Urinary catheterisation and nasogastric tube safety

Before urinary catheterisation, verify indication: acute retention, accurate output in critical illness, selected perioperative care, protected wound or comfort in specific palliative circumstances. Incontinence alone is not a routine indication. Consider bladder scan, prompted toileting, urinal, commode or intermittent catheterisation. Check anatomy, urethral surgery or stricture, trauma, infection, latex and lubricant allergy, pregnancy and consent.

Suspected urethral injury—blood at meatus, perineal bruising, pelvic trauma or abnormal prostate position—requires senior urological assessment rather than blind urethral insertion. Difficult anatomy, previous reconstruction, artificial sphincter or repeated failure needs expert help. Prepare sterile catheter pack, appropriate smallest-gauge catheter, sterile closed drainage, single-use lubricant or anaesthetic gel, cleansing solution per local policy, securement and PPE.

Position with privacy and a chaperone. Perform hand hygiene, open the sterile field and arrange key parts. Clean the meatus according to local policy using aseptic technique. Instil the single-use lubricant and allow product-specified anaesthetic time if relevant. Maintain sterility; if the catheter touches non-sterile skin or bedding, replace it rather than wiping.

For vulval anatomy, separate labia with the non-dominant hand, clean front to back and keep that hand in position because it is now contaminated. Visualise the meatus and advance the catheter until urine flows, then a little farther as taught before balloon inflation. If it enters the vagina, leave it as a landmark if policy supports and use a new sterile catheter.

For penile anatomy, retract foreskin if present, hold penis gently to straighten the urethra and clean from meatus outward. Instil lubricant without force. Advance the catheter to the bifurcation or protocol depth before inflating only after urine flows. Never inflate in the urethra; severe pain or resistance requires stopping. Do not use force to pass an enlarged prostate or stricture.

Inflate the balloon with exactly the sterile-water volume printed for that catheter, never air or an arbitrary syringe volume. Gently withdraw until seated, connect or maintain the closed system, secure to prevent traction and replace foreskin to avoid paraphimosis. Position the bag below bladder, off floor, without kinks or dependent loops. Record residual volume when clinically relevant but do not clamp routine acute retention drainage without a protocol.

Aftercare includes urine colour, volume, pain, leakage and haematuria. Maintain unobstructed flow and minimal handling. Empty with a clean individual container without tap contact. Take culture specimens from the disinfected sampling port. Do not disconnect the closed system merely to obtain urine. Review need daily and remove promptly under a documented trial-without-catheter plan.

Stop and seek help for severe pain, resistance, no urine despite suspected full bladder, balloon inflation pain, heavy haematuria, autonomic dysreflexia or signs of sepsis. After removal, inspect balloon/device and monitor voiding, bladder symptoms and residual according to indication. Catheter-associated bacteriuria is common over time; treat symptomatic infection according to current guidance, not cloudy urine alone.

Before NG placement, confirm indication and whether gastric feeding, decompression or medicine delivery is intended. Assess swallowing and airway protection, facial or basal-skull trauma, oesophageal disease or surgery, varices, caustic ingestion and bleeding risk. Some are relative risks needing senior decision; suspected basal skull fracture may require an alternative route. Explain gagging, obtain consent and ensure suction and senior help are available when risk warrants.

Prepare the correct radio-opaque NG tube with external markings, water-soluble lubricant, pH indicator strips made for gastric aspirate, enteral syringe, fixation, cup and straw if safe, PPE and X-ray pathway. Check tube integrity and expiry. Measure proposed insertion length using the organisation’s validated method and record it; different national resource sets and tube designs mean a locally approved method is essential.

Sit the patient upright with head neutral initially. Inspect nostrils, choose the clearer side and lubricate. Pass along the floor of the nose, not upward. At the oropharynx, pause; if swallow is safe, ask the patient to sip and swallow while advancing to the marked length. Do not force against resistance. Withdraw immediately for persistent coughing, cyanosis, breathlessness, voice change or physiological deterioration.

Secure temporarily and attempt aspiration with an enteral syringe. Place aspirate on approved pH paper and read at the stated time. A pH of 1–5.5 is within the NHS England safe range for initial placement when obtained and tested correctly. Acid-suppressing treatment and continuous feeds can raise pH; aspirate appearance is not sufficient. If no aspirate or pH exceeds 5.5, do not use the tube and follow the X-ray pathway.

The X-ray must include the full route needed to assess tube course and be interpreted by someone documented as competent using the four criteria: tube follows oesophagus, bisects carina appropriately, crosses diaphragm in midline and tip lies below the left hemidiaphragm in stomach. Record the decision and who authorised use. “X-ray satisfactory” without criteria is unsafe. Never use auscultatory whoosh, bubbling, litmus or absence of respiratory distress.

Before every use and after coughing, vomiting, retching, transfer or external-length change, follow the local recheck policy. Compare external length and fixation and repeat approved placement confirmation. Do not flush to obtain aspirate until safe placement is established because flushing a respiratory tube causes harm. If placement cannot be confirmed, withhold tube contents and seek senior or radiology help.

Once authorised, secure without pressure injury, document nostril, external length, tube type, confirmation method and review date. Elevate appropriately during feeding and follow enteral-feed, flushing and medicine-administration protocols. Use only enteral-design syringes and connectors. Check nasal skin, mouth care, blockage, aspiration symptoms and continued indication.

NG insertion and X-ray interpretation require assessed competence. A learner must not practise without direct supervision. Repeated attempts increase trauma and misplacement; follow local attempt limits and consider guided placement. In a deteriorating patient, protect airway and treat aspiration or pneumothorax urgently. Report a never-event or near miss through patient-safety systems while caring openly for the person.