Name: Niña Jean T.

Aldaba Inclusive Date of duty: March 11, 2022

Year Level: BSN- 2A Clinical Area Assigned: OB
Assigned Clinical Instructor: Milky Adajar-Escober RN, MN

INDWELLING URINARY CATHETERIZATION

Definition:
Also known as a Foley catheter, an indwelling urinary catheter remains in the bladder to provide
continuous urine drainage. A balloon inflated at the catheter’s distal end prevents it from slipping
out of the bladder after insertion.
Objectives:
1. To withdraw urine and monitor urinary output
2. To provide relief of discomfort from bladder distention or urinary retention / decompression of
the bladder
3. To empty the bladder before and during surgery where general or spinal anesthesia is used and
before certain diagnostic examinations
Materials/Equipment to Use:

INSERTION REMOVAL
1. Double-Lumen Catheter 1. Dressing pack containing paper
2. Drapes towel, swabs and gallipot;
2. Kidney dish to receive the catheter;
3. Lubricant 3. Syringe for deflating the balloon
4. Cleansing solution incorporated in an (usually a 10ml syringe);
applicator or to be added to cotton balls 4. Disposable gloves and apron
(forceps to pick up cotton balls) 5. Cleansing solution, for example
5. Prefilled syringe with sterile water for 0.9% sodium chloride.
balloon inflation
6. Sterile drainage tubing bag
7. Sterile gloves
9. Specimen Container

Procedures Rationale

1. Check the physian’s order catheter Catheterization is a dependent nursing action

insertion
2. Check the client’s identification name.
Explain the procedure and gain consent.
Provide opportunity to ask questions
3. Asses the bladder for fullness or pain by
palpation.
Check current medications and any known
allergies
4. Perform hand hygiene
5. Provide privacy by closing room door and
bedside curtain
6. Raise bed to appropriate working height.
If side rails in use:
 Lower the working side
 Close the opposite side
7. Place waterproof pad under patient.
8. Provide perineal hygiene if needed (apply
clean gloves, complete cleansing, discard
To ensure that the patient has a good
understanding of the procedure and gives informed
consent.
To elicit cooperation.
Palpation of full bladder will cause an urge to void
and / or pain
Assess the patient to prevent reaction
Reduces transmission of microorganisms.
Protects patient confidentiality.
Promotes good body mechanics. Use of side rails in
this manner promotes patient safety.
Prevents soiling of bed linen.
Hygiene before catheter insertion removes
secretions, urine, and feces that could contaminate
gloves and perform hand hygiene).
9. Position and drape patient:
a. Female Patient
(1) Help to dorsal recumbent position (supine
with knees flexed ). Ask patient to relax
thighs to externally rotate hip joints
(2) Alternate female position: Position side-
lying (Sims') position with upper leg flexed at
knee and hip.
the sterile field and increase risk for catheter-
associated urinary tract infection (CAUTI).
Provides good visualization of structures of
perineum and decreases risk for fecal
contamination.
Alternate position is more comfortable if patient
cannot abduct leg at hip joint (e.g., patient has
arthritic joints or contractures).

b. Male Patient
1) Position supine with legs extended and Comfortable position for patient that aids in
thighs slightly abducted. visualization of penis.

c. Drape Patient: Cover upper part of body Protects patient dignity by avoiding unnecessary
with small sheet or blanket. Cover lower exposure of body parts.
extremities with sheet or blanket, exposing
only genitalia. In women it is helpful to place
blanket diamond fashion over patient, with
one corner at patient's neck, side corners
over each arm and side, and last corner over
perineum (see illustration).

10. Position light to illuminate genitals or
have assistant available to hold light source
to visualize urinary meatus.
11. Perform hand hygiene.
12. Open catheterization kit
*Place opened kit on clean bedside table or,
if possible, between patient's open legs.
13. If present, open inner sterile wrap
covering box using sterile technique
Adequate visualization of urinary meatus helps with
speed and accuracy of catheter insertion.
Provides easy access to supplies during catheter
insertion.
Inner sterile wrap serves as sterile field. Straight
catheterization trays do not routinely come with
double wrapping.

b. Indwelling catheterization open system: An open drainage bag system requires separate
* Open separate package containing sterile packaging for sterile catheter, drainage bag,
drainage bag and tubing and insertion kit
*check to make sure that clamp on drainage
port is closed, and place drainage bag and
tubing easily accessible.
* Open outer package of sterile catheter,
maintaining sterility of inner wrapper.

c. Indwelling catheterization closed Closed drainage bag systems have catheter pre-
system: All supplies are in sterile tray. Once attached to drainage tubing and bag.
sterile gloves are put on, check to make sure
clamp on drainage bag is closed.

14. Apply sterile gloves. Drape perineum, Sterile drapes provide sterile field over which nurse
keeping gloves and working surface of drape will work during catheterization.
sterile

a. Sterile Drape Female

(1) *Pick up square drape, unfold without When creating cuff over sterile gloved hands,
touching unsterile surface. sterility of gloves and workspace is maintained. If
*Allow top edge of drape to form cuff over gloves are contaminated, remove and apply new
both hands. pair.
* Place drape with shiny side down on bed
between patient's thighs. Slip cuffed edge just
under buttocks as you ask patient to lift hips.
Take care not to touch contaminated
surfaces with sterile gloves.

(2) * Pick up fenestrated sterile drape. Opening in drape creates sterile field around labia.
* Allow drape to unfold without touching
unsterile surfaces.
* Allow top edge of drape to form cuff over
both hands. Drape over perineum, exposing
labia

b. Sterile Drape Male: Pick up square drape

and allow unfolding without touching unsterile
surfaces. Place over thighs with shiny side
down, just below penis. Place fenestrated
drape with opening centered over penis

c. In some kits sterile gloves may be below Sequence of supplies in kit varies. Use supplies in
square sterile drape. In this case, pick up the order to prevent contamination of underlying
square drape from tray by edges and allow it supplies.
to unfold without touching unsterile surfaces.
The top edge is then folded away (sterile side
up, hands on shiny underside) from patient to
form cuff over both hands and carefully
placed. Then put on sterile gloves and place
fenestrated drape.

12. Arrange supplies on sterile field, Provides easy access to supplies during catheter
maintaining sterility of gloves. Place sterile insertion and helps to maintain aseptic technique.
tray with cleaning medium (premoistened Appropriate placement is determined by size of
swab sticks or cotton balls, forceps, and patient and position during catheterization.
solution), lubricant, catheter, and prefilled
balloon inflation syringe (indwelling
catheterization only) on sterile drape.

a. Open package of sterile antiseptic solution. Use of sterile supplies and antiseptic solution will
Open end of package for easy access. Pour reduce risk of CAUTI
solution over sterile cotton balls. Some kits
may contain a package of premoistened
swab sticks or sticks that will be in the tray in
which you pour antiseptic.

b. Open sterile specimen container if urine Makes container accessible to receive urine from
specimen required. catheter if specimen is needed.

c. Indwelling catheterization: Open inner

sterile wrapper of catheter. If part of kit,
remove tray with catheter and attached
drainage bag and place on sterile drape.
Make sure that clamp on drainage port of bag
is closed.

d. Open packet of lubricant (some kit
lubricant comes in a syringe) and squeeze
out on sterile field. Lubricate catheter by
dipping catheter into water-soluble gel 2.5 cm
to 5 cm (1 to 2 inches) for women and 12.5 to
17.5 cm (5 to 7 inches) for men.
Lubrication minimizes trauma to urethra and
discomfort during catheter insertion. Male catheter
needs enough lubricant to cover length of catheter
inserted

13. Cleanse urethral meatus:

a. Female Patient
(1) Gently separate labia with fingers of Optimal visualization of urethral meatus is possible.
nondominant hand (now contaminated) to Closure of labia during cleansing means that area is
fully expose urinary meatus. now contaminated and requires cleaning procedure
to be repeated.
(2) Maintain position of nondominant hand
throughout remainder of procedure.

(3) Use forceps to hold one cotton ball or hold Front-to-back cleansing is cleaning from area of
one swab stick at a time. Clean labia and least contamination toward highly contaminated
urinary meatus from clitoris toward anus. Use area (see Chapter 29). Dominant gloved hand
new cotton ball or swab for each area you remains sterile.
cleanse. Cleanse by wiping far labial fold,
near labial fold, and directly over center of
urethral meatus (see illustration).

b. Male Patient
(1) With nondominant hand (now
contaminated) retract foreskin (if
uncircumcised) and gently grasp penis at
shaft just below glans. Hold shaft of penis at
right angle to body. This hand remains in this
position for remainder of procedure.
When grasping shaft of penis, avoid pressure on
dorsal surface to prevent compression of urethra.
Positioning penis at this 90-degree angle to patient
straightens out curvature of male urethra and eases
insertion

2) With uncontaminated dominant hand Circular cleansing pattern follows principles of

cleanse meatus with cotton balls/swab sticks, medical asepsis
using circular strokes, beginning at meatus
and working outward in spiral motion. Repeat
3 times using clean cotton ball/stick each
time
14. Pick up and hold catheter 7.5 to 10 cm (3 Holding catheter near tip allows for easier
to 4 inches) from catheter tip with catheter manipulation of catheter during insertion. Coiling
loosely coiled in palm of hand. If catheter is catheter in palm prevents distal end from striking
not attached to drainage bag, make sure to nonsterile surface.
position urine tray so end of catheter can be
placed there once insertion begins.

15. Insert catheter:

a. Female Patient
(1) Ask patient to bear down gently and Bearing down may help visualize urinary meatus
slowly insert catheter through urethral and promotes relaxation of external urinary
meatus. sphincter, aiding in catheter insertion.
2) Advance catheter total of 5 to 7.5 cm (2 to
3 inches) in an adult or until urine flows out
end of catheter. Release labia but maintain
secure hold on catheter.
b. Male Patient
(1) Gently apply upward traction to penis as it
is held in 90-degree angle from body.
(2) Ask patient to bear down as if to void and
slowly insert catheter through urethral
meatus.
(3) Advance catheter 17 to 22.5 cm (7 to 9
inches) or until urine flows out end of
catheter.
(4) Lower penis and hold catheter securely in
nondominant hand.
16. Allow bladder to empty fully unless
institution policy restricts maximum volume of
urine drained (see agency policy).
17. Collect urine specimen as needed by
holding end of catheter over cup. Fill to
desired level. Label and bag specimen
according to agency policy. Send specimen
to laboratory as soon as possible.
19. Indwelling catheterization: inflate catheter
balloon.
a. Female patient
(1) As soon as urine appears, advance
catheter another 2.5 to 5 cm (1 to 2 inches).
Do not force catheter if resistance is met.
(2) Release labia but maintain secure hold of
catheter with nondominant hand.
b. Male patient
(1) After catheter is inserted through meatus
and urine appears, advance catheter to
bifurcation of drainage and balloon inflation
port.
2) Lower penis and hold catheter securely in
nondominant hand.
c. With free dominant hand, connect prefilled
syringe in injection port at end of catheter.
Slowly inject amount of solution required to fill
balloon as designated by manufacturer (see
illustration).
Urine flow indicates that catheter tip is in bladder.
Prevents accidental dislodgement of catheter
Straightens urethra to ease catheter insertion.
Relaxation of external sphincter aids in insertion of
catheter.
Length of male urethra varies. Flow of urine
indicates that tip of catheter is in bladder but not
necessarily the balloon part of an indwelling
catheter.
Prevents accidental dislodgement of catheter.
There is no definitive evidence regarding whether
there is benefit in limiting maximal volume drained.
A sterile specimen for culture analysis can be
obtained. Fresh urine specimen ensures more
accurate findings
Ensures catheter tip is completely inside bladder.
Prevents accidental removal.
There is natural resistance as the catheter passes
through the Ushaped bulbar urethra. Further
advancement of catheter to bifurcation of drainage
and balloon inflation port ensures that balloon part
of catheter is not still in prostatic urethra.
Indwelling catheter balloons should not be
overinflated or underinflated to prevent occlusion of
catheter drainage holes, balloon distortion, and
bladder irritation (Geng et al., 2012). Catheter
balloons are only filled with sterile water. Other
solutions might precipitate and occlude the fill tubing
 and catheter balloon fill valve (Mendez-Probst et al.,
2012).

d. After inflating catheter balloon, release Withdrawing catheter places catheter balloon at
catheter from nondominant hand. Gently base of bladder; slight advancement reduces risk of
withdraw catheter until resistance is felt. Then excessive pressure (Geng et al., 2012).
advance catheter slightly.

e. Male patient: If retracted, replace foreskin Leaving foreskin retracted can cause discomfort
over glans penis. and dangerous edema.

f. Connect drainage tubing to catheter if it is Ensures proper drainage by gravity. Placement on

not already preconnected.
20. Secure catheter with catheter securement
device at catheter bifurcation (see
manufacturer directions). Allow enough slack
to allow leg movement and avoid any traction
on catheter.
side rails increases risk for tension applied to
catheter, and bag can be raised above level of
bladder.
Securing indwelling catheters reduces risk of
urethral trauma, urethral erosion, CAUTI, or
accidental removal.

a. Female Patient: Secure catheter tubing to

inner thigh.
b. Male Patient: Secure catheter tubing to
top of thigh or lower abdomen (with penis
directed toward chest).
21. Clip drainage tubing to edge of mattress. Drainage bags that are below level of bladder
Position drainage bag lower than bladder by ensure free flow of urine, thus decreasing risk for
attaching to bedframe. Do not attach to side CAUTI (Gould et al., 2009). Bags attached to
rails of bed (see illustration). movable objects such as a side rail increase risk for
urethral trauma because of pulling or accidental
dislodgement (Gould et al., 2009)
22. Check to make sure that there is no Obstruction prevents free flow of urine and
obstruction to urine flow. Coil excess tubing increases risk for CAUTI (Geng et al., 2012; Gould
on bed and fasten to bottom sheet with clip or et al., 2009)
other securement device.
23. Provide hygiene as needed. Help patient
to comfortable position.
24. Dispose of used equipment in appropriate Reduces transmission of microorganisms.
receptacles.
25. Label specimen container correctly for Ensures prompt diagnostic analysis.
culture with patient present, place in
biohazard container, and send to laboratory
with completed requisition.
26. Measure urine and record
27. Remove gloves and perform hand
hygiene.
 Removal of indwelling Foley catheter

1. Review medical order for removal of Premature removal of catheter inpatients who
catheter. In cases of genitourinary surgery, it have undergone GU surgery could injure
is especially important to obtain an order. patient.

2. Perform hand hygiene, put on clean gloves, Procedure requires use of medical asepsis.
and provide privacy

3. Prepare the patient:

(a) Provide an explanation of procedure. Prepares patient to minimize anxiety.

(b) Position patient with waterproof pad Shows respect for patient dignity by only
under buttocks and cover with bath exposing genital area and catheter.
blanket, exposing only genital area and
catheter. Position females in dorsal
recumbent position and male patients in
supine position.

(c) Remove catheter securement device

and free drainage tubing.

4. If needed provide hygiene of genital area Antiseptic cleaners have not been proven to
with soap and water. decrease risk for CAUTI.

5. Move syringe plunger up and down to loosen
and then withdraw plunger to 0.5 mL. Insert
hub of syringe into inflation valve (balloon
port). Allow balloon fluid to drain into syringe
by gravity. Make sure that entire amount of
fluid is removed by comparing removed
amount to volume needed for inflation.
Partially inflated balloon can traumatize urethral
wall during removal.
Passive drainage of catheter balloon will
prevent formation of ridges in balloon. These
ridges can cause discomfort or trauma during
removal.

6. Pull catheter out smoothly and slowly. Promotes patient comfort and safety.
Examine it to ensure that it is whole.
Catheter should slide out easily. Do not use
force. If you note any resistance, repeat Step
5 to remove remaining water. Notify health
care provider if balloon does not deflate
completely.
7. Wrap contaminated catheter in waterproof Prevents transmission of microorganisms.
pad. Unhook collection bag and drainage
tubing from bed.

8. Reposition patient as necessary. Provide

hygiene as needed. Lower level of bed and
position side rails accordingly.

9. Empty, measure, and record urine present in Records urinary output.

drainage bag. Discard in appropriate Reduces transmission of microorganisms.
receptacle. Remove and discard gloves.
Perform hand hygiene

10. Encourage patient to maintain or increase Maintains normal urine output.

fluid intake (unless contraindicated).

11. Initiate voiding record or bladder diary. Evaluates bladder function.

Instruct patient to report when urge to void
occurs and that all urine needs to be
measured. Make sure that patient
understands how to use collection container.

12. Ensure easy access to toilet, bedpan, or

urinal. Place urine “hat” on toilet seat if
patient is using toilet. Place call bell within
easy reach.