No One Talks About… An Easier Way to Catheterize Women (and Prevent Complications)

[melissamabd, DNP, RN]

Inserting a urinary catheter properly is a skilled task entrusted only to licensed nurses. The risk of catheter-induced urinary tract infection (CAUTI) is real—it's still the number one healthcare-acquired infection in the United States, representing over 12% of hospital-acquired infections. Virtually all healthcare-associated urinary tract infections are caused by instrumentation of the urinary tract. The incidence of infection has been correlated with the level of training of the inserter, so having a great skill set is integral to performing this task expertly (Urinary Tract Infection (catheter-associated, 2016).

All nursing students learn proper urinary catheterization technique in nursing school, sometimes with rubrics twenty steps long. However, learning theoretical content well, and even practicing in the simulation laboratory, may not prepare graduate nurses for the realities of catheter insertion, particularly with female patients. Patients are apprehensive; they may lock their thighs together, tip over our carefully constructed sterile fields, or be unable to cooperate in positioning due to neurological or musculoskeletal issues.

Holding a patient's lower extremities in the lithotomy position, aiming a flashlight, and maintaining an intact sterile field is a daunting challenge for any nurse. Obese women pose a particular difficulty to the lone nurse attempting to insert a urinary catheter, as folds of flesh may obscure the nurse's vision and/or the patient's anatomy and especially the urinary meatus, leaving him or her with a point and pray” approach at best. Sometimes tissue is too wet to handle effectively, preventing the nurse from positioning labia optimally for visualization of the meatus. These all-too-real situations increase the possibility of contaminating catheters prior to or during insertion, despite the nurse's best efforts, and raising the probability of causing a catheter-associated urinary tract infection.

One technique, not often discussed but familiar to the seasoned nurse, is placing the female patient comfortably in Sim's position and approaching from behind to insert the urinary catheter. From the posterior, the entire perineal floor may be much easier to view, and this maneuver does not require patients to spread their legs in painful, awkward, or undignified positions. The labia is opened as with the traditional approach, and the urinary meatus is often far more easily visualized. Cleansing the tissue with Betadine or other antibacterial solutions is done in the same manner, and the catheter is inserted more easily into a visible orifice (the correct one).

Of course, the fundamental principles and safety measures inherent to any catheterization still apply. Nurses need to perform hand hygiene and explain to the patient the procedure and its purpose; and afford the patient some control, if possible. Having input into the procedure offers patients a sense of security and trust in the nurse. Sterile technique is maintained by the standard steps in setting up and using a sterile field… opening drapes in the proper direction, touching only within one inch of the drape's edge, preventing moisture from contaminating the field from the behind, and applying sterols gloves last. The gold-standard sign of proper catheter insertion is the return flow of urine in the tubing. Only then should the balloon be inflated.

Catheters should always be secured to the thigh with tape or a commercial catheter-securing device, leaving some slack in the tubing so traction is avoided on the urinary bladder. Catheter bags are always maintained at or below the level of the bladder, and perineal hygiene, including cleansing the urinary meatus with soap and water, is an essential part of catheter-associated urinary tract infection which should be done twice daily. Always clean from the cleanest portion to the dirtiest, and remove any organic matter from the meatus and catheter as soon as it is noted.

The result of using this outside-the-box technique may be a quicker, safer, and easier catheter insertion for the patient—and for you as well. References Urinary tract infection (catheter-associated urinary tract infection [CAUTI] and non-catheter-associated urinary tract infection [uTI]) and other urinary system infection [uSI]) events. (2016, January). Retrieved February 14, 2016, from http://www.cdc.gov/nhsn/pdfs/pscmanual/7psccauticurrent.pdf

[NuGuyNurse2b]

Paragraphs really would've helped here. did you copy and paste? it seems like you did.

[NickiLaughs, ADN, BSN, RN]

I use this method frequently in the ER. However not every patient can tolerate and it won't always be effective in this position. I've tried it a couple times for morbidly obese patients. Doesn't work very well as I'm still unable to visualize. The best patients for this are the combative ones and little old ladies who can turn.

[mmc51264, BSN, MSN, RN]

Inserting a urinary catheter properly is a skilled task entrusted only to licensed nurses.

In NC we have CNA IIs and CMAs that it is within their scope of practice to insert urinary catheters. I was a CNAII while I was in nursing school and was able to insert Foleys, d/c IVs, wound care to wounds >48 hours old, G-tube feeds, established trach care.

[melissamabd, DNP, RN]

Thank you; I didn't know that! I guess I was working off NYS standards. That's interesting.

[VANurse2010]

(1) Most patients are cooperative enough not to lock their legs or tip or "trip" onto the field.

(2) Most (better) hospitals have policies now for 2 person insertion of Foley catheters. My facility only allows single-person insertion on non-obese males

(3) Sims is a good idea, but often not practical with critical patients (such as the mechanically ventilated) where I think most Foley catheters are seen nowadays (urology floors and OR aside).

[FineAgain]

And the gold standard should be expanded in that you should never inflate the balloon when you see urine. You should always keep inserting up to the hub, then inflate and pull back.

Cannot tell you how many painful foleys I have found that were inflated in the urethra and not the bladder.

[AliNajaCat]

Found this helpful hint doing search here.

https://allnurses.com/general-nursing-discussion/female-cathing-890772-page2.html

Quote from klone

The clitoral hood often has so many folds that look like there could be a hole in there. I can understand why there would be confusion. At least with the clitoral hood, they can still try again when they miss, whereas when they stick it in the lady parts, they theoretically have to get a new kit.

To avoid contaminating the catheter by inadvertent lady partsl placement, try this: When you do your prep, tuck the last betadine-soaked ball into the introitus, just enough to keep it in place. Then if you slide posteriorly, your catheter hits only sterile cotton ball, and you are free to then slide anteriorly until you hit the urethra. Asking your patient to cough a bit might help, as sometimes a bit of urine is expressed from the urethra with increased intraabdominal pressure. Don't forget to retrieve the cotton ball when you're done.

[AliNajaCat]

Hard to read. Paragraphs to break it up would be good. School paper?

[melissamabd, DNP, RN]

Sorry, no. Original formatting lost in submission of text.

[Adele_Michal7, ASN, RN]

Only commenting to say "point and pray" is hysterical.

[dishes, BSN, RN]

I don't know if you are aware but the Society of Urology Nurses (SUNA) has clinical practice guidelines for adult female urethral catheterizations.