Core skills challenge

F1 DOCTORS must demonstrate competence in 15 procedures to become eligible for full GMC registration. Here are some helpful tips on male and female urethral catheterisation, and airway care including simple adjuncts.

Urethral catheterisation (male)

I first inserted a male catheter on my first job on a geriatric ward when I had a patient in urinary retention who needed to be catheterised urgently.

I went to the treatment room in search of all the items I needed. I checked with the nursing staff which catheter size was most suitable and to double check I had selected a male catheter. After finding a trolley and cleaning it, I made sure I opened all my items out into my sterile field being careful not to contaminate anything, using aseptic non-touch technique (ANTT). I placed the catheter bag under the trolley.

At the bedside I explained to the patient what I was going to do and why. After putting on an apron and using alcohol gel I remembered to pour the water for cleaning into the sterile tray before donning my sterile gloves. With the nurse as a chaperone and an extra pair of very helpful hands, I cleaned the patient ensuring I maintained the “clean hand, dirty hand” technique, something that I still have to actively think about during these procedures to maintain sterility. I inserted 10ml of the lubricant with local anaesthetic into the urethral opening/meatus and waited a few minutes.

At this point I changed my sterile gloves and opened the inner sterile catheter package. I inserted the catheter, ensuring the distal end was over the tray to catch any urine likely to appear – in this situation at high pressure. I inflated the balloon with the prefilled 10ml syringe and pulled gently back on the catheter until there was resistance. It is important to ensure the patient isn’t in discomfort during balloon inflation as there is a risk of rupturing the urethral sphincter as you do so. I attached the catheter bag with the help of the nurse, I told the patient the procedure was all done and cleared away the rubbish. Remember to replace the retracted foreskin to avoid paraphimosis, ensure you keep the catheter labels for documentation purposes and also send a urine sample.

Urethral catheterisation (female)

I inserted my first female catheter again on a geriatric ward during my first job, this time for a lady with a neurogenic bladder who required a long-term catheter. In this case, I had to remove a catheter to insert a new one.

Again I identified the correctly sized catheter, this time for a female, and made sure it was suitable for long-term insertion. I gathered and prepared my equipment in the clean environment of the treatment room. After explaining the procedure, I ensured I had all the correct equipment laid out in the sterile field at the bedside using ANTT.

I removed the current catheter and then began the cleaning process in a downward motion, ensuring not to contaminate already clean areas. I find it useful to take more gauze than is provided in sterile packs for cleaning during catheter insertion; in reality it is never enough.

Making sure the patient was informed of what I was doing at all times but being mindful of the non-soundproof curtains, I explained why, where and how I was going to proceed with the catheter insertion. Confident I had identified the urethral opening, an area of female catheterisation that can be challenging, I inserted 10ml of anaesthetising lubricant and waited for it to take effect.

After changing my sterile gloves I introduced the catheter, with the distal end over a tray to catch any residual urine. Once urine was flowing I inflated the balloon with 10ml of water and retracted the catheter until I felt resistance. I attached the catheter bag and informed the patient I had finished. I peeled off the catheter stickers for documentation and cleared away my rubbish.

Airway care including simple adjuncts

Using simple airway adjuncts isn’t something I have often had to do. There are a few options to choose from in situations where a patient is unable to maintain their own airway and has a decreased level of consciousness such that they can tolerate an airway adjunct. If jaw thrusts and/or head tilt chin lift are insufficient then you may want to use an oropharangeal or nasopharyngeal airway. For both of these airway adjuncts it is import you use the correct size for the patient. The nasopharyngeal airway (NPA) most commonly used in adults is 6-7mm in diameter. These cannot be used in patients who have had a head injury. They are inserted, with lubrication, horizontally into the patient’s nostril – usually the right nostril due to the angled tip of the NPA. It is commonly said that you should attach a safety pin to the distal end of the NPA to avoid losing it up the nostril! Often pins are already in place on the crash trolley NPAs to save time.

An oropharyngeal airway (OPA) is a curved, rigid plastic tube which is inserted upside down then twisted 180 degrees in the patient’s mouth to avoid initially pushing the tongue backwards and occluding the airway further. There are different ways of measuring oropharyngeal airways: I use the angle of the jaw to tragus method. You put the tip of the OPA at the angle of the patient’s jaw, directing the flat end of the OPA, up to the patient’s tragus; you should use the size that is long enough to reach both those anatomical points.

Remember if you find yourself in a situation where you need to use an airway adjunct, you should be informing a senior and seeking their advice on further management.

Dr Sophie Rogers is a foundation year one doctor based in Bolton