EXTERNAL DOUCHE

Definition: It is the washing of genitals and anal area with water, soap and/or medicated
solution.
Purposes:
1. To cleanse the area of secretion and excretions.
2. To reduce unpleasant odors.
3. To prevent skin irritation and excoriation.
4. To control the potential for infection.
5. To promote comfort.
Equipment:
1. Bedpan with cover.
2. Waterproof underpad.
3. Bath blanket (optional)
4. A tray containing the following:
a. Sterile covered flushing can with sterile water or solution to be used.
b. Sterile pick up forceps in a disinfectant solution.
c. A jar of dry sterile CB (optional).
d. A jar of sterile CB soaked in soap sud solution.
e. A jar of sterile CB soaked in antiseptic solution.
f. Kidney basin lined with paper for waste.
g. Toilet paper. (client’s supply)
h. A piece of paper to wrap vaginal pads.
i. Working forceps in a sterile pack
j. Working gloves (2 pairs)
k. Sterile bowl or sterile kidney basin
5. Adult diaper or sanitary pad (client’s supply; optional)
6. Perineal cream or lotion if needed

Procedure
Action Rationale
1. Assess the need for external douche.
Exchanging information allays fears and
2. Identify the patient and explain the promotes cooperation.
procedure.

3. Wash your hands. Handwashing reduce the transient

microorganism thus, deters the spread to
client and self.

4. Assemble and bring equipment to Organization promotes efficient time

the bedside. management.

5. Screen the client and close the door/ This ensures the patient’s privacy.
windows if possible.

6. Raise the bed to working height.

7. Don gloves
To protect the nurse from infection
8. Place waterproof pad, if available, as
well as change the top sheet with Cleansing may wet or soil an unprotected bed.
bath blanket if available.
9. Drape the client.

10. Remove adult diaper/sanitary pad. This provides warmth and respect the privacy
Roll with the contaminated inside of the client.
and wrap with a piece of paper. Place
it on the paper lining under the bed.
11. Place the client on a bedpan in a
dorsal recumbent position.

12. Change working gloves. Prepare A bedpan will collect the water used during
sterile pack. Open sterile bowl or perineal cleansing.
kidney basin. Place 7 or more CB
soaked in soap suds solution. Open
sterile working forceps and place it
on the sterile field with the handle at
the edge. Prepare tissue wipes at the
edge of the sterile field.

13. Lift the cover of the flushing can and To protect the inner side of the flushing can
fold with sterile side inside. Test the from contamination. Testing the temperature
water temperature (105°F or 41°C) of water prevents burns.
by pouring small amount of water
over the back of your hand and then
on the client’s thigh.
14. Flush the area with warm water or a Water dissolves or dilutes dried secretions.
soapy solution until the area is clean. Soap emulsifies fatty substances in the skin
and reduces the ability of microbes to grow
15. With one cotton ball soaked in SSS, and multiply.
wash the mons veneris in zigzag
motion going upward toward the
lower portion of the hypogastrium.
16. Use a second cotton ball in SSS to Thorough cleansing and care should be taken
wash the inner aspect of the farther to avoid introducing secretions and bacteria
thigh. Beginning in the crease of the into the opening through which urine is
groin and continuing outward release. Contamination of this area can lead to
toward the knee. These strokes are a urinary tract infection.
made with a back – and - forth
motion and are carried well
underneath the thigh.
17. A third cotton ball in SSS is used to
wash the inner aspect of the nearer
thigh using similar stroke.
18. A fourth cotton ball in SSS is used to
wash the farther labia majora in a
downward stroke towards the groin.
19. Do the same on the other labia.
20. A sixth cotton ball in SSS is used to
wash, with one downward stroke,
from the clitoris, meatus, vaginal
opening to perineum.

21. The above step is repeated with a 7th

cotton ball in SSS, and to include the
anus.
22. Rinse with sterile water and pat dry Moisture supports the growth of
using toilet paper from front to back. microorganisms and contributes to
discomfort.
23. Remove the client from the bedpan.
Loosen the drape from the legs. Turn
to side and dry the buttocks.

24. Apply lotion on the buttocks as An emollient helps to soothe excoriated

needed (optional). tissue.
25. Put on diaper or sanitary pad and or
underwear. Remove the waterproof
pad and replace the bath blanket
with topsheet. Make the patient
comfortable.
24. Bring equipment back to the utility Controlling the spread of pathogens is a
room and do the after care. primary principle of asepsis.

25. Remove gloves and wash your hands. Handwashing deters the spread of
microorganisms.
26. Document the performance of the
procedure, the objective and Written information documents the
subjective findings and the patient’s individualized care of the patient.
response.

1
2 3

4 5

Legend:
1. mons 4. far labia
2. far leg 5. near labia
3. near leg 6. meatus to anus

Figure 2. Strokes Used in External Douche

SAMPLE DOCUMENTATION

Date Time Nurse’s Notes

4 – 28 – 2017 8:00 AM Perineal care provided. Moderate amount

of lochia rubra noted on perineal pad.
Episiotomy wound and perineum swollen. Bean-
sized external hemorrhoids noted. Verbalized
feeling of comfort after the procedure.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
EXTERNAL DOUCHE

Name: __________________________________ Grade: ________________________

Year and Sec.: _________________ Date : ________________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating
5 4 3 2 1
1. Washes hands thoroughly.
2. Prepares equipment and adjusts bed to a comfortable
working height.
3. Brings preparation to the bedside. Identifies patient and
explains procedure.
4. Provides privacy to the patient. Positions the patient
supine.
5. Changes topsheet with bath blanket.
6. Places bed protector.
7. Drapes patient with bath blanket and exposes the
perineal area.
8. Places patient on bedpan in a dorsal recumbent position.
9. Tests temperature of the water (410C or 1050F).
10. Flushes the area with warm water.
11. Applies soap using CB soaked with soap sud solution
using zigzag motion starting from the mons pubis. Uses
one cotton ball on each stroke.
12. Applies another cotton ball on the far groin going up
using zigzag stroke. Uses the same stroke on the near
groin.
13. Separates labia and applies another CB on each labia
using gentle downward stroke.
14. Applies the 6th CB soaked in soap sud solution using
downward stroke from the clitoris, meatus, vaginal
opening and perineum. The stroke is repeated with the
last CB, including the anus.
15. Rinses the area well.
16. Dries area from top down using toilet paper.
17. Removes bedpan and turns client to side immediately.
Dries the buttocks with toilet paper.
18. Applies lotion as needed.
19. Removes bed protector by rolling it to the center.
 20. Replaces blanket with topsheet and makes client
comfortable.
21. Examines the content of the bedpan and throws it into
the toilet bowl.
22. Brings equipment back to the utility room and does the
after care.
23. Removes gloves and washes hands.
24. Documents the procedure and other pertinent
observation.
25. Maintains body mechanics throughout the performance
of the procedures.
26. Manifests neatness in the performed procedure.
27. Receptive to criticisms.
28. Observes courtesy.
29. Shows calmness while performing the procedure.
30. Uses correct English.
31. Shows mastery of the procedure.

Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%

________________________________ __________________________
Student’s Signature Over Printed Name Date

________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 APPLICATION OF HEAT AND COLD THERAPIES

Body temperature represents the difference between the heat produced in the body and
heat lost. Heat regulation takes place in the hypothalamus. Heat is lost from the skin by
radiation, conduction, convection and evaporation.

Many factors affect body temperature, including body rhythms, menstrual cycle, muscle
action, age, deficient sweat glands, environmental conditions, medications, etc. Because many
health decisions are based on body temperature readings, accuracy in temperature–taking is
essential.

Problems of hyperthermia and hypothermia require nursing assessment, planning,

implementation, and frequent evaluation. Applications of heat and cold therapies are part of
this treatment. Whether the application is cold or warm, temperature tolerance varies with the
individual and the part of the body to which it is applied, length of time of the application, size
of area under application, and whether it is moist or dry.

Heat and cold therapies are applied frequently in both the home and the hospital. In
the hospital setting, a doctor’s order is required before heat is applied.

I - APPLICATION OF ICE CAP

Purposes:
Uses of Cold Application
1. To provide topical anesthesia (for example, by placing an ice bag on the injection
site before giving the injection).
2. To prevent edema after bruises, spasms and sprains.
3. To lessen hemorrhage.
4. To reduce inflammation.
5. To decrease metabolism.
6. To lower body temperature.

Cold applications are either local or general, moist or dry.

Special Consideration:

Cold applications cause vasoconstriction with reduced blood flow to the skin, therefore
the skin becomes pale, mottled, cool to touch and numb. Whether the application is cold or
warm, temperature tolerance varies with the individual, the part of the body to which it is
applied, the area of application, and the length of time it is applied.

Equipment:

1. ice bag and cover 3. gel preparation

2. cracked ice 4. hand towel

Procedure

Action Rationale

1. Assess the need for application

2. Identify client and explain the An explanation facilitates cooperation of the

procedure. client.
 3. Fill the ice bag with small pieces of ice
chips to approximately 2/3 full.

4. Press the air out of the bag and
tighten. Then test for leaks by
inverting the ice cap.
Air is a poor conductor of heat which will
interfere with the removal of heat from the
body surface. Inverting the ice bag would
determine the tightness of the cover. Leakage
can cause discomfort to the patient.

5. Cover the bag or case with towel.
Bring to the bedside and apply to the
area. Refill when the ice melts.
Observe the length of application as
ordered.
A cover should be used to provide for
absorption of the moisture which condenses
on the outside of the bag.

6. Do after care. Proper care of equipment ensures its

durability.

7. Wash hands. Handwashing deters the spread of

microorganisms.

8. Document the site, time, duration of Charting provides accurate documentation of

application and the client’s response. the implementation of treatment and the
client’s progress.

Note:
1. To be effective, the ice bag should be applied for ½ to 1 hour with an interval of
approximately 1 hour. In this way, the tissues are able to react to the effects of cold.
2. Placing the ice directly on the skin could cause burn.

After care of ice bag:

1. Empty ice bag.

2. Soap and rinse under running water.
3. Turn upside down to dry.
4. When dry, inflate with air to prevent damage of rubber lining. Screw cover in place.
5. Return to proper place.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
APPLICATION OF ICE CAP
Name:_________________________________ Grade: ________________
Year and Sec.: _________________ Date : ________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating
5 4 3 2 1
1. Checks the physician’s order
2. Identifies client and explains the procedure.
3. Washes hands.
4. Assembles equipment.
5. Tests bag for leaks.
6. Fills ice bag with small pieces of ice about 2/3 full.
7. Expels air correctly.
8. Covers the bag.
9. Applies bag to the area.
10. Does after care.
11. Records procedure and client’s reaction.
12. Maintains body mechanics throughout the
performance of the procedure.
13. Manifests neatness in the performed procedure.
14. Receptive to criticisms.
15. Observes courtesy.
16. Shows calmness while performing the procedure.
17. Uses correct English.
18. Shows mastery of the procedure.
Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%

________________________________ __________________________
Student’s Signature Over Printed Name Date
________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 TECHNIQUE FOR THE APPLICATION OF HOT WATER BAG

Purposes:
1. To relieve pain.
2. To reduce swelling, congestion and inflammation.
3. To relieve muscle spasm.
4. To provide comfort.
5. To decrease the blood supply in other areas of the body.
6. To raise the body temperature.
7. To increase the blood supply to the injured part thus promotes healing.
8. To stimulate metabolism.

Special Considerations

Prolonged exposure to heat can damage tissues from thermal burns. Special care is
required when heat is applied to the very young and very old who cannot tolerate heat well.
Special care is also given to persons who have circulatory disorders, debilitated, unconscious
and with impaired sensation, decreased or absent response to pain which may lead to the risk
of burns. Direct heat treatment is contraindicated if the patient has an open wound and a
sprained limb as vasodilation would increase pain and swelling.
Hot applications must be ORDERED by the PHYSICIAN.

Equipment:

1. Hot water bag and cover

2. Bath thermometer
3. A pitcher of hot water
4. A pitcher of cold water
5. Empty pitcher
6. Hand towel

Desired Temperature

Infants under 2 years - 105 – 1150F (40.50 - 460 C)

Children over 2 years and adult - 1150 – 1250F (460 - 510 C)

Procedure

Action Rationale

1. Check that there is a physician’s order Reading the order clarifies the procedure.
for heat application and obtain the
treatment (blue) ticket.

2. Identify client and assess for any
circulatory impairment to the area
where the compress is to be applied
(numbness, tingling, impairment in
temperature, sensation or cyanosis).
Circulatory impairment may interfere with the
client’s ability to perceive heat and place him
at risk for injury from the application of heat.

3. Explain the procedure to the client. An explanation encourages the client’s

cooperation and reduces apprehension.
4. Gather the equipment. Organization promotes efficient time
management.
5. Pour an adequate amount of tap
water into an empty pitcher and add
hot water to meet the desired water
temperature .
6. Test the temperature of water using
the bath thermometer.
7. Pour the water from the pitcher into
the bag until it is about ½ - 2/3 full.
8. Expel the air from the bag by resting
the bag on the table. Holding the
neck of the bag upright, flatten bag
against the table until the water
reaches the neck portion. Or expel
air by holding the bag up and
pressing the unfilled portion until
the water fills the neck of the bag.
9. Screw the stopper or fasten the top
tightly.
10. Turn upside down and examine for
leakage.
11. Dry the bag using the hand towel.
12. Place the cloth cover of the bag and
fasten securely.
13. Place the prepared hot water bag
over one’s arm with the opening
away from you. Bring to the bedside.
14. Apply it on the affected area with
the neck of the bag away from the
client’s body.
15. Stay with the client for the first 15
minutes to monitor the client’s
response to heat application.
16. Remove the hot water bag. Carefully
evaluate the skin’s condition and
effectiveness of the heat
application.
17. Do the after care of equipment.
Wash your hands.
18. Record the treatment and the
client’s response.
To determine the right temperature.
Right temperature of water prevents burning.
More than this amount of water will make the
bag heavy.
The bag can easily be molded to the body
parts when applied. Absence of air makes it
less flat and less bulky.
Expelling air would make the bag more
flexible.
To prevent leakage or accidental spill of hot
water which can result to burns.
To ensure safe application.
Provides opportunity to test the temperature
of the hot water bag and protects the nurse
from burns.
Prevents the risk of burn.
Impaired circulation may affect the sensitivity
to heat and to ensure client’s safety.
Maximum therapeutic effects of heat occur
within 20–30 minutes. Extended use of heat
(beyond 45 minutes) results in tissue
congestion and vasoconstriction. This
rebound phenomenon results in increased
risk of burns from the application of heat.
These techniques support the principle of
asepsis.
Written records provide documentation of
the procedure.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
APPLICATION OF HOT WATER BAG

Name: _________________________________ Grade: __________________

Year and Sec.: _________________ Date : __________________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating

5 4 3 2 1
1. Confirms the written physician’s order.
2. Identifies client and explains the procedure.
3. Assesses the area for any circulatory impairment
4. Washes hands.
5. Assembles the equipment.
6. Tests the temperature of the water.
7. Pours water from the pitcher into the bag until it is about
one – half full.
8. Expels the air correctly.
9. Screws in the stopper securely.
10. Wipes the bag.
11. Examines very well for leaks.
12. Covers bag with cloth.
13. Applies to affected area with the neck away from the
client’s body.
14. Assesses the response of the client to the heat.
15. Removes the hot water bag after 30 minutes or according
to the time prescribed by the physician.
16. Replaces wet linen.
17. Assists the client to a safe and comfortable position.
18. Does the after care of equipment appropriately.
19. Washes hands.
20. Charts the procedure and other significant observations.
Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%
________________________________ __________________________
Student’s Signature Over Printed Name Date
________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 GIVING A SITZ BATH

Definition: Sitz bath is a local hot water bath which consists of the immersion of the pelvic
region of the client who is in a sitting position.
Giving a Sitz Bath:
To give a Sitz bath, a client is placed in a shallow tub or basin containing enough warm
water so that only the pelvic area is submerged.

The nurse should implement the plans for the care of assigned clients so as to allow
approximately 15 to 30 minutes for the sitz bath. Although intended to cause vasodilation,
prolonged heat may cause the reverse effect if the warm temperature is sustained. By
coordinating the preparation of the equipment with the client’s readiness, the maximum effects
of the procedure are likely to be achieved.

Purposes:

1. To increase local circulation.

2. To reduce swelling.
3. To promote healing.
4. To help relax local muscles.
5. To relieve pain.

Assessment:
1. Ensure that there is a physician’s written order.
2. Consult the agency’s policy for the amount of time and temperature recommended
for Sitz bath (if not ordered).
3. Read the client’s record to determine the reason for the Sitz bath, such as promoting
healing of perineal incision.
4. Assess the client’s mental status and any evidence of sensory or cardiovascular
disease.
5. Inspect the perineal area for color, swelling, discharge, integrity, evidence of
external hemorrhoids, drains, packing or dressing material.
6. Observe the client’s ability to sit directly on the buttocks; note signs of discomfort.
7. Take the client’s vital signs and compare them with the recommended range for the
client’s age; determine the pattern of the vital sign recordings.
8. Ask the client to describe the sensations he experiences in the perineum and rectum
especially with sitting, walking and when eliminating urine or stool.

Equipment:
1. Sitz bath chair
2. Bath thermometer
3. Bath towels and clean gown
4. Bath blanket
5. Sterile dressings and T – binder (optional)
6. Pitcher of hot water
7. Pail ¾ filled with tap water
8. 2 Safety pins (large)
Procedure
Action
1. Check the physician’s order.
2. Identify the client and explain the
procedure.
3. Assess the client’s condition.
Take patient’s vital signs.
4. Wash your hands and assemble
equipment.
5. Pour some amount of hot water
into the pail and test the
temperature of the water with a
bath thermometer and maintain at
43-46 ‘C or 110-115 ‘F.
6. Fill the Sitz basin 1/3 to ½ full.
7. Close the door and window in the
private room or by drawing the
curtains in the ward.
8. Have the patient void.
9. Remove clothing from below the
waist. Wrap the towel around the
waist with opening at the back
portion.
10. Assist the client to sit in the basin
without pressure on the perineum
and with the feet flat on the floor.
Provide a foot stool if necessary
11. Cover the client’s back,
shoulders, and lower legs with a
cotton bath blanket.
12. Stay with client and observe
closely for signs of weakness,
vertigo, pallor, tachycardia and
nausea. If noted, stop the
procedure and assist the client to
sit. Take the vital signs and
inform CI/NOD.
Rationale
It is a way of insuring that the procedure is
implemented according to the physician’s
directions.
An explanation relieves apprehension and
promotes of cooperation.
Serves as a baseline data.
Handwashing reduce the transient
microorganism thus, deters the spread to
client and self.
Using the thermometer is the most reliable
method for determining the actual temperature.
When the client’s hips are submerged, the
water will be displaced and the level of the
water will increase.
To provide privacy.
Prevents interruption of the procedure as warm
water stimulates voiding.
Leaving the upper part of the body covered
maintains modesty and warmth. Towel
prevents undue exposure of the lower part of
the body.
Direct pressure may heighten discomfort.
Changes in the distribution of blood and
external heat can increase the potential for
adverse effects.
A footstool can prevent pressure at the back of
the thigh.
This maintains body warmth and prevents
chilling.
The nurse should not leave the client alone
unless absolutely certain that it safe to do so.
 13. Help the client out of the chair Being clean and dry promotes a refreshed
upon completion of the procedure feeling.
and assist to dry and change with
clean clothes/gown.

14. Help the client return to bed. The client may feel dizzy with changes in
Recheck the pulse and instruct to posture and the redistribution of blood volume
stay in bed for 30 minutes. to the pelvic region.

15. Notify the doctor for presence of Removal of rectal / vaginal plugs might induce
vaginal/rectal plugs. (Do not bleeding.
attempt to remove.)

16. Empty the Sitz basin, clean and Water left on the floor can lead to accidental
dry before returning to the utility falls and injury.
room. Wipe away water that may
have dripped on the floor.

17. Wash your hands. Washing reduce the transient microorganism

thus, deters the spread to client and self.

18. Document pertinent Accurate written report provides a permanent

observations. record of the individuals care.

Sample Documentation

DATE TIME NURSES NOTES

4 / 25 /2017 10 AM Minimal amount of bloody drainage noted

on peri-pad from the area of
hemorrhoidectomy. Verbalized that the
area is tender and that sitting is difficult.
Has not felt the urge to defecate since
surgery (4-23-17).
10:15 AM Hot sitz bath provided at 43-46’C for 20
minutes as ordered. Verbalized “Maghulat
gyud ko ani kay maayo akong pamati
pagkahuman.”
10:30 Rectal plug removed by Dr. Arce. Dry and
sterile dressing applied.

Angel Locsin, St.N.

 SAN PEDRO COLLEGE
Davao City
PERFORMANCE CHECKLIST
HOT SITZ BATH
Name: __________________________________ Grade:_____________________
Year and Sec.: _________________ Date : _____________________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor
Rating
5 4 3 2 1
1. Checks the physician’s order.
2. Identifies client and explains procedure.
3. Checks client’s vital signs and general condition.
4. Washes hands.
5. Assembles equipment.
6. Tests the temperature of the water with a bath
thermometer (43-460C or 110-1150F).
7. Fills the Sitz basin 1/3 to ½ full.
8. Provides privacy.
9. Asks client to void.
10. Removes client’s clothing and wraps towel around the
waist with the opening at the back .
11. Assists the client into the sitz basin.
12. Covers the client’s back, shoulders and lower legs with a
blanket.
13. Observes the response of the client frequently.
14. Helps the client out of the sitz bath chair and assists to dry
and put on clean bed clothes/ gown.
15. Assists client to return to bed.
16. Rechecks the client’s VS and instructs to stay in bed for
30 minutes.
17. Empties the Sitz basin, cleans and dries it before
returning to the utility room.
18. Washes hands.
19. Documents pertinent observations.
Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%
________________________________ __________________________
Student’s Signature Over Printed Name Date
________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 TEPID SPONGE BATH

Definition: A bath using tepid water and wash cloth or sponge to reduce fever.
Equipment:
Basin
Pitcher filled with hot water.
Pitcher with cold water.
Waterproof underpad or rubbersheet
Bath blanket
Wash clothes (about 6 pieces)
Bath towel
Thermometer in a thermometer tray
Working gloves
Bath thermometer

Procedure

Action Rationale

1. Identify the client and take vital
signs. Assess patient’s condition.
2. Explain the procedure to client or
watcher.
Provides the baseline data to be used when
evaluating the client’s response to the
treatment.
Informing the client elicits cooperation.

3. Wash hands and assemble all Removes transient microorganism and reduces
equipment and bring to bedside. the risk of cross-contamination to client and
self.
4. Close doors and windows in To provide privacy, and protect from draft.
private rooms or draw curtains in
the ward. Put off air conditioner
or electric fan.

5. Adjust the bed to the working Protects your back from strain.
height.
6. Don gloves. Lay the waterproof Prevents the linens from getting wet.
underpad.
7. Change the topsheet with a bath Avoids exposure to draft.
blanket. Remove client’s gown.
Starting from the farther arm.
NOTE: If with IVF, refer to
cleansing bed bath for the
removal of gown.
8. Pour/ mix water in a basin with This is the normal range of water temperature
the temperature of 27-370C (80- in a tepid bath.
980F). Immerse 6 washcloths into
the basin. Pour cold water and
mix with hot water until the
temperature reaches 27-37 oC
(80-90OF).
 9. Wring, roll and apply washcloth
to the forehead.
Note: Check regularly the
temperature of the washcloths.
10. Gently pat the 6 wash cloths on
the client’s face, neck extremities,
back and buttocks. The whole
procedure should last for 30
minutes.
Abdomen and chest are not
usually sponged.
11. After sponging each body part,
pat dry with bath towel and cover
it with the bath blanket.
12. Monitor the client’s reaction to
treatment, and recheck TPR after
15 minutes and after completing
the bath.
Discontinue procedure if 1-20F
above desired level is obtained.
13. Remove washcloths from
forehead, axillae, groins and pat
dry these areas. Change the
client’s gown and replace the bath
blanket with the topsheet.
14. Lower the bed to its previous
height.
15. Do the aftercare of equipment
used.
16. Document the treatment
performed, client’s vital signs,
response and any complications.
DOCUMENTATION:
DATE TIME
5- 22 -17 8 AM
8:15 AM
8:30 AM
These areas contain large superficial blood
vessels that help the transfer of heat.
Promotes a decrease in temperature within a
safe time frame and avoid the chance of
chilling.
A bath given less than 30 minutes tend to
increase body heat production by causing
shivering.
Blood vessels are located deeper and TSB is
not very effective to reduce temperature.
The friction caused by rubbing may raise the
body temperature and covering prevents
exposure to draft.
When client’s temperature is slightly above
normal, procedure can be discontinued to
prevent rebound effect.
Temperature will go down naturally.
Light clothing maintains the body temperature.
Excessive clothing and covering can result to a
temperature elevation.
Promotes client’s safety and convenience.
Provides information to the health care team
regarding the client’s response to the
treatment; a legal record of the care giver.
NURSES NOTES
Vital signs checked.
Temperature 39‘C. Tepid
sponge bath done
continuously for 20 minutes.
Temperature rechecked
38’C. Encouraged to
increase oral fluid intake.
Temperature decreased to
37.5‘C . Kept comfortable in
bed
Sandra Park, St.N.
 BASIC GUIDELINES FOR MAINTAINING SURGICAL ASEPSIS

All practitioners involved in the intraoperative phase have a responsibility to provide

and maintain a safe environment. Adherence to aseptic practice is part of this responsibility.
The 8 basic principles of aseptic technique are as follows:

1. All materials in contact with the surgical wound and used within the sterile field must
be sterile. Sterile surfaces or articles may touch other sterile surfaces or articles and
remain sterile; contact with unsterile objects at any point renders a sterile area
contaminated.

2. Gowns of the surgical team are considered sterile from the front the chest to the level
of the sterile field. The sleeves are also considered sterile from 2 inches above the elbow
to the stockinette cuff.

3. Sterile drapes are used to create a sterile field. Only the top surface of a draped table is
considered sterile. During draping of a table or patient, the sterile drape is held well
above the surface to be covered and is positioned from front to back.

4. Items should be dispensed to a sterile field by methods that preserve the sterility of the
items and the integrity of the sterile field. After a sterile package is opened, the edges
are considered unsterile. The sterile supplies, including solutions, are delivered to a
sterile field or handed to a scrubbed person in such a way that the sterility of the object
or fluid remains intact.

5. The movements of the surgical team are from sterile to sterile areas and from unsterile
to unsterile areas. Scrubbed persons and sterile items contact only sterile areas;
circulating nurses and unsterile items contact only unsterile areas.

6. Movement around a sterile field must not cause contamination of the field. Sterile areas
must be kept in view during movement around the area. At least a 1-foot distance from
the sterile field must be maintained to prevent inadvertent contamination.

7. Whenever a sterile barrier is breached, the area must be considered contaminated. A

tear or puncture of the drape permitting access to an unsterile surface underneath
renders the area unsterile. Such a drape must be replaced.

8. Every sterile field should be constantly monitored and maintained. Items of doubtful
sterility are considered unsterile. Sterile fields should be prepared as close as possible
to the time of use.
 DONNING and REMOVING STERILE GLOVES
(Open Glove Technique)

The sterile gloves provide a barrier between the nurse’s hands and the objects she
contacts. She is able to freely touch objects in a sterile field without fear of contamination.
When wearing sterile gloves, she should always remain conscious of which objects are sterile
and which are not.

Equipment:
A pair of sterile prepowdered gloves

Procedure

Action Rationale
To don gloves:

1. Perform thorough hand hygiene / Reduces number of microorganisms residing

scrub hands thoroughly. on surfaces of hands.

2. Remove carefully the outer package Prevents inner glove package from
wrapper by separately peeling apart accidentally opening and touching
the sides. contaminated objects.

3. Grasp inner package and lay it on a
clean flat surface just above waist
level. Open the package keeping the
gloves on the wrappers inside
surface.
Sterile objects held below your waist is
considered contaminated. Inner surface of
your glove package is considered sterile.

4. Identify right and left gloves. Each Proper identification of gloves prevents
glove has a cuff approximately 5 contamination by improper fit. Gloving of
cms. (2 inches) wide. Glove your dominant hand first improves your dexterity.
dominant hand first.

5. With thumb and first two fingers of Inner edge of cuff will lie against your skin and
your non–dominant hand, grasp that is not considered sterile.
edge of cuff of glove for dominant
hand. Touch only inside surface of
glove.

6. Carefully pull glove over your If glove’s outer surface touches your hand or
dominant hand, leaving a cuff and wrist, it is contaminated.
being sure that cuff does not roll up
to your wrist. Be sure that thumb
and fingers are in proper spaces.

7. With your gloved dominant hand, Cuff protects your gloved fingers. Sterile
slip your four fingers underneath touching sterile prevents glove
second glove’s cuff with the thumb contamination.
abducted.

8. Carefully pull second glove over your

non–dominant hand. Do not allow
 fingers and thumb of gloved Contact of gloved hand with exposed hand
dominant hand to touch any part of results in contamination.
your exposed non dominant hand.

To remove gloves:

9. Use dominant hand to grasp the

opposite glove near cuff end on the
outside exposed area. Remove it by Contaminated area does not come in contact
pulling it off, inserting it as it is with hands or waist.
pulled, keeping the contaminated
area on the inside. Hold the
removed glove on the remaining
glove hand.

10. Slide fingers of ungloved hand

between the remaining glove and
wrist, remove it by pulling it off,
inverting as it is pulled keeping the
contaminated area on the inside
and securing the first glove inside
the second.
11. Discard gloves inside the wrapper Proper disposal reduces risk for infection,
into the appropriate container and transmission and contamination of othe
wash hands. items. Handwashing reduces the spread of
microorganism.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
DONNING AND REMOVING STERILE GLOVES
Name:__________________________________ Grade: ___________________
Year and Sec.: _________________ Date : ___________________
Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor
Rating
5 4 3 2 1
1. Washes hands.
2. Selects appropriate size of gloves.
3. Prepares adequate work area at waist height.
4. Opens wrapper correctly.
5. Places gloves with cuff end toward the body.
6. Grasps first glove touching inside only.
7. Turns to side of sterile field and pulls glove.
8. Lifts second glove by slipping gloved fingers under cuff.
9. Turns to side of sterile field and pulls glove on.
10. Unrolls cuff touching only outside of glove.
11. After use, removes gloves by turning them inside out
without touching outside surface with bare hands.
12. Drops used gloves onto wrapper.
13. Rolls gloves in wrapper and disposes them properly.
14. Maintains body mechanics throughout the
performance of the procedures.
15. Manifests neatness in the performed procedure.
16. Receptive to criticisms.
17. Observes courtesy.
18. Shows calmness while performing the procedure.
19. Uses correct English.
20. Shows mastery of the procedure.
Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%
________________________________ __________________________
Student’s Signature Over Printed Name Date
________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 FEMALE CATHETERIZATION

Definition:
It is the introduction of a catheter through the urethra into the bladder for instilling or
removing fluids.

Purposes:
1. To control urinary incontinence.
2. To relieve urinary retention.
3. To obtain a sterile urine specimen.
4. To measure the residual urine remaining in the bladder after voiding.
5. To maintain an empty bladder during surgery.
6. To provide access for instilling medication into the bladder.
7. To monitor hourly urine production in seriously ill patient.

General Instructions:
1. Keep the drainage bag below the level of the condom to prevent urinary reflux
which may cause urinary tract infection.
2. Avoid loops and kinks in the tubing to allow continuous drainage of the urine.
3. Never attempt to remove catheter without physician’s order. Inform NOD for any
discomfort or inconvenience felt by the patient.
4. Never allow the urine bag to touch the floor as this may cause ascending infection.
5. Change the condom catheter daily and provide skin care to prevent undue
complication.

Equipment:
1. External douche tray
2. Bedpan with cover
3. Waterproof underpad
4. Bath blanket
5. A tray containing the following:
a. Pick–up forceps in disinfectant solution
b. Working forceps in a sterile pack
c. Lubricant – Ky Jelly
d. Gloves of your size
e. Betadine solution
f. Sterile dry CB – one pack
g. Catheter – Fr. 12 – 14 for adults; Fr. 8 – 10 for children
h. Sterile catheterization pack containing:
a. drape – fenestrated drape or eye sheet
b. OS
c. Kidney basin
d. Specimen bottle -
i. Equipment for indwelling Catheter
a. foley catheter
b. sterile 5cc syringe (to be filled with 5cc triple distilled water)
c. vial of triple distilled water, sterile
d. plaster
e. urine bag

6. Gooseneck lamp (optional)

Procedure
Action
1. Check for doctor’s order.
2. Assess whether patient is allergic to
iodine or plaster.
3. Perform hand hygiene. Assemble
equipment.
4. Identify and explain the procedure to
the patient.
5. Provide a good light.
6. Provide for privacy by screening and
closing the door/ windows.
7. Raise bed to appropriate working
height. Stand on the patient’s right
side if you are right-handed, on the
patient’s left side if you are left-
handed.
8. Replace top sheet with bath blanket.
Place waterproof underpad under
the patient.
9. Place patient on a dorsal recumbent
position (supine with knees flexed
and feet apart) and drape him/her.
10. Do perineal flushing.
11. Prepare the urine receptacle and
tubing if an indwelling catheter is to
be inserted.
12. Open the sterile pack and bring it
near the perineal area. Observe
aseptic technique. Squeeze a small
amount of lubricant over the sterile
OS placed in the sterile field.
Rationale
Verifying the medical order ensures that the
correct intervention is administered to the
right patient.
There is possibility of exposure to allergens in
antiseptic, tape, latex and lubricant. Allergy to
povidone is common.
Hand hygiene deters the spread of
microorganisms. Organization promotes
efficient time management.
Ensures it is the right patient. An explanation
reduces apprehension and encourages
cooperation.
Good lighting is necessary to see the meatus
clearly (may be different in multiparous
women).
Privacy reduces embarrassment and aids in
relaxation during the procedure.
Having the bed at the proper height prevents
back and muscle strain. Positioning allows for
ease of use of dominant hand for catheter
insertion.
Prevents soiling of bed linen.
Good visualization of the meatus is important.
Avoids unnecessary exposure of body parts
and maintains patient’s comfort.
Cleansing the area with soap decreases the
possibility of introducing organisms into the
bladder.
The tubing facilitates connecting the catheter
to the drainage system.
Placement of the equipment near the work
site increases efficiency. Sterile technique
protects the patient and prevents the spread
of microorganisms.
Organization promotes efficient time
management.
13. Get 2 CBs with betadine from the jar
and place on the sterile field on top
of the several OS. Uncover the
specimen bottles.
14. Put on sterile gloves. Grasp the
upper corners of the fenestrated or
eye drape and unfold it. Apply drape
over perineum, exposing labia. Be
sure not to touch contaminated
surface,
15. Lubricate 1 – 2 inches of the catheter
tip. Avoid clogging the lumen.
16. With the thumb and forefinger of
your non – dominant hand, spread
the labia and identify the urinary
meatus. Maintain the hold until the
catheter has been inserted.
17. Use your dominant hand or pick up
forceps to pick up a cotton ball with
betadine. Clean one labial fold, top
to bottom then discard the cotton
ball. Using a new cotton ball for each
stroke, continue to clean the other
labial fold then directly over the
meatus.
18. Pick up catheter with gloved
dominant hand 3-4 inches from
catheter tip. Hold end of catheter
loosely coiled in palm of dominant
hand. Place distal end of catheter in
urine receptacle if straight
catheterization is ordered.
19. Insert the tip of the catheter into the
dimple-like structures below the
clitoris which is the meatus about 2 –
3 inches or until urine flows. Do not
force the catheter through the
urethra. Ask the patient to breathe
deeply and rotate the catheter
gently if slight resistance is met.
20. Hold the catheter securely with your
non-dominant hand while the
bladder empties. Collect a specimen,
about 20-30 ml if required. Continue
A drape provides a sterile field where the
equipment and hands will be placed.
Lubrication facilitates the insertion of the
catheter and reduces urethral trauma and
discomfort when inserting it.
Separating the labia helps expose the meatus
so its location is visible.
Moving from an area where there is likely to
be less contamination to an area where there
is more contamination helps prevent the
spread of microorganisms. Cleaning the
meatus last helps reduce the possibility of
introducing microorganisms into the bladder.
Prevents soiling of patient and bed with
draining urine.
The female urethra is about 3.5 cm to 6.2 cm
( 1 ½ - 2 ½ inches) long. Applying force on the
catheter is likely to injure mucous
membranes. The sphincter relaxes and the
catheter can enter the bladder easily when
the patient relaxes. Advancing an indwelling
catheter an additional ½ inch to 1 inch ensures
placement within the bladder and facilitates
inflation of the balloon (if Foley catheter)
without damaging the urethra.
Movement, however slight, increases the risk
of introducing organisms within the urethra.
In general, no more than 750ml -1,000 ml. of
urine should be removed at one time. Pelvic
floor blood vessels may become engorged
 drainage according to hospital
policy.
21. Remove the catheter smoothly and
slowly (if straight catheter is used).
22. If a Foley catheter is used, introduce
5 cc (or follow manufacturer’s
instruction) of distilled water/ air to
secure the catheter. Gently pull the
catheter until the retention balloon
is snuggled against the bladder neck.
(Resistance will be met). Remove the
fenestrated drape.
23. Attach catheter to urine bag below
the level of the bladder. Tape
catheter to the inner thigh.
24. Remove and clean the equipment
and make patient comfortable. Label
the urine specimen and send to the
laboratory promptly.
25. Remove gloves and wash your
hands.
26. Record the time of the
catheterization, the amount of the
urine removed, a description of the
urine and the patient’s reaction to
the procedure.
from the sudden release of pressure leading
to a possible hypotensive episode.
The catheter is only needed to drain urine
present in the bladder and is not intended for
continuous use.
Creates a balloon to ensure catheter
retention. Maximizes continuous bladder
drainage Proper attachment prevents trauma
to the urethra and meatus from tension on
the tubing. Ensures that catheter tip is
anchored.
Ensures proper drainage by gravity. Prevents
urinary reflux which may cause UTI.
Urine kept at room temperature may cause
organisms, if present, to grow and distort
laboratory findings.
Handwashing deters the spread of
microorganisms.
A careful record is important for documenting
data after the patient’s care.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
FEMALE CATHETERIZATION

Name: _________________________________ Grade:____________________

Year and Sec.: _________________ Date :___________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1– Poor

Rating
5 4 3 2 1
1. Checks for completeness of supply.
2. Assesses whether patient is allergic to iodine or plaster.
3. Washes hands. Assembles equipment.
4. Identifies and explains the procedure to the patient.
5. Provides good light.
6. Provides privacy

7. Replaces top sheet with a bath blanket. Places waterproof

underpad.
8. Positions the client on a dorsal recumbent with knees flexed
and feet apart and drapes the client.
9. Does perineal flushing.
10. Prepares the urine receptacle and tubing if an indwelling
catheter is to be inserted.
11. With aseptic technique, opens the pack between the clients
thigh and brings it near the perineal area.
12. Squeezes a small amount of lubricant over the sterile OS .
13. Gets 2 CBs with betadine from the jar and places it on the
sterile field.
14. Puts on sterile gloves. Places fenestrated drape over the
vulvar area exposing the labia.
15. Lubricates 1-2 inches of the catheter tip.
16. With the thumb and forefinger of your non-dominant hand
spread the labia. With the dominant hand, disinfects the
meatus twice using CB with betadine.
17. Maintains hold until after catheter has been inserted.
18. Inserts the tip of the catheter into the dimple- like structure
just below the clitoris about 2-3 inches or until urine flows.
Asks the patient to breathe deeply as catheter is inserted.
19. Holds the catheter securely with the non-dominant hand
while bladder is emptied. Collects a specimen if required.
20. Removes the catheter smoothly and slowly (if straight
catheter is used)
21. If a Foley Catheter is used, introduces 5 cc of sterile distilled
H2O to secure the catheter; gently pulls the catheter until
retention balloon is snuggled against the neck of the
bladder. Tapes the catheter to the inner thigh.
 22. Attaches catheter to the urinary drainage bag below the
level of the bladder.
23. Removes and cleans the equipment. Makes the patient
comfortable. Labels the urine specimen and sends to the
laboratory promptly.
24. Removes gloves and washes hands.
25. Records the time of the catheterization, the amount of the
urine removed, a description of the urine and the patients
reaction to the procedure.

Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%

________________________________ __________________________
Student’s Signature Over Printed Name Date

________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 MALE CATHETERIZATION

Equipment:
1. Foley cath of the appropriate size.
2. Bath blanket.
3. Waterproof underpad.
4. Plaster.
5. Gooseneck lamp ( optional)
6. A tray containing the following:

1. Lubricant 6. A jar with CB in sterile H2O

2. Sterile forceps in a pack 7. Packed sterile dry CB
3. Working and sterile gloves of your size 8. Catheterization Pack
4. Beta dine solution 9. Sterile 5cc syringe filled ĉ sterile H2O
5. Jar with CB in SSS 10. Vial of sterile distilled H2O

Procedure:

Action Rationale

1. Follow steps 1-7 (female cath)

8. Raise the siderails at the opposite side of Ensures patient’s safety and provide
the bed. Assist the patient to move away adequate space for opening of the sterile
from you. pack.

9. With the patient supine and knees slightly Draping keeps the patient warm and
apart, drape by fanfolding the bedcovers reduces embarrassment.
down to the midthigh exposing the perineal
area. Use a bath blanket to cover the trunk.
Place the waterproof underpad under the
buttocks.

10. Place sterile pack on the bed at the level of Placement of the equipment near the
the hips. Open the pack observing the work site increase efficiency. Sterile
proper sterile technique. Bring the sterile technique protects the patient.
kidney basin near the working area

11. Don working gloves. Do perineal care; Cleansing the area with soap decreases
remove and discard gloves properly. the possibility of introducing organisms
Perform hand hygiene again. into the bladder. Hand hygiene deters the
spread of microorganisms.

12. Open the sterile catheterization pack and Placement of equipment near the
place it on the bed at the level of the hips worksite increases efficiency. Sterile
using sterile technique. Bring the sterile technique protects the patient and
kidney basin near the working area prevents the spread of microorganisms.

13. Squeeze a small amount of lubricant over Organization promotes efficient time
the sterile OS placed in the sterile field. management.
Get 2 CBs with betadine from the jar and
place on the sterile field on top of the
several OS. Open the covers of the
specimen bottles.
14. Don sterile gloves. To protect nurse from infection.

15. Place the opening of the fenestrated drape Maintain sterility of work surface.
over the penis and onto the perineum
without touching the upper top surface.

16. Lubricate around 3 -4 inches of the

catheter. Avoid clogging the lumen.

17. With the non- dominant hand, lift penis to
position perpendicular to patient’s body
and cleanse in a circular motion moving
outward from the meatus down to the base
of glans with the use of CB with betadine.
Discard and cleanse again with 2 more
CBs in betadine if necessary.
Prevents undue trauma when inserting
the catheter into the urethra.
Straighten urethral canal to ease cath
insertion.
Disinfects the area and prevents the
spread of microorganisms.

18. Maintaining the hold of the shaft, pick up Relaxation of external sphincter aids in
the catheter with the dominant hand. Hold insertion of catheter.
end of the catheter loosely coiled in palm
of dominant hand. Pull the penis slightly
upward and ask the patient to beardown as
if to void. Slowly insert the catheter into
the meatus about 7-9” using a rotating
motion until urine flows. If resistance
is felt, withdraw the catheter a little and Forcing the entry of the catheter through
ask the patient to take a slow deep breath urethra may cause damage to the mucosa.
again while you insert the catheter slowly.
If resistance persists and the catheter will
not advance, remove it and notify the
physician.

19. Gently push the catheter in 1-2 inches Further advancement of catheter ensures
more after urine starts to flow. Allow 30cc proper placement.
or more urine to flow and collect the
specimen as ordered. Instruct patient
to breathe deeply and remove the catheter
gently (if straight catheter is used).

20. If Foley catheter is used, inject the Creates a balloon to ensure catheter
contents of the pre - filled syringe (or retention.
follow manufacturers order) to secure the
catheter. Gently pull the catheter until the Maximizes continuous bladder drainage.
retention balloon is snuggled against the
bladder neck. (Resistance will be met). Proper attachment prevents trauma to the
Remove the fenestrated drape. Tape urethra and meatus tension on the tubing.
catheter on the anterior thigh or lower
abdomen.

21. Attach the catheter to the urinary bag Proper placement of the urinary bag
below the level of the bladder. Coil excess facilitates drainage and prevents urinary
tubing on the mattress and secure it on the reflux that may cause UTI.
bed frame.
22. Remove and clean the equipment and Urine kept at room temperature may
make patient comfortable. Label the urine cause organisms, if present, to grow and
specimen and send to the laboratory distort laboratory findings.
promptly.

23. Remove gloves and wash your hands. Handwashing deters the spread of
microorganisms.

24. Record the time of the catheterization, the A careful record is important for
amount of the urine removed, a documenting data after the patient’s care.
description of the urine and the patient’s
reaction on the procedure.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
MALE CATHETERIZATION

Name: __________________________________ Grade:___________________

Year and Sec.: _________________ Date : ___________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating
5 4 3 2 1
1. Checks the physicians order.
2. Assesses whether patient is allergic to iodine or plaster.
3. Washes hands. Assembles equipment.
4. Identifies and explains the procedure to the patient.
5. Provides privacy.
6. Positions the patient on supine with knees slightly apart.
Drapes by fanfolding the bedcover down to the midthigh
exposing the perineal area. Uses a bath blanket to cover the
trunk. Places the waterproof underpad under the buttocks.
7. Dons working gloves. Does perineal care. Removes and
discards gloves properly. Washes hands.
8. Opens the pack aseptically and places it on the bed at the
level of the hips. Brings the sterile kidney basin near the
working area.
9. Squeezes a small amount of lubricant over the sterile OS.
10. Gets 2 CBs from the pack and places them on the sterile field.
Pours betadine over them.
11. Dons sterile gloves.
12. Places the opening of the sterile drape over the penis and
onto the perineum without touching the upper top surface.
13. Lubricates around 3-4 inches of the catheter.
14. With the non- dominant hand, lifts the penis and cleanses in
a circular motion moving outward from the meatus down to
the base of glans with the use of CB with betadine. Discards
and cleanses again with 2 more CBs in betadine.
15. With the hand still holding the shaft of the penis, picks up
the catheter with the dominant hand 3-4 inches below the
tip. Pulls the penis slightly upward and asks the patient to
bear down as if to void.
16. Slowly inserts the catheter in the meatus about 7-9 inches
using a rotating motion until urine flows.
17. If resistance is felt, withdraws a little the catheter and asks
the patient to take a deep breath again if resistance persists,
removes it and notifies the physician.
 18. Gently pushes the catheter in 1-2 inches more after urine
starts to flow. As the bladder empties collects the specimen
if required.
19. Removes the catheter smoothly and slowly if straight
catheter is used.
20. If Foley catheter is used, injects content of the pre-filled
syringe to secure the catheter. Gently pulls the catheter until
the retention balloon is snuggled against the bladder neck.
21. Removes the fenestrated drape and tapes the catheter to
lower abdomen or anterior thigh.
22. Attaches the catheter to the urinary bag below the level of
the bladder. Coils the excess tubing on the mattress and
secures on the bed frame.
23. Removes and cleans the equipment. Makes the patient
comfortable. Labels the urine specimen and sends to the
laboratory promptly
24. Removes gloves and washes hands.
25. Records the time of the catheterization, the amount of the
urine removed, a description of the urine, and the patient’s
reaction to the procedure.

Remarks

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%

________________________________ __________________________
Student’s Signature Over Printed Name Date

________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 REMOVING AN INDWELLING CATHETER

Requisite:
When the physician writes the order to discontinue the indwelling catheter, the catheter
is removed. The catheter and bag should be disposed of in the dirty utility room, not
left in the patients room trash can.

Equipment:
- Treatment Ticket - needle ( if needed) - 2 CBs with Water
- 5 or 10 cc syringe - working gloves - tissue paper/ absorbent towel

Procedure:
Action Rationale

1. Check the order on the patient’s
chart.
2. Obtain a 5 to 10 ml syringe
(depending on the size of the
balloon of the catheter) and an
absorbent towel.
3. Wash your hands.
4. Check the patient’s identification
band and explain the procedure.
Warn the patient that there may be
a slight discomfort as the catheter
is removed.
5. Don gloves.
6. Place the absorbent towel on the
mattress under the catheter and
attach the syringe to the balloon
port. Withdraw all the water or
solutions from the balloon.
Prevents removing a catheter from the
wrong patient.
The water in the balloon must be withdrawn
prior to removing the catheter.
Prevents the spread of microorganisms.
Correctly identifies the right patient;
reduces fear of the unknown.
To prevent the possible transmission of
microorganisms when there is a chance of
coming into contact with any bodily fluid.
Protects the mattress. If a portion of the
water/solution remains in the balloon, the
inflated balloon will injure the urethral
canal.

7. Hold the absorbent towel in your Prevents soiling by spilled urine.

non –dominant hand in front of the The upward position of the catheter will
perineum. Pinch the catheter near allow urine in the tubing to flow faster into
the meatus with your dominant the urine bag.
hand and pull it steadily out onto
the absorbent towel until the end is
retrieved. Hold the catheter at an
upward angle to the drainage
tubing so that any urine in it will
drain into the drainage bag.
8. Inspect the catheter to make Ensures that a piece of catheter is not left in
certain it is intact. If it is not, notify the bladder.
the physician immediately.
9. Measure the output in the drainage Reduces transfer of microorganisms.
bag. Record the output on the I & To make an accurate record of I & O.
O sheet. Empty the urine into the
 toilet bowl and dispose the urine
by into the yellow bin.

10. Remove gloves, wash hands and
make the patient comfortable.
Instruct the patient to drink extra
fluid and warn that there may be
mild burning with the first few
voidings.
Remove transient microorganisms and risk
of transmission to others. Extra fluid helps
to flush the bladder.
Irritation of the mucosa in the urethra may
cause burning sensation with voiding.

11. Document the time of removal and Sets guideline by which all nurses will
time by which patient should have know when to check to see if the patient has
next voiding time. voided.

Note:
Make sure the patient voids within 4-6 hrs. after the removal of catheter. If unable, refer
to the CI or nurse on duty.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
REMOVING AN INDWELLING CATHETER
Name:__________________________________ Grade: ___________________
Year and Sec.: _________________ Date : ___________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating

5 4 3 2 1
1. Checks the order on the patient’s chart.
2. Obtains the medicine ticket, 5 to 10 ml syringe and an
absorbent towel.
3. Washes hands.
4. Checks the patient’s identification and explains the
procedure
5. Dons gloves.
6. Places the absorbent towel on the mattress under the
catheter.
7. Attaches the syringe to the balloon part, withdraws the water
from the balloon until resistance is met.
8. With the non-dominant hand, holds the absorbent towel in
front of the perineum.
9. Pinches of the catheter near the meatus and pulls it steadily
out onto the absorbent towel until the end is retrieved.
10. Holds the catheter at an upward angle to the drainage
tubing so that the urine drains to the drainage bag.
11. Inspects the catheter to make certain it is intact. If it is not,
notifies the physician immediately.
12. Measures the output in the drainage bag.
13. Empties the urine into the toilet and disposes the drainage
unit in the yellow garbage bin and cleans the measuring
equipment.
14. Removes gloves, washes hands and makes patient
comfortable. Instructs the patient to drink extra fluid and
warns that there may be mild burning with the first few
voiding.
15. Documents the time of removal, amount of urine collected
into the I and O flow sheet and the time the patient should
have void.
Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%
________________________________ __________________________
Student’s Signature Over Printed Name Date

________________________________ __________________________
Instructor’s Signature Over Printed Name Date
 APPLYING A CONDOM CATHETER

Definition:
Condom Catheter is a device that resembles a condom with a large caliber connection at
its distal end. This is connected to drainage bag, to contain the urine. The device adheres to the
penile skin without producing irritation and has sufficient elasticity to maintain its watertight
seal whether the penis is in erect or flaccid state.
Equipment:
-Urinary drainage bag with tubing - washcloth towel
- condom catheter - plaster
- bath blanket - working gloves

Procedure:
Action Rationale

1. Follow steps 1-11 (male

catheterization)
2. Grasp the penis firmly with your This space prevents irritation of the tip of
nondominant hand. Roll the condom the penis and provides for full drainage of
smoothly over the penis with your the urine.
dominant hand leaving about 1 to 2
inches of space between the end of
the penis and the rubber or plastic
connecting tube.
3. Secure the condom catheter firmly
but not too tightly to the penis by Prevents impending the blood circulation
wrapping a strip of elastic tape of the penis.
around the base of the penis over the
condom catheter.

4. Securely attach the urinary drainage Allows drainage of urine into the
system into the condom collecting bag. Kinked tubing encourages
catheter.Avoid kinking or twisting backflow of urine.
the drainage bag.

5. Remove gloves.

6. Anchor the tube to the anterior thigh
or lower abdomen of the client.
7. Hang the urine drainage bag below
the level of the bladder to the bed
frame away from the entrance.
Proper attachment prevents tension on the
condom sheath and potential inadvertent
removal.
This facilitates drainage of urine and
prevents the backflow of urine.

8. Wash your hands. Do after care.

Proper disposal of equipment prevents
transmission of microorganisms.
9. Document the application of the
condom, time and pertinent To ensure that procedure was done
observations. correctly.
10. Inspect the penis 30 minutes after
the procedure and check urine flow.
 SAN PEDRO COLLEGE
Davao City

PERFORMANCE CHECKLIST
CONDOM CATHETERIZATION

Name: __________________________________ Grade: __________________

Year and Sec.: _________________ Date: ___________________

Legend: 5 – Excellent; 4 – Very good; 3 – Good; 2 – Fair; 1 – Poor

Rating
5 4 3 2 1
1. Checks the physician’s order.
2. Assesses whether patient is allergic to iodine or plaster.
3. Washes hands . Assembles equipment.
4. Identifies and explains the procedure to the patient.
5. Provides privacy.
6. Positions the patient on supine and knees slightly apart.
Drapes by fanfolding the bedcover down to the midthigh
exposing the perineal area. Uses a bath blanket to cover the
trunk. Places the waterproof underpad under the buttocks.
7. Dons working gloves and does perineal care.
8. Rolls the condom smoothly over the penis leaving about 1
inch between the end of the penis and the rubber or plastic
connecting tube.
9. Secures the condom catheter firmly by wrapping a strip of
elastic tape around the base of the penis over the condom
catheter.
10. Attaches the urinary drainage system severely into the
condom catheter.
11. Removes gloves and disposes in yellow garbage bin.
12. Plasters the tube to the thigh or abdomen of the patient.
13. Hangs the urine drainage bag to the bed frame away from
the rooms entrance.
14. Washes hands. Do after care.
15. Teaches the patient about the drainage system :
a. To keep the drainage bag below the level of the
condom.
b. To avoid loops and kinks in the tubing.
 16. Documents the application of the condom time and
pertinent observations.
17. Inspects the penis 30 minutes after the procedure and
checks urine flow.
18. Changes the condom catheter daily and provide skin care.

Remarks:

Criteria : I Knowledge (quiz) 30%

II Performance 70%
100%

________________________________ __________________________
Student’s Signature Over Printed Name Date

________________________________ __________________________
Instructor’s Over Signature Printed Name Date