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Essential Nursing Care of the Critically Ill Patient 117

ESSENTIAL NURSING CARE: URINARY solution should be kept minimal, as it is a potentially
CATHETERISATION irritant chemical that can cause tissue damage: 50 mL is
Catheter insertion and maintenance should be under- as effective as 100 mL, and two sequential 50 mL wash-
taken by people adequately trained in the procedures. outs are more effective at removing encrustation than one
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Aseptic technique should be observed, and hands should 100 mL washout.
be washed immediately before and after catheter inser- Critically ill patients should be provided with appropriate
tion and any manipulation of the catheter or drainage information about their catheters and drainage system,
system. Protective clothing should be used in accordance according to their needs and ability to understand. The
with Standard Precautions guidelines (see Infection control drainage system should be simple to operate with one
later this chapter). hand, easy to position, and the tap should have an open–
close device. Contamination of the outlet must be avoided
The urine drainage system should be sterile and continu- and alcohol-based sprays may be used to decontaminate
ously closed with an outlet designed to avoid contamina- the outlet (inside and outside) before and after emptying.
tion. It should have a sample port for taking urine An aseptic technique and sterile equipment must be used
samples. If possible and appropriate, patients should be when taking a urine sample via the sample port. The
given a choice of system appropriate to their needs: for sample port should be cleaned with an alcohol wipe for
example, a shorter drainage tube with a leg-bag may be 30 seconds before and after sampling. Urine samples
more comfortable for a patient who is mobile.
should be taken on clinical need and must be refrigerated
Catheter Maintenance if more than 1 hour is expected to elapse before the speci-
men reaches the laboratory.
The continued need for a urinary catheter should be
assessed on a daily basis. Daily reminders by nursing staff The whole drainage system should be maintained with
to doctors results in shorter duration of catheter insertion, patient comfort in mind, and care should be taken to
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with a lower associated infection rate. The introduction ensure that the patient is not lying on the drainage tube,
of criteria that enable registered nurses to remove cathe- which can cause pressure sores and blockage. Further-
ters without a doctor’s order may result in a significant more, the catheter itself should be positioned so that it
reduction in catheter-related infections. Penile meatal is not pulling on the urethra or kinked. The drainage bag
care with soap and water 104,106 should be performed at should be kept below the level of the bladder at all times
appropriate intervals for patient comfort and to keep the to maintain an unobstructed flow of urine, and it should
meatus free of encrustation and contamination. Cleans- be emptied into a disinfected or single-use container. The
ing with antiseptic solution is not recommended and can drainage bag should be changed according to the manu-
lead to multi-resistant organism infection. facturer’s instructions, which is usually in the range of
5–7 days. In addition, it should be replaced if it is leaking
Urinary catheters should be changed according to clinical or whenever the catheter is changed.
need and with regard to the manufacturer’s guidelines,
and the closed drainage system should be broken only
for limited, clearly defined clinical reasons. Bladder
washout or irrigation should be performed only for a Practice tip
specific clinical reason, for example catheter blockage or
high risk of blood clot formation, and should not be Using a catheter support bandage on the leg to secure the
considered as routine practice. A variety of solutions may urinary catheter can assist with comfort by minimising tension
be used for washouts (see Table 6.11) although research and irritation from catheter movement, promote effective
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in this area is limited. The volume of bladder washout drainage and in the restless patients may prevent accidental
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catheter removal as well.
TABLE 6.11 Solutions used for bladder washouts
BARIATRIC CONSIDERATIONS
Solution Indication Obesity is known to be a major health issue around
Sodium For the removal of small pieces of debris. Effect the world. While many bariatric patients will present to
chloride 9% is purely mechanical. May be used as hospital with various health issues, obesity has its own
required. physiological impact to be considered also, such as
Citric acid Used to dissolve encrustations. Aids impaired chest expansion and respiration from a large
3.23% reacidification of urine. May be used up to abdomen or insulin resistance related to altered glucose
(Solution G) twice daily. metabolism. 110,111 Close glucose monitoring regimens
Citric acid 6% Used to unblock an encrusted catheter. Can be should be implemented and appropriately calculated
(Solution R) used before removal to reduce trauma from dosages for medications be prescribed. Adapted tech-
encrustation. May be used up to twice daily. niques to enhance patient assessment may be required,
Chlorhexidine Used to reduce bacterial growth in the bladder, such as auscultating over the left lateral chest wall to hear
0.02% though research does not support its use. heart sounds while the patient is positioned towards their
May lead to the development of resistant left side or using a thigh or regular blood pressure cuff
organisms.
on the patient’s forearm. 110