Caring for a Suprapubic Urinary Catheter

Skill 12-12

Caring for a Suprapubic Urinary Catheter

A suprapubic urinary catheter is an indwelling catheter used for long-term continuous urinary drainage. This type of catheter is surgically inserted through a small incision above the pubic area (Figure 1). Suprapubic bladder drainage diverts urine from the urethra when injury, stricture, prostatic obstruction, or gynecologic or abdominal surgery has compromised the flow of urine through the urethra (Hill & Mitchell, 2018). A suprapubic catheter may be preferred over indwelling urethral catheters for long-term urinary drainage (Gibson et al., 2019). Suprapubic catheters are associated with decreased risk of contamination with organisms from fecal material, elimination of damage to the urethra; does not interfere with sexual activity; increased comfort for patients with limited mobility; and lower risk of CAUTIs (Buehrle et al., 2020; Gibson et al., 2019; Hooton et al., 2010). The drainage tube may be secured with sutures and should be secured with a catheter fixation device or tape (Holroyd, 2019). Care of the patient with a suprapubic catheter includes skin care around the insertion site; care of the drainage tubing and drainage bag is the same as for an indwelling catheter (refer to Box 12-1 on page 739).

Delegation Considerations

The care of a suprapubic urinary catheter, in the postoperative period, is not delegated to assistive personnel (AP) in the acute care setting. The care of a healed suprapubic catheter site in some settings may be delegated to assistive personnel (AP) who have received appropriate training, after assessment of the catheter by the registered nurse. Depending on the state's nurse practice act and the organization's policies and procedures, the care of a suprapubic urinary catheter may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Premoistened disposable washcloths or
- Basin with warm water
- Skin cleanser, towel, washcloth
Disposable gloves
Additional PPE, as indicated
Velcro tube holder or tape to secure tube
Drainage sponge (if necessary)
Plastic trash bag
Sterile cotton-tipped applicators and sterile saline solution (if the patient has a new suprapubic catheter)

Assessment

Assess the suprapubic catheter and bag, observing the condition of the catheter and the drainage bag connected to the catheter, and the product style. If a dressing is in place at the insertion site, assess the dressing for drainage. Inspect the site around the suprapubic catheter, looking for drainage, erythema, or excoriation. Assess the method used to secure the catheter in place. If sutures are present, assess for intactness. Also, assess the characteristics of the urine in the drainage bag. Assess the patient's knowledge of caring for a suprapubic catheter.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Impaired urination
Infection risk
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to be achieved when caring for a suprapubic catheter are that the catheter site and the patient's skin remains clean, dry, intact, and without evidence of irritation or breakdown, and that the patient verbalizes an understanding of the purpose for, and care of, the catheter, as appropriate. Other appropriate outcomes include that the patient's urinary elimination is maintained, and the patient's bladder is not distended.

Implementation

Action	Rationale
1. Gather equipment.	Assembling equipment provides for an organized approach to task.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Close the curtains around the bed and close the door to the room, if possible. Explain to the patient what you are going to do and why. Encourage the patient to observe or participate, if possible.	This ensures the patient's privacy. Explanation relieves anxiety and facilitates engagement. Having the patient observe or assist encourages self-acceptance.
5. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and prevents unnecessary stretching and twisting of muscles on the part of the nurse.
6. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Assist the patient to a supine position. Place a waterproof pad under the patient at the tube exit site.	Having the bed at the proper height prevents back and muscle strain. The supine position is usually the best way to gain access to the suprapubic urinary catheter. A waterproof pad protects linens and patient from moisture.
7. Put on gloves. Gently remove the old dressing, if one is in place. Place dressing in the trash bag. Remove gloves. Perform hand hygiene.	Gloves prevent contact with blood and body fluids. Proper disposal of contaminated dressing and hand hygiene deter the spread of microorganisms.
8. Assess the exit site and surrounding skin.	Any changes in assessment could indicate potential infection.
9. Put on gloves. Remove one disposable washcloth from the package or wet a washcloth with warm water and apply skin cleanser. Gently cleanse around the suprapubic exit site (Figure 2). Remove any encrustations. Alternatively, if this is a new suprapubic catheter, use sterile cotton-tipped applicators and sterile saline to clean the site until the incision has healed. Moisten the applicators with the saline. Clean in a circular motion from the insertion site outward (Figure 3).	Gloves prevent contact with blood and body fluids. Using a gentle skin cleanser helps to protect the skin. The exit site is the most common area of skin irritation with a suprapubic catheter. If encrustations are left on the skin, they provide a medium for bacteria and an area of skin irritation.
10. Rinse the area of all cleanser. Pat dry.	The skin needs to be kept dry to prevent any irritation.
11. If the exit site has been draining, place a small drain sponge around the catheter to absorb any drainage (Figure 4). Be prepared to change this sponge throughout the day, depending on the amount of drainage. Do not cut a 4 × 4 gauze to make a drain sponge.	A small amount of drainage from the exit site is normal. The sponge needs to be changed when it becomes soiled to prevent skin irritation and breakdown. The fibers from a cut 4 × 4 gauze may enter the exit site and cause irritation or infection.
12. Remove gloves. Perform hand hygiene. Form a loop in the tubing and anchor it on the patient's abdomen with a catheter fixation device or tape (Holroyd, 2019) (Figure 5).	Proper removal of gloves and hand hygiene deter the spread of microorganisms. Anchoring the catheter and tubing absorbs any tugging, preventing tension on, and irritation to, the skin or bladder (Queensland Spinal Cord Injuries Service, 2019).
13. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Positioning and covering provide warmth and promote comfort. The bed in the lowest position promotes patient safety.
14. Put on gloves. Remove or discard equipment and assess the patient's response to the procedure.	Gloves prevent contact with blood and body fluids. The patient's response may indicate acceptance of the catheter or the need for health teaching.
15. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the patient's skin has remained clean, dry, intact, and without evidence of irritation or breakdown; the patient has verbalized an understanding of the purpose for, and care of, the catheter, as appropriate; the patient's urinary elimination has been maintained; and the patient's bladder has not distended.

Documentation

Guidelines

Document the appearance of the catheter exit site and surrounding skin, urine amount and characteristics, and the patient's reaction to the procedure.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

When cleaning the site, the catheter becomes dislodged and pulls out: Notify the health care team. It takes approximately 4 weeks for the suprapubic tract to become established, the time at which it can be safely changed (SUNA, 2016). The site of insertion can close fairly quickly prior to the establishment of the tract, so prompt attention is needed (Mount Sinai, 2019; Queensland Spinal Cord Injuries Service, 2019). If this is a well-healed site, the health care provider or advanced practice nurse can replace a new catheter easily. If this is a new suprapubic tube, the primary care provider may want to assess for any trauma to the bladder wall.
Exit site is extremely excoriated: Consult the wound, ostomy, and incontinence nurse for evaluation. A skin protectant or barrier may need to be applied as well as more frequent cleansing of the area and changing of the drain sponge (if applied).

Special Considerations

Depending on the patient's situation, they may have both a suprapubic and indwelling urethral catheter. Urine will drain from both catheters; usually, drainage from the suprapubic catheter is the larger volume.
If the suprapubic catheter is not draining into the bag but, instead, has a valve at the end of the catheter, open the valve at least every 6 hours (or more frequently depending on the prescribed intervention in the health record or institutional policy) to drain the urine from the bladder.
Powder, creams, or sprays should not be used at the insertion site (Mount Sinai, 2019; Queensland Spinal Cord Injuries Service, 2019).
Encourage patients to drink adequate fluids to keep the urine clear and free flowing (Mount Sinai, 2019; Queensland Spinal Cord Injuries Service, 2019).
Keep the drainage bag below the insertion site level to prevent backflow of urine into the bladder (Mount Sinai, 2019; Queensland Spinal Cord Injuries Service, 2019).

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Skill 12-12