Catheter Came out. Should I reinsert it?

Nurses General Nursing

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I was working overnight in a retirement home and it was reported to me that a patient had pulled out their catheter. When I went to assess them I noted that they had no output in the catheter bag and their urethra was bleeding. I drained the balloon to help relieve pressure, but I didn't take the catheter out because I was scared of causing more damage. I wanted to reinsert a new catheter but I wasn't sure if I was going to cause harm to the patient, so I decided to send them to the hospital. Please help, I'm not sure if I made the right choice, I know it's better that I was overly cautious by sending them, but I never like to send people to the hospital unless it is absolutely necessary. I didn't feel comfortable reinserting it but I had to do something. Did I make the right choice?!

OP-

This just sounds like a crappy work environment. No doc, no effective protocols. Even if you could reach your supervisor, you would still have no doc, no protocols. From a nursing perspective, you would have a peer expressing an opinion. At least, that's how we roll in the states.

I think you did the right thing. You are in a system that seems to be designed to hang you out to dry, and you shifted the responsibility.

As far as sending to the hospital to have the patient checked for damage? How? ER nurse here, and I see stuff like this- CYA transfers. I don't really think we would "check this out" very much. Assuming the foley is actually indicated, the choices are a foley or supra pubic tube. Sure, we might scan the bladder, but all that would really tell us whether they have an empty bladder, or are retaining. Is there some sort of test to assese whether the urethra is damaged to the point that a SP tube is indicated?

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Specializes in Geriatrics, Dialysis.

Wow, those policies are more than a little bonkers. If I am understanding this right there is no licensed provider on call for medical concerns after office hours? So it seems like your only option with any concern is send them out to the emergency room. Not very cost effective to say the least. In that case though, you absolutely did the right thing to send the patient out for further evaluation.

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Obviously you were not at the bedside when it happened so time is an issue. If you were in the hospital most places that I've worked would expect you to remove the one and insert another. Being in a nursing home is different so you were correct in sending them away since you had already exhausted your chain of command, I guess.

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You did the right thing in the end: never perform a procedure without a physician's order. If the patient is not in danger or acute distress, waiting for an order might be the safest thing for the patient. If the patient was catheterized for maintenence of incontinence vs for urinary retention for example, then just careplan them for Q2 urinary incontinence changes or whatever your policy is, and they are safe until the physician can make the decision. If it is just for incontinence then I would just use other nursing interventions to ensure they are safe from consequences of incontinence. Urinary rtn would be of urgent nature of course.

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I certainly think you made the right decision. You wouldn't want to reinsert the same foley bc it isn't sterile anymore. The hospital might have been a little much, but it was the safest option. She probably will she put on prophylactic antibiotics and have a new foley inserted.

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I certainly think you made the right decision. You wouldn't want to reinsert the same foley bc it isn't sterile anymore. The hospital might have been a little much, but it was the safest option. She probably will she put on prophylactic antibiotics and have a new foley inserted.

Nope. No antibiotics for a dislodged foley.

In all likelihood, I would get the patient from EMS. Ideally, I would get a nurse-to-nurse from the OP. Presumably, the foley is actually medically indicated. In that case, I would just re-insert the foley, using the exact same process as would be used in the nursing home. I would tell the doc my plan, and then call it a verbal order. Then, after doing what could have been done in the retirement home had the doc left reasonable PRN and protocols for this entirely predictable and unpreventable situation, I would send the patient back. We have actually done stuff like this on the EMS litter, and put them back in the same truck, but it kind of freaks the registration team out.

I can't think of an assessment a doc might do that a nurse can't do. Maybe there is one,

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Specializes in Med-Surg., LTC,, OB/GYN, L& D,, Office.
I have worked in skilled nursing in the US, and you generally can't call an on-call MD for Foley problems. What you didn't include in your original question is other assessment data: What was his output in the last shift? Why does he have the Foley? Any bladder distention? Any discomfort? You may want to flush the Foley next time, to make sure it's patent. If you have access to a bladder scanner that would be a helpful tool. You also don't mention if there is an order to reinsert the Foley if it becomes dislodged or clogged. This might be helpful in the future.

EXCELLENT OBSERVATIONS...also, the gauge and balloon inflation amount, of a latex or silicone catheter, male or female, the original reason for the indwelling catheter could also shed some light on the action needed.

There is also a remote a possibility the catheter may not have been inserted properly from the onset or was pulled down into the shaft, where over a period of time set up some local irritation to which the resident reacted by pulling it out.

In past experience the physician/or urologist advised reinsertion as it was thought to apply mild pressure to a tear in the mucosa and keep from occlusion.

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This is for long term care, I work in retirement which is separate in Ontario. Although I do have another job in LTC and at night there is no on call physician so there must be some kind of loop hole.

I think doctors often enough just turn off their phones at night. While I understand they want some sleep, it should be illegal to just be unavailable. Same with your unavailable Nurse Director or whatever her title is.

And if these people make themselves unavailable, decision-making is on you. Fine. You made an apparently safe decision.

I don't know what I would have done. First you said the pt had pulled out the cath, then you said you deflated the balloon, so it sounds like the cath was still in, which you later stated was so.

Why the cath didn't slip out after deflation? I guess there was swelling in the urethra. Poor patient has probably had the darned cath forever and likely has a UTI, with associated pain, itching,burning, thus was pulling on it.

Where do things stand now?

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Of course they have a doctor, but the doctor only comes once a week and if it is not urgent, I usually leave a note for the doctor to assess them when they come in. Sorry what does PCP stand for? And the doctor is not on call, so if somethings happens it is often based solely on my judgement. (which can be a lot of pressure) The only person I can call for advice (which doesn't mean they can order me to re insert the catheter, or order medications) is my boss who is a nurse as well, and they often don't answer the phone.

Do you think there should be consequences for her not being available? Is she legally supposed to be available 24/7? If so, she should be flogged.

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I too have had a resident who frequently pulled his catheter due to dementia issues. We had asked for an order to reinsert however, provider specifically denied it stating he wants him sent out each time due to possible urethral damage, etc.

My only question for you is did you have an order? Because if you didn't have one for reinsertion you absolutely risk your license if you DID NOT send the resident out. Also, make sure you have orders to change and flush.

My previous job was also 1 nurse for a building with 500 residents. My immediate charge was the health center and memory care which total about 50 residents, then 2 floors of assisted living above that. The rest were independent residents in the same building, and a seperate apartment housing unit on the property. You definitely need to know your scope, and dont hesitate to call 911. We in fact had also lost our MD on call. So for at least 6 months there was no doctor to visit or take call. This isnt all that uncommon, but a reason highly skilled and experienced nurses be employed. Dont be afraid to learn, grow, and ask for help. The nurse that doesnt ask for help has a dead patient on their hands!

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I too have had a resident who frequently pulled his catheter due to dementia issues. We had asked for an order to reinsert however, provider specifically denied it stating he wants him sent out each time due to possible urethral damage, etc.

My only question for you is did you have an order? Because if you didn't have one for reinsertion you absolutely risk your license if you DID NOT send the resident out. Also, make sure you have orders to change and flush.

My previous job was also 1 nurse for a building with 500 residents. My immediate charge was the health center and memory care which total about 50 residents, then 2 floors of assisted living above that. The rest were independent residents in the same building, and a seperate apartment housing unit on the property. You definitely need to know your scope, and dont hesitate to call 911. We in fact had also lost our MD on call. So for at least 6 months there was no doctor to visit or take call. This isnt all that uncommon, but a reason highly skilled and experienced nurses be employed. Dont be afraid to learn, grow, and ask for help. The nurse that doesnt ask for help has a dead patient on their hands!

How does a doc assess for urethral damage?

I have no idea of how many dislodged foleys I have replaced, and can't remember this happening.

Maybe it should have been.

What is the standard of care here?

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I know this is in Canada so things may be different, but I'm not understanding the amount of US nurses who think this is ok. Or who have never had a patient tug at their catheter and cause some blood. I would be in so much trouble and be side eyed for leaving a deflated catheter in the urethra.

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