Bladder ScanBladder Scan

uasonic

ULTRASOUND

100ANSMISSION GEL

Before undertaking a trial removal of a urinary catheter, also known as trial without catheter (TWOC), it is important for the healthcare professional to have an in-depth understanding of the reasons why a TWOC is necessary (Skills for Health, 2010). Factors to consider when undertaking a TWOC include: • The rationale for the TWOC. Consider whether the TWOC is appropriate and how the patient will cope with the effects of having the catheter removed. Over what period of time will you and the patient assess the success or failure of the procedure?• The need to respect the patient’s privacy and dignity at this particularly intimate time. • The need to remove the catheter in a safe and skilled manner. • The adverse effects and potential complications that can arise during a TWOC and ways to minimise these. • How to perform a TWOC in a patient who has a suprapubic catheter. • What equipment you will need in order to undertake a TWOC.

If TWOC is to take place in the outpatient setting, or in the patient’s own home, it is better to consider undertaking this procedure at the beginning of the week, to ensure that support is available to the patient in the first few days after the removal, should they need it.

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CatheterisationAdults

Trial removal of a urinary catheterEdited by Rachel Leaver, Lecturer Practitioner—Urological Nursing,

University College London Hospital NHS Foundation Trust ©2019 Clinical Skills Limited. All rights reserved

Assessment

Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Bladder ultrasound Wash your hands and put on gloves

It is considered best practice to use bladder ultrasound to measure residual urine, in order to determine success or failure of a TWOC (NICE, 2019). If ultrasound is available, the healthcare professional must be competent to use it. In the absence of a bladder ultrasound machine it may be necessary to recatheterise the patient using an intermittent catheter, in order to measure any residual volume of urine in the bladder.

Apply standard universal precautions for infection prevention. Put on an apron, decontaminate your hands and wear clean gloves.

Assess the patient so that you offer them the most suitable method of TWOC. Always obtain the patient’s consent before removing the catheter.

MR WILLIAMS 5/3/527/02/2019

200 WATER200 COFFEE200 WATER200 TEA

50 MLS 75 MLS100 MLS

3.15pm

Distended detrusor with unvoided residual urine

Catheterisation

Adults

Trial removal of a urinary catheter Page 2

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Remove catheter (a) Deflate balloon (b) Gently pull on the catheter

Patient documentation Hydration

Suprapubic catheters Extending the trial

Attach an empty syringe to the deflation channel on the catheter and allow the water-filled balloon to deflate using gravity. Do not pull on the end of the syringe to force the water out. Allowing the balloon to empty using gravity means that it will deflate symmetrically, therefore causing less trauma to the urethra.

Once deflated, gently pull on the catheter and remove it. Patients may find this uncomfortable, so make sure they are aware beforehand and reassure them this is normal.

Provide the patient with fluid balance charts to document fluid intake and urine output.

Encourage the patient to drink a cup of fluid every 30 minutes. Follow local policy if the patient has hypertension or heart failure.

If the patient has a suprapubic catheter instead of, or as well as, a urethral catheter, this needs to be fitted with a catheter valve to stop the flow of urine. Encourage the patient to drink as described, and to void via the urethra. If the patient gets too uncomfortable and cannot pass urine, you can open the valve to drain the bladder. You can also use the valve to check for the residual urine instead of a bladder scanner. The catheter can be removed if the TWOC is successful.

When the patient feels the need to pass urine, they must use a jug to measure the amount passed. Follow local policy on the duration of the TWOC, which may be over 4 or 8 hours, or overnight. Check residual urine intermittently as the trial progresses to monitor progress.

FLUID INTAKETime Amount drunk in mls

8.30am9am9.30am10.00am10.30am11.00am11.30am12noon12.30pm1pm1.30pm2pm2.30pm3pm3.30pm

URINARY OUTPUTTime Urine passed in mls Unable to void

8.45am9.15am9.45am10.15am10.45am11.15am11.45am12.15pm12.45pm1.15pm1.45pm2.15pm2.45pm3.15pm3.45pm

OUTCOME Post void ultrasound mls Time undertakenBladder control during trial Good Fair Poor Unable to voidBladder emptying Completely Partially Not at allSuccessful TWOC Unsuccessful TWOC Recatheterised Amount

Brand inserted Material Ch size Balloon mlsLot number Length LubricantCleansing agent Drainage systemProblemsDate for next change

Signature of nurse

200 WATER200 COFFEE200 WATER200 TEA200 WATER100 WATERNIL200 TEA200 ORANGE100 WATER100 WATER200 WATER

50ML

75ML100ML75ML200ML175ML

200ML

175ML100ML

30 300PM

HYGIENE. You should bath,shower or wash around where you catheter goeswith simple soap. Do not let creams, talc or antiseptics come into contacthands before and after handling your catheter, bag or valve.

FLUIDS. Ensure you drink 8 cups of mixed fluid each day (1.5 Litres, 2.75

EQUIPMENT. Catheters, bags and valves are all prescribed by your District Nurse willchemist will dispense these items. A variety of bags, volumes, tube lengths, taps, valves. bag supportgarments are all available. Store all equipment in a dark, cool, flat, dry place as it is sterileitem is damaged do not use it. Catheter bags and valves must be changed every seven daysCatheters must all be changed at least every three months (suprapubic catheters every two months)Wash bags and valves, place and seal in a plastic bag and put in household rubbish.

LIFESTYLE. There are no specific restrictions to any activity eg. sport, holidays and work, but extracare may be needed. A catheter may interfere with sexual activity. if this is a problem contact yourDistrict Nurse or GP.

COMMON PROBLEMS. In all the following situations contact your District Nurse or GP.

INFECTION. Urinary tract infection is more comon when you have a catheter. The symptoms mayinclude: red or orange coloured urine, fishy smell, urine looks cloudy, soreness, fever and feelingunwell. If these symptoms appear contact your GP or District Nurse within 24 hours. Certain foodsormedication can also change the colour and smell of urine. Cranberry juice if you are diabetic, sufferfromIrritable Bowel Syndrome, stomach problems or arthritis. ask for our leaflet on Cranberry juiceTherapy

CONSTIPATION. It is advisable to avoid constipation as it can cause bladder spasm and bypassing(leaking around your catheter) It is quite common to leak a small amount of urine around yourcatheter when you have your bowels open.

BASIC CATHETER CARE INFORMATION

A GUIDE FOR PATIENTS

At HomeWith YourCatheter Valve

Catheterisation

Adults

Trial removal of a urinary catheter Page 3

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Do not undertake or attempt any procedure unless you are, or have supervision from, a properly trained, experienced and competent person.Always first explain the procedure to the patient and obtain their consent, in line with the policies of your employer or educational institution.

Patient information Reassess the patient

Recatheterisation Clinical signs of an enlarged bladder

Documentation Catheter care

Depending on local policy, those patients who are able may choose to go home for the few hours of their TWOC. Reassure them that they can telephone or return to the clinic or department if they become concerned about the progress of the TWOC.

After a few hours, evaluate the fluid chart, considering intake and output. Follow local policy for action to be taken in assessing residual volume. If the patient is distressed and has not passed urine, it is important to recatheterise them as soon as possible.

If ultrasound shows a significant residual volume and the patient has lower urinary tract symptoms, consider recatheterisation or teaching the patient to self-catheterise until residual volume reduces.

Healthcare professionals must be competent at recognising the signs and symptoms of urinary retention. In the absence of a bladder ultrasound machine, they must be able to perform palpation of the bladder.

Document the outcome of the TWOC and ongoing treatment in the patient’s notes. Inform the appropriate medical practitioner of the outcome and discuss any further treatment required.

If the TWOC is unsuccessful and the patient needs to be recatheterised or learn self-catheterisation, make sure the patient receives appropriate information and supporting leaflets about catheter care. If the TWOC is successful, ensure the patient is aware of potential complications and has information and contact numbers in case there is a problem.