foley catheter placement question

EastCoast · Nov 3, 2003

i'd go with the urologist.

traumatic foley.

i am often called for new onset hematuria/clot retention.

what i find is that the foley is not inserted all the way. the balloon is inflated somewhere between the urethra and the prostate.

as a rule of thumb i will tell nurses to insert foley all the way to the junction of the foley, inflate and then begin to pull foley back to position.

clot retention is a nightmare. if it happens during foley insertion it is generally not a patient issue but an operator issue.

this is not to say the patient may not have a prostate issue. however, generally with an enlarged prostate there is some difficulty inserting the foley and you did not indicate the nurse had trouble.

PCT needs to learn how to put foley's in better.

Hellllllo Nurse, BSN, RN · Nov 4, 2003

Better yet- only licensed personnel should be inserting foleys.

rileygrl11, BSN, RN · Nov 4, 2003

I got an update today from another RN,.....seems the PCT DID inflate the balloon in the pt's urethra :eek: All you-know-what broke out b/c urologist was furious (as he should be). He is trying to change our policy that only licensed personnel can insert foley's at our hospital. I have to agree with him. Thanks for the posts!

BLESSEDX5 · Sep 21, 2007

when it comes to catheters I know more than I want to, For 34 years I have been jamming one into myself. When you get carried away and push it all the way its like being stuck with a dull blade. [iT HURTS BAD] 2 months ago my psa test came back real High they first did a new test sending it out of state,then they put me in and took 30 by even today I see fire when I put in the catheter and still having lots of blood and they say it take time.

diabo, RN · Sep 23, 2007

What in the world is a PCT doing inserting a catheter? Absolutely a no no. Yeah I've worked in places that allow it, but if something happens, like in this case, the one with the license will be the one that is sued. PCTs don't have the knowledge of the anatomy that nurses do and should'nt be doing ANY invasive procedures.

81Bubbles, BSN, RN · Sep 28, 2007

Where I work there are no PCT's placing catheters it's considered an invasive procedure and is out of their scope.

caroladybelle, BSN, RN · Sep 28, 2007

Did this patient have chemo recently?

In particular with "liquid tumors" (leukemia/lymphomas), the treatments involve more neutropenias and thrombocytopenias. As such, we stay away from caths, especially foleys d/t much higher risk for bleeding/infection in these patients.

The other is that some of the treatments can predispose patients for development of hemmorrhagic cystitis d/t chemo and hematuria d/t BK virus. Though this is more common with leukemia/BMT cases.

If done, you really want someone with perfect sterile technique and that is very careful.

DeLana_RN, BSN, RN · Sep 28, 2007

caroladybelle,

thanks for explaining this, I was wondering. Not long ago, I and another acute dialysis nurse had a 58 y/o pt in the ER who had AML; his chemo had caused acute renal failure. The attending had NOT ordered a Foley, but my colleague - who thinks she knows more than she does sometimes :uhoh3: - thought the pt (like many new acute kidney failure pts) should have a Foley. So she got an order from the nephrologist (not the oncologist) to put one in.

However, she was unable to insert the Foley - the pt had too much pain. He denied having any prostate problems. Coworker got on the phone and got a urology consult for Foley placement.

Later, I wondered if this pt should have ever gotten a Foley - and thought the oncologist might be furious once he found out (I don't know if this happened, I've been on vacation since then).

Thanks for clarifying this.

DeLana

diabo, RN · Sep 28, 2007

The nephrologist really shouldn't give phone orders without fist assessing the patient. I don't take them unless I know the doctor is already familar with the case, and even then he shouldn't give orders outside of basic routine ones. It's the doctor's job to assess the situation, not the nurse. Lots of doctors want you to do their leg work only to chew you out later if they don't agree.

caroladybelle, BSN, RN · Sep 28, 2007

caroladybelle,
thanks for explaining this, I was wondering. Not long ago, I and another acute dialysis nurse had a 58 y/o pt in the ER who had AML; his chemo had caused acute renal failure. The attending had NOT ordered a Foley, but my colleague - who thinks she knows more than she does sometimes - thought the pt (like many new acute kidney failure pts) should have a Foley. So she got an order from the nephrologist (not the oncologist) to put one in.

AML patients are rather unique. Since one can not surgically remove "the tumor". nor radiate it....chemo is the only weapon and used to the Nth degree. And since the cancer is involving the bone marrow, the treatments pretty much clear out the bone marrow. The patient will be transfusion dependent for a week to several weeks....with refractory/relapsed patients and some newer drugs, for monthes.

Also, with AML, chemo is different than for solid tumors. With solids, you may operate, may radiate, and may give chemo over a matter of weeks/monthes. There is limited, better controlled tumor cell destruction. The body has increased time to breakdown the destroyed cells, resources to recycle the byproducts, using up the excess potassium, phosphates, etc. With AML, we have to try to take out the WHOLE tumor burden with the first round of chemo....and there is (if it works) a much more massive cellular destruction, pouring huge amounts of byproducts into the body to be processed over a much shorter period time. When these accumulate, it is called Tumor Lysis Syndrome, and while it can occur with any cancer and it can occur without chemo (due to the innate instability of cancer cells - they can lysis spontaneously), it is most common w/leukemias and lymphomas. And then many of them have acure renal insufficiency and require dialysis. I have worked with drugs in some research units that the patients temporarily required CVVHD within hours of getting some high level chemos. TLS is probably what occurred with your AML.

Risk factors include very high WBC counts, especially if accompanied by high percentages of blasts (defective WBCs produced in leukemia - known as "blast crisis") and a higher than normal LDH (occurs often when certain cancer cells have greater activity). Also recent CT scans with IV contrast, and preexisting renal failure. When the major dose of chemo hits the elevated number of highly active cancerous cells, especially when reproducing rapidly, the fallout of byproducts can be major.

Within 7-10 days of the start of the chemo the patient becomes pancytopenic, and very prone to infection. And while we can transfuse platelets and RBCs, this is not something easily done with granulocytes/WBCs...quite risky and often more dangerous than doing without for a while. And neupogen is usually contraindicated in AMLers. Cancer cells are the most rapid reproducing cells, so if you give a drug that mobilizes WBC production, if there are ANY cancerous cells left, you may trigger them to reproduce. Thus the immunosuppression for these patients is more severe than most chemo patients and will be extended.

The only times that I have seen foleys used in major teaching facilities for leukemics at risk for neutropenia (Johns Hopkins/NIH/etc.) has been when there was serious retention or massive hematuria needing a CBI. For retention, the MDs try to stick to straight cath. A male might have a condom cath, but foleys are a much more major infection risk than in the standard immunosuppressed patient.

Do you ever have to leucopherese (remove WBCs) from AMLers? That is to take down the WBC count to help prevent tumor lysis, when chemo starts.

DeLana_RN, BSN, RN · Sep 29, 2007

Also, with AML, chemo is different than for solid tumors. With solids, you may operate, may radiate, and may give chemo over a matter of weeks/monthes. There is limited, better controlled tumor cell destruction. The body has increased time to breakdown the destroyed cells, resources to recycle the byproducts, using up the excess potassium, phosphates, etc. With AML, we have to try to take out the WHOLE tumor burden with the first round of chemo....and there is (if it works) a much more massive cellular destruction, pouring huge amounts of byproducts into the body to be processed over a much shorter period time. When these accumulate, it is called Tumor Lysis Syndrome, and while it can occur with any cancer and it can occur without chemo (due to the innate instability of cancer cells - they can lysis spontaneously), it is most common w/leukemias and lymphomas. And then many of them have acure renal insufficiency and require dialysis. I have worked with drugs in some research units that the patients temporarily required CVVHD within hours of getting some high level chemos. TLS is probably what occurred with your AML.
Risk factors include very high WBC counts, especially if accompanied by high percentages of blasts (defective WBCs produced in leukemia - known as "blast crisis") and a higher than normal LDH (occurs often when certain cancer cells have greater activity). Also recent CT scans with IV contrast, and preexisting renal failure. When the major dose of chemo hits the elevated number of highly active cancerous cells, especially when reproducing rapidly, the fallout of byproducts can be major.
Within 7-10 days of the start of the chemo the patient becomes pancytopenic, and very prone to infection. And while we can transfuse platelets and RBCs, this is not something easily done with granulocytes/WBCs...quite risky and often more dangerous than doing without for a while. And neupogen is usually contraindicated in AMLers. Cancer cells are the most rapid reproducing cells, so if you give a drug that mobilizes WBC production, if there are ANY cancerous cells left, you may trigger them to reproduce. Thus the immunosuppression for these patients is more severe than most chemo patients and will be extended.
The only times that I have seen foleys used in major teaching facilities for leukemics at risk for neutropenia (Johns Hopkins/NIH/etc.) has been when there was serious retention or massive hematuria needing a CBI. For retention, the MDs try to stick to straight cath. A male might have a condom cath, but foleys are a much more major infection risk than in the standard immunosuppressed patient.
Do you ever have to leucopherese (remove WBCs) from AMLers? That is to take down the WBC count to help prevent tumor lysis, when chemo starts.

Thank you for your detailed explanation! Yes, TLS is exactly what happened to my pt (it was the oncologist's dx, and I read up on it after that; I used to work in oncology - it's my other passion (had a conflict with the head nurse and therefore didn't stay long when I was a new grad) - so I still have some reference books.

I'm sad to hear that the pt most definitely should not have gotten a Foley; I had suspected that (and my suspicion is that the nephrologist who gave the order - on the dialysis nurse's suggestion - was not sufficiently familiar with the pt's hx). I hope it didn't cause him any harm.

Regarding your question about leucopheresis: my dialysis unit does not do apheresis procecures (the local blood bank does that).

DeLana