Managing continence is one of the fundamental aspects of providing high quality nursing care.
Maintaining a person's continence needs can improve their quality of life significantly.
Many older people in residential care settings need support to manage their continence needs via the use of continence products and/or physical care from nurses and carers.
Long-term indwelling catheters are commonly utilised in community care settings; however, there are worrying statistics around the use of these devices.
Urinary tract infection (UTI) is the most common Healthcare Associated Infection (HCAI), accounting for 17.2% of all HCAIs, with around 50% of UTIs associated with an indwelling urethral catheter.
Patients with invasive devices such as urinary catheters are at a greater risk of developing an infection (NICE, 2012).
Long-term catheterisation carries a significant risk of symptomatic UTI, which can lead to serious complications such as blood stream infections (NICE, 2012).
The diagnosis of a Catheter Associated UTI increases the use of antibiotics, which will increase the burden, and development of antimicrobial resistance (DH, 2007).
Catheterisation is required if a person is unable to empty their bladder in the usual way.
Common reasons include:
- Retention, a full bladder and inability to pass urine
- Neurological conditions meaning the bladder function is impaired and the person is unable to void
- A catheter may be required to administer medication into the bladder, such as chemotherapy for bladder cancer
- An enlarged prostate may mean that a man is unable to void without a catheter insitu to bypass the obstruction
- Catheters may be inserted before surgery, and to measure output following surgery
- Catheters are often inserted if people are unconscious and receiving critical care
- Accurately measuring urine output in the acutely ill
- Relieve incontinence and maintain skin integrity after all conservative strategies have been attempted (RCN, 2012)
It is no longer acceptable to routinely catheterise for incontinence because it is convenient.
Long-term indwelling catheters carry high risks and should be avoided where possible.
Intermittent catheterisation is now considered best practice. Modern day intermittent catheterisation was introduced in the 70's as an alternative method of bladder emptying.
The concept of intermittent catheterisation is not new however. In ancient times people realised that they could insert reeds or straws into the urethra and empty their bladder.
Intermittent catheterisation can be performed by the person themselves or by someone trained to do so. This could be a nurse, carer or even carers in the community such as spouses.
Intermittent catheterisation involves inserting a sterile, single use catheter into the bladder and draining it as and when needed throughout the day.
Advantages of Intermittent Catheterisation
- If carried out independently it minimises dependency and improves self-care
- Reduces the risk of infection
- Eliminates the problem of catheter encrustation
- Improves body image
- Allows people to continue a sexual relationship
Limitations of Intermittent Catheterisation
Intermittent catheterisation is not possible for all people and is especially difficult in those with:
- Small bladder capacity
- Poor manual dexterity - being unable to carry catheterisation out independently, or finding it too painful to get into a suitable position
- Psychological barriers
- Being unable to maintain continence between catheterisation makes this method unsuitable
Indwelling catheters were not used regularly until the 1930's when Frederic Foley invented the Foley Catheter. Its design has changed very little since then.
The Foley Catheter is a thin sterile tube with a fluid filled balloon that holds the catheter in the bladder. The catheter comes in a shorter length for females and a longer length for males.
Males have a much longer urethra than females (around 20cms compared to 4cm) and it is dangerous to use a female length catheter for a man. The shorter urethra makes females far more prone to UTIs.
Shortly after inserting an indwelling catheter, colonisation of bacteria will occur and the person becomes at risk of infection.
The daily risk to catheterised patients of developing bacteriuria is 3-6% and cumulatively increases the longer the catheter remains in place (Pratt et al, 2007).
The overuse of antibiotics now means that there are few left to treat common infections, as many bacteria have become resistant to treatment.
Good Catheter Care
If an indwelling catheter is the only suitable option, then caregivers need to ensure that they are appropriately maintained in order to reduce the risk of complications.
It is important that nurses use an aseptic technique when performing a catheterisation.
Once the catheter is inserted it is important to maintain a closed system in order to minimise the risk of infections.
A closed system involves keeping breaks in the system to a minimum. Most drainage bags have taps and can be left intact for longer periods. It is important that a clean technique is used to empty a catheter drainage bag. They should ideally be emptied into a single use urinal which is then discarded.
Catheter bags should be kept below the level of the bladder to prevent any backflow of urine.
Good hygiene should be maintained to the catheter tubing and meatal area.
Catheter drainage bags should be secured properly to prevent damage to the urethra, especially in men where the meatal opening often becomes sore due to the catheter dragging.
There is no evidence demonstrating any beneficial effect of bladder irrigation, instillation or washout with a variety of antiseptic or antimicrobial agents in preventing CAUTI (Muncie et al, 1989; Saint and Lipsky, 1999; Kennedy et al).
Bladder washouts can be useful for people prone to encrustation where the catheter would otherwise become blocked and have to be replaced frequently.
The NMC Code of Professional Standards of Practice and Behaviour for Nurses and Midwives (2015) states that all nurses must maintain the knowledge and skills they need for safe and effective practice.
The code also highlights that nurses have a duty to keep their knowledge and skills up to date by taking part in appropriate and regular learning and professional development activities that aim to maintain and develop competence and improve performance.
It is best practice that people who perform catheterisation refresh their skills with an update every five years.