How to catheterise a female.

OK, now pay attention, because we are about demystify the most tricky art of female catheterisation.
As always, check my guidelines against your own hospital policy  before proceeding.

Preparation:

Preparation is the key to first pass success.

Obtain consent from your patient and inform her of what she should expect to experience. Check for latex allergies and any previous urological issues.

You should always evaluate the need for a second nurse to be present before commencing:

“As catheterisation is an intimate procedure, the psychsocial effects should always be considered. I would advise all nurses to explain the procedure well to all patients, then assess if a second nurse should be present. Our patients have diverse feelings about what’s appropriate. Transcultural nursing should encompass these differences” — @DamianHurrell (Nurse)

Assemble catheterisation equipment as per your hospital policy.
Usually this will include

  • a catheterisation pack
  • a 12 – 14 Fr female Foley catheter
  • a catheter bag
  • saline solution
  • sterile gloves
  • lignocaine gel
  • a 10ml sterile water-filled syringe

Remember, studies have found that Lignocaine anaesthetic gel (as used in males) used to lubricate the catheter substantially reduces the procedural pain of female urethral catheterisation in comparison with use of a water-based lubricating gel.

Quality lighting of the area will show you what is what and where is where. Take time to position a good light source.

Take time in preparation of both the patient and equipment.
Good lighting is essential.
Use Lignocaine gel if available to lubricate catheter.
Sound aseptic technique is vital to prevent urinary tract infection.

Positioning:

Position the patient by asking her to draw her knees up with ankles together, and then relax and let her knees drop to either side. The other nurse can assist with maintaining comfortable positioning. (Make sure the patient remains covered whilst you are scrubbing up to guard against this.)

Note: At times patients will be unable to co-operate or unable to comply due to injury and you will have to improvise on the best way to obtain an access trajectory.
If the patient is unable to separate their legs enough for you to get a good view, some nurses swear by using the lateral approach. Ask the patient to lie on her side and draw her legs up towards her chest. You then position yourself behind the patient to pass the catheter.

Scrub up:

Perform a thorough hand wash and then don sterile gloves.

Many catheterisation kits contain a second pair of sterile gloves to place over the first pair. This is my preferred approach. You can then remove the outer pair once you have cleaned the site with swabs.

Cleaning:

Clean along the length of each of the labia majora.
Use a new saline soaked gauze swab for each pass, in a smooth front to rear action to minimise risk of contaminating your work with bowel flora.
Discard used swabs into the bin which you have placed close by.

Using your non-dominant hand, separate the labia majora and clean the labia minora in the same way.
Next, swab in a downwards motion between the clitoris and the vagina.

OK. Now cautiously remove your outer gloves and discard.

Pick up the fenestrated towel and drape the patient.

Once again with your non dominant hand separate the labia. You may need to use gauze swabs if things are getting slippery.

With your dominant hand pick up the catheter. I like to have the catheter in a small sterile dish (that comes in the pack) I place the dish on the sterile field between the patients thighs. I then ‘feed’ the catheter out of the dish as I advance it.

Pass the catheter:

In females the urethra is relatively short (around 4cm).
The urethral opening or meatus is usually located in the superior fornix of the vulva, between the clitoris and the vagina.

Sometimes it is easy to spot, looking like a small stoma or a dimple or a slit.

Once you think you have the meatus in your sights hold the lubricated catheter in your dominant hand and gently introduce it into the urethra. This may cause some discomfort to the patient so take care.
At this point you can ask her to take a few deep breaths and relax.

Some guidelines recommend injecting the lignocaine jelly directly into the meatus with an applicator prior to catheter insertion. Some even suggest then placing your finger against the meatus to hold the gel in place.
I do not do this.

It is not uncommon for the catheter to slide off some mysterious bit of anatomy that was not actually the meatus after all, and end up in the vagina.

Never mind. Leave the catheter in situ and try again with a new sterile one.

If you simply cannot locate the urinary meatus here is a tip from the British Journal of Urology:

The index finger of the non dominant hand is inserted into the vagina. The urethral orifice can then be palpated on the anterior vaginal wall, and the finger can be held there to both block the vagina and guide the catheter in to the correct position.

Now I have never tried this, and sticking a finger into a patients vagina is extremely invasive. But, following explanation to the patient it may prove helpful if absolutely all else fails.

When you hit the bullseye (tip: try not to yell out “bullseye!”) you may get a return of urine. Sometimes there is a delay in urine due to the lignocaine jelly obstructing the end of the catheter.
If no urine is forthcoming, you can gently aspirate using a sterile bladder syringe.

Once you have flow, advance the catheter a further 4cm just to make sure you are well within the bladder before inflating the balloon.

Inflate the balloon with sterile water (check the catheter pack for correct amount. Usually 10mls) and then apply gentle traction to bring the balloon up snug against the trigone ( the area where the urethra leaves the bladder.).

Secure the catheter:

Connect the catheter to the urinary drainage bag.

Tape the catheter as per your hospital policy. Make sure that there is enough slack in the system that any movement of the patients legs does not put traction on the catheter.

Dry the patient and make them comfortable.

Documentation:

Clean up the whole area, and document your procedure in the nursing notes including:

  • Date and time.
  • confirmation that consent was obtained.
  • size and type of catheter
  • indication for inserting the catheter.
  • residual amount of urine drained.
  • appearance of the urine (e.g. straw coloured, dark)

The whole art of urinary catheterisation is to minimise the risk of introducing a urinary tract infection; so take time to prepare and clean the area as well as developing a sound aseptic technique.


References:

  1. Urethral Catheterization in Women Technique. (n.d.). Retrieved June 16, 2015, from http://emedicine.medscape.com/article/80735-technique
  2. Digital guidance of female urethral catheterization – Jenkins – 2002 – British Journal of Urology – Wiley Online Library. (n.d.). Retrieved June 16, 2015, from http://onlinelibrary.wiley.com/doi/10.1046/j.1464–410X.1998.00859.x/full
  3. Helpful Hints: Female Patient Urinary Catheter Insertion | allnurses. (n.d.). Retrieved June 16, 2015, from http://allnurses.com/general-nursing-discussion/helpful-hints-female–261915.html

One thought on “How to catheterise a female.

  1. Grossly obese female patients lay on side bringing knees up if possible, like for lumber puncture, easiest way by far. Rather than fighting constraints of size and overhang.

    Like

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