Nurse Driven Protocol

White River Medical Center

Arkansas

Urinary Catheter in Place

Physician order?

Yes

No

Does the patient meet criteria?

Yes No

Urinary catheter remains in place

Contact charge nurse,clinical lead, or APN to assessfor continued need

Catheterneeded?

Yes No

Leave catheterin place

Removeurinary catheter

Contact physician for clarification of continued need basedon criteria

Criteria for insertion of a urinary catheter:

•Acute urinary retention or obstruction•To aid in Surgical Procedure •To assist healing of open sacral or perineum wounds•Immobilization due to multiple trauma•Accurate I and O measurement for the critically ill•Comfort measure for end of life care

******If patient is being followed by OB/GYN or Urologist call physician prior to removal

Urinary Catheter Decision Flowchart

If urinary catheter placed by OB/GYN or urologist,call physician prior to removal.

Document reason

Urinary Retention Nursing ProtocolUrinary catheter

discontinued or onset of

urinary retention

Able to void

No

•Encourage PO fluids•Assist patient to BR every 2-4 hr•Consider Warm bath/shower•Turn on water in bathroom

Able to voidNo

•Assess presence of bladder distention•Assess patient’s discomfort/urgency

Bladder distended or discomfort/urgency

present

Yes

No

Perform bladder scan

250cc or greater urine in bladder

Yes

Yes

No

Intermittentcath

Able to void within 4-6 hours

Yes

No

Place indwelling urinary catheter and notify

physician and requestFlomax

Yes

Reassess every 4 hours andPRN and follow protocol

as necessary

Urinary Retention Nurse Protocol

1. Once indwelling catheter is discontinued and or patient is experiencing urinary retention encourage fluids on the patient that is not NPO.

2. Get patient up to the bathroom every 2 to 4 hours to attempt to void. (May need to run water in the sink or pour warm water over the patient’s perineum)

3. If patient unable to void after 4-6 hours or complains of inability to void assess:

a) presence of bladder distention

b) patient’s discomfort and urgency to void

c) amount of urine in bladder using Bladder Scan and if greater than 250cc do in and out (intermittent catheterization) using sterile technique.

4. Document bladder scan results, patient assessment of need to void, your attempts to help the patient void, and amount of urine obtained from in and out catheterization

5. Continue to take patient to the bathroom every 2 to 4 hours

6. If in 4-6 hours patient still unable to void, may repeat in and out cath. Leave catheter in place on 2nd in/out cath and contact physician of urinary retention

7. Consider Flomax

 

References:

 

Nazarko, L. (2009). Managing bladder dysfunction using intermittent self-catheterization. British Journal of Nursing, Vol.18, No 2, pp. 110-115.