Unseen Perils of Urinary Catheters
A hospitalized older man with a complicated medical history had not voided in several hours. The hospitalist ordered insertion of a urinary catheter. The patient voided just prior to catheter insertion, which produced no urine, and the nurse assumed that meant the patient's bladder was empty. Two hours later the patient complained of discomfort and a blood clot was found in his tubing. Continuous bladder irrigation was ordered, but the pain became worse. Urgent consultation by urology revealed that the urinary catheter was not in the bladder. Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RN, all of the University of Pennsylvania, discuss complications associated with catheter insertion and maintenance and review best practices to reduce risks.
Unseen Perils of Urinary Catheters
Commentary by Diane K. Newman, DNP, MSN; Robyn Strauss, MSN; Liza Abraham, CRNP; and Bridget Major-Joynes, MSN, RNThe Case
A 68-year-old man with a history of hypothyroidism, hypertension, seizures, cerebral vascular attack with hemiplegia, dysphagia, vascular dementia, speech disorder, benign hypertrophy of prostate with urinary retention, and monocular blindness was admitted to the hospital. He had no known allergies. The patient required total care for his activities of daily living. He received bolus feedings through a gastrostomy tube and required occasional suctioning of his tracheostomy. He was incontinent of bowel and bladder. He was alert and oriented to person and place. He was only able to answer simple yes-or-no questions.
During the day-to-evening shift change, a nursing assistant reported the patient had not voided all shift. The patient's bladder was not distended nor did he complain of discomfort. The hospitalist was called and ordered a urinary catheter insertion. Just prior to insertion of the catheter by a registered nurse (RN), the patient voided but the amount was not recorded. The RN reported this to the charge nurse, who informed the RN to proceed with the catheter insertion. The RN did so, but the procedure did not produce any urine. Since the patient had just voided, the RN assumed the patient's bladder was empty. Two hours later, the patient began to complain of discomfort. The RN attempted to irrigate the catheter but met resistance.
The charge nurse was called to assess the situation and found a blood clot in the tubing. The hospitalist was notified and ordered continuous bladder irrigation (CBI). The same RN removed the catheter and inserted a three-way catheter and the CBI began. An hour later, the patient's pain increased and his bladder was distended. The CBI intake and output were in equal amounts. The patient was transferred to emergency room. A urologist was called, who performed a bladder scan and discovered the urinary catheter was not in the bladder. The second catheter was removed and a new three-way catheter was inserted by the emergency room RN. Blood returned from the new catheter. It was irrigated until clear, and then CBI resumed. The patient was transferred back to the ward for observation and the next day he received two units of blood. CBI was continued for 2 days.
The patient experienced pain from a distended bladder, a misplaced catheter, and three catheter [re-]insertions. He was put at risk for complications that included urinary tract infection, urosepsis, and bladder rupture. The misplaced catheter caused trauma to the urethra and blood loss. The patient's wife filed a complaint with the facility, which prompted an in-house investigation. The investigation revealed that the nursing staff on duty were unaware of the policy regarding bladder scanning prior to catheter insertion or the CBI policy that required documentation of both input/output and urinary volume.
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