Urinary Catheterization: A Case Study
Background
Urinary catheterization is needed to ensure that the drainage of urine is adequate and to preserve kidney function (Smeltzer, 2010). It is also performed in order to achieve the following: relieve obstruction, assist with drainage in the postoperative patient, provides the ability to monitor urine output accurately, allows for drainage in patients with neurogenic bladder dysfunction and in patient with urinary retention, and prevents leakage in patients with pressure ulcers (Smeltzer, 2010). Catherization is estimated to have begun around 300 AD or even earlier (Herter, et al, 2010). An indwelling catheter is one in which the catheter is held in place in the bladder with the use of an inflated balloon (Smeltzer, 2010). Urine is emptied through the catheter to a drainage bag, where it accumulates until it is emptied (Smeltzer, 2010).
Problem
An indwelling catheter can cause problems by irritating the mucosa of the bladder and allowing a medium for the growth of a bacterial biofilm (Redd, 2012). This increases the risk for a patient to develop a …show more content…
catheter-associated urinary tract infection (hereinafter referred to as “CAUTI”) (Herter, et al, 2010). Bacteria can gain entry through two routes: the periurethral route and the intraluminal route (Herter, et al, 2010). In the periurethral route, bacteria moves into the bladder between the outside of the catheter and the wall of the urethra (Herter, et al, 2010). In the intraluminal route, bacteria moves from drainage system, after the drainage system has been contaminated, into the bladder (Herter, et al, 2010). Redd stated in her article in American Nurse that, “Roughly 25% of patients in acute-care hospitals have indwelling catheters at some point.” Urinary tract infections account for about 35% of all of the hospital-acquired infections (Bernard, et al, 2012). Indwelling catheter use is attributed to 80% of those urinary tract infections (Bernard, et al, 2012). Patients encounter an increased risk of 3% to 6% for every day that an indwelling catheter in kept in place and around 50% of patients who are hospitalized and have an indwelling catheter for longer than 7-10 days develop a CAUTI (Pellowe, 2009). In almost 100% of patients who have had an indwelling catheter for 30 days, bacteriuria will be present (Herter,et al, 2010).
There are many problems associated with CAUTIs. It is estimated that CAUTIs prolong a hospital stay by 2.4 to 4.5 days (Jones, et al, 2007), increased mortality rates (Schneider, 2012), increased morbidity and on average adds $675 per patient to costs (Redd, 2012). In elderly patients who develop CAUTI the risks include falls, delirium and immobility (Bernard, et al, 2012). In approximately 3% of patients with indwelling catheters, they will develop bacteremia, which is a potentially life-threatening complication (Herter, et al, 2010) and mortality from bacteremia can be as high as 10% (Bernard, et al, 2012).
Not only is it a financial concern for patients, but a financial concern for hospitals as well. The Centers of Medicare and Medicaid Services will no longer reimburse hospitals for additional costs associated with CAUTI (Schneider, 2012). These additional costs include treatment and an increased in the length of stay for patients (Bernard, et al, 2012).
Indwelling catheters are being placed in patients inappropriately in an estimated 21% to more than 50% of patients (Herter, et al, 2010) with a majority of these catheters being started in the emergency department (Bernard, et al, 2012). Around a third of all patients where an indwelling catheter was inserted, there was no physician’s order (Bernard, et al, 2012). There is also a lack of documented rationale for patients with indwelling catheters and assessment for the continued need of catheters is overlooked and the catheter remains without indication (Bernard, et al, 2012). Patients who are 65 years and older have an increased risk for catherization that is not necessary (Bernard, et al, 2012).
How CAUTI were Prevented in Patients with Catheters in the Past Catheter management to help prevent CAUTIs in the past includes instilling antibiotics in the drainage bag, but recent information about this has shown no support for this (Herter, et al, 2010). Systemic antibiotics were also routinely given to patients to prevent CAUTIs (Herter, et al, 2010), but doing so might contribute to antibiotic-resistant bacteria (Redd, 2012). Irrigation of the system and bladder with antiseptic or antimicrobial agents were also prescribed, but studies have shown that not only do these procedures break the closed system and actually introduces bacteria to the system, but it can also contribute to resistant microorganisms (Pellowe, 2009). This is now only prescribed if it is medically necessary and indicated (Pellowe, 2009). Cranberry juice was also given to patients with catheters to help prevent CAUTIs, but while cranberry juice does help prevent urinary tract infections in patients without indwelling catheters, it does not reduce the risk of urinary tract infections in patients with catheters (Herter, et al, 2010).
Preventing Infection The first step to reduce the incidence of CAUTIs is to avoid unnecessary catherization.
Since it poses such significant and serious risks, it should only be used when all other interventions have been unsuccessful (Herter, et al, 2010). Other incontinence aids include the use of bed pans, adult briefs and condom catheters (Schneider, 2012). Catheters should never be used as a means of convenience for the staff (Pellowe, 2009). If other interventions have failed and it is found that catherization is necessary, then intermittent catherization should be considered first (Herter, et al, 2010). If intermittent catherization is not successful and an indwelling catheter is necessary then its length of time to stay inserted should be a short as possible (Herter, et al, 2010). The incidence of CAUTIs increases significantly the longer the catheter stays in place (Schneider,
2012). Hand hygiene and the donning of gloves is the first and most important step before inserting a catheter (Herter,et al, 2010). It should also be done right after insertion and anytime before and after manipulation of the device or site (Herter, et al, 2010). It is also important to cleanse the perineal area thoroughly to decrease bacteria in the area (Herter, et al, 2010). To minimize trauma to the mucosa, the smallest gauge possible should be used so that will allow the urine to flow freely (Pellowe, 2009) and to adequately lubricate the catheter before insertion (Herter, et al, 2010). The balloon should also be no larger than 10 milliliters (Pellowe, 2009). There is evidence that catheters that are coated in silver alloy are more effective at reducing CAUTIs (Pellowe, 2009). Catherization should only be performed by staff that is trained because this will help reduce the incidence of CAUTIs (Pellowe, 2009). Only sterile equipment should be used and aseptic technique (Herter, et al, 2010). The catheter should be secured to the thigh to prevent excessive force and movement on the urethra (Herter, et al, 2010). The most important thing to do in the maintenance and management of an indwelling catheter is to maintain a closed drainage system (Redd, 2012). Anytime there is an opening, it creates a route for bacteria, which can lead to a CAUTI (Redd, 2012). Urine samples should only be taken from sample port by cleansing the port with 70% isopropyl alcohol before aspirating with a sterile syringe and cleansing the port when finished with 70% isopropyl alcohol (Redd, 2012). When emptying the drainage bag, use a separate container for each patient and never let the drainage tap come in contact with collecting container (Redd, 2012). The drainage bag should be drained frequently enough that urine flow is maintained and reflux is prevent (Jones, et al, 2007). The outlet tap should be clean with 70% isopropyl alcohol before and after opening (Jones, et al, 2007). Always ensure that the tubing is not kinked and that the collection bag is maintained below the level of the bladder to ensure that urine does not backflow into the bladder (Redd, 2012). The use of sealed drainage systems that are attached together by the manufacturer have shown 41% reduction in CAUTIs by a United Kingdom study (Pellowe, 2009). Vigorous meatal cleansing is not necessary since it can increase the risk for infection, instead routine meatal care with only soap and water during daily showers is all that is necessary (Herter, et al, 2010) since there is no evidence to support the use of antiseptic solutions (Pellowe, 2009). This should be done twice a day working from the front to the back of the perineal area (Redd, 2012). Avoid irrigation unless necessary or to prevent or relieve obstructions (Herter, et al, 2010). Increase the patient’s fluid intake if patient is not on a restriction to help prevent CAUTIs (Redd, 2012). This decreases the incidence of CAUTIs by diluting the urine and flushing the bacteria out (Redd, 2012). Always change indwelling catheters if there is a break in the closed system or if there is indications of infection or obstruction (Herter, et al, 2010). It is also cautioned against putting two patients with indwelling catheters in the same room (Redd, 2012). This can prevent the temptation of the caregiver to provide maintenance for the catheters without washing hands or changing collection equipment (Redd, 2012). Assessment of continued catheter need is an essential part of caring for a patient with an indwelling catheter and should be assessed at every visit (Herter, et al, 2010). Research has shown that daily consultation of the need for a catheter reduced the number of days per month that an indwelling catheter was used and also decreased the number of CAUTIs (Bernard, et al, 2012). There have been several methods that have been studied that have reminded doctors and nurses about removal of indwelling catheters. Once of these was a daily reminder five days after insertion to assess the need for continuing catherization (Bernard, et al, 2012). One observation study showed that most CAUTIs occurred on days 5 and 6 of catherization so a study was done where the target removal day was on day 4 (Bernard, et al, 2012). There was not a significant decrease in the number of days of catherization, but there was a significant reduction in CAUTIs from 12.8 to 1.8 (Bernard, et al, 2012). In a study in Thailand, the intervention was a daily reminder to nurses on the computerized entry system to identify and assess patients who have had an indwelling catheter for more than 3 days and to notify physicians if they were no longer indicated (Bernard, et al, 2012). There was a significant decrease in the number of days and the number of CAUTIs (Bernard, et al, 2012). This evidence suggests that chart reminders to physicians and nurses on a consistent daily basis about the continued need to catherization demonstrated a significant decrease in the duration of catherization and incidence of CAUTIs (Bernard, et al, 2012). This evidence also implies that nurses have a critical role in advocating for their patients in regard to reducing the complications from indwelling urinary catheters (Bernard, et al, 2012). Lastly, more education and training should be given to nurses and physicians regarding catherization. Education should be used first on when to determine when catherization is necessary and how to properly insert an indwelling catheter (Redd, 2012). Troubleshooting training should also be done in order to learn how to respond to common problems occurring with catheters (Herter, et al, 2010). Patients, caregivers, nurses and physicians should be educated on recognizing the signs and symptoms of infection in patients with indwelling catheters (Herter, et al, 2010). These include an increase in urinary urgency, frequency, dysuria, suprapubic tenderness, fever and color or consistency changes of urine (Herter, et al, 2010). In older patients, signs and symptoms may not be the same (Herter, et al, 2010). Assess for changes in mental status, physical condition or behavior (Herter, et al, 2010).
Conclusion
In the past, it was seen as normal and inevitable that a patient hospitalized with an indwelling catheter would get a CAUTI (Redd, 2012). Now especially with hospitals no longer getting reimbursed for these infections, it is seen as unacceptable. Hospitals now have a huge incentive to reduce the occurrences of CAUTIs. Just by using infection control methods, CAUTIs may be prevented an estimated 17% to 69% (Herter, et al, 2010). By adhering to manufacturer recommendations and the guidelines above, the risk of CAUTIs can be lessened. The use of indwelling catheters in patients should be a therapeutic management and not a cause of infection, pain or trauma. By using indwelling catheters only when necessary, removing the catheter as soon as possible, using proper insertion and management techniques, proper hygiene, keep the system closed, reminder systems for nurses and physicians and continuing education for caregivers, the risk of CAUTIs could significantly decrease.
References
Bernard, M., Hunter, K., & Moore, K. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urology Nursing, 32(1), 29-37. Retrieved from http://www.medscape.com/viewarticle/759922.
Herter, Rebecca & Kazer, Meredith Wallace (2010). Best practices in urinary catheter care. Home Healthcare Nurse, 28(6), 342-349. Retrieved from http://www.nursingcenter.com/lnc/cearticle?tid=1027118.
Jones, S., Kent, W., Brooks, A., Foxley, S., & Dunkin, J. (2007). Evidence: Care of urinary catheters and drainage systems. Nursing Times, 103, 42, 48-50. Retrieved from http://www.nursingtimes.net/evidence-care-of-urinary-catheters-and-drainage-systems/439075.article.
Pellowe, Carol (2009). Reducing the risk of infection with indwelling urethral catheters. Nursing Times 105, 105. Retrieved from http://www.nursingtimes.net/nursing-practice/clinical-zones/infection-control/reducing-the-risk-of-infection-with-indwelling-urethral-catheters/5005830.article.
Redd, Linda M. (2012). Preventing urinary tract infections in patients with indwelling catheters. American Nurse Today, 7(2). Retrieved from http://www.americannursetoday.com/article.aspx?id=8754.
Schneider, Melissa A. (2012). Prevention of catheter-associated urinary tract infections in patients with hip fractures through education of nurses to specific catheter protocols. Orthopaedic Nursing, 31(1), 12-18. Retrieved from http://www.nursingcenter.com/lnc/cearticle?=1299235.
Smeltzer, S., Hinkle, J., Bare, B., & Cheever, K. (2010). Management of Patients with Urinary Disorders. Brunner and suddarth 's textbook of medical -surgical nursing, 12th ed., (12th ed., pp. 1372-1374). Philadelphia: Lippincott, Williams & Wilkins.
Urinary catheterization is needed to ensure that the drainage of urine is adequate and to preserve kidney function (Smeltzer, 2010). It is also performed in order to achieve the following: relieve obstruction, assist with drainage in the postoperative patient, provides the ability to monitor urine output accurately, allows for drainage in patients with neurogenic bladder dysfunction and in patient with urinary retention, and prevents leakage in patients with pressure ulcers (Smeltzer, 2010). Catherization is estimated to have begun around 300 AD or even earlier (Herter, et al, 2010). An indwelling catheter is one in which the catheter is held in place in the bladder with the use of an inflated balloon (Smeltzer, 2010). Urine is emptied through the catheter to a drainage bag, where it accumulates until it is emptied (Smeltzer, 2010).
Problem
An indwelling catheter can cause problems by irritating the mucosa of the bladder and allowing a medium for the growth of a bacterial biofilm (Redd, 2012). This increases the risk for a patient to develop a …show more content…
catheter-associated urinary tract infection (hereinafter referred to as “CAUTI”) (Herter, et al, 2010). Bacteria can gain entry through two routes: the periurethral route and the intraluminal route (Herter, et al, 2010). In the periurethral route, bacteria moves into the bladder between the outside of the catheter and the wall of the urethra (Herter, et al, 2010). In the intraluminal route, bacteria moves from drainage system, after the drainage system has been contaminated, into the bladder (Herter, et al, 2010). Redd stated in her article in American Nurse that, “Roughly 25% of patients in acute-care hospitals have indwelling catheters at some point.” Urinary tract infections account for about 35% of all of the hospital-acquired infections (Bernard, et al, 2012). Indwelling catheter use is attributed to 80% of those urinary tract infections (Bernard, et al, 2012). Patients encounter an increased risk of 3% to 6% for every day that an indwelling catheter in kept in place and around 50% of patients who are hospitalized and have an indwelling catheter for longer than 7-10 days develop a CAUTI (Pellowe, 2009). In almost 100% of patients who have had an indwelling catheter for 30 days, bacteriuria will be present (Herter,et al, 2010).
There are many problems associated with CAUTIs. It is estimated that CAUTIs prolong a hospital stay by 2.4 to 4.5 days (Jones, et al, 2007), increased mortality rates (Schneider, 2012), increased morbidity and on average adds $675 per patient to costs (Redd, 2012). In elderly patients who develop CAUTI the risks include falls, delirium and immobility (Bernard, et al, 2012). In approximately 3% of patients with indwelling catheters, they will develop bacteremia, which is a potentially life-threatening complication (Herter, et al, 2010) and mortality from bacteremia can be as high as 10% (Bernard, et al, 2012).
Not only is it a financial concern for patients, but a financial concern for hospitals as well. The Centers of Medicare and Medicaid Services will no longer reimburse hospitals for additional costs associated with CAUTI (Schneider, 2012). These additional costs include treatment and an increased in the length of stay for patients (Bernard, et al, 2012).
Indwelling catheters are being placed in patients inappropriately in an estimated 21% to more than 50% of patients (Herter, et al, 2010) with a majority of these catheters being started in the emergency department (Bernard, et al, 2012). Around a third of all patients where an indwelling catheter was inserted, there was no physician’s order (Bernard, et al, 2012). There is also a lack of documented rationale for patients with indwelling catheters and assessment for the continued need of catheters is overlooked and the catheter remains without indication (Bernard, et al, 2012). Patients who are 65 years and older have an increased risk for catherization that is not necessary (Bernard, et al, 2012).
How CAUTI were Prevented in Patients with Catheters in the Past Catheter management to help prevent CAUTIs in the past includes instilling antibiotics in the drainage bag, but recent information about this has shown no support for this (Herter, et al, 2010). Systemic antibiotics were also routinely given to patients to prevent CAUTIs (Herter, et al, 2010), but doing so might contribute to antibiotic-resistant bacteria (Redd, 2012). Irrigation of the system and bladder with antiseptic or antimicrobial agents were also prescribed, but studies have shown that not only do these procedures break the closed system and actually introduces bacteria to the system, but it can also contribute to resistant microorganisms (Pellowe, 2009). This is now only prescribed if it is medically necessary and indicated (Pellowe, 2009). Cranberry juice was also given to patients with catheters to help prevent CAUTIs, but while cranberry juice does help prevent urinary tract infections in patients without indwelling catheters, it does not reduce the risk of urinary tract infections in patients with catheters (Herter, et al, 2010).
Preventing Infection The first step to reduce the incidence of CAUTIs is to avoid unnecessary catherization.
Since it poses such significant and serious risks, it should only be used when all other interventions have been unsuccessful (Herter, et al, 2010). Other incontinence aids include the use of bed pans, adult briefs and condom catheters (Schneider, 2012). Catheters should never be used as a means of convenience for the staff (Pellowe, 2009). If other interventions have failed and it is found that catherization is necessary, then intermittent catherization should be considered first (Herter, et al, 2010). If intermittent catherization is not successful and an indwelling catheter is necessary then its length of time to stay inserted should be a short as possible (Herter, et al, 2010). The incidence of CAUTIs increases significantly the longer the catheter stays in place (Schneider,
2012). Hand hygiene and the donning of gloves is the first and most important step before inserting a catheter (Herter,et al, 2010). It should also be done right after insertion and anytime before and after manipulation of the device or site (Herter, et al, 2010). It is also important to cleanse the perineal area thoroughly to decrease bacteria in the area (Herter, et al, 2010). To minimize trauma to the mucosa, the smallest gauge possible should be used so that will allow the urine to flow freely (Pellowe, 2009) and to adequately lubricate the catheter before insertion (Herter, et al, 2010). The balloon should also be no larger than 10 milliliters (Pellowe, 2009). There is evidence that catheters that are coated in silver alloy are more effective at reducing CAUTIs (Pellowe, 2009). Catherization should only be performed by staff that is trained because this will help reduce the incidence of CAUTIs (Pellowe, 2009). Only sterile equipment should be used and aseptic technique (Herter, et al, 2010). The catheter should be secured to the thigh to prevent excessive force and movement on the urethra (Herter, et al, 2010). The most important thing to do in the maintenance and management of an indwelling catheter is to maintain a closed drainage system (Redd, 2012). Anytime there is an opening, it creates a route for bacteria, which can lead to a CAUTI (Redd, 2012). Urine samples should only be taken from sample port by cleansing the port with 70% isopropyl alcohol before aspirating with a sterile syringe and cleansing the port when finished with 70% isopropyl alcohol (Redd, 2012). When emptying the drainage bag, use a separate container for each patient and never let the drainage tap come in contact with collecting container (Redd, 2012). The drainage bag should be drained frequently enough that urine flow is maintained and reflux is prevent (Jones, et al, 2007). The outlet tap should be clean with 70% isopropyl alcohol before and after opening (Jones, et al, 2007). Always ensure that the tubing is not kinked and that the collection bag is maintained below the level of the bladder to ensure that urine does not backflow into the bladder (Redd, 2012). The use of sealed drainage systems that are attached together by the manufacturer have shown 41% reduction in CAUTIs by a United Kingdom study (Pellowe, 2009). Vigorous meatal cleansing is not necessary since it can increase the risk for infection, instead routine meatal care with only soap and water during daily showers is all that is necessary (Herter, et al, 2010) since there is no evidence to support the use of antiseptic solutions (Pellowe, 2009). This should be done twice a day working from the front to the back of the perineal area (Redd, 2012). Avoid irrigation unless necessary or to prevent or relieve obstructions (Herter, et al, 2010). Increase the patient’s fluid intake if patient is not on a restriction to help prevent CAUTIs (Redd, 2012). This decreases the incidence of CAUTIs by diluting the urine and flushing the bacteria out (Redd, 2012). Always change indwelling catheters if there is a break in the closed system or if there is indications of infection or obstruction (Herter, et al, 2010). It is also cautioned against putting two patients with indwelling catheters in the same room (Redd, 2012). This can prevent the temptation of the caregiver to provide maintenance for the catheters without washing hands or changing collection equipment (Redd, 2012). Assessment of continued catheter need is an essential part of caring for a patient with an indwelling catheter and should be assessed at every visit (Herter, et al, 2010). Research has shown that daily consultation of the need for a catheter reduced the number of days per month that an indwelling catheter was used and also decreased the number of CAUTIs (Bernard, et al, 2012). There have been several methods that have been studied that have reminded doctors and nurses about removal of indwelling catheters. Once of these was a daily reminder five days after insertion to assess the need for continuing catherization (Bernard, et al, 2012). One observation study showed that most CAUTIs occurred on days 5 and 6 of catherization so a study was done where the target removal day was on day 4 (Bernard, et al, 2012). There was not a significant decrease in the number of days of catherization, but there was a significant reduction in CAUTIs from 12.8 to 1.8 (Bernard, et al, 2012). In a study in Thailand, the intervention was a daily reminder to nurses on the computerized entry system to identify and assess patients who have had an indwelling catheter for more than 3 days and to notify physicians if they were no longer indicated (Bernard, et al, 2012). There was a significant decrease in the number of days and the number of CAUTIs (Bernard, et al, 2012). This evidence suggests that chart reminders to physicians and nurses on a consistent daily basis about the continued need to catherization demonstrated a significant decrease in the duration of catherization and incidence of CAUTIs (Bernard, et al, 2012). This evidence also implies that nurses have a critical role in advocating for their patients in regard to reducing the complications from indwelling urinary catheters (Bernard, et al, 2012). Lastly, more education and training should be given to nurses and physicians regarding catherization. Education should be used first on when to determine when catherization is necessary and how to properly insert an indwelling catheter (Redd, 2012). Troubleshooting training should also be done in order to learn how to respond to common problems occurring with catheters (Herter, et al, 2010). Patients, caregivers, nurses and physicians should be educated on recognizing the signs and symptoms of infection in patients with indwelling catheters (Herter, et al, 2010). These include an increase in urinary urgency, frequency, dysuria, suprapubic tenderness, fever and color or consistency changes of urine (Herter, et al, 2010). In older patients, signs and symptoms may not be the same (Herter, et al, 2010). Assess for changes in mental status, physical condition or behavior (Herter, et al, 2010).
Conclusion
In the past, it was seen as normal and inevitable that a patient hospitalized with an indwelling catheter would get a CAUTI (Redd, 2012). Now especially with hospitals no longer getting reimbursed for these infections, it is seen as unacceptable. Hospitals now have a huge incentive to reduce the occurrences of CAUTIs. Just by using infection control methods, CAUTIs may be prevented an estimated 17% to 69% (Herter, et al, 2010). By adhering to manufacturer recommendations and the guidelines above, the risk of CAUTIs can be lessened. The use of indwelling catheters in patients should be a therapeutic management and not a cause of infection, pain or trauma. By using indwelling catheters only when necessary, removing the catheter as soon as possible, using proper insertion and management techniques, proper hygiene, keep the system closed, reminder systems for nurses and physicians and continuing education for caregivers, the risk of CAUTIs could significantly decrease.
References
Bernard, M., Hunter, K., & Moore, K. (2012). A review of strategies to decrease the duration of indwelling urethral catheters and potentially reduce the incidence of catheter-associated urinary tract infections. Urology Nursing, 32(1), 29-37. Retrieved from http://www.medscape.com/viewarticle/759922.
Herter, Rebecca & Kazer, Meredith Wallace (2010). Best practices in urinary catheter care. Home Healthcare Nurse, 28(6), 342-349. Retrieved from http://www.nursingcenter.com/lnc/cearticle?tid=1027118.
Jones, S., Kent, W., Brooks, A., Foxley, S., & Dunkin, J. (2007). Evidence: Care of urinary catheters and drainage systems. Nursing Times, 103, 42, 48-50. Retrieved from http://www.nursingtimes.net/evidence-care-of-urinary-catheters-and-drainage-systems/439075.article.
Pellowe, Carol (2009). Reducing the risk of infection with indwelling urethral catheters. Nursing Times 105, 105. Retrieved from http://www.nursingtimes.net/nursing-practice/clinical-zones/infection-control/reducing-the-risk-of-infection-with-indwelling-urethral-catheters/5005830.article.
Redd, Linda M. (2012). Preventing urinary tract infections in patients with indwelling catheters. American Nurse Today, 7(2). Retrieved from http://www.americannursetoday.com/article.aspx?id=8754.
Schneider, Melissa A. (2012). Prevention of catheter-associated urinary tract infections in patients with hip fractures through education of nurses to specific catheter protocols. Orthopaedic Nursing, 31(1), 12-18. Retrieved from http://www.nursingcenter.com/lnc/cearticle?=1299235.
Smeltzer, S., Hinkle, J., Bare, B., & Cheever, K. (2010). Management of Patients with Urinary Disorders. Brunner and suddarth 's textbook of medical -surgical nursing, 12th ed., (12th ed., pp. 1372-1374). Philadelphia: Lippincott, Williams & Wilkins.