NAME OF STUDENT: ____________________________________________

LEVEL & BLOCK: SCHOOL YEAR & TERM:

_____________________________ ___________________________ OVERALL RATING

MODULE 2. CATHETERIZATION

PERFORMANCE EVALUATION CHECKLIST 2

PROCEDURE PERFORMED PERFORMED UNABLE

INDEPENDENTLY WITH TO
ASSISTANCE PERFOR REMARKS
M
4-5 2-3 0-1

ASSESSMENT
1. Assess the need for catheterization and
the type of catheterization ordered.

2. Assess the urinary meatus. Ask the client

for any history of difficulty prior to
catheterization.

PLANNING
1. Gather the equipment needed.

2. Check for the doctor’s order, the consent

and Identify the client and explain the
procedure.

3. Wash hands.
IMPLEMENTATION
1. Assist the client to an appropriate position
and drape all areas except the perineum.

2. Establish adequate lighting.

3. Open the catheterization set and arrange

the sterile field.

4. Set-up receptacle for soiled cleaning

swabs.

5. If drainage bag is in separate bag, open

and attach it to the bed.

6. Put on sterile gloves.

 7. For an indwelling catheter, attach syringe
and test balloon by instilling sterile water
and deflating balloon by withdrawing the
water.

8. If drainage bag is in set, connect distal

end of catheter to drainage tubing.

9. Clean urinary meatus with antiseptic

solution using a downward stroke.

10. Lubricate the distal portion of the catheter

and place it on a nearby sterile field.

11. Insert the catheter gently, in rotating

motion. Instruct the client to take a slow
deep breath upon insertion.

 For male patient, hold the penis

at 45-degree angle until urine
flows.

 For female patient, gently spread

the labia minora with your finger
and visualize the urinary meatus
and steadily insert the catheter.

12. Inflate the retention balloon with sterile

water.

13. Tape the catheter to the thigh of a female

patient and to the lower abdomen for a
male patient.

14. Secure the drainage tubing and place

drainage bag below the level of the
bladder.

15. Assist the client to a comfortable position.

16. Gather and discard disposable

equipment.

17. Remove gloves and do handwashing.

DOCUMENTATION
18. Record the specific procedure performed
and patient’s response and status.

REMARKS:
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CONFORME: STUDENTS SIGNATURE CLINICAL INSTRUCTOR