catheterisation... how many attemps until you call it quits?

[Skylar86]

I am a newgrad working in the ED (in my 3rd week). I have had previous experience as an EMT and also did a placement in ED as a 3rd year nursing student so I feel as if I am really getting the hang of things.

Last night we were extremely busy. My preceptor (i am in orientation for 6 weeks with her) was getting slammed at triage so the charge nurse asked me if I felt comfortable enough looking after 2 patients on my own. At this point I was feeling confident so I said yes, afterall how hard could two status 3/4 patients be?

Patient 1 (Suzy*)had a fractured hip and was awaiting a femoral nerve block before being transferred to the ortho ward... Patient 2 (Barb*) JUST arrived and was c/o L) leg pain/numbness/tingling (has had it for 3ish weeks) and all i had to do was just work her up (bloods/ECG/OBS/ etc..)

Just as I was starting to get a history from Barb, the other patient Suzy called me over saying she BADLY needed to go to the bathroom. I asked another nurse for help to put a bedpan underneath her but the pain was too much for Suzy... i then decided to give her PRN morphine and attempt to catheterise her. It was difficult since she couldnt open her legs but I tried anyways.. no luck.. the other RN tried 3 times after me with no luck. It was a horrible experience and I felt awful for Suzy... I am surprised she was able to hold her bladder for that long to be honest. I was getting a bit overwhelmed with how uncomfortable Suzy was and to make matters worse, one of the doctors called me over saying he needed Barb transferred immediately to get an MRI. Luckily the nurse who was helping me with the catheter told me to just finish what I was doing with Barb and that she would take over Suzy.

I am wondering what would I have done if i didnt receive help from that other nurse? Would i keep trying to catheterise her until i got it? Would i have just stuck a incont pad under her and told her to just go? I would normally reflect on this situation with my preceptor but we were too busy last night so I thought i'd get some other opinions on here.

[GleeGum, BSN, RN]

I would not try to cath more than twice and even the second time i would not do unless i had the patient's consent to try again and felt confident i could do it. yes, diaper or bedpan if no other option.

but giving you two patients on your own, in the ED, as a new grad, 3rd week in? that's not right. say no next time. this is the time to learn and absorb and do. otherwise they will as you again and you won't get the training you deserve.\

welcome to the ER! ( :

[Anna Flaxis, BSN, RN]

I don't think 2 noncritical/stable patients halfway through orientation is unreasonable, so long as you have someone you can go to for help if you need it.

Next time, once hip fracture is confirmed, just put the foley in. Don't wait until the person needs to void to address that need. That just puts extra pressure on you, and extra stress on the patient, who is trying to "hold it" while having you messing around down there. With a hip fracture, have them bend the unaffected knee and adduct away from the midline as much as they are able without too much discomfort (sometimes it's not much). Premedicating can be helpful. Having a second person to assist with positioning and with holding back tissue to expose the meatus can be helpful. Sometimes using sterile gauze 2x2s to hold the labia out of the way is really helpful. If you can visualize the meatus, it shouldn't take you more than one try. Sometimes you do have to go in blind, but you'll get better at that with experience.

[DixieRedHead, ASN, RN]

The single most valuable piece of advice that I can give you is do not attempt to put that catheter in until you can see the meatus. Get as much help as you need. It shouldn't take long. You know that catheter is going to have to go in at some point. So go ahead and put it in. It will give mental and physical relief to you patient to know they will neither have to void on themselves nor have the procedure done again.

If you have to do it more than once, well then, sometimes you just gotta do what you just gotta do

[Amanda.RN]

I never try more than twice. I would have had someone help hold open the nonfractured leg, someone hold a flashlight (if needed -- I've found this helpful), and attempt with a Coude cathetar. (If the patient is really heavy and/or has a pendulous abdomen, sometimes I have yet someone else hold back excess skin/fat.) If that's unsuccessful and the bedpan is too uncomfortable, an absorbant pad on the bed works just fine. Sometimes it's just impossible no matter what you do.

[RainMom]

One suggestion I've heard on my ortho floor is to put the pt in trendelenburg's if it is difficult to get the cath in. It may be due to a prolapse of the uterus or bladder & changing position allows you to put the cath right in. I've never had the chance to try this out yet though.

[VICEDRN, BSN, RN]

To address both of your thoughts:

I consider the foley policy to be the same as the failed stick policy. Two tries and I find another RN to help me.

Your other thought: the one where you wonder what would happen if you had to do it yourself: If you find yourself working in an ER where you can't ask other RNs to help you, then you are working in a bad spot. Most ER nurses that I have met are team oriented. You can always ask SOMEONE to help even if it means you take their vitals, discharge their patient or medicate someone while they try your foley.

You can also always ask someone just to "look" with you. I am a lefty and foley from the left. I don't know how many times I have seen what the righty hasn't been able to see.

Please please please reconsider the idea that you ever need to go it alone in the ER at any time, no matter how much experience you gain and if your ER just isn't team oriented, its the odd one, not the normal one.