60 ml bladder syringe with saline and alternately depressing and withdrawing the plunger until the debris is removed (Kennedy, 1984)
Bladder maintenance solutions are frequently used as a method of prolonging catheter life; however the research surrounding their use has been inconclusive (Getliffe, 1994). In practice, I have come across blocked catheters on a number of occasions and have witnessed and participated in the use of the solutions that aim to unblock the catheter and have unfortunately not seen this work which would seem to support the idea that these bladder solutions are unproven and more research should perhaps be done into their effectiveness.
Bypassing, when urine leaks around the catheter, occurs at some time in up to 89% of patients with a long-term catheter (Roe and Brocklehurst, 1987). This causes much distress and embarrassment to the patient, and can hinder the accurate monitoring of urine output.
In relation to catheter care, constipation can cause pressure on the drainage lumen and prevent the catheter from draining (Rigby, 1998). If constipation is suspected, an examination is required and the appropriate treatment given. An adequate intake of fluid and fibre is an important part of a healthy diet and could reduce the occurrence of laxative overuse. The general recommendation for the minimum amount of fluid intake to maintain good health is 1.5 litres/day (Addison, 1997), but this must take into account an individual’s body weight and any specific fluid requirements. For example, if the patient is pyrexial he/she may need extra fluids; similarly, a person with constipation may require extra fluids as this may prevent constipation (Bush, 2000).
If the catheter or the drainage tubing becomes kinked or compressed this will cause occlusion and the urine, being unable to drain freely, will build up and may bypass around the catheter. Kinked tubing also may lead to an increased infection risk to the patient (Godfrey and Evans, 2000).
Many people experience pain and discomfort, which may not be related to trauma (Winn, 1998). In one study, 39% of patients had some discomfort (Crow et al, 1986), and it is a continual problem for 8% of patients (Kennedy et al, 1983). Patients often complain of cramping pain, similar to dysmenorrhoea. If this is the case, simple analgesia should be offered. Whilst on placement I also recognised that a number of people complained of their catheter pulling which sometimes resulted in trauma. In these cases we aimed to secure the catheter bag more securely usually using Velcro straps. Billington, (2007) did a study into Indwelling catheters should be properly secured after insertion to prevent movement and urethral traction. The use of tapes and straps for securing urinary catheters is inadequate, ineffective and not validated by clinical research. Any migration of the catheter is potentially dangerous – for the patient, effective catheter fixation means comfort, security, peace of mind, reduced anxiety, and the prevention of both trauma and pain.
Rew (2001) concluded that patients with long-term urinary catheters need to be studied from their own unique perspectives. The treatment of catheter problems and the use of solutions must be undertaken only after careful assessment and documentation of the patient and his/her catheter history
A catheter which is too large may cause trauma to the urethral mucosa and may obstruct paraurethral glands and cause urethritis (Alderman, 1989). Once again this highlights the need for selection of a small balloon, inflated with 10 ml of sterile water for injections. Once inserted, the catheter may be anchored to prevent urethral traction and trauma (Cravens and Zweig, 2000). The study also recommended a number of interventions to avoid the complications discussed. These include compiling a documented catheter history helps to anticipate and manage blockage problems. Do not treat bypassing by replacing the catheter with a larger one. Investigate the cause. Always choose the smallest catheter that will drain adequately. Always screen for latex allergy before catheterisation is undertaken. If a catheter is ‘rejected’ try to find an alternative method of managing urinary problems. Try simple methods of dealing with balloon non-deflation before resorting to percutaneous puncture. In placement a lot of these recommendations were followed as the patient’s catheters were documented in a detailed way and any problems were documented so a history of the patient’s experience of the catheter was created over time and the smallest catheter was always used.
The bladder is designed to fill and empty. Emptying the bladder using a catheter and drainage bag means that the bladder does not fill and empty as it is designed to do. Catheterisation and continual drainage reduces bladder capacity. It can also lead to the bladder becoming misshapen. The use of catheter valves allows the bladder to fill normally and to be drained when full. This mimicking of normal bladder function is considered to reduce the risk of bladder damage (Fader et al, 1997)
For some people, catheters can provide independence and freedom; however, for others catheterisation can be depressing and embarrassing as they feel that they can no longer control a ‘normal’ bodily function (Getliffe and Dolman, 1997). As well as the physical factors associated with catheters, it is also important to consider their psychological effects.
Therefore, to overcome this problem catheter care should begin before the catheter is inserted, except in an emergency when education should commence as soon as possible following insertion. Patient education should cover such issues as how a catheter works, catheter management, what types of drainage systems are available, how they work, and how they are secured correctly.
Conclusion, summary of important points.
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