PERFORMING MALE CATHETERIZATION

Purpose: * Allows emptying of the bladder * Allows sterile urine specimens to be obtained * Allows amount of residual urine in the bladder to be determined * Allows for continuous, accurate monitoring of urinary output * Provides avenue for bladder irrigation

Equipments needed:

* Urethral catheterization set which includes: * Forceps * Sterile gloves * Specimen collection container * Catheter * Drapes * Graduated measurement receptacle * Antiseptic solution * Cotton balls * Saline solution * French 8 and 10 Children * French 12 and 14 Female * French 16 and 18 Male

Other materials include:

* Basin of warm soapy water * Wash cloth * Large towel * Non sterile gloves * Sheets for draping * Linen saver * Tape * Bedpan, urinal or second collecting container if specimen is needed * Extra lighting

Types and Sizes of Catheter

1. Straight-single use catheters

* o Have a single lumen with a small 1 cm opening.

2. 2-way Foley catheters (retention catheters)

* o Have an inflatable balloon that encircles the tip near the lumen or opening of the catheter.

3. Curved or Coude

o Catheters have a rounded curved tip (elbowed) used in older male patients with enlarged prostates which partially obstruct the urethra.

4. 3-way Foley catheter

* o Often called retention catheter, they have 2 or 3 lumens that encircle the body of the catheter. One lumen drains the urine through the catheter into a collection bag. The second lumen holds the sterile water when the catheter is inflated and is also used to deflate the balloon. The third lumen may be used to instill medications into the bladder or provide a route for continuous bladder irrigation.

INDICATION:

* Infection * Enlarge Prostate * Urinary Surgery

Other Indication: (Diagnostic)

* Collection of uncontaminated urine specimen * Monitoring of urine output

* Imaging of urinary tract

Therapeutic Indication:

* Acute Urinary Retention (e.g benign prostatic hypertrophy, blood clots) * Chronic obstruction that causes hydronephrosis * Initiation of continuous bladder irrigation * Hygienic care for bedridden patient

ASSESSMENT:

Assessment should focus on the following:

Types of catheterization (eg. straight, foley, residual)

Status of the bladder(distention before catheterization)

Abnormalities of genitalia of prostate gland

History of conditions that may interfere with smooth insertion of catheter

Client allergy to iodine-based anti-septic

NURSING DIAGNOSIS:

Nursing diagnosis may include the following:

Acute pain related to bladder distention

Urinary retention related to neuromuscular dysfunction

OUTCOME IDENTIFICATION AND PLANNING:

Desired outcomes:

Client attains and maintains urine output of atleats 250 ml per shift during hospital days

Client verbalizes relief of lower abdominal pain within one hour of catheter insertion

SPECIAL CONSIDERATIONS in PLANNING and IMPLEMENTATION:

v General:

* Never force the catheter if it does not pass through the urethral canal smoothly * Suggest trouble shooting methods, discontinue the procedure and report to the physician. * Forcing the catheter may damage the catheter and the surrounding structures.

v Pediatric:

* The bladder is higher and more anterior in an infant than in an adult. * Common catheter sizes are French 8 and 10. * Catheterization is very threatening and anxiety provoking experience for the children, so they need explanation, support and understanding.

v Geriatric:

* A common pathologic feature in elderly men is enlargement of the prostate gland, which often makes inserting a catheter difficult.

v Home:

* Because indwelling catheterization is used on a long term basis for the homebound clients the potential for infection is high. * Be alert for early signs of infection adhere to a strict schedule for changing catheters. * Explore the possibility of an external catheter is an alternative to an indwelling catheter. If the client uses intermittent self-catheterization, store sterilized catheters in a sterile jar.

COST-CUTTING TIPS:

* When replacing a Foley catheter, note the size of the previous catheter to void waste from inserting too small catheter. This occurs frequently with clients on a long-term catheterization.

DELEGATION

In some agencies, catheterization may be delegate to specially trained personnel. Note agency policies concerning delegation of this procedure (e.g., what level of personnel)

IMPLEMENTATION

NURSING ACTIONS

RATIONALE

1. Perform hand hygiene.

Reduces microorganism transfer

2. Explain procedure to client.

Decrease anxiety

3. Determine if client is allergic to iodine based antiseptics.

Avoid allergic reactions

4. Provide privacy.

Decrease embarrassment

5. Put on non sterile gloves.

Reduces nurse's exposure to client's body secretions

6. If catheterization is being done for residual urine, ask client to void in urinal, and measure and record the amount voided; empty urinal.

Determines amount of urine client is able to void without catheterization

7. Lower side rails, assist client into a supine position, and place linen saver under client's buttocks.

Avoid soiling linens

8. Wash genital area with warm, soapy water, rinse and pat dry with towel.

Decrease microorganisms around urethral opening

9. Discard gloves, bath water, washcloth and towel; perform hand hygiene.

Decreases clutter; reduces microorganism transfer

10. Drape client so only penis exposed.

Provides privacy; reduces embarrassment

11. Set up work field:

* Open Catheter set and remove from outer plastic package * Tape outer package to bedside table with top edge turned inside out * Place catheter kit beside client's knees and carefully open outer edges * Ask client to open legs slightly * Remove full drape from kit with fingertips and place across thighs, plastic side down, just below penis; keep other side sterile * If Catheter and bag are separate, use sterile technique to open package containing bag and place bag on work field

Removes kit without opening inner folds

Provides waste bag

Places items within easy reach

Relaxes pelvic muscles

Provides sterile field

Promotes establishment of sterile closed catheter system

12. Put on sterile gloves

Avoids contaminating other items in kit

13. Prepare items in kit for use during insertion as follows:

* Pour iodine solution over cotton balls

* Separate cotton balls with forceps

* Lubricate 6 to 7 inches of catheter tip and place carefully on tray so tip is secure in tray. * If inserting indwelling catheter, attach prefilled syringe of sterile water to balloon port of catheter. * Inject 2 to 3 ml of sterile water from prefilled syringe into balloon and observe balloon for leaks as it fills. * If any leaks are noted, discard and obtain another kit. * Deflate balloon and leave syringe connected. * Attach catheter to drainage container tubing (or if drainage tubing is already attached to the catheter, place tubing and bag securely on sterile field, close to the other equipment). * Check clamp on collection bag to be sure it is closed. Place catheter and collection tray close to perineum. * Open specimen collection container and place on sterile field.

Prepares cotton balls for cleaning

Promotes easy manipulation

Prevents local irritation of meatus during catheter insertion; promotes ease of insertion.

Connects to balloon port the syringe needed to inflate balloon.

Tests balloon for defects.

Prevents catheter from dislodging after insertion

Leaves syringe within reach

Facilitates organizations while maintaining sterility

Prevents loss of urine before measurement

Places container within easy reach for specimen collection

14. Remove fenestrated drape from kit and place penis through hole in drape with non dominant hand. KEEP DOMINANT HAND STERILE

Expands sterile field.

15. Pull penis up at a 90-degree angle to clients supine body.

Straightens urethra

16. With non dominant hand. Gently grasp glands (tip) of penis; retract foreskin, if necessary.

Provides grasp of penis, preventing contamination of sterile field later.

17. With forceps in dominant hand, cleanse meatus and glands with cotton balls, beginning at urethral opening and moving toward shaft of penis; make one complete circle around penis with each cotton ball, discarding cotton ball after each wipe.

Cleanses meatus without cross contaminating or contaminating hand.

18. After all cotton balls have been used, discard forceps.

Prevents contamination of sterile field

19. With thumb and first finger, pick catheter up about 1.5 to 2 inches from tip.

Gives nurse good control of catheter tip (which easily bends)

20. Carefully gather additional tubing in hand.

Gives nurse good control of full catheter length.

21. Ask client to bear down as if voiding and to take slow, deep breaths; encourage him to continue to breathe deeply until catheter is inserted.

Opens sphincter; relaxes sphincter muscles of bladder and urethra.

22. Insert tip of catheter slowly through urethral opening 7 to 9 inches (or until urine returns)

Inserts catheter

23. Lower penis to about a 45-degree angle after catheter is inserted about halfway and hold open end of catheter over collection container(if it is not connected to a drainage bag)

Places penis in position of urine to be released into collection container so accurate amount is measured.

24. If resistance is met:

* Stop for a few seconds. * Encourage client to continue taking slow, deep breaths * Do not force; remove catheter tip and notify doctor if above sequence is unsuccessful

Allows sphincters to relax and reduces anxiety.

Promotes relaxation of the client and sphincter muscles

Prevents injury to the prostate, urethra, and surroundings structure

25. After catheter has been advanced appropriate distance, advance another 1 to 1.5 inches.

Ensure that catheter is advanced for enough not to be dislodged

26. For straight catheterization

Obtain urine specimen in specimen container if ordered.

Obtain sterile specimen

Allow urine to drain until it stops or until maximum number of milliliters specified by agency (usually 1,000 to 1500 ml) has drained into container; use second container, bedpan, or urinal, if necessary.

Empties bladder; obtains residual urine amount

27. For an indwelling catheter, inflate balloon with attached syringe a gently pull back on catheter until it stops (catches).

Secure catheter placement

28. Secure catheter loosely with tape to lower abdomen on side from which drainage bag will be hanging (preferably away from door); make certain that tubing is not caught on railing locks or obstructed.

Stabilizes catheter; prevents accidental dislodgement

29. Clear bed of all equipment

Removes waste from bed

30. Reposition client for comfort, and replace linens for warmth and privacy

Promote general comfort.

31. Raise side rails

Prevent falls.

32. Measure amount of urine in collection container or drainage or drainage bag and discard urine and disposable supplies.

Provides assessment data

33. Gather all additional equipment and discard gloves.

Promotes clean environment

34. Perform hand hygiene.

Reduces microorganism transfer

EVALUATION:

Were desired outcomes achieved? Examples of evaluation include:

* Desired outcome met: Urine output 250ml per shift maintained during hospital stay.

* Desired outcome met: Client verbalized relief of lower abdominal pain within 1 hour of catheter insertion.

DOCUMENTATION:

The following should be noted on the clients chart:

* Presence of distention before catheterization * Assessment of genitalia, if abnormalities noted * Type of catheterization * Size of catheter * Amount color and consistency of urine returned upon catheterization (if residual urine catherization) * Difficulties encountered, if any, in passing the catheter smoothly * Reports unusual discomfort during insertion * Urine specimen obtained culture

CVP READING

MEASURING CENTRAL VENOUS PRESSURE

Central Venous Pressure (CVP)

is considered a direct measurement of the blood pressure in the right atrium and vena cava. It is acquired by threading a central venous catheter (subclavian double lumen central line shown) into any of several large veins. It is threaded so that the tip of the catheter rests in the lower third of the superior vena cava. The pressure monitoring assembly is attached to the

distal port of a multilumen central vein catheter.

Time: 5 minutes

Purpose

* To obtain accurate CVP reading (measurement of preload in the heart) * To monitor pressures in the right atrium and central veins * To determine status of clients shock (diagnosis) or in response to treatment * To give direct access for infusion and medications (e.g. inotropes), and frequent blood withdrawal for laboratory samples * To obtain blood for analysis * To serve as guide for fluid replacement * To estimate blood volume deficits * To evaluate circulatory failure

Indications

* Measurement of differences in venous pressure * Used for hypotensive clients who are not responding to basic clinical management * To assess the clients venous tone, blood viscosity, and volume of blood returning to the right atrium * Patients requiring infusion of inotropes

Equipments

* IV pole * Prescribed intravenous fluid * 2 cm rulers * Central venous pressure (CVP) monitor (stopcock, IVF, manometer) * Gloves

Procedure:

Assessment

Assess physician's order, client's medications, and treatments.

Asses for all pertinent allergies.

Assess CV site for signs of erythema, pain, tenderness, and edema

Assess for any conditions that may alter venous return, circulating blood volume, or cardiac performance.

Note: Normal CVP ranges from 5 to 10 cm H2O or 2 to 6 mm Hg

Implementation

ACTION

RATIONALE

1. Check Doctors order.

To check whether the order will be carried out properly.

1. Gather necessary equipment.

To prepare things needed for the procedure.

1. Identify client. Confirm the client's ID. Do not start the treatment if the client is not wearing an ID bracelet.

Checking identification ensures client safety through concept of correct procedure for correct client.

1. Provide privacy and explain the procedure to the client.

Explanation protects client's rights and reduces anxiety.

1. Wash your hands and don gloves.

Handwashing and gloves reduce transfer of microorganisms.

1. Connect the IV tubing to the manometer. Prime the IV tubing and manometer setup. Ensure all air bubbles are removed from tubing. Attach the water manometer to an IV pole.

Bubbles can alter CVP readings.

1. Swab the injection port with an antiseptic. Allow the injection port to dry.

Antiseptic prevents introduction of microorganisms during flushing.

1. With the CV line in place, position the client flat, with the bed in its lowest position. The CVP reflects right atrial pressure; you must align the right atrium (the zero reference point) with the zero mark on the manometer. To find the right atrium, locate the fourth intercostal space at the midaxillary line. Mark the appropriate place on the client's chest. Align the base of the manometer with the zero reference point by using a leveling device and secure it in place.

Marking client's chest ensures all subsequent recordings will be made using same location.

1. If the client cannot tolerate a flat position, place the client in the semiFowler's position. When the head of the bed is elevated, the phlebostatic axis remains constant but the midaxillary line changes.

Each time client changes position, positioning of manometer will need to be readjusted to zero reference point.

10. Turn the stopcock off to the client and slowly fill the manometer with IV solution until the fluid level is 10- to 20-cm H2O higher than the client's expected CVP value. Do not overfill the tube.

If tube is overfilled, fluid that spills over top can become a source of contamination.

11. Turn the stopcock off to the IV solution and open to the client. The fluid level in the manometer will drop. When the fluid level comes to a rest, it will fluctuate slightly with respirations.

Fluid will drop during inspiration and rise during expiration.

12. Record CVP at the end of expiration, when intrathoracic pressure has a negligible effect and the fluctuation is at its highest point. Depending on the type of water manometer used, note the value at the bottom of the meniscus or at the midline of the small floating ball.

13. After obtaining the CVP value, turn the stopcock to resume the IV infusion, if indicated.

14. Confirm the stopcock is turned so that the IV solution port, CVP column port, and client port are open. Be aware that, with this stopcock position, infusion of the IV solution increases CVP. Therefore, expect higher readings than those taken with the stopcock turned off to the IV solution.

Initial CVP reading with IV solution infusing at a constant rate will be higher. Assess client closely for changes because CVP will change as client's condition changes, even though initial reading was higher.

15. After the initial CVP reading, reevaluate readings frequently to establish a baseline for the client. Authorities recommend obtaining readings at 15-, 30-, and 60-minute intervals to establish a baseline. If the client's CVP fluctuates by more than 2 cm H2O, suspect a change in clinical status and report this finding to the physician.

Contacting physician facilitates intervention for client.

16. Place the client in a comfortable position.

To promote clients safety and comfort.

17. Remove the gloves and wash your hands.

Handwashing reduces transfer of microorganisms.

18. Document the CVP reading on the flow sheet. Note the condition of the catheter insertion site. Note any complications and actions taken.

For monitoring and to allow early detection of complications.

Normal CVP measurements

- The normal CVP is between 5 10 cm of H2O (it increases 3 5 cm H2O when patient is being ventilated)

CVP normal range:

(2-5) mmHg

(3-8)cm H2O

Increase of CVP

Over hydration

Right-sided heart failure

Cardiac tamponade

Constrictive pericarditis

Pulmonary hypertension

Tricuspid stenosis and regurgitation

Stroke volume is high

CVP reading is High?

Decrease of CVP

Hypovolemia

Decreased venous return

Excessive veno or vasodilation

Shock ?

- If the measure is less than 5 cm water that mean that the circulating volume is decrease.

CVP reading is Low?

Evaluation

(Sample)

* Desired outcome not met: Client remained free of signs and symptoms of embolism, pleural effusion, and infection, both systematically and at catheter site. * Desired outcome not met: Client maintained skin turgor during TPN administration. * Desired outcome not met: Central line remained patent. * Desired outcome not met: Client gained 1 to 2 Ib each week

Documentation

The following should be noted on the clients chart:

* Date and time of catheter insertion * Type and location of catheter, including the number of lumens * Care and maintenance procedures performed * Equipment used with catheter, including any flushing * Appearance of insertion site * Problem noted, such as resistance to flushing * Client tolerance of procedures

Sample Documentation

03/12/10

1700

CVP reading taken from left subclavian triple lumen catheter, see flow sheet. No redness or swelling noted at the insertion site, dressing is clean, dry, and intact. IV fluids continue to infuse, as ordered.