The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [186]
Key areas have been identified as having a direct link with the development of urinary tract infection.
Assessing the need for catheterization and the length of time the catheter is in situ (Nazarko 2007).
Selection of the most appropriate type of catheter and drainage system to be used.
The aseptic conditions and process by which the catheter is inserted and maintained as a closed drainage system.
Training and competence of the person performing the procedure and those undertaking the aftercare, that is, patients, relatives and health professionals.
The maintenance of a closed drainage system is central in reducing the risk of catheter-associated infection. It is thought that micro-organisms reach the bladder by two possible routes: from the urine in the drainage bag or via the space between the catheter and the urethral mucosa (Getliffe 1995, Gould 1994). To reduce the risk of infection, it is important to keep manipulations of the closed system to a minimum; this includes unnecessary emptying, changing the drainage bags or taking samples.There is now an intregal catheter and drainage bag available to reduce the number of potential disconnection sites and infection risk. Before handling catheter drainage systems, hands must be decontaminated and a pair of clean non-sterile gloves should be worn (Pratt et al. 2007). All urine samples should only be obtained via the specially designed sampling ports using an aseptic technique.
Urinary tract infections (male): meatal cleaning
Cleaning the urethral meatus, where the catheter enters the body, is a nursing procedure intended to minimize infection of the urinary tract for men (DH and CMO 2003, Mangnall and Watterson 2006). Studies examining the use of a variety of antiseptic, antimicrobial agents or soap and water found that there was no reduction in bacteriuria when using any of these preparations for meatal cleaning compared to routine bathing or showering (Pratt et al. 2007). Further studies support the view that vigorous meatal cleaning is unnecessary and may compromise the integrity of the skin, thus increasing the risk of infection (Leaver 2007, Saint and Lipsky 1999 ). Therefore it is recommended that routine daily personal hygiene with soap and water (NICE 2003) is all that is needed to maintain meatal hygiene (Pomfret and Tew 2004, Pratt et al. 2007). Nursing intervention is necessary if there is a poor standard of hygiene or a risk of contamination (Gilbert 2006); removal of a smegma ring, where the catheter meets the meatus, is important to prevent ascending infections and meatal trauma (Wilson 2005).
A urinary tract infection (UTI) may be introduced during catheterization because of faulty aseptic technique, inadequate urethral cleaning or contamination of catheter tip. UTI may be introduced via the drainage system because of faulty handling of equipment, breaking the closed system or raising the drainage bag above bladder level causing urine reflux.
If a UTI is suspected a catheter specimen of urine must be sent for analysis. The patient should be encouraged to have a fluid intake of 2–3 litres a day. Medical staff should be informed if the problem persists so antibiotics can be prescribed.
Table 6.2 details other complications that may arise if a patient is catheterized.
Table 6.2 Complications of catheterization
Problem Cause Suggested action
Inability to tolerate indwelling catheter Urethral mucosal irritation Nurse may need to remove the catheter and seek an alternative means of urine drainage
Psychological trauma Explain the need for and the functioning of the catheter
Unstable bladder
Radiation cystitis
Inadequate drainage of urine Incorrect placement of a catheter
Kinked drainage tubing Resite the catheter
Inspect the system and straighten any kinks
Blocked tubing, for example pus, urates, phosphates, blood clots If a three-way catheter, such as a Foley, is in place, irrigate it. If an ordinary