Procedures Flashcards
Urinary catheterisation
Urinary catheterisation is a procedure used to drain the bladder and collect urine, through a flexible tube called a catheter.
Urinary catheters are usually inserted by doctors or nurses in hospital or the community.
They can either be inserted through the tube that carries urine out of the bladder (urethral catheter) or through a small opening made in your lower tummy (suprapubic catheter).
The catheter usually remains in the bladder, allowing urine to flow through it and into a drainage bag.
Depending on the type of catheter you have and why it’s being used, the catheter may be removed after a few minutes, hours or days, or it may be needed for the long term.
Why urinary catheters are used
A urinary catheter is usually used in people who have difficulty passing urine naturally. It can also be used to empty the bladder before or after surgery and to help perform certain tests. Specific reasons include:
to allow urine to drain if you have an obstruction in the tube that carries urine out of the bladder (urethra) – for example, because of scarring or prostate enlargement
to allow you to urinate if you have bladder weakness or nerve damage which affects your ability to pee
to drain your bladder during childbirth, if you have an epidural anaesthetic
to drain your bladder before, during and/or after some types of surgery, such as operations on the womb, ovaries or bowels
to deliver medication directly into the bladder, such as during chemotherapy for bladder cancer
as a treatment for urinary incontinence when other types of treatment haven’t worked
The catheter will be used until it’s no longer needed. This may be for a short time and will be removed before leaving hospital, or it may be needed for longer or even permanently.
Types of urinary catheter
There are 2 main types of urinary catheter:
intermittent catheters – catheters that are temporarily inserted into the bladder and removed once the bladder is empty
indwelling catheters – catheters that remain in place for many days or weeks and are held in position by a water-filled balloon in the bladder
Many people prefer to use an indwelling catheter because it’s more convenient and avoids the repeated catheter insertions associated with intermittent catheters. However, indwelling catheters are more likely to cause problems such as infections (see below).
Inserting either type of catheter can be uncomfortable, so anaesthetic gel is used to reduce any pain. You may also experience some discomfort while the catheter is in place, but most people with a long-term catheter get used to this over time.
Read more about the types of urinary catheter.
Looking after your catheter
If you need a long-term urinary catheter, you will be given detailed advice about looking after it before you leave hospital.
This will include advice about getting new catheter supplies, reducing the risk of complications such as infections, spotting signs of potential problems, and when you should seek further medical advice.
You should be able to live a relatively normal life with a urinary catheter. The catheter and bag can be concealed under clothes and you should be able to carry out most everyday activities, including working, exercising, swimming and having sex.
Read more about living with a urinary catheter.
Risks and potential problems
The main problem caused by urinary catheters are infections in the urethra, bladder, or less commonly the kidneys.
These types of infection are known as urinary tract infections (UTIs) and they usually need to be treated with antibiotics.
Catheters can also sometimes lead to other problems, such as bladder spasms (similar to stomach cramps), leakages, blockages and damage to the urethra.
Risks
The main disadvantage of using a urinary catheter is that it can sometimes allow bacteria to enter the body.
This can cause an infection in the urethra, bladder, or less commonly the kidneys. These types of infection are known as urinary tract infections (UTIs).
Urinary tract infections (UTIs)
UTIs resulting from catheter use are one of the most common types of infection affecting people staying in hospital. This risk is particularly high if your catheter is left in place continuously (an indwelling catheter).
Symptoms of a catheter-associated UTI include:
pain low down in your tummy or around your groin
a high temperature (fever)
chills
confusion
Contact your GP, district nurse or nurse practitioner if you think you have a UTI, as you may need to take antibiotics.
Other risks
Bladder spasms, which feel like stomach cramps, are also quite common when you have a catheter in your bladder. The pain is caused by the bladder trying to squeeze out the balloon. Medication may be necessary to reduce the frequency and intensity of the spasms.
Leakage around the catheter is another problem associated with indwelling catheters. This is called by-passing and can occur as a result of bladder spasms or when you open your bowels. Leakage can be a sign that the catheter is blocked, so it’s essential to check that the catheter is draining.
Blood or debris in the catheter tube is also fairly common with an indwelling catheter. This could become a problem if the catheter drainage system becomes blocked
Seek medical advice if you think your catheter may be blocked, or if you’re passing large pieces of debris or blood clots.
Other, less common, potential problems include:
injury to the urethra (the tube that carries urine out of the body) when the catheter is inserted
narrowing of the urethra because of scar tissue caused by repeated use of a catheter
injury to the bladder or rectum (back passage) caused by incorrectly inserting the catheter
bladder stones (although these usually only develop after years of catheterisation)
Abdominal Paracentesis
Abdominal paracentesis is a safe and effective diagnostic and therapeutic procedure used in the evaluation of a variety of abdominal problems, including ascites, abdominal injury, acute abdomen, and peritonitis. Ascites may be recognized on physical examination as abdominal distention and the presence of a fluid wave. Therapeutic paracentesis is employed to relieve respiratory difficulty due to increased intra-abdominal pressure caused by ascites.
Midline and lateral approaches can be used for paracentesis, with the left-lateral technique more commonly employed. The left-lateral approach avoids air-filled bowel that usually floats in the ascitic fluid. The patient is placed in the supine position and slightly rotated to the side of the procedure to further minimize the risk of perforation during paracentesis. Because the cecum is relatively fixed on the right side, the left-lateral approach is most commonly used.
Most ascetic fluid reaccumulates rapidly. Some experts recommend that no more than 1.5 L of fluid be removed in any single procedure. Patients with severe hypoproteinemia may lose additional albumen into reaccumulations of ascites fluid and develop acute hypotension and heart failure. Cancer patients with malignant effusions may also need repetitive therapeutic paracentesis. Intravenous fluid and vascular volume support may be required in these patients if larger volumes are removed.
After diagnostic paracentesis, fluid should be sent to the laboratory for Gram stain; culture; cytology; protein, glucose, and lactate dehydrogenase levels; and blood cell count with a differential cell count. A polymorphonuclear cell count of >500 cells/mm3 is highly suggestive of bacterial peritonitis. An elevated peritoneal fluid amylase level or a level greater than the serum amylase level is found in pancreatitis. Grossly bloody fluid in the abdomen (>100,000 red blood cells/mm3) indicates more severe trauma or perforation of an abdominal organ. The classic positive test for hemoperitoneum is the inability to read newspaper type through the paracentesis lavage fluid.
Equipment
Disposable paracentesis/thoracentesis kits usually include the following:
Antiseptic swab sticks
Fenestrated drape
Lidocaine 1%, 5-mL ampule
Syringe, 10 mL
2-inch-long injection needle
No. 11 blade scalpel
14-gauge catheter over 17-gauge × 6-inch needle with three-way stopcock or one-way valve, self-sealing valve, and a 5-mL Luer Lock syringe
Syringe, 60 mL
Tubing set with roller clamp
Drainage bag or vacuum container
Specimen vials or collection bottles (3)
Gauze, 4 inch × 4 inch
Adhesive dressing
Indications
Evaluation of ascites fluid to help determine etiology, to differentiate transudate versus exudate, to detect the presence of cancerous cells, or to address other considerations
Evaluation of blunt or penetrating abdominal injury
Relief of respiratory distress due to increased intra-abdominal pressure
Evaluation of acute abdomen
Evaluation of acute or spontaneous peritonitis
Evaluation of acute pancreatitis
Contraindications
Acute abdomen requiring immediate surgery (absolute contraindication)
Severe thrombocytopenia (platelet count <20 × 103/μL)
Coagulopathy (international normalized ratio [INR] >2.0)
In patients without clinical evidence of active bleeding, routine labs such as prothrombin time (PT), activated partial thromboplastin time (aPTT), and platelet counts may not be needed prior to the procedure.
Severe bowel distention (use extra caution)
Multiple previous abdominal operations
Pregnancy (absolute to midline procedure)
Distended bladder that cannot be emptied with a Foley catheter (relative contraindication)
Obvious infection at the intended site of insertion (relative contraindication)
Severe hypoproteinemia (relative contraindication)
Intra-abdominal adhesions
The Procedure
Step 1
The anatomy of the abdominal wall is shown. The insertion sites may be midline or through the oblique transversus muscle, which is lateral to the thicker rectus abdominus muscles.
Step 2
Empty the patient’s bladder either voluntarily or with a Foley catheter. Place the patient in the horizontal supine position, and tilt the patient slightly to the side of the collection (usually the left lower quadrant). Slightly rotate the hip down on the table on the side of needle insertion to make that quadrant of the abdomen more dependent. The insertion sites are shown.
Step 3
Prep the skin with povidone-iodine or chlorhexidine solution, and allow it to dry while applying sterile gloves and a mask (see Appendix E: Skin Preparation Recommendations).
Pearl: Prep a wide area so that an undraped area is not inadvertently exposed if the drape slides a little.
Step 4
Center the sterile drape about one third of the distance from the umbilicus to the anterior iliac crest.
Step 5
Infiltrate the skin and subcutaneous tissues with a 1% solution of lidocaine with epinephrine. A 2-inch needle is then inserted perpendicular to the skin to infiltrate the deeper tissues and peritoneum with anesthetic.
Step 6
Insert the catheter/introducer through the skin. The nondominant hand then stretches the skin to one side of the puncture site, and the needle is further inserted to create a Z tract.
Step 7
Advance the catheter until a “pop” is felt and the catheter penetrates the peritoneum. Release the pressure on the skin after the introducer enters the peritoneum. Advance the catheter into the abdominal cavity.
Step 8
Remove the introducer, and attach the syringe. Draw the fluid into the syringe. If no fluid returns, rotate, slightly withdraw, or advance the catheter until fluid is obtained. If still no fluid returns, abort the procedure, and try an alternative site or method. Ascites fluid may be removed by attaching a three-way stopcock or one-way valve, a 60-cc syringe to one arm, and drainage tubing and bag to the other arm. If lavage is desired, such as for detecting hemoperitoneum after trauma, connect intravenous tubing to the three-way stopcock. Remove excess fluid and then infuse 700 to 1,000 mL of Ringer lactate or normal saline into the abdominal cavity. Gently roll the patient from side to side. Then, remove the fluid as described above or using a trap-suction arrangement.
Step 9
After the procedure, gently remove the catheter, and apply direct pressure to the wound. Observe the characteristics of the fluid, and send it for the appropriate studies. If the insertion site is still leaking fluid after 5 minutes of direct pressure, suture the site with a vertical mattress suture. Apply a pressure dressing.
PITFALL: Gauze dressing should be applied when rare, persistent drainage occurs.
Complications
Abdominal radiographs should be obtained before paracentesis, because air may be introduced during the procedure and may interfere with interpretation.
Perforation of bladder and stomach (emptied prior to the procedure to decrease the risk)
Bowel perforation
Laceration of a major blood vessel
Loss of catheter or guide wire in the peritoneal cavity
Abdominal wall hematomas
Pneumoperitoneum
Bleeding
Perforation of the pregnant uterus
Infection
Persistent leak from the puncture site
Postparacentesis hypotension
Dilutional hyponatremia
Hepatorenal syndrome
Pediatric Considerations
Pediatric patients may not cooperate with placement of catheter placement. Because of the risks of damage to vessels, nerves, and so forth, consider conscious sedation with intramuscular injections or oral administration of sedating medications such as Versed and Ketamine.
Postprocedure Instructions
The patient should be instructed to monitor the bleeding of the area and return if any abnormal bleeding is noted. The patient should also be educated to call with questions or concerns regarding pain, numbness, or discomfort in the area. The patient should also monitor for evidence of infection. Lastly, the patient should be advised to clean the area with warm soap and water and pat the area dry.
Coding Information and Supply Sources
Paracentesis trays that include all instruments needed to perform the procedure can be ordered from the following manufacturers:
