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URINARY TRACT MANAGEMENT IN SPINAL CORD INJURY: URINATION AND THE URINARY TRACT IN SCI: INTERMITTENT CATHETERIZATION PROGRAM (ICP)

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   If you do start urinating, intermittent catheterization is done to release the remaining urine from the bladder and measure the amount of urine left in the bladder after you urinated. Ideally, there should be no urine left in the bladder when the catheter is removed. However, most people have some residual urine. The amount of residual urine will be measured routinely until the amount is as low as possible. Amounts routinely under 100cc are usually acceptable. Your doctor will tell you what is safe. Residuals are checked periodically as long as you are in the hospital and also after you go home.

  At the start of rehabilitation, intermittent catheterization is routinely done on all patients every 4 to 6 hours. As you improve and your bladder empties better, intermittent catheterization for residual urine will change from every 4 to 6 hours, to every 8 to 12 hours. One of the goals of the intermittent catheterization program is to decrease the incidence of urinary tract infections by using a "sterile" technique. Some bacteria is expected but should be kept at a low level. Bacteria in the urine does not necessarily indicate a UTI.

PROCEDURE FOR INTERMITTENT CATHETERIZATION - STERILE TECHNIQUE -FEMALE

1. Gather the necessary equipment:

  • Towelettes (or a soapy washcloth)
  • Wet wash cloth for rinsing, and a Towel
  • Cotton balls, antiseptic, and forceps
  • Container for collecting the urine
  • Water-soluble lubricant
  • Catheter (# 14 French; 5 inches long)
  • Mirror (unless a helper is catheterizing), Lamp or flashlight

2. Urinate first if you are doing an intermittent catheterization to measure residual urine

3. Wash your hands

4. Position legs and mirror so you can see the urinary opening. Hints:

  • Make sure lighting is good.
  • You will probably need to be propped up so that you are in a semi-sitting position.
  • If someone else is doing the procedure, you can lie flat.
  • A spreader bar with mirror attached can help.
  • Tennis shoes may help prevent you from slipping.

5. Open catheter tray

  • Touch only the outside of the wrapper when opening the outer paper.
  • Start so that the first flap is opened away from you; the inside of the covering is sterile.
  • Save the plastic wrapper to throw the used equipment in.

6. Sterile drape

  • Pick up the sterile drape by the corners and open it
  • The side you've touched should be next to the bed.
  • Place the sterile drape under the buttocks

7. Put on the Sterile Gloves

  • Touch only the inside of the gloves with your hand
  • Touch the outside of the glove only with another sterile glove
  • Anything that touches the catheter must be sterile.

8. Open package of antiseptic and pour it over all the cotton balls

9. Open package of lubricant

  • Lubricate catheter to about six inches from the end
  • Put lubricated catheter back in tray
  • Be sure all equipment is set up before cleansing

10. Open labia (see diagram above)

  • Use your left hand to open the labia; if you are left-handed, use your right hand.
  • Keep labia apart until the catheter is in place.

11. Cleanse the urethral opening (see diagram above)

  • With one hand, use forceps to pick up one cotton ball and clean one side of the urethral opening.
  • With a second ball, clean the other side of the urethral opening.
  • With two new cotton balls, clean over the urethral opening.
  • Use each cotton ball for only one stroke from front to back. Never re-use.
  • Drop used cotton balls on white paper surrounding the tray.

12. Insert the sterile catheter

  • Still holding the labia apart, pick up the catheter with your "sterile" hand, about 4 inches from the tip.
  • Gently insert the catheter into the urethral opening until the urine flows, directing it upward and forward. Don't let fingertips of gloves touch labia or any part of the area around the rectum and urethral opening.
  • Insert one inch further.

Problems:

   If you have difficulty finding the urinary opening, mark the vaginal opening by leaving the last cotton ball, or a tampon, in the vaginal opening.

   If you should insert the catheter into the vagina by mistake, use a new catheter kit.

   If you should have a spasm while catheterizing, stop and wait until the spasm has passed and then continue.

   If you meet continued resistance, stop and call your doctor. Do not force the catheter in.

13. Hold end of catheter in the tray and wait for urine to drain.  If the bladder seems empty, but you aren't sure if the catheter tip is all the way in, apply pressure on the abdomen over your bladder with the palm of your hand, or, cough. A small amount of residual urine will be expelled if the catheter is in the right place.

14. Gently withdraw the catheter when the urine stops draining. Do not drain more than 500 cc of urine at one time. If there is more than 500 cc, clamp the catheter for 5-10m minutes before draining another 500 cc or the remainder.

15. Measure the amount of urine and record the amount urinated and the residual amount if you are keeping an accurate record.

16. Examine the urine and contact your nurse or doctor, IF you see:

  • Any change in the color or odor of the urine
  • Cloudiness in the urine
  • Bleeding or sediment in the urine

17. Discard all used supplies

18. Wash your hands

PROCEDURE FOR INTERMITTENT CATHETERIZATION - STERILE TECHNIQUE - MALE

1. Gather the necessary equipment

  • Special Intermittent Catheterization Pack
  • Basin of water
  • Soap
  • Three (3) disposable paper wash cloths
  • Linen saver (chux)

2. Wash penis and scrotum with soap and water, rinse, and dry.

3. Open catheterization pack

  • Touch only the outside of the wrapper when opening the outside package.
  • Start so that the first flap is opened away from you; the inside of the covering is sterile.
  • Save the plastic wrapper to throw the used equipment in.

4. Put on the Sterile Gloves

  • Touch only the inside of the gloves with your hand.
  • Touch the outside of the gloves only with another sterile glove.
  • Anything that touches the catheter must be sterile.

5. Sterile drape

  • Pick up the sterile drape by the corners.
  • Open the sterile drape, making sure it does not touch your body or the bed.
  • Place the sterile drape over the genital area, with the hole in the center of the drape over the head of the penis.

6. Pour cleansing solution over the cotton balls in the tray.

7. Open package of lubricant that is in the tray and squeeze lubricant over entire length of the catheter.

8. Pick up penis with your left hand, using the drape between your hand and the penis.

  • Hold penis erect.
  • With right hand, use a pair of forceps to pick up the saturated cotton balls.
  • Cleanse penis by wiping from front to back over the urethral opening and then around the head of the penis. If uncircumcised, pull back foreskin and clean entire head of penis.
  • Discard cotton balls, away from the sterile field.

9. Repeat Step 9 until all cotton balls are used.

10. Discard first pair of forceps, away from the sterile area.

11. Insert the sterile catheter

  • Pick up the catheter with the second pair of forceps.
  • Insert catheter into the urethra by sliding the catheter along the upper edge of the urethra.
  • Do not touch the penis with the forceps.

Problems:

   If the catheter meets resistance, pause for one or two minutes at the point where resistance is felt, and then apply gentle pressure with the catheter. This will usually fatigue the sphincter muscle causing the muscle to relax and allowing the catheter to pass.

   If you are unable to pass the catheter, do not force it. Stop the procedure and notify your physician.

12. Drain the urine

  • When the catheter is in, drain urine into the sterile tray.
  • Allow urine to drain until you are sure the bladder is empty.

13. Gently remove the catheter when the urine stops draining and place it in the tray.

14. Measure the amount of urine and record the amount if you are keeping an accurate record.

15. Examine the urine and contact your nurse or doctor, IF you see:

  • Any change in the color or odor of the urine
  • Cloudiness in the urine
  • Bleeding or sediment in the urine

16. Dispose of urine and all equipment.

Touchless disposable catheters are also available and are often used when you are out in the community. They require less setup and can be used while sitting in the wheelchair.

PROCEDURE FOR INTERMITTENT CATHETERIZATION - STERILE TECHNIQUE - MALE AND FEMALE

Equipment List:

  • Single urinary catheter
  • Catheter bag/Urinal
  • Non-sterile gloves
  • Liquid soap and tap water
  • Wash cloth or towelette
  • Clean towel
  • Wash Basin/Sink
  • Water-soluble lubricant
  • Irrigation set

  1. Gather equipment

  2. Wash hands with soap and water

  3. Assemble equipment on a clean surface

  4. Position yourself

  5. Put on clean gloves

  6. Cleanse urinary passage with soap and water

  7. Lubricate catheter tip with water-soluble lubricant

  8. Insert catheter into urinary passage and drain urine into appropriate receptacle, i.e. drainage bag, toilet, bedpan or urinal

  9. Remove catheter

  10. Using liquid soap solution, rinse catheter and irrigate with 60cc piston syringe. Rinse with tap water.

  11. Pat catheter dry using paper towel. Use a piston syringe to instill air through catheter to remove excess droplets from inside catheter

  12. Place clean catheter in clean sealed container for storage

  13. If drainage bag is used, the urine is emptied into the toilet and the system is cleaned. Use the following steps:

    a.   Flush the tubing and the bag thoroughly with a soap and warm water solution. Wash back and forth several times before emptying into the toilet. Rinse thoroughly in the same manner with plain water.

    b.   Cover the drainage tube with the original cap.

  14. Store all items in basin

  15. Wash hands with soap and water

It is important to sterilize your supplies 3 times per week with one part of bleach for ten parts of tap water. Let it soak overnight then rinse thoroughly with water again.

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