Urology – Catheter Insertion and Management, Bladder Irrigation, Nephrectomy and Trans Urethral Prostatectomy (turp)

8.3 Removal of Indwelling Urinary Catheter

To remove an indwelling urinary catheter
Equipment:

• 
  Clean gloves
  
• 
  Safety glasses or goggles
  
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  Procedural under pad
  
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  Syringe (10 or 20ml)
  
• 
  Clean kidney dish
  

Procedure:

1. 
   Inform the patient and ensure privacy is maintained
   
2. 
   Explain procedure to patient and ensure privacy
   
3. 
   Consent must be gained for all interactions with patients
   
4. 
   Patient identification and allergy band are checked against clinical notes and stickers
   
5. 
   Prepare equipment
   
6. 
   Place patient in supine position
   
7. 
   Check balloon capacity Inpatient’s clinical records
   
8. 
   Don safety glasses
   
9. 
   Don gloves
   
10. 
    Detach catheter from Foleys Statlock device
    
11. 
    Attach syringe to catheter balloon lumen and aspirate fluid slowly to deflate
    
12. 
    Gently pull catheter to check balloon is deflated
    
13. 
    Inform patient to breathe slow deep breaths then withdraw the catheter gently
    
14. 
    Check catheter tip is intact, if not inform medical officer immediately
    
15. 
    Place catheter in kidney dish
    
16. 
    Remove Foleys Statlock device from patient’s body with Alcohol swabs and clean skin area as required (See Attachment A)
    
17. 
    Discard equipment and ensure patient is comfortable
    
18. 
    Document procedure including patient response Inpatient’s clinical record
    
19. 
    Remove gloves and perform hand hygiene after a procedure or body fluid exposure risk as per the 5 moments of hand hygiene
    
20. 
    Document the time and date of removal in the patient’s clinical record, Patient Accountability and Care Plan and FBC.
    

Alert: Do not cut the balloon lumen, as the balloon may not be fully deflated
Alert: Patients undergoing a trial of void (TOV) must be provided with either a pan or urinal and inform nursing staff once they have voided. Nursing staff must check for residual urine with Bladder scanner, record on fluid balance chart and inform medical officer of results prior to discharge
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Section 9 – Trans Urethral Prostatectomy (TURP)

Surgical procedure performed via the urethra to debulk the prostatic adenoma and relieve obstruction. A transurethral resection removes only enlarged prostatic tissue, as in benign

Prostatic Hypertrophy (BPH). Normal prostatic tissue and its outer capsule are left intact.
Background:

• 
  Patient usually attends preadmission clinic (PAC) and is admitted on the day of surgery (DOSA). Investigations attended in the PAC are as follows:
  

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  Baseline observations, including usual Systolic BP
  
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  Height, weight and urinalysis
  
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  Bloods – UEC, FBC, COAG’s, X – MATCH (2-4 units), LFT’s ECG, CXR, as per hospital policy. Additional bloods, CT, MRI and or bone scan to determine probability of metastasis to the body and the skeleton
  
• 
  Micro culture & sensitivity of urine (MSU) one week prior to surgery
  

• 
  Ensure UTI therapy has been completed prior to surgery as per recommendations in the latest version of the Therapeutic Guidelines: Antibiotic, Prophylaxis: urological surgery
  
• 
  Consent completed reflecting the Consent to Treatment Procedure
  
• 
  Check reason for admission Inpatient’s clinical record and length of stay as per Request for Admission form to predict estimated date of discharge (EDD), i.e., commencement of Discharge Planning
  

Alert: Patients on anticoagulation therapy require further medical investigation, advice and support and nursing observation
Admission

• 
  Explain the process and purpose of the Patient Care and Accountability Plan
  
• 
  Patient identification and allergy band are checked against clinical notes/ stickers
  
• 
  Document findings from Patient Care and Accountability Plan (PCAP) including Risk Assessments and management plans in clinical records, provide education and CHHS information booklet to patient and family regarding Patient’s Pressure Injury, fall and VTE Risks and management. Measure and fit patient with short leg TED stockings
  
• 
  Attend to height, weight and ward urinalysis and document in clinical records, Patient Care and Accountability Plan and Observation Chart
  
• 
  Obtain baseline observations, usual systolic BP and MEWS Score
  
• 
  Provide patient with verbal and inform Pharmacist of patient’s admission and request Medication Reconciliation is completed
  
• 
  Ensure that patient is informed and educated in relation to fasting guidelines as per guidelines or specific medical orders. Document care provided in clinical record. Inform Food Services via DIETPas
  
• 
  Commence discharge planning
  
• 
  Educate patient in deep breathing and coughing exercises, and leg exercises
  
• 
  Check consent form completed
  
• 
  Bowel preparation if ordered
  

Preoperative:

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  Attend to all documentation including Pre-op Checklist
  
• 
  Measure and fit knee length Anti-embolic stockings and ensure documentation on Medication Chart
  
• 
  Ensure patient has early morning shower and dressed in theatre gown
  
• 
  Usual medications are given at 0600
  

Receiving the patient from PACU:

• 
  Don PPE as required
  
• 
  Patient identification and allergy band are checked against clinical notes/ stickers. Practice to reflect Patient Identification Checklist Procedure, Patient Identification Band Procedure, Correct Patient, Correct Site, Correct Procedure
  
• 
  Check patient’s airway is clear and observe for effort of breathing (i.e. use of accessory muscles)
  
• 
  If airway is compromised place the patient in the lateral position (if not contraindicated), and consider Medical Officer review
  
• 
  Ensure the oxygen is attached to wall oxygen outlet
  
• 
  Confirm flow rate as ordered (PACU staff responsibility on arrival at ward – checked by ward staff to ensure correct flow rate)
  
• 
  Ensure equipment has been plugged in and cords are positioned safely under bed or off the floor
  
• 
  Clarify the operative procedure performed. All actions to reflect Correct Patient, Correct Site, Correct Procedure
  
• 
  Discussion of patient medical history and impacting co morbidities should occur whilst ensuring privacy
  
• 
  The PACU nurse hands over verbally to the ward nurse at the patient bed side. At the completion of Handover the PACU observation chart should be signed and dated by both the PACU and ward nurse. Handover should include:
  
• 
  Review of post operative vital signs, including any interventions required for stabilisation
  
• 
  Review the Fluid Balance Chart, check intravenous fluid insitu, received in PACU and continuing orders, check IV device site e.g. CVC, PICC, IVC (date of insertion, patency, site, and is appropriately secured) Monitor intravenous therapy and record IVT on Fluid Balance Chart)
  
• 
  Ensure that continuous bladder irrigation (CBI) and indwelling urethral catheter (IDC) are patent – only 0.9% Sodium Chloride 2000ml solution to be used as irrigant for CBI
  
• 
  Ensure Bladder Irrigation Chart is maintained- balances to be recorded on FBC
  
• 
  Maintain accurate fluid balance chart for input and output, ensuring CBI fluid included, and describe the type of output, for example, claret, rose or straw).
  
• 
  IDC to be anchored with Statlock unless the surgeon specifically documents request for Statlock not to used as per Urinary Catheter Management Procedure
  
• 
  Ensure Indwelling Catheter is secured with appropriate device, e.g., Statlock
  
• 
  Ensure traction is maintained on IDC to provide maximum pressure on the prostatic bed following surgery. This traction helps to control bleeding and decreases the risk of bladder neck damage. Check post-operative orders regarding the use of traction and the length of time traction is to be applied, usually only for the first 24 hours
  
• 
  If clotting occurs, nurse to initiate manual irrigation using aseptic technique
  
• 
  Urine output is to be recorded hourly for 48 hours postoperatively
  
• 
  Ensure all output is documented on Fluid Balance Chart
  
• 
  Medications administered and documented on medication chart review
  
• 
  Any intravenous medications ordered and given (e.g. antibiotics, antihypertensive)
  
• 
  Observe the Catheter site for ooze or blood loss.
  
• 
  Perform and document a full set of Vital signs and Modified Early Warning Score (MEWS) including:
  
  • 
    Respiratory Rate (RR)
    
  • 
    Oxygen Saturations
    
  • 
    Temperature
    
  • 
    Blood Pressure (BP)
    
  • 
    Pulse (P)
    
  • 
    Level of Consciousness (LOC)
    
  • 
    Urine Output (UOP)
    

All observations are to be recorded on the Modified Early Warning Score (MEWS) charts and appropriate adjunct charts (i.e. Continuous Bladder Irrigation etc). Ensure all of the above interventions are completed prior to PACU nurse leaving ward area and patient care is accepted.

• 
  Complete Patient Care and Accountability Plan and action appropriately
  
• 
  Record in the patient's clinical record all post-operative nursing care provided and the patients response
  
• 
  Administer analgesia as per Medical Practitioner’s orders for pain and/ or spasms
  
• 
  Administer IV antiemetic for nausea as per Medical Practitioner’s orders
  
• 
  Offer and attend to post-operative bed bath
  
• 
  Dress in personal nightwear if desired
  
• 
  Offer and attend to mouth care, replacing dentures if applicable
  
• 
  Position the patient in accordance to post operative instructions
  
• 
  Ensure that the call bell is within reach and
  
• 
  Lower bed and bed rails to maintain patient safety if required. Note: where patients are disorientated consider hi low bed
  
• 
  Educate and encourage deep breathing and leg exercises
  
• 
  Ensure 2/24 Pressure area care and skin integrity checks and repositioning performed (off affected side)
  
• 
  Document all observations on the appropriate charts, e.g. MEWS, fluid balance chart, in the patient’s clinical record and escalate if required according to MEWS and MET criteria
  
• 
  Record in the patient's clinical record all post-operative nursing care provided
  

Post operative Day 1:

• 
  Attend to general observations fourth hourly
  
• 
  Review by Medical Officer
  
• 
  Medical Officer will cease CBI depending on consistency and type of urine output
  
• 
  General post-operative diet
  
• 
  Cease IV fluids if oral intake is adequate
  
• 
  Continue oral analgesia as required
  
• 
  Patient may shower if stable, or assist sponge
  
• 
  Encourage patient to sit out of bed for a few hours
  
• 
  Continue discharge planning – contact Discharge Liaison Nurse (DLN) if appropriate
  
• 
  Continue patient education
  
• 
  Commence ambulation (ensure patient has a functioning IV pole with tongue depressor taped to the pole for hanging the urinary bag)
  
• 
  Continue deep breathing and coughing, and leg exercises
  
• 
  Attend to blood specimens – FBC and UEC’s as ordered by Medical Officer
  
• 
  Ensure anti embolic stockings are in situ, correctly measured and fitted with no creases
  
• 
  Request Medical Officer to commence Discharge summary document in preparation for discharge
  

Post operative Day 2:

• 
  Continue fourth hourly observations
  
• 
  IDC removed at 2400 or 0600 hours or otherwise ordered by Medical Officer
  
• 
  CBI ceased if not attended to during day one
  
• 
  Trial of void (TOV) – document when patient voids – amount, consistency, pain, colour etc., and attend bladder scan post void
  
• 
  Review by Medical Officer after three consecutive bladder scans
  
• 
  Patient to attend to self care
  
• 
  Complete patient education prior to discharge and provide written instructions (Prostatectomy package)
  
• 
  Ensure patient has received adequate education, and is self caring with leg bag should discharge occurs with IDC insitu
  

Discharge:

• 
  Advise patient to organise own follow-up appointment with Visiting Medical Officer (VMO) if seeing Urologist privately
  
• 
  Follow up in Outpatient Department Clinic (OPD) is usually in 4 weeks. Notification to OPD of patient’s details is completed by RMO completing the Discharge summary
  
• 
  Resident Medical Officer (RMO) to provide patient with Cystogram appointment details prior to discharge
  
• 
  Discharge with analgesia if deemed necessary by Medical Officer
  
• 
  Educate the patient regarding the VMO’s post-operative instructions – no driving, heavy lifting or sexual intercourse etc, until reviewed at follow-up appointment
  

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