Instructions
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Ensure adequate urine flow and fluid intake Lower urine pH Prevention strategies include the assurance of urine flow, ensuring adequate fluid intake, lowering urine pH, catheter irrigation, and potential use of methenamine salts to reduce the risk for encrustation. To assure urine flow, the catheter bag may be elevated to lower bladder pressure. If there is a high risk for blockage, a closed continuous bladder irrigation may be appropriate. Intermittent drainage every two to four hours may reduce bladder blockage rates compared to continuous flow. Ensuring adequate fluid intake can help to flush the bladder, keep the urine diluted, and maintain pH to reduce risk for encrustation. A recommendation is for about 30 mL/kg/day, which generally translates to approximately 2 liters per day. This may help to assure a urine output of 50-100 mL/hour and achieve optimal urine specific gravity of 1.015 or less. Estimating adequate fluid intake will need to consider fluid loss, function of circulatory and renal systems, and food intake. Avoiding long intervals without fluid intake is recommended. Urine pH can be lowered to less than 7.0, but the best way to do this is unclear. Some methods include cranberry products and betaine hydrochloride supplementation of 650 mg orally three times/day with meals. Catheter irrigation with antimicrobials may be considered in selected cases for surgical patients with short-term catheterization. Treatment Antimicrobials for Proteus mirabilis Chronic blockers may not be candidates for antimicrobial therapies Systemic antimicrobials only if clinically indicated Other strategies for prevention or treatment may consider the type of catheter materials and antimicrobial treatments. Catheter materials may allow biofilm formation. 100% silicone catheters may be preferred to reduce the risk of encrustation if a patient has a long-term need for a catheter and has frequent obstructions. It has been suggested that the reduced risk for obstruction in silicone catheters may be related to the larger lumen. Antimicrobials should be used only with clinical indications. Antibiotics to treat Proteus mirabilis immediately when identified could reduce blockage, stones, and encrustation. However, antibiotic treatment for patients who chronically experience blockages and stones may not be as effective due to the resistance to penetration by crystalline biofilm. And, unless there is a clinical indication, such as bacteriuria on catheter removal post-urologic surgery, systemic antimicrobials should not be used to routinely prevent infections in short- or long-term catheterization.
Other Catheter-Related Complications Catheter-Related Bladder Discomfort Several other complications may occur, such as bladder discomfort, bypass leakage, and skin breakdown.
Catheter-related bladder discomfort (or CRBD) includes the symptoms of the urge to void, bladder spasms, or burning and pain in suprapubic, urethral, and bladder areas. This may be caused by large lumen catheters (>18 French), a large balloon or a partially filled balloon, catheter material, pressure from the catheter, manipulation, traction, and position of the catheter, technique or procedure for catheter change, bladder irritation or stones, local bladder irritation, and constipation or fecal impaction.
Prevention and treatment of CRBD may include reversing some of the causes, such as switching to a smaller lumen catheter or changing catheter material, securing the catheter, filling the balloon according to recommendations, maintaining adequate fluid intake to assure urine dilution, prevention of constipation, and, finally, the use of medications to prevent or reduce spasms and pain.
Bypass leakage Leakage around the catheter can due to bladder contractions that push urine out quickly and sometimes around the catheter. Urethral damage from long-term use or traumatic insertion or removal, or inflation of the balloon in the urethra can cause urine to leak. This can also occur with obstructed catheters that are kinked or twisted or blocked with stones, or encrusted. To prevent and treat this problem, securing the catheter to prevent movement, using a smaller French catheter, filling the balloon to recommended levels, and possibly treating with anticholinergic medications to reduce spasms may help. In addition, the prevention of constipation may reduce the risk for leakage.
Skin breakdown Skin breakdown may occur around the urethral areas and where the catheter and/or drainage tubes are secured. Other risk factors for skin irritation and breakdown may include urinary leakage and moisture from the catheter, positioning of the catheter or drainage tube straps and securements, sensitivity to the catheter’s materials, or infection with yeast or fungus. Risks can be reduced and treatment may include an alternative means for securing the catheter or drainage tube in areas that can accommodate movement while changing body position, careful cleaning and the use of ointments for the skin, the use of hypoallergenic catheters and treatment as necessary, for yeast or fungus.
Summary As with all patient and caregiver education, a wide variety of sources can be tapped, including written instructions and guidelines, verbal review of instructions and recommendations, and internet sources for further education. Links to support groups can also be helpful if there is a long-term need. Self-monitoring tools can help to establish healthy behaviors related to their catheter care and maintenance. Routine care habits may include the selection of appropriate supplies with resources and consideration for financial limitations. Instruction should include frequency of changes for catheter and drainage bag, care for the drainage system, hygiene practices, prevention of constipation, fluid intake, and recommendations for clothing that can cover the catheter and bag. Routine checklists can help the patient and caregiver to schedule routine maintenance procedures. In addition, it will be important to provide information to assist in identifying complications and actions that should be taken, including contact information for advice and support. Sexual behavior can be discussed along with strategies to maintain intimacy without compromising the catheter or bag. And, of course, the healthcare provider and caregiver should remain open and non-judgmental in this discussion. |
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