Adventist University of the Philippines

COLLEGE OF NURSING

FUNDAMENTALS OF N U R S I N G CY 2021- 2022

URINARY CATHETIRIZATION P RIS Remarks

1 Prepare all supplies needed for catheterization. catheterization kit (Urethral Cath.
Uninary bag, betadine, forcep, 10cc syringe, KY Jelly, sterile gloves, Syringe 5cc,water proof
drape)

2 Make sure that routine perineal care has been performed to cleanse gross
contamination.
3 Introduce self and verify the client’s identity.
Explain the procedure to the patient.
4 Perform hand hygiene.
5 Provide for client privacy.
6 Place the client in the appropriate position and drape all areas except the
perineum.
 Female: supine with knees flexed, feet about 2 feet apart, and hips slightly eternally
rotated, if possible.
 Male: supine, thighs slightly abducted or apart.

7 Establish adequate lighting and stand on the client’s right side.

8 Open urine bag drainage package and place the end of the tubing within reach.

9 Open the catheterization kit. Place a waterproof drape under the buttocks (female)
or penis (male) without contaminating the center of the drape with your hands.
10 Apply sterile gloves
11 Organize the remaining supplies:
 Saturate the cleansing balls with the antiseptic solution.
 Open the lubricant package
 Remove the specimen container and place it nearby with the lid loosely on top

12 Attach the prefilled syringe on the indwelling catheter inflation hub and test the
balloon.
13 Lubricate the catheter 2.5 to 5 cm (1 to 2 in.) for females, 15 to 17.5 cm (6 to7 in.)
for males and place it with the drainage end inside the collection container.
14 Cleanse the meatus.

15 Grasp the catheter firmly 5 to 7.5 cm (2 to 3 in.) from the tip.

Note: Ask the client to take a slow deep breath and insert the catheter as the client exhales.

16 Advance the catheter 5 cm (2 in.) farther after the urine begins to flow through it.
Note: If the catheter accidentally contacts the labia or slips into the vagina, it is considered
contaminated and a new, sterile catheter must be used.
17 Hold the catheter with the nondominant hand.
18 Inflate the retention balloon with the designated volume.
Note: If the client complains of discomfort, immediately withdraw the instilled fluid, advance
the catheter farther, and attempt to inflate the balloon again.

19 Pull gently on the catheter until resistance is felt to ensure that the balloon has
inflated and to place in the trigone of the bladder.

20 Attach the drainage end of an indwelling catheter to the collecting tubing and bag.

21 Collect a urine specimen if needed.

22 Examine and measure the urine.
23 Secure the catheter tubing to the thigh for female clients or the upper thigh or lower
abdomen for male clients with enough slack to allow usual movement.
24 Wipe any remaining antiseptic or lubricant from the perineal area.
 Replace the foreskin of male client if retracted earlier.
 Return the client to a comfortable position.
 Instruct the client on positioning and moving with the catheter in place.

25 Assess patient and terminate relationship.

26 Discard all used supplies in appropriate receptacles.

27 Remove and discard gloves. Perform hand hygiene.
28 Document the catheterization procedure including catheter size and results in the
client record using forms or checklists supplemented by narrative notes when
appropriate.

Student’s name and signature: Student’s Score:

Evaluator’s name and signature Total Score: 56 + 10
Legend: P (2 points) –Performed well , RIS (1point)- Requires further Instruction Passing Score: 58

Revised 2s2020-2021