Urinary Catheterization: Insertion and Removal with Rationale

Urinary catheters are devices used to promote elimination on patients who can otherwise void normally without a diagnosed health problem. These devices are usually made up of silicone material and are introduced to the urinary bladder by inserting it through the urethra. Usually, urinary catheters stay in place until it is no longer needed for the patient to have them in place.

Patients with problems in urinary elimination are faced with challenges in one of the most basic bodily functions. Their ability to eliminate body wastes via the urinary tract is often compromised by illnesses, surgical procedures, and other health problems, whether acute or chronic. In some cases, patients are prescribed to be inserted with a urinary catheter when they experience one or more of the following:

• Urinary retention
• A need to thoroughly monitor fluid intake and urine output
• As part of preoperative management
• For patients who are incontinent or on prolonged bed rest
• Patients with sacral or perineal wounds
• Bedridden patients
• Those who are at the end-of-life care

Other purposes of inserting urinary catheters include:

• Obtaining sterile urine specimens from patients
• Measuring the amount of residual urine in the bladder
• Complete bladder emptying, especially prior to diagnostic or surgical procedures
• To serve as irrigation route for patients needing bladder irrigation

The Intermittent and Indwelling Catheters

Inserting a urinary catheter into the bladder is considered part of routine nursing interventions and is not necessarily a complex skill. However, it can also be a difficult skill for the nurse to master as both male and female patients face challenges in inserting the catheter.

It is important to ensure adequate lighting to help visualization of the urethra, especially among female patients. Positioning the patient correctly is also important, taking into consideration of the patient’s condition and any contraindications for certain positions (i.e., female in the last trimester of pregnancy in the supine lithotomy position).

There are two major types of catheterization generally used for patients needing them: intermittent and indwelling. 

Intermittent catheterization is done using a single-lumen catheter and is usually used for patients needing:

1. Immediate relief from urinary retention, 
2. Long-term management of an incompetent bladder; 
3. Obtaining a sterile urine specimen for diagnostic tests; and
4. Assessment of the urinary bladder for residual urine after voiding.

An indwelling catheter, on the other hand, may use a double or triple lumen catheter and is used for:

• Promotion of normal urinary elimination patterns
• Measuring the accurate amounts of urine output
• Prevention of skin breakdown
• Helps facilitate wound management
• In helping surgical sites such as the urethra, bladder, and surrounding structures heal after surgery
• Instillation of irrigation fluids and/or medications
• Assessment of persistent abdominal or pelvic pain
• Assisting in the diagnosis of conditions involving the genitourinary system

The lumens of the indwelling catheters have their distinct uses. In the double-lumen catheter, one of the lumens is used mainly for draining urine into a collection bag, while the other lumen is used as a port for the liquid used in inflating the balloon to keep it in place. In the triple-lumen setup, the third lumen is usually used to instill medication and/or irrigating solution into the bladder. The catheter is also attached to a collection bag hung lower than the catheter so that the flow of urine remains unrestricted.

Catheters inserted into the bladder are also used based on the French (Fr) scale sizes. This scale is used to denote the diameter of the tubes.

Recommended Fr sizes for female patients range from 12 to 16, while male patients normally use Fr 14 to Fr 16.

Insertion of the Catheter

Prior to the actual insertion of the catheter, the nurse must remember to check and verify the order and refer to the protocols implemented in the facility regarding the procedure. An informed consent for catheterization is also required to be signed prior to the actual procedure. It may be signed by the patient or an authorized guardian if he is unable to give consent.

Prior to Insertion

Prior to inserting the catheter, the nurse must prepare the following materials to be used in the procedure: sterile gloves, catheterization kit, cleaning solution, water-based lubricant (if not included in the kit), prefilled syringe for balloon inflation based on catheter size, foley catheter and urine bag. The following tips should also be remembered:

1. Perform hand washing to reduce the risk of transferring infections.
2. Assess the patients’ room/environment thoroughly to determine appropriate lighting, need for privacy and other additional precautions.
3. Confirm the patient’s identity and explain the procedure and how he can cooperate with the process.
4. Prepare the necessary materials for easier access during the insertion of the catheter.
5. Inflate the balloon using a syringe before use to determine the patency of the balloon. Aspirate the fluid back into the syringe and set it aside.
6. Prepare the necessary materials to be used in a sterile field.

During Insertion

The table below presents the steps to be followed in catheter insertion with the rationale for each action.

After Insertion

Ensure that the patient’s response to the procedure is appropriately monitored and that urine output is documented. Ensure also that the urine bag and insertion sites are free from obstructions, and if there is a need to replace any part of the system.

Once the goal of the catheterization is met, its removal is expected to be ordered since prolonged use of the catheter may place the patient at an increased risk of developing infections. Preferably, catheters should be removed within 24 hours.

Patients require an order to have an indwelling catheter removed. Although the order is necessary, the health care provider’s responsibility is to evaluate if the indwelling catheter is required for the patient’s recovery. Removal of the catheter should be done after assessing whether the patient’s bladder function has returned and any untoward responses to the therapy should be reported to the physician. These symptoms include:

• Hematuria
• Inability or difficulty in voiding
• Incontinence after catheter removal
• Signs of infection such as pain upon urination, fever, and chills

Moreover, the nurse should also include in the patient education the expected symptoms after catheter removal, such as mild burning sensation immediately after removal. Also, patients should receive the following instructions while on catheter:

• Increase fluid intake to at least 3000ml per day unless contraindicated
• Bladder training, if needed: instruct the patient to void when he can do so and to make sure that he empties his bladder within 6 hours of catheter removal.
• Take note of the first voided urine characteristics and report these to the health care provider: color, volume, sensation upon urination, and any abnormality in smell and transparency.
• Report any pain, burning sensation, or blood tinged-urine
• Inform the nurse or other members of the health team of any signs indicating catheter-acquired urinary tract infection

Removing the Catheter

The table below presents the steps to be followed in the insertion of the catheter with the rationale for each action.

References

1. Basavanthappa, B., (2015). Medical Surgical Nursing. New Delhi: Jaypee Brothers Medical Publishers.
2. Billings, D. and Hensel, D., 2019. Lippincott Q & A Review For NCLEX-RN. 13th ed. St. Louis, MO., USA.: Wolters Kluwer Medical.
3. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
4. Morton, P., & Fontaine, D. (2018). Critical Care Nursing. Wolters Kluwer.
5. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.