N113 - Sterile Technique & Urinary Catheter

What direction would the nurse provide to unlicensed assistive personnel (UAP) while establishing and maintaining a sterile field?

"Remember, reaching over the sterile field constitutes a break in sterile technique." In assisting the nurse during the procedure, the UAP might reach over the field if not reminded that doing so would constitute a break in sterile technique. The nurse cannot delegate the establishment of a sterile field to UAP. The nurse cannot delegate the establishment of a sterile field to UAP.

Indications for Intermittent Catherization

- Bladder distension (e.g. urinary retention - COULD USE AN INTERMITTENT CATH INSTEAD) - above can be result of spinal cord injury, neuromuscular degeneration or incompetent bladders - pts can be taught how to perform self-catheterization - to obtain a sterile urine specimen when can't do "clean catch"

Reasons for urinary catheterization

- Neurogenic bladder - Strict I&Os monitoring urine output accurately in seriously ill patients (e.g. ICU) - Bladder distension (e.g. urinary retention - COULD USE AN INTERMITTENT CATH INSTEAD) - Urinary Obstruction - Hematuria with clots or GU procedure - Aid healing advanced pressure stage ulcer (III, Iv or unstageable) - Comfort/EOL care for dying pt - Post-op or laboring pt provides continuous urinary bladder drainage (decompresses the bladder) for example during a long surgery to prevent injury or complications related to surgeon nipping the bladder during the procedure.

INAPPROPRIATE Catheter Uses

- Urinary incontinence - Fall risk - Bedrest - w/o strict mobility limitations - Coma for all above use frequent cleaning, toileting and barrier products - Post Void Residual -PVR - use bladder scanner instead - to prevent UTI in pt with diarrhea - pt or family request for non-dying pt

Size of contaminated border around sterile fields

1 in

Steps to remove a foley catheter

1) Wash hands 2) wear clean gloves during removal 3) explain that this procedure is nearly always pain-free 4) instruct the patient to assume a supine position 5) place the catheter receptacle near the patient 6) place a towel or waterproof drape between the patients legs and up by the urethral meatus 7) Obtain a sterile specimen if needed. 8) Remove the tape or device securing the catheter to the patient. 9) Deflate the balloon completely by inserting a syringe into the balloon valve and aspirating the fluid. Verify that the total fluid volume has been removed by checking the balloon size written on the valve port. 10) Ask the patient to relax and take a few deep breaths as I slowly withdraw the catheter from the urethra. 11) Wrap the catheter in the towel or drape 12) Using warm water and a washcloth, cleanse the perineal area . rinse. 13) Measure the urine and then empty it in the toilet; discard the catheter, drainage tube, and collection bag in the biohazard waste. 14) Monitor for signs of infection

A 68 year old female patient is admitted for knee-replacement surgery with an expected hospital stay of 2 weeks. She has no known allergies. The physician has ordered an indwelling Foley catheter to be inserted preoperatively. Which catheter should you choose?

14 French, 5 mL ballon, latex catheter

If a patient's indwelling catheter is removed by 0900, the patient should be due to void by

1500-1700 (3:00-5:00PM)

A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The physician has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient?

16 French 5mL ballon

A 40-year-old male patient has been admitted for abdominal surgery. He has no history of prostate problems. The physician has ordered that the patient be catheterized. Which of the following would be an appropriate size catheter for this patient?

16 French, 10-mL balloon DEPENDS ON GENDER AND AGE The most common size for an indwelling catheter in adults is 14-16 Fr and a 10-mL balloon. Larger catheter diameters increase the risk for urethral trauma. However, larger sizes are used in special circumstances such as after urological surgery or in the presence of gross hematuria. Indwelling catheters come in a variety of balloon sizes from 3 mL (for a child) to 30 mL for CBI. The size of the balloon is usually printed on the catheter port. The recommended balloon size for an adult is a 10-mL balloon (the balloon is 5 ml and requires 10 mL to fill completely). Long-term use of larger balloons (30 mL) has been associated with increased patient discomfort, irritation and trauma to the urethra, increased risk of catheter expulsion, and incomplete emptying of the bladder resulting from urine that pools below the level of the catheter drainage eyes

Conversion of cm to in

2.5 cm to 1 in

Amount of mL that trigger "normal" urge to void

250-300mL might be urinary retention if cannot void at this point

What is the recommended amount of time to leave the catheter clamped when obtaining a urine specimen from an indwelling catheter?

30 mins

A male patient with back and lower abdominal injuries from a motor vehicle accident is unable to void. His physician has requested the insertion of a catheter to determine the amount of residual urine and possibly to assist him with voiding. What type of urinary catheter should the nurse anticipate using?

A foley catheter

Which of the following are true regarding the impact of aging related to urinary elimination?

Aging can affect continence if the patient experiences impaired mobility or decreased muscle tone; The elderly are at increased risk of UTI because of retained urine in the bladder

The nurse is catheterizing a male patient and obtains a clear amber urine return. As the nurse begins to inflate the balloon the patient complains of pain and resistance is felt. What is the nurse's best action?

Allow fluid to flow back into syringe, and advance the catheter a little more before attempting to reinflate

Patient is an incontinent male who empties his bladder fully

Apply condom catheter

You are inserting an indwelling Foley catheter in a male patient. You have asked the patient to bear down as if to void, and you slowly insert the catheter through the urethral meatus. You advance the catheter and meet resistance. What is your best initial action at this time?

Ask the patient to take slow deep breaths while you insert the catheter slowly

A patient who is 48 hours post Foley insertion is running a low-grade fever and complains of lower abdominal discomfort, and his urine appears cloudy. The NAP states that his urine had a foul odor when his drainage bag was emptied. Which of the following would be an appropriate nursing action?

Assess the patient for back or flank pain; obtain a physician's order then obtain a sterile urine specimen for culture and sensitivity

The nursing assistive personnel (NAP) reports leakage around a patient's urinary catheter. What action should the nurse take first?

Attempt to reinflate the ballon

Which protocol does not vary among institutions?

By definition, a procedure is not sterile if sterile gloves are not worn. Many, but not all, health care institutions prohibit artificial nails and extenders in clinical areas. In some settings, nurses are allowed to cover open lesions with a sterile, impervious, transparent dressing. In other settings, the presence of such a lesion may prevent the nurse from participating in a sterile procedure. Review your agency's policy before performing a sterile procedure. Sterile gloves are available in various sizes, such as 6½ and 7. The availability of gloves will vary among institutions.

CAUTI

Catheter associated urinary tract infection is an infection involving any part of the urinary system, including urethra, bladder, ureters, and kidney teaching to prevent: good pericare don't want it overfilled keep it level lower than the bladder monitor for signs of UTI - cloudy urine, burning, pain

The nurse has been called to make a home visit to a patient with a history of a spinal cord injury and an indwelling Foley catheter. The patient appears diaphoretic and his face is flushed. The nurse takes the patient's vital signs with the following results: Temperature 98.4°F, pulse 54, respirations 20 and blood pressure 160/100. The patient's head of the bed is elevated. What action should the nurse take next?

Check for any kinks in catheter tubing

Step 1 for collecting a urine sample from an indwelling catheter

Clamp the drainage tubing below the sampling port of the catheter for 30 minutes. Apply gloves, cleanse the sampling port with a disinfectant swab, and allow to dry

Asepsis

Clean technique; involves procedures and practices that reduce the number and transfer of pathogens and microorganisms (hand washing, wearing gloves)

Catheter leaks after insertion

Consider catheter too small, balloon deflated, or catheter has slipped out of bladder

While attempting to perform a straight catheterization for a male patient, the nurse advances the catheter 3 to 4 inches into the meatus but observes no urine flow. Which action would the nurse take at this time?

Continue to advance the catheter until 5 to 7 inches of the catheter tube has been introduced into the urethra. The male urethra may be longer than 3 to 4 inches.

Which of the following demonstrate that further teaching is required to prevent an infection related to being catheterized? Select all that apply.

Correct! As a patient is being transferred in a wheelchair, he places the drainage bag in his lap. Correct! The unlicensed assistive personnel (UAP) places a patient's drainage bag on a lowered side rail or on the floor. Correct! An elderly female carries her urinary drainage bag like a purse under her arm as she ambulates. The urinary drainage bag should be kept below the level of the bladder to prevent reflux of urine into the bladder. Patients should be instructed to carry the drainage bag below the level of the bladder, and to secure the drainage bag to the side of the wheelchair below the level of the bladder during transfer. The urinary drainage bag should never be placed on a bedside rail because it could accidentally be raised to a height higher than the level of the bladder and urine could reflux into the bladder. The urinary drainage bag should never be placed on the floor; this is to avoid having bacteria enter the system through the drainage port. If allowed, fluids should be encouraged. The catheter should be secured to the patient in order to prevent trauma to the urethra. Swelling of tissues can impair urine flow and place the patient at further risk for urinary tract infection.

A nursing student is watching a nurse catheterize a female patient with an indwelling catheter. Which of the following, if it occurs, indicates a break in sterile technique? (Select all that apply.)

Correct!The nurse lubricates the catheter and places it back into the sterile tray when it uncoils and touches the bed. Correct! After the nurse cleans the labia, the labia become slippery and closes as the nurse attempts to obtain a clear view of the urethra. Correct! The nurse inserts the urinary catheter, and when urine does not return, the nurse removes the catheter and makes a second attempt to locate the urethra with the same catheter. You should never use the same catheter to attempt an insertion a second time because the catheter is contaminated. You should leave the first catheter in the vagina as a landmark and insert another sterile catheter. If the catheter touches the bed, you should obtain a new sterile catheter because the first one has become contaminated. If closure of the labia occurs during cleansing, the cleansing procedure should be repeated because the area has become contaminated. Once urine appears, you should advance the catheter to ensure bladder placement. The nurse is correct in releasing the labia and holding onto the catheter with the nondominant hand, because bladder or sphincter contraction may cause accidental expulsion of the catheter. The dominant hand is used to inflate the balloon of the catheter. The nurse also used the correct technique in cleansing the area.

Step 4 for collecting a urine sample from an indwelling catheter

Document the collection of the specimen

Urine output from Foley catheter is less than 30 mL per hour

Ensure tubing/catheter is kink free then assess patient for renal failure or severe dehydration

Identify the indicators of a UTI

Fever, Complaints of pain, Abdominal pressure and discomfort, cloudiness of the urine

Scale used to describe the diameter of the lumen of a catheter

French usually 14-16 for an adult smaller and larger in specific circumstances

Difference b/w "French" tubing measurement and PIV/needle G measurement

French (ng tubes; catheters) goes in correct numerical order from lowest to highest (e.g., 14 is small, 20 is larger) PIV tubing measurement is inverse smaller numbers are larger in diameter

Step 2 for collecting a urine sample from an indwelling catheter

Insert a 21-gauge, 1-inch needle attached to a 3- or 20-mL syringe into the center of the sampling port, or a 3- or 20- mL leurlok syringe to a needleless port. Draw the correct amount of urine into the syringe (3 mL or 20 mL).

After applying sterile gloves, the patient states she is uncomfortable and would like to move to her left side. What is the best way for the nurse to keep the gloves sterile while waiting for unlicensed assistive personnel (UAP) to position the patient for a sterile dressing change?

Interlocking the fingers and keeping the hands above waist level Once the gloves have been applied, the fingers should be interlocked and held in front of the body above waist level. This position is not appropriate sterile technique. Leaving the room is not appropriate; the nurse will stay in the treatment area after gloving. Stepping back from the bedside and other traffic areas is prudent, since turbulent air can contaminate gloves, but it is not the most important step the nurse can take to keep gloves sterile.

A nurse is explaining the procedure for inserting an indwelling urinary catheter. Which of the following explanations regarding the anchoring of the catheter would be most accurate?

It is important to anchor the catheter tubing to minimize the risk for urethral trauma, bladder spasms from traction, and to prevent accidental dislodgement

You are teaching the male patient and family caregiver about the advantages of a condom catheter. Which of the following would you include in the teaching?

It is relatively safe and noninvasive; It is a convenient method of draining urine; It is used for male patients who are incontinent; It carries less risk of developing a UTI than an indwelling catheter

Match the unexpected outcome with the probable cause: Unable to advance catheter into bladder: Enlarged prostate After catheter insertion and urine return, patient continues complaining of discomfort: Spasm, bladder infection, or injury to the urinary tract Lack of urine: Catheter in urethra (not bladder) or catheter in the vagina

Lack of urine may be due to the bladder being empty, to renal failure, or to urinary tract obstruction. A common cause is that the catheter is misplaced; that is, the catheter is in the urethra but outside of the bladder, or the catheter is in the vagina rather than in the urethra. Inability to advance the catheter is caused by urethral obstruction such as an enlarged prostate in the male patient. Bladder discomfort may be caused by spasm, infection, or injury to the urinary tract.

Complete the following statements with the dropdown menu selections:

On a MALE patient: The patient should be positioned in "supine position, with legs extended and thighs slightly abducted" The shaft of the penis should be held at a "90°" angle to body. The catheter should be lubricated "5-7 inches" . The urethral meatus should be cleansed "3" times, using "circular strokes, beginning at the meatus and working outward in spiral pattern" The catheter should be inserted until urine is seen and then "to the bifurcation". On a FEMALE patient: The patient should be positioned in "dorsal recumbent position" The catheter should be lubricated "1-2 inches" The urethral meatus should be cleansed from clitoris toward the anus in the following sequence: "far labial fold", "near labial fold" The catheter should be inserted until urine is seen and then "additional 1-2 inches"

Which action is the most important step the nurse can take to keep the field sterile when using an overbed table as the work surface for a sterile field?

Position the height of the table to be above waist level. To remain sterile, the field must be above the level of the waist. Anything below waist level is considered contaminated. Although positioning the table out of the patient's reach is prudent, it is not the most important step the nurse can take to keep the field sterile. Although assessing the stability of the table is prudent, doing so pertains to safety, not sterile technique. Although assembling the necessary additional supplies ahead of time is prudent, this step is unrelated to the use of the overbed table as the work surface for the sterile field.

What is the most important step the nurse can take to minimize the risk of tearing a sterile glove when applying it to the hands?

Selecting the proper glove size Improper glove size is the leading cause of glove tears. Most sterile gloves are powdered. Since using unpowdered gloves is usually not an option, using powdered gloves does not reduce the risk of tearing a sterile glove. Keeping the fingernails well trimmed and smoothly filed is prudent, but it is not the most important step the nurse can take to reduce the risk of tearing a glove. Drying the hands thoroughly before applying gloves is prudent, but it is not the most important step the nurse can take to reduce the risk of glove tears.

A patient requires all of the following interventions. Which one would the nurse perform last? Position the patient for maximum comfort and ease of breathing. Correct! Change the dressing on the patient's newly established suprapubic catheter. Offer the patient a bedpan. Administer the patient's prescribed medication.

Since this a sterile procedure, the nurse will address the patient's oxygen requirements and his or her comfort and elimination needs prior to completing the procedure. The nurse will also complete priority tasks such as medication administration before establishing a sterile field.

When adding a sterile liquid to a sterile field, which action will contaminate the field?

Sterile technique requires that you avoid reaching over the sterile field as you introduce supplies. Holding the bottle with the label side facing the palm will not contaminate the sterile field. The liquid has not yet expired and therefore will not contaminate the sterile field. Placing the receptacle 1 inch from the edge of the sterile field will not contaminate the field.

The unlicensed assistive personnel (UAP) is helping the nurse insert a Foley catheter on a male patient. In which position should the UAP place the patient?

Supine with legs slightly abducted Sim's position would be appropriate for a female patient with mobility limitations or for a male who cannot lie flat. The dorsal recumbent position would be appropriate for catheterizing a female patient. Legs adducted means that the patient's legs are together. The appropriate position for catheterizing a male patient is supine with the legs slightly abducted.

The NAP documents "Peri-care given" next to "Urinary Catheter" on a patient with an indwelling urinary catheter. What is the best explanation of what the NAP did after application of clean gloves?

The NAP stabilized the catheter and washed the catheter with soap and water from where the catheter enters the meatus down 4 inches toward the drainage tubing.

Identify the reasons why a patient with an indwelling catheter may have less than 30 mL per hour of urine in the collection bag

The catheter has slipped out of the bladder; The patient is severely dehydrated; The patient's kidneys are damaged or injured

What is the best reason for a nurse to select a prepackaged sterile kit for a sterile procedure?

The wrapper of the sterile kit can be used as a sterile field. The container is designed to provide a readily accessible sterile field. Sterile kits do expire and the nurse should check the date prior to use. The kit may be outdated or its integrity compromised. Adding supplies to a sterile field can be time consuming and there is a high risk of contamination. Although a prepackaged kit may be more compact, space usage on the bedside table is not the top priority.

A patient had an indwelling catheter for 3 weeks. The patient had the catheter removed 3 hours ago and now complains of having to go to the bathroom frequently and that it is painful to void. Which instruction is appropriate for you to give the patient?

This is a normal occurrence after having a catheter in place for more than several days

Step 3 for collecting a urine sample from an indwelling catheter

Transfer the urine to the appropriate container. Place the lid on the container. Unclamp the catheter. Discard the gloves and used supplies; perform hand hygiene; attach the identification label to the container and complete the requisition; send the sample to the lab in a biohazard bag.

Genitourinary Assessment: WDL v. NWDL

WDL GU Symptoms Continent Urine Color Yellow Pale/Straw Amber Urine Odor Normal/Non-odorous Urine Clarity Clear Urine Amount Quantity sufficient Drains None NWDL Occasionally incontinent Continuously incontinent Burning Dysuria Frequency Urgency Retention Nocturia Other: Urine Color Pink Bright Red Dark brown Other: Urine Odor Foul Sweet Urine Clarity Cloudy Sediment Clots Urine Amount Polyuria Oliguria Anuria Drains Indwelling urinary catheter External urinary collection device Intermittent urinary catheter

A 53-year-old patient is being treated for hypertension and a history of thrombophlebitis (blood clots). She comes to the clinic complaining, "I have to get up all night to go to the bathroom, and I think my urine looks orange!" What is your best response?

What medications are you taking and when?

When are sterile nonlatex gloves recommended for a sterile procedure?

When there is a possible sensitivity issue The possibility of a serious allergic reaction to latex necessitates the use of nonlatex gloves when the patient or nurse is sensitive to latex.

Bladder Scanner

a noninvasive device that creates an ultrasound image of the bladder for measuring the volume of urine in the bladder; use it to assess bladder volume whenever inadequate bladder emptying is suspected - such as after the removal of a catheter, evaluation of incontinence, or after urologic surgery if volume is > 350 mL insert a straight cath or call the provider

Height of sterile field

above the waist

How sterile fields become contaminated

air turbulence long exposure to air capillary action gravity

Prostrate Gland

along w/ seminal fluid and bulbourethral gland, seminal fluid is produced through this gives fluid mildly alkaline properties => survive relative acidity of female reproductive tract enlarged => surrounds urethra => urinary freq. and urgency

Three Way Catheter

also called a triple lumen catheter - used only after a male patient has had a transurethral resection of the prostate - allows instillation of sterile fluid into the bladder during continuous bladder irrigation

Where on a sterile field may a sterile, gloved hand touch?

anywhere

COCA

color, odor, consistency, amount assessment of urine

Coude Catheter

curved and has a rounded or bulbous tip that is easier to insert into the male urethra when the prostate is enlarged. (usually inserted by urologist)

What do you do if the sterile gloves are not packed in the top of the catheter kit?

don sterile gloves, use those gloves to put on new sterol gloves

Post-op indwelling catheter must be removed by

end of POD #2

Nurse position relative to sterile field

frontal never turn back on sterile field

How should you open the first flap of a sterile tray?

grasp the edge of the outermost flap and open the package away from you toward the back side of the table this prevents you reaching across the sterile field and contaminating it

Where can an ungloved hand touch on a sterile field?

no where

Surgical asepsis (sterile technique)

procedures to completely eliminate the presence of pathogens from objects and areas

Post Void Residual (PVR)

the amount of urine remaining in the bladder immediately after voiding

Amount of time after indwelling catheter removal it is appropriate for pt to void on their own

w/in 6-8h after foley removal