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
