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Guideline for Indwelling Urethral Catheterisation (Paediatric Care)
Draft : January 2008
Review: January 2010
INTRODUCTION
A urethral catheter is a hollow tube inserted through the urethra into the
bladder for the purpose of urine drainage, instillation of medical treatments or
urine output monitoring. Insertion of an indwelling urethral catheter is an
invasive procedure that should only be carried out when necessary for
individual patient care by a qualified competent health care professional using
an aseptic technique.
Aims of urethral catheterisation
• To promote the child’s dignity and comfort
• To recognise and minimise risks of secondary complications
• Ensure the child has age appropriate explanation of procedure using
play therapy and distraction tools where appropriate
• Ensure parents/carers have adequate explanation of procedure
• To ensure that a quality service is offered to all patients
• To ensure that current research based practices are implemented
Please note: This guideline may need to be adapted to suit clinical
area/practice
Indications for urethral catheterisation
• To drain the bladder prior to or following abdominal/pelvic/rectal surgery
• Prior to investigations
• To relieve retention of urine
• To measure accurate urine output
• To relieve urinary incontinence when no other means is practical
Date: January 2008 Page 1 of 12 Review Date: January 2010
Factors to consider prior to catheterisation
1. Is there an alternative less invasive method of management (EPIC 2007)
2. History of haematuria and or discharge
3. History of urethral obstruction or previous difficult catheterisation
4. History of fused or labial adhesions
5. History of recent surgery to the lower urinary tract
6. Patients with congenital abnormalities
7. Trauma to the pelvis or abdomen
8. Inflammation of the genito-urinary tract; cystitis, urethritis, vaginal pain
9. Immunocompromised patients
10. Spinal cord injured patients due to risk of autonomic dysreflexia
• If the child has any of the above concerns advice should be sought
from a suitably qualified and experienced practitioner working in the
relevant clinical area.
Documentation
Following catheterisation a record must be made in the patient record. The
information must follow the NMC (2002) Guidelines for records and record
keeping and should include:
• Reason(s) for catheterisation
• Type of catheter used, the size (Ch/Fr), length, material, balloon size,
batch number and manufacturer
• Cleansing solution and lubricant/anaesthetic agent used
• Any problem encountered during procedure
• Volume of urine drained
• Date for re-assessment
• Signature of the Practitioner who carried out the catheterisation
Catheter Selection
Catheters should be used in line with the manufacturer recommendations in
order to avoid product liability (Medicines and Healthcare Products Regulatory
Agency). Selection of catheter depends upon the individual patient’s needs,
latex allergy, anticipated duration of catheterisation and need for bladder
washout.
Duration of catheter
• Short term (up to 28 days) PTFE bonded latex
• Long term (up to 12 weeks) Silicone elastomer coated
All Silicone
Hydrogel coated
Date: January 2008 Page 2 of 12 Review Date: January 2010
Catheter size
Do not use feeding tubes they can become knotted in the bladder and
unable to be removed
Choose the smallest to provide adequate drainage.
Size 6ch……………up to 2 years
Size 8ch……………2-10 years
Size 10ch…………10-14 years
Size 12ch…………14 years upwards
These sizes are an approximate guide. The appropriate size of catheter
should be chosen according to the experienced practitioners judgement.
Length of catheter
Paediatric catheters are available up to size 12ch and are standard length.
For older children using a size 12ch then select male or female
• Paediatric approximately 30cm
• Female approximately 26 cm
• Male approximately 43 cm
Balloon size
Instruction on the catheter packaging should be followed
• Routine 5ml in paediatric catheters
• Adult 10ml
Date: January 2008 Page 3 of 12 Review Date: January 2010
ACTION RATIONALE
Insertion of an indwelling urethral Maintains the child’s safety.
catheter should be carried out
aseptically by a qualified and
competent health professional.
Discuss the proposed procedure with Gain patient or carers consent and
the child and parents/guardians co-operation (DOH, 2001; EPIC
(carers). Check for allergies including 2007)
latex and any known reactions to .
anaesthetic gels.
Cultural and religious beliefs need to (Jogee and Lal 1999)
be considered before performing the
catheterisation.
Where a child of any age refuses Allows time to prepare the child.
urethral catheterisation the procedure
should be delayed if possible.
Enlist assistance from the hospital Enhances the child’s ability to cope
play specialist to support the child with the procedure, and minimises
throughout the procedure. distress.
Prepare a quiet room, which allows To maintain the child’s privacy, dignity
sufficient space for the play specialist and sense of security.
and carer to accompany the child.
Collect Catheter dressing pack Have equipment prepared before
Normal Saline (warmed) child enters room
Plastic Apron
Collecting bowl
Drainage bag and holder or straps
Tape
Lubricating anaesthetic gel
Select a urethral catheter of the Prevents unnecessary replacement
appropriate type and size. and adverse reactions.
Prepare the clinical area (where DOH Saving Lives (2006)
possible using the treatment room)
with the appropriate equipment using
an aseptic technique.
Date: January 2008 Page 4 of 12 Review Date: January 2010
ACTION RATIONALE
The child should have the procedure To try and help the child understand
explained with age appropriate play the procedure
preparation, using dolls, catheter
tubes, and equipment to demonstrate
the process.
Reassure the child and carer Maintains the child’s sense of control
throughout the procedure, stopping of the situation, and his or her trust in
any time the child asks for a rest. the nurse, thus supporting co-
operation, and minimising distress.
Put on plastic apron disinfect and To reduce the risk of infection (EPIC
wash hands with antimicrobial 2007) Saving Lives (2006)
solution, apply sterile gloves and
plastic apron.
Draw up sterile water into a syringe The recommended amount on the
for the catheter balloon. Some catheter packaging must be used as
catheters come with a pre filled too little will result in the balloon filling
syringe. unevenly, causing undue pressure on
one area of the bladder neck. Too
much water will result in the balloon
bursting
Check anaesthetic gel and volume. Maintains the child’s safety.
Prevents unnecessary delay during
the procedure
Position child appropriately – To visualise the urethra clearly and
Ideally babies and children are insert the catheter with ease.
catheterised on the bed with their hips
flat on the bed, but alternatively –
female toddlers can be held on carers
knee with their legs in the frog
position. The child faces forward,
leans back upon parent with buttocks
almost at the parent’s knee.
Date: January 2008 Page 5 of 12 Review Date: January 2010
ACTION RATIONALE
Female urethral catheterisation:
Clean the urethral meatus before (EPIC 2007)
insertion of the catheter. Use only
soap and water or normal saline,
using a single downward stroke,
using the dominant hand then discard
the swab into a yellow clinical waste
bag.
Hold labia firmly open with the other Allows a clear view of the internal
hand and identify the urethral meatus. genitalia, allows accurate insertion of
the catheter.
If Nurse feels it is appropriate Can minimises the discomfort caused
Instil anaesthetic gel to the area by the catheter being inserted into the
around and just inside the urethral urethra and allows urethral orifice to
meatus. Wait for 3-5 minutes and be seen clearly by opening up the
lubricate catheter with anaesthetic urethral mucosa, helps prevents
gel. infection
Minimises the introduction of
Hold the catheter 8 – 10cm from the infection.
tip, ensuring the other end is over the
collecting bowl and gently insert it into
the urethra until urine flows.
Male urethral catheterisation: To visualise the urethra clearly and
All boys are encouraged to lie on their insert the catheter with ease.
back on the bed, remove their
underwear and sit on the disposable
underpad.
With the non-dominant hand gently Minimises the discomfort caused by
retract the foreskin using sterile the catheter being inserted into the
gauze until the urethral meatus is urethra and helps prevents infection
visible. With the dominant hand clean
the glans with a sterile swab and
0.9% normal saline, Instil anaesthetic
gel into the urethra and squeeze the
penis gently, wait for 3-5 minutes and
lubricate catheter with anaesthetic
gel.
Date: January 2008 Page 6 of 12 Review Date: January 2010
ACTION RATIONALE
Hold the penis upright and firmly at Keeps the urethra straight, thus
the base. Hold the catheter 15 – facilitating easy passage of the
20cm from the tip and gently insert it catheter. Allows a clear view of the
into the urethra. Continue insertion urethral meatus.
very slowly until resistance is felt, Reduces the risk of urethral spasm,
when the catheter reaches the which prevents insertion through the
bladder neck. Gently rotate the bladder neck into the bladder.
catheter slightly between the fingers
and thumb until the sphincter relaxes
and allows the catheter to enter the
bladder, resulting in a flow of urine.
In both female and male
Advance the catheter a further 4cm. Ensures the catheter tip is sufficiently
Inflate the balloon with sterile water. far into the bladder to avoid damage
to the bladder neck or urethra on
inflation of the balloon.
Prevents the catheter from falling out
prematurely.
Connect indwelling urethral catheter (EPIC 2007)
to a sterile closed urinary drainage
system.
Position urine drainage bag below the (EPIC 2007)
level of the bladder or on a stand that Incorrect positioning of the bag
prevents contact with the floor. system has been linked to higher
rates of bacteriuria (Mulhall et al
1991)
Attach the catheter with tape to the Prevents damage to the bladder
child’s groin, avoiding tension to the neck.
bladder neck.
Ensure movement of the child’s leg is
not restricted.
Remove and discard gloves and (EPIC 2007)
wash hands with antimicrobial
solution.
Ensure that the patient is comfortable.
Date: January 2008 Page 7 of 12 Review Date: January 2010
ACTION RATIONALE
Dispose of all equipment according to (EPIC 2007) Trust Waste
clinical waste procedures. Management Policy
Disinfect and wash hands with (EPIC 2007)
antimicrobial solution.
Document catheter insertion: To provide a point of reference or
Reason for catheterisation comparison.
Catheter type, size (Ch), length,
balloon size, material and batch
number of the catheter used
Cleansing solution used
Lubricating agent used
Record any problems negotiated
during the procedure
Volume of urine drained
Date and time of catheterisation
Planned date for re-assessment
Urinary Drainage Equipment
Drainage system should always be Selecting a system involves
based on an individual assessment of consideration of the reasons for
need. catheterisation, the intended duration,
the wishes of the patient and infection
control issues (Wilson and Coates
1996)
Empty the drainage bag often enough (EPIC 2007)
to maintain urinary flow and prevent
reflux. Use a clean separate container
for each patient and avoid contact
between tap and the container.
Change drainage bags when they
become discoloured, have sediment,
offensive smell or are damaged. All
bags must be changed following
manufacturers recommendations.
Link system – this applies to patients
who require a leg bag by day and a
higher capacity bed bag by night. The
leg bag is not disconnected from the
catheter, but rather the night bag is
connected to the drainage tap of the
leg bag. Patients in hospital must To prevent nosocomial infections
have a new night bag every night (ACA 2006)
Date: January 2008 Page 8 of 12 Review Date: January 2010
ACTION RATIONALE
When removing the catheter:
The qualified practitioner should Risk of infection increase with time
reassess the need for the catheter on a (EPIC 2007)
daily basis. The catheter should be
removed as soon as the patient’s
condition allows.
The catheter should be removed early Any retention problems can be dealt
morning. with during the day
Explain the procedure to the child /
carer inform them of post catheter
symptoms, i.e. urgency, frequency and
discomfort, which are often caused by
irritation of the urethra by the catheter.
Symptoms should resolve over the
following 24-48 hours. If not further
investigations may be needed.
Attach an empty syringe to the balloon Prevents the balloon from “cuffing”
port on the catheter, and allow it to fill which causes pain and potential
with the water from the balloon. Do not trauma when the catheter is removed.
pull the water out.
Gently check the catheter is free to be Removing slowly can reduce
removed, and then proceed to remove discomfort
the catheter slowly from the bladder
and urethra and discard.
Ensure adequate oral intake and For adequate flushing of the bladder,
document. especially to dilute and expel debris
Monitor urine output after removal. The
first void should occur within 6-7 hours
of removal and document.
Date: January 2008 Page 9 of 12 Review Date: January 2010
Appendix 1
Instillagel Dosage Regime for children
0-2 Years 1 - 2ml
2-5 Years 2 - 4ml
5-10 Years 4 – 6ml
10+ Years 6ml
Date: January 2008 Page 10 of 12 Review Date: January 2010
References
Association of Continence Advise, Notes on Good Practice (2006) Urethral
Catheterisation NO. 6.
Clinimed (2005) Catheterisation needn’t be a pain. At what age can instillagel
be adminisistered
De Courcy-Ireland K. (1993) An issue of sensitivity: use of anaesthetic gel in
catheterising women. Professional Nurse. 8; 11: 738-742
Department of Health 12 Key points on consent: the law in England. March
2001
Department of Health Saving Lives. 2006
Jogee, M. & Lal S. (1999) Religions and Cultures. Religions and Cultures
publication, PO Box 28420. Edinburgh
Kleiber C & McCarthy A M (1999) Parent behaviour and child distress during
urethral catheterisation. Journal of the Society of Pediatric Nurses Jul- Sept 4
(3): 95-104
Medical Device Agency (2000) Equipped to care. The safe use of medical
devices in the 21st century. Medical Devices Agency, London.
Muctar, S. (1991) The importance of a lubricant in Transurethral interventions.
Urology. (B) 35: 153-155
Mulhall, A.B., King, S., Lee, K. & Wiggington, E. (1993) Maintenance of closed
urinary drainage systems: are practitioners aware of the dangers? Journal of
Clinical Nursing. 2, 135-140
NMC (2002) Code of Professional Conduct. NMC, London
Pratt, R.J. et al (2007) Guidelines for preventing infections associated with the
insertion and maintenance of short-term indwelling urethral catheters in acute
care. Epic2: Journal of Hospital Infection Feb 2007 65S:S1-S64
Robson, J. (2001) Urethral catheter selection. Nursing Standard. 15 (25)
Robinson J (2003) Deflation of a Foley Catheter Balloon. Nursing Standard
Mar 19-25, 17(27):33-8
Smith L (2003) Which Catheter? Criteria for selection of urinary catheters for
children. Paediatric Nursing Apr, 15(3): 14-18
Date: January 2008 Page 11 of 12 Review Date: January 2010
The Royal Marsden Manual of Clinical Nursing Procedures. 6th Edition,
Blackwell Science
Further Trust Policies to be used as a reference:
Waste Management Policy and Procedures
Hand Hygiene Policy
Consent to Examination and Treatment
This pack was compiled by Mary Vallely Paediatric Nurse Specialist with the
support of Jackie Rees Clinical Nurse Specialist, Continence Advisor. For
further advice please contact Mary Vallely or Sally Harding on extension
24890 or DECT 29083
Date: January 2008 Page 12 of 12 Review Date: January 2010
