URINARY CATHETERIZATION FOR PEDIATRICS

Introduction
Insertion of an indwelling urethral catheter is an invasive procedure that should only be carried out by a
qualified competent health care professional using aseptic technique. Catheterization of the urinary tract
should only be done when there is a specific and adequate clinical indication, as it carries a high risk of
infection.

Aim
To ensure the insertion and care of the urinary catheter is carried out in a manner that minimizes trauma
and infection risks.

Definition of Terms
IDC: Indwelling Urinary Catheter

Indications

To drain the bladder prior to, during, or after surgery

For investigations
To relieve retention of urine
To accurately measure the urine output
To relieve urinary incontinence when no other means is practical

Environment

Explained procedure to the child and the parents and obtain consent
The bed is screened to ensure privacy
Keep the child warm at all times
Ensure adequate light source

Equipment

Dressing trolley
Catheterization pack and drapes
Sterile gloves
Appropriate size catheter (see catheter size guideline below)
Xylocaine jelly syringe (plain sterile lubricant for infants)
Sterile water for balloon
5ml Syringe
Specimen jar
Antiseptic solution. Aqueous Chlorhexidine 0.1% with Cetrimide (yellow solution) or Aqueous
Chlorhexidine 0.1% (blue solution).
Tape to secure catheter to leg
 Drainage bag
Urine bag holder

Catheter size guideline

Use the smallest bore that will allow good drainage to minimise bladder and urethral trauma
Consider silicone catheter if for long term use

AGE WEIGHT FOLEY

Procedure for insertion of urinary catheter

The procedure should be carried out by a nurse or doctor competent in urinary

catheterization only

Female child

1. Place child in supine position with knees bent and hips flexed
2. If soiling evident, clean genital area with soap and water first
3. Perform hand hygiene
4. Open catheter pack
5. Add equipment needed using aseptic technique
6. Pour antiseptic onto tray
7. Perform aseptic hand wash and don sterile gloves
8. Apply drapes
9. Separate labia with one hand and expose urethral meatus.
10. Using swabs held in forceps in the other hand clean the labial folds and the urethral meatus.
Move swab from above the urethral meatus down towards the rectum. Discard swab after each
urethral stroke.
11. Lubricate catheter
12. Place sterile tray onto drape.
13. Insert catheter into meatus, upward at approximately 30 degree angle until urine begins to flow.
14. Inflate the balloon slowly (do not use balloon catheter in neonates) using sterile water to the
volume recommended on the catheter. Check that child feels no pain. If there is pain, it could
indicate the catheter is not in the bladder. Deflate the balloon and insert further into the bladder.
ALWAYS ensure urine is flowing before inflating the balloon.
15. Withdraw the catheter slightly till resistance is felt and attach to drainage system.
16. Secure the catheter to the thigh with tape
17. Ensure the child is left dry and comfortable.
18. Remove gloves and dispose of used articles into yellow biohazard bag.
19. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine handwash
Male child

1. Place child in supine position

2. If soiling evident, clean genital area with soap and water first
3. Perform hand hygiene
4. Open catheter pack
5. Add equipment needed using aseptic technique
6. Pour antiseptic onto tray
7. Perform aseptic hand wash and don sterile gloves
8. Apply the drapes
9. Lift the penis and retract the foreskin if non circumcised. Do not force the foreskin back,
especially in infants
10. Using other hand, clean the meatus with swabs held in forceps. Use a circular motion from the
meatus to the base of the penis.
11. For older boys insert the Xylocaine gel into the urethra. Hold the distal urethra closed and wait 2 -
3 minutes to give the gel time to work. For infants apply sterile lubricant to catheter before
insertion. Post urology surgery consider using two syringes
12. Place the sterile tray on the drapes.
13. Hold the penis with slight upward tension and perpendicular to the child's body. Insert the
catheter.
14. When the first sphincter is reached (at level pelvic floor muscles) lower the penis 90
degrees (facing child's toes), apply constant gentle pressure. If resistance is felt the following
strategies should be considered:
a. 2nd tube lubricant
b. Increase traction on penis and apply gentle pressure on the catheter
c. Ask the child to take a deep breath
d. Ask the child to cough and bear down eg try to pass urine
e. Gently rotate the catheter.
f. If unable to pass the catheter seek assistance from treating medical team or Urology
registrar
g. DO NOT use force as you may damage the urethra
15. Advance the catheter and gently insert it into the urethra until urine flows.
16. Inflate the balloon slowly (do not use balloon catheter in neonates) using sterile water to the
volume recommended on the catheter. Check that child feels no pain. If there is pain, it could
indicate the catheter is not in the bladder. Deflate the balloon and insert further into the bladder.
ALWAYS ensure urine is flowing before inflating the balloon.
17. Withdraw the catheter slightly till resistance is felt and attach to drainage system.
18. Secure the catheter to the thigh with tape
19. Reposition the foreskin if applicable.
20. Ensure the child is left dry and comfortable.
21. Remove gloves and dispose of used articles into yellow biohazard bag.
22. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine handwash
Special precautions

Rapid drainage of large volumes of urine from the bladder may result in hypotension and/or
haemorrhage
Clamp catheter if the volume seems excessive. Release clamp after 20 minutes to allow
more urine to drain
For post obstructive diuresis IV replacement of electrolytes may be required.

Documentation
The procedure is documented in the child's Care Plan Activity. The documentation should be signed by
the person inserting the catheter. Documentation should include:

Indication for catheterization

Time and date of procedure
Type of catheter.
Size of catheter
Expiry date of catheter
Amount of water in balloon
Any problems with insertion
Description of urine, colour and volume
Specimen collected
Review date

Ongoing nursing management

Measure urine output hourly and document

Normal urine output is 0.5-1ml/kg/hr. Report any variation from this
If oliguric ensure catheter is not blocked (see trouble shooting below)
No routine change of urinary catheter or drainage bag is necessary. Change for
clinical indicators if infection, obstruction or if system disconnects or leaks.
Replace system and/or catheter using aseptic technique and sterile equipment
Maintain unobstructed urine flow. Gravity is important for drainage and prevention of
urine backflow. Ensure the drainage bag is below the level of the bladder, is not kinked
and is secured
Urine for urinalysis or culture should be collected fresh from sampling port of
catheter tubing (not drainage bag). Clean port with disinfectant first
Drainage system
Adherence to a sterile continuously closed method of urinary drainage has been shown
to markedly reduce the risk of acquiring a catheter associated infection
Hygiene
Daily warm soapy water is sufficient meatal care or PRN if build up of secretions is
evident
Uncircumcised boys should have the foreskin gently eased down over the catheter after
cleaning
 Infection surveillance
Consider daily the need for the IDC to remain insitu. Remove as soon as no longer
required to reduce risk of UTI
Cloudy, offensive smelling or unexplained blood stained urine is not normal and needs
further investigation
Full Ward Test (dipstick) should be done each day. This test can detect urinary protein,
blood, nitrates (produced by bacterial reduction of urinary nitrate) and leucocyte esterase
(an enzyme present in White Blood Cells)
Specimen collection
Large volumes e.g. 24hr collection, can be collected from drainage bag
Record fluid balance. A fluid balance which keeps the urine dilute will lessen the risk of infection.
This may not be possible due to the clinical condition of the child.

Troubleshooting

Catheter not draining/ patient oliguric

Check catheter/tubing not kinked
Check catheter is still secured to patient leg and hasn't migrated out of bladder
Checking patency by irrigating catheter with 2-3ml of sterile 0.9% normal saline. Do not
use force to instil fluid. This is an aseptic procedure
Catheter leaking
Remove catheter. If indication for IDC remains follow insertion procedure with new
catheter.

Removal of urinary catheter

1. Explain procedure to child and family

2. Perform hand hygiene & don gloves
3. Deflate balloon completely
4. Gently withdraw catheter
If resistance felt, and catheter cannot be removed easily do not force, leave catheter
insitu and consult medical team
5. Inspect catheter for intactness. Report if not intact
6. Dispose of catheter and drainage system in appropriate waste
7. Remove gloves & perform social hand wash
8. Document catheter removal in patient notes
9. Observe for urine output post catheter removal

Complications

Inability to catheterize
Urethral injury from trauma sustained during insertion or balloon inflation in incorrect position
Haemorrhage
False passage
Urethral strictures following damage to urethra. This may be a long term problem
Infection
 Psychological trauma
Paraphimosis due to failure to return foreskin to normal position following catheter insertion

References

A guide for nurses- Management and care of catheters and collection systems (2001). USA: Bard
Gould, C; Umscheid,C; Agarwal,R; Kuntz,G; Pegues, D; and the Healthcare Infection Control
Practices Advisory Committee (HICPAC).(2009). Guideline For Prevention Of Catheter-
Associated Urinary Tract Infections. Centre for Disease Control. Downloaded
from:http://www.cdc.gov/hicpac/cauti/001_cauti.html
Department of Health. (2001). Guidelines for preventing Infections associated with the Insertion
and Maintenance of Short Term Catheters in Acute Care. Journal of Hospital Infection, 47(Suppl),
S39 - S46
Laker, C (1995). Urological Nursing. Great Britain, Alden Press Ltd.
Royal Children's Hospital, Infection Control Dept. Antiseptic and Disinfectant Usage.
Association of Continence Advice, Notes on Good Practice (2006) Urethral Catheterisation NO.6
Robson, J (2001) Urethral Catheter Selection. Nursing Standard. 15 (25)
Royal College of Nursing Catheter Care RCN Guidance for Nurses ( 2007)
The Australian and New Zealand Urological Nurses Society INC. (ANZUNS) Talbot, Kay (2006)
Kids Health Info for Parents. The Royal Children's Hospital, Melbourne. Indwelling Urinary
Catheter Fact Sheet. ( 2008)
Simpson, L (2001) Indwelling Urethral Catheters. Nursing Standard. 15 (46) : 47 - 54