The importance of following guidelines and using appropriate procedures when inserting a catheter.

A Case Example

In this case, the elderly male patient had been catheterised several times previously the year prior, with no undue complications or problems but on this one occasion, he reported pain and bleeding several hours afterwards, not at the time of the initial insertion. The same-sized catheter was used as previous catheter changes and he did not report that the nurse used too much force or had inserted it roughly. This was a routine catheter change but after several hours there had been very little urine drainage and there was blood at the tip of the penis. He was kept in hospital for 2 days and was given analgesics and a course of co-amoxiclav (antibiotics with an additional acid to enhance the anti-bacterial effect).

Main Learning Points

  • Urinary-catheterisation procedures have standard protocols which are aimed at producing as little discomfort as possible for this intrusive procedure. Nurses undergo extensive training in the procedure, and it is standard practice to keep up-to-date with any advances in technique.

  • Standard procedure is to insert an appropriately-sized catheter and to check urine is draining before a balloon is inflated in the catheter. In this case, the balloon was inflated before there was any urine detected and it appears this may have been the cause of the discomfort and trauma. The nurse should not leave the patient until they are satisfied that urine is draining correctly and the patient is not in discomfort.

  • There are various sizes of catheter available including 12ch, 14ch and sometimes 16ch. If pain or problems are encountered, then it is usual to try a different size usually smaller.

  • It is not standard practice to offer antibiotics after a normal catheter change, only if there has been trauma and discomfort has been felt. In this case, the patient did not report any discomfort or problems immediately. This only became apparent several hours later.

Reducing the Risk of Litigation

By not following the standard protocols of waiting for evidence of urine draining before inflating the balloon and confirming that the flow was progressing normally, the nurse fell short of expected standards which leads to enhanced risk of litigation.

TMLEP recommends the following:

  • Catheter changes in males need to be completed by a competent nurse due to complexity of the male anatomy.
  • • The smallest catheter possible that provides adequate drainage should be used to minimise risk of trauma.
  • The balloon in the catheter should not be inflated until there is urine visible.
  • Nurses should check that drainage is functioning correctly before leaving the patient.
  • Nurses need to maintain competencies and skills in catheterisation.

Conclusions

Incorrect catheter changes in males and trauma to the urethra/prostate have the potential not only to cause discomfort and bleeding, but also serious urinary tract infections which can be very dangerous, particularly to elderly patients. Nurses need to be competent in the standard protocols of catheterisation. These include choosing the smallest possible catheter which functions correctly, checking for urine drainage prior to inflating the balloon and confirming with the patient that they are not experiencing discomfort and that the urine is draining.