St.

Paul College of Ilocos Sur

(Member, St. Paul University System)
St. Paul Avenue 2727, Bantay, Ilocos Sur

COLLEGE DEPARMENT

DEPARTMENT OF NURSING

NURSING PROCEDURE
Name: __Paul Adriane B. Renon__________________________
Course/ Year/Section : __BSN2 C________________

Rationalization on CATHETERIZATION
STEPS
1. Silently recite a prayer for the success of the procedure.
ASSESSMENT
2. Assess client’s status.
3. Assess client’s knowledge of the purpose of catheterization.
4. Verify prescriber’s order for catheterization.
5. Obtain client’s baseline weight.
PLANNING
6. Introduce yourself to the client.
7. Explain procedure and rationale.
8. Perform handwashing.
9.Provide privacy to the client.
IMPLEMENTATION
10. Raise bed to appropriate working height.
11. Stand on left side of bed if right- handed (or vice versa). Clear
bedside table and arrange equipment.
12. Raise side rail on opposite side of bed, and put side rail down
on working side.
13. Place waterproof pad under client.
14. Position client: Female client: Assist client to dorsal recumbent.
Ask client to relax thighs so hip joints can be externally rotated.
Position client in side- lying position with upper leg flexed at knee
and hip if client cannot be in supine position.
15. Position client: Male client: Assist client to supine position with
thighs slightly abducted.
16. Drape client: Female client: Diamond drape client.
17. Drape client: Male client: Male client’s upper trunk with bath
blanket and cover lower extremities with bed sheets so only
genitalia is exposed.
RATIONALE
To have guidance from the Lord.
To have a baseline data of the patient.
To know if the patient is already experien
catheterization.
To know when to catheterize the patient
To determine the fluid status of the patie
For the patient to be aware who you are
To be aware about the procedure and w
you have to put catheter to the patient.
To cleanse your hands and to prevent
spreading of bacteria.
For the comfort and privacy of the patien
To have an easy access to the patient a
also for comfortability.
To save time and effort.
To prevent the patient from falling.
To prevent the bed to get poured with ur
To have easily access for the female per
area especially the urinary meatus.
To have an easy access of the patient’s
perineal area or penis.
Be sure that you have access to its perin
area.
For the patients comfortability and privac
18. Apply disposable glove. To prevent contamination from the patie
19. Wash client’s perineal area with soap and water as needed. Dry To remove dirt around the perineal area.
area thoroughly.
20. Remove gloves. Used gloves is already contaminated, re
and put to its proper place to prevent
spreading of bacteria.
21. Position light to illuminate perineal area. To visualize the perineal area clearly.
22. Open package containing drainage system. Place drainage bag To prevent urine pouring in the bed of th
over edge of bottom of bed frame, and bring drainage tube up patient.
between side rail and mattress (indwelling catheter only).
23. Open catheterization kit according to directions, keeping bottom For easy access and to prevent
container sterile. contamination.
24. Apply sterile gloves. To access the sterile equipment for
catheterization.
25. Organize supplies on sterile field. Open inner sterile package Organizing is also saving time by having
containing catheter. Pour sterile antiseptic solution into correct access to the equipments in putting cath
compartment containing sterile cotton balls. Open packet to the patient.
containing lubricant. Remove specimen container (lid should be
loosely placed on top) and prefilled syringe from collection
compartment of tray, and set them aside on sterile field.
26. Test balloon by injecting flid from prefilled syringe into balloon To see if the catheter tube has no dama
port.
27. Lubricate 2.5 to 5 cm of catheter for female clients and 12.5 to For easier insertion of catheter.
17.5 cm for male clients.
28. Pick up catheter with gloved dominant hand 7.5 to 10cm from Proper holding and positioning helps you
catheter tip. Hold end of catheter loosely coiled in palm of dominant insert a catheter properly.
hand.
29. Insert catheter: Female client: Ask client to bear down gently as To reduce the pain that the patient will fe
if to void urine, and slowly insert catheter through urethral meatus.
Advance catheter a total of 5 to 7.5 cm in adult or until urine flows
out catheter’s end. Advance catheter another 2.5 to 5 cm when
urine appears. Do not force. Place end of catheter securely with
nondominant hand. Inflate balloon of retention catheter.
30. Insert catheter: Male client: Lift client’s penis to position Proper holding for easier insertion.
perpendicular to client’s body and apply light traction.
31. Ask client to bear down as if to void urine, and slowly insert To reduce the pain for the patient.
catheter through urethral meatus.
32. Advance catheter 17 to 22.5 cm in adult or until urine flows out To insert and secure the catheter proper
catheter’s end. Withdraw catheter if resistance is felt. Advance
catheter another 2.5 to 5 cm when urine appears. Lower client’s
penis and hold catheter securely in nondominant hand. Place end
of catheter in urine tray receptacle. Inflate balloon of retention
catheter.
33. Collect urine specimen as needed. Fill specimen cup or jar to For urine examination or test.
desired level by holding end of catheter in dominant hand over cup.
34. Allow client’s bladder to empty fully if institution policy permits. To remove the urine in the bladder clear
35. Remove straight, single-use catheter: Withdraw catheter slowly To reduce pain in removing the single us
but smoothly until removed. catheter.
36. Slowly inflate bvalloon with fluid from prefilled syringe. To be able to prevent the catheter from
dislodging.
37. Release catheter with non-dominant hand and pull gently to feel To be able to know if the catheter is sec
resistnace.
38. Attach end of retention catheter to collecting tube of drainage To prevent the drainage bag from falling
system. Keep drainage bag below level of bladder. Do not place the ground.
bag on side rails of bed.
39. Anchor catheter, allowing sufficient slack for client movement. To promote comfortability with the cathe
Female client: Secure catheter tubing to client’s inner thigh with
strip of nonallergenic tape.
40. Male client: Secure catheter tubing to top of thigh or lower To secure the flowing of urine in the cath
abdomen.
41. Assist client to a comfortable position. Wash and dry client’s For the comfortability of the patient after
perineal area as needed. procedure.
42. Remove and dispose of gloves. Disposing to their proper places to achie
clean environment and prevent also
contamination.
43. Dispose of equipment, drapes and urine in proper receptacles. To prevent the spreading of bacteria.
44. Wash hands. To achieve and to have a clean hands a
the procedure.
EVALUATION
45. Palpate client’s bladder. To palpate if there’s still urine in the patie
bladder.
46. Ask if client is comfortable. To know if there are things that is not
comfortable for the patient for us to know
what should we do next and what are the
things that the patient wants.
47. Observe character and amount of urine in drainage system. To have a baseline data if there are chan
and to know the amount of urine excrete
48. Determine that no urine is leaking from catheter or tubing To prevent leaking from the catheter and
connections. prevent the bed from dripping of urine.