need help with catheter insertion on a contracted alert patient

[hannaboo]

Hi all, I am in need of your advise regarding a patient who is extremely contracted, has severe rheumatoid arthritis and refuses to have her legs touched. Her legs are closed and to the side, which makes position changes highly uncomfortable and not a pleasant experience for both the patient and us, her caregiver. The patient who is only 31 years old is alert and oriented x 4, she cries and screams loudly if her legs are even accidentally touched. There is no way we can even attempt to open her legs to change her. She was admitted with a stage 4 pressure injury on the sacrum with undermining and full thickness slough. I need to insert a foley catheter to aid in keeping the wound in a dry environment especially since the patient would only let us change her twice a day, once when I'm present and the other time is only when her mom is present to change her. I have no idea how to even approach inserting the catheter when I can not even open the patient's legs to be able to view the urethra. The patient is also highly anxious about this including the parents. Any time I even broach the subject of the catheter, the patient goes in a panic attack and cries loudly. The family is no help in this matter as they don't want their child to be in pain and they stated the nurses at the hospital were also unable to insert a foley catheter. I'm at a loss on what to do. I feel like putting the matter of the foley insertion to rest since both the patient and family are adamant that they don't want it but at the same time, I know for a fact that this will put the patient at further risk of infection and worsening of the patient's wounds. What should I do? Any ideas on how I can approach the catheter insertion if even I am able to convince both the family and the patient? Any other alternatives? I'm also thinking of ordering a pure wick external catheter for the patient BUT, upon viewing the placement instruction, there is no way I can open the patient's legs to place this in. Any opinions/advise/expertise would be greatly appreciated! Thank you very much!

[K+MgSO4, BSN]

Conscious sedation in all honesty is the best option for all I feel. You are never going to be able to do it otherwise an SPC.

[heron, ASN, RN]

Have you tried a posterior approach with the pt in a side-lying position? I find that it works quite well with my elderly ladies with limited ROM in their hips or large abdomens that make it hard for them to lie flat on their backs. You might need an extra pair of hands to help position her during the procedure.

The only other thing I can suggest is substantial premedication or some form of anesthesia.

Once this alert and competent patient understands the need for a catheter and the consequences of a non-healing ulcer, there's not much you can do if she continues to refuse the procedure.

[iluvivt, BSN, RN]

I was just going to suggest the posterior approach as well as I have done this on contracted patients.Roll them to their side and try to pull up the knees so patient is in a curled type pf position...be prepared with a few kits.a good assistant to hold a flashligt and the pts legs as described and if you get in the lady parts at first leave it in until you get the correct orifice as you may have limited visibility

[JKL33]

Agree w/ heron.

Posterior approach + anesth/sedation.

[Horseshoe, BSN, RN]

Have you tried a posterior approach with the pt in a side-lying position? I find that it works quite well with my elderly ladies with limited ROM in their hips or large abdomens that make it hard for them to lie flat on their backs. You might need an extra pair of hands to help position her during the procedure.

You took the words right out of my computer. :)

They used to call m the Foley Queen on my unit, lol. This method is tried and true.