Indwelling catheterisation in adults – Urethral and suprapubic (2024)

12. DOCUMENTATION

Careful documentation of date of catheter insertion and implementation of a protocol, to ensure evidence-based guidelines such as this one are followed, form the basis for prevention of CAUTI and other complications as well as prevention of unnecessary catheter days. [222, 223] Carers can convert these guidelines into local policies and procedures.

There are still a lot of issues that patients with long-term indwelling catheters can experience. [224] Without an ongoing catheter care protocol for patients with indwelling urinary catheters, important issues are likely to be neglected. [225]

There are different rules and experiences of documentation in different countries. [226] Written catheter care protocols are necessary to secure details of the procedure in the appropriate place. [18, 27, 69] The following issues should be recorded in the medical/nurse record:

1. Indication
2. Catheter type/balloon/Ch/length
3. Date of insertion
4. Reason for catheterisation or changing catheter
5. Patient reaction to catheterisation and any complaints due to catheter in situ
6. Issues with catheter insertion and type of problem
7. Description of urine, colour and volume drained
8. Specimen collected
9. Identity of catheteriser

In addition, printed booklets for this purpose can be useful to involve patients and carers in self-care. [217]

Rew developed a form (catheter change record) in which the above issues are represented. [121] Patients with long-term indwelling urethral catheters may benefit from such a change record, because it may help detect and thus prevent potential problems such as encrustation.

Example – Catheter change record (adapted from Rew 2005 [121], see Appendix Q

Mitchell developed an evidence-based long-term urinary catheter management flow chart. [100] It is a tool to be discussed with the patient and the clinical team on an individual basis. In case of catheter blockage, the literature advises reviewing at least the last 3 catheter changes (the catheter change record can be used for this). In Mitchell’s chart, there is no recommendation about catheter maintenance solutions, because there is no evidence for this.

Decision flow chart – catheter drainage (adapted from Mitchell 2008) [100], see Appendix R