Mini cath on peds

amzyRN · May 5, 2018

That doesn't seem right to me either. It's such a traumatic experience for everyone involved. The doctors at my last hospital would only make a cath required if absolutely necessary where the risks clearly outweighted the benefits. Maybe go to your manager and ask why you don't have Ubags available.

PeakRN · May 5, 2018

It depends on what you are looking for, but generally speaking U-Bags are a poor choice in the ED.

If we are performing any kind of serious work up on a high risk patient (be it neonates/infants less than 30 days, oncology patients, transplant patients, et cetera) they should not only have a UA but also a culture regardless of UA results, an early UTI would be devastating for these kids. Urine bags should never be cultured, it is not appropriate and leads to false culture results that end up in unnecessary risk from unwarranted antibiotics.

If we are just checking a UA on a trauma patient to ensure that they are not having any hematuria or checking a Ph during a course of chemo then a U-Bag is okay, but these are far from the majority of cases in the Peds ED.

There was some recent literature that suggested that placing a cool wash cloth and applying super-pubic pressure was reducing caths by 50% while still providing a clean mid stream catch. I have tried this and not found huge success, however it is certainly an alternative option.

The foreskin should never be forcefully retracted, however the urethral opening should be cleaned, and without any foreskin retraction this is not possible. If you are introducing a catheter into the urethra without cleaning correctly you are placing that child at risk of a UTI from your cath and is an unsafe practice.

A cath does not need to be especially traumatic, and I'm not sure why parents are stopping you halfway through, it shouldn't take that long. Cleaning is not painful (though the cold sensation might be uncomfortable), and once you are ready to insert the catheter it should take only a few seconds before you get urine. If nurses are unsure where the urethra is and are randomly poking at various areas that is of course painful, but also unnecessary and very poor practice. If kids have significant adhesions or phimosis that prohibits a catheterization then they should either be treated empirically or admitted, and should have a treatment for this as part of their care.

I think that a better way to look at catheterizations in the ED is like most other treatments we do for kids, they are often not pleasent but are performed to ensure safe and efficacious treatment. Suctioning, enemas, splints, LPs, IVs, most medications, and many other treatments are unpleasant however we perform them to help the patients. It would be inappropriate to avoid these treatments when they are indicated just because they are unpleasant or painful.

amzyRN · May 5, 2018

I've always had to have 2 additional nurses to hold a pediatric patient down who was kicking and screaming at the tops of their lungs when I've had to do caths. Most kids hate it and it is one of the worst tasks I've every had to do. That's just been my experience.

Editorial Team / Moderator · May 6, 2018

As Peak mentioned, UBag samples are not a true alternative to a cath urine - they often produce contaminated specimens, and that UA then provides zero value in deciding if you have determined a source of infection. Getting cath urines from children isn't always easy, but get plenty of holding help and ensure that you can visualize the anatomy before you proceed so that you decrease the poking and prodding. Like pediatric IVs, it takes practice, and in the same vein (no pun intended), children usually hate being held down more than they are protesting the procedure itself.

OldDude · May 6, 2018

Catch UAs are always hardest on the parents. But best for the patient's diagnosis and commencement of treatment; especially infants. Peak and Pixie summed it up well. We still us urine collection bags in the pedi Urgent Care I work in but very seldom. Thank goodness. Extends the visit and in many cases a waste of time.

CBlover, BSN, RN · May 6, 2018

Where I work, the doctor orders which one he/she wants. We don't get to choose, much less the parent.

JKL33 · May 6, 2018

Excellent response by Peak.

I don't know if this has been mentioned yet, but education before the procedure can be helpful for parents observing - - for instance, you probably have enough experience with peds now to have recognized that they are primarily traumatized by leaving their parents' arms and lying on the stretcher and having their movements restricted. If parents understand that developmentally this is likely what is going to happen, they can help soothe the child (if they wish), but they also have some baseline for not thinking of appropriate nursing care as "torture" - if I'm making sense. This is an even more important clarification given the nature of the procedure.

Next, yes, this can be one of the more difficult-to-accomplish things we need to do, but excellent technique and just the right amount of help make things go tremendously easier. My most helpful tip is to realize that vigorous crying/bearing down can literally prevent the catheter from being passed just the few mms more that it needs to go. Patience is key. Visualize the urethral meatus, place the catheter in the correct spot, and wait for a a deep breath to advance it. Second major tip - - use great care with the labia; that skin across the posterior fourchette can be friable. I much prefer to have a helper who uses sterile 2x2s under each thumb to press into (like, towards the head/cephalo) the labia, thereby gently opening them without traumatically "spreading" them. The 2x2s help with "grip" also - since any of you who have cathed female peds know how very slippery/rubbery the anatomy becomes while cleaning. Third tip - the person at the child's head (whether that be parent or staff) has the important job of keeping the shoulders from being able to slide towards the head of the stretcher (in other words, prevent child from using feet to push away from the person attempting the catheterization). Lastly, for the love of everything, don't forget excellent lighting.

The foreskin of intact male children should be very minimally retracted only to the slightest extent needed to cleanse the meatus. It is not okay for staff to not be educated about this, so talk to your mgr if you feel additional unit education is needed.

Good luck.

Ooh, one more thing: some collection devices are a tube with a cap through which the catheter extends. If that cap is on too tightly there will be a (?) pressure lock situation that won't allow urine to flow in even when the tube is in the correct place. Loosen cap slightly before beginning to prevent this.

UrbanHealthRN, BSN, RN · May 6, 2018

At a pediatric practice I once worked at, we had a baby go from UTI to urosepsis with ICU admission in a matter of about 8 hours. UTIs are no joke in infants and toddlers, and the gold standard for UTi identification is still UA/Urine culture from straight cath (or mid-stream clean catch, on the off chance a cold breeze startles them!)

Would parents hate to watch me straight cath their little ones? Absolutely. Did I ever feel bad about it? Never, because I was helping to keep their little ones safe and cared for. I always took the time to explain what I was going to do and emphasize that I would be as gentle as possible while obtaining a cath sample. The MDs also had a lot of confidence and trust in the UA and culture results we'd get from cath samples vs. bag samples, and the parents could see that as well.

I'm all for giving families a choice when it's available, but bag samples just aren't that great for accurate UTI detection, and so I don't believe it should be presented to families as a valid form of medical care for their little ones.

gemmi999 · May 7, 2018

The only time I've used ubags are when

1) I straight cath'd a kid but no urine output for whatever reason. I place the ubag until I try again in approx. 30 - 45 minutes, just in case they urinate in that time. It can be helpful for determining how dehydrated the kid is, etc.

2) Parent refuses straight cath

3) MD states he just wants a u-bag to see if kiddo is passing glucose or something in his/her urine

Otherwise, straight cath with extra urine cup at bedside because half the time when you're cleaning the kid, the kid ends up peeing and if you're lucky you can literally catch some mid stream.

amzyRN · May 7, 2018

How do you find the right spot in a female patient? I haven't ever been able to see it and have put the catheter in the wrong place before then I would know what wasn't the right spot but would have to do it twice. Honestly, I usually have somenone else do it (and I'll help hold a the shoulders or legs) because I hate it so much.

JKL33 · May 8, 2018

^

The best way to learn exactly where you're aiming is to have a very experienced person show you. It's often easier to see at the time of cleansing because you can use a tiny bit of pressure in your downward motion with the swabstick and see a peek of the urethral meatus. When you are ready to use the catheter, the approach is different than an adult female. It's neither a straight or upward approach, but almost better if you come from from above (not cephalo, but directly above) and angle ever-so-slightly towards the feet. I sometimes hold the catheter like a pencil so I can direct this precisely. I just checked and there are a couple of videos on YT ("Catheterization of the Urethra in Girls" - in that one, which I'm not linking, you can see around 6:10 exactly what I'm talking about; a tiny slightly darker area just above the lady partsl tissue which is the target. You can also take note of the way they hold and manipulate the catheter to see the approach I'm talking about).