Straight cath vs indwelling question

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Specializes in cardiac/medical.

Hi I am a relatively new RN and have encountered a situation that has left me stumped. I just knew that all my friends at allnurses.com could give me a little insight. Here is my question...

The other night I had an elderly lady (98, A&O and the sweetest little lady ever) that was admitted for SIRS and was + for CDiff (from antibiotics used to treat a UTI in the ECF). She had a foley, I believe placed when she arrived at the hospital. It started draining a really nasty milky urine. The Dr ordered to remove the foley and in a few hours straight cath for a urine specimen. The dayshift nurse did this and also drained 300cc of urine because the pt had been unable to void on her own. The results came back and were negative for uti, which I couldn't believe.

Anyway, on my shift (7p-7a), she was unable to void. Bladder scanned her and she had anywhere from 300-525 of urine. Orders were to check post void residual and if greater than 100cc, straight cath. Well, about the second time I had to straight cath her, I called the resident and clarified that this was really what they wanted. I ensured he was aware that there weren't really any post void residuals since she was unable to void independently. He said he thought that they wanted to avoid another indwelling foley and just continue to straight cath as needed. I thought if the point was to avoid UTI, straight cath'ing every few hours is not the solution.

Before I went home, I left a note on the chart for the attending to address the situation detailing everything that is going on with my patient. I thought for sure they would order a foley and maybe order some bladder training or something. However, as it stands right now, the order is to straight cath q4-6hrs prn. I do not understand why the reluctance to place another indwelling, it seems to me there would be less risk of infection, not to mention what we are putting this little lady through every time we have to straight cath her. Any ideas on why the Dr would choose this route? :uhoh3:

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Usually an indwelling catheter is more risky due to the fact that it is basically a staircase for bacteria to walk right up and hang out. Studies have shown that its less risky to straight cath someone because you are in and out, but with an indwelling catheter going directly to your bladder bacteria can just travel right up there and settle in. As for comfort of a little old lady, I think for sure an indwelling catheter would be the way to go! I can't imagine having to be straight cathed every 4-6 hours!!!

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Specializes in home health, dialysis, others.

Believe it or not, there are many women who straight cath at home, q 4-6 hrs.

Even older women. And they use a clean technique, not sterile, at home.

Not everyone wants to have a bag attached to them.

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Specializes in Cardiac Telemetry, ED.

The doctor may also be looking at the bigger picture, that her inability to void will resolve over time. There is no way to know if this is the case if she has an indwelling catheter.

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Specializes in Rodeo Nursing (Neuro).

I thought the same as the OP when I was newer. Experience has brought me to hutgirl's viewpoint. And Virgo's. Just recently had a post-op who had to be straight-cathed 2-3 times, then resumed voiding on her own.

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Specializes in Psych, ER, OB, M/S, teaching, FNP.

There is research out there (don't have a reference right now) that periodic strait cathing is less likly to cause infection than an indwelling catheter. This is a big thing in OB as some docs want a mom to have a foley as soon as an epidural is placed but research shows the above and strait cathing is the way to go.

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Personally, I'd look at the big picture.

Is she difficult to cath? Some women that age are very, very difficult to cath due to weight, diminished ROM, breathing issues, etc.

What does the patient want, after education and experiencing the cathing process a couple of times?

What is the doc's plan? If she doesn't start voiding independently, what's the plan?

Personally, with our hospitalists, if I have to straight cath more than once, and the pt is a difficult cath or is unhappy with the cathing process, I'll leave the foley in and clarify in the am. I would not have done that in your situation unless there were extreme circumstances--having to restrain a confused and combative pt for the cathing, extreme physical difficulties cathing, etc-- since you had already clarified once.

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Specializes in Psych, ER, OB, M/S, teaching, FNP.

ooops

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Specializes in Psych, ER, OB, M/S, teaching, FNP.

not sure how i made two posts, but this one has been spell-checked!

the other piece (after thinking a bit more on this) is that the way the new guidelines are, if a person does not have a uti when they come in to the hospital and they get one while there, the hospital does not get paid for its treatment, even if it gets really bad and the person gets septic and they end up in icu, etc. maybe the doc has a bigger picture to look at as well. is he a nice guy that you could ask? in a "i am trying to learn" kind of question?

in situations like this i try to always remember what view i have. if i am on the dance floor i see the other dancers and maybe some of the band and the floor. the view from the balcony (the view the provider has) is much broader, deeper and probably has more clarity. he can see the full band, all the dancers, the walls, door, and everything. this is an analogy obviously but i always try to decide if i have a view from the balcony or the floor before i make judgments.

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In addition to reducing the risk of infection, there are other advantages to using intermittent cathing (IC) instead of an indwelling:

-- It is much easier to get bladder control back after IC than it is after having a Foley. It's very common for those using a Foley, even for a brief period of time, to experience leakage and urgency for several days to several weeks after the Foley is removed. This is especially true if the individual has also been under general anesthesia.

--There is a chance of bladder shrinkage with the Foley, even if the Foley is only in place for a short time. (Shrinkage can be reduced by the use of anticholinergics.) IC will preserve bladder capacity.

--The Foley can cause painful bladder spasms, which won't occur with IC.

--If this lady will be getting up and around, it will be easier for her to manage that without being attached to a leg or overnight bag.

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