NCMA113

The introduction of catheter thru the

urethra into the bladder in order to
remove urine
1.To obtain sterile
urine specimen for
examination
2. To relieve urinary
retention
 3. To ensure
emptying of the
bladder prior to
surgery or delivery
4.To prevent
bedwetting in a
incontinebce
patient
5. To remove urine
when it is not
advisable for
patient to void
6. To determine
whether failure to
void is due to
urinary retention or
urinary suppression
7. To determine
residual urine
8. To measure
hourly urine
output
1. Identified patient’s using two
identifiers.
2. Reviewed patient’s medical record,
noted previous catheterization.
3. Reviewed medical record for any
pathological condition that may
impair passage of catheter.
4. Performed hand hygiene, asked
patient and checked for allergies.
5. Assessed patient’s weight, LOC,
developmental level, ability to
cooperate, and mobility.
6. Assessed patient’s gender and
age.
7. Assessed patient’s knowledge, prior
experience with catheterization, and
feelings about procedure.
8. Assessed for pain and bladder fullness.
9. Performed hand hygiene, applied gloves,
inspected perineal region, removed
gloves, performed hand hygiene.
1. Identified expected
outcomes.
2. Explained procedure to
patient.
3. Arranged for extra personnel
to assist as necessary,
organized supplies at bedside.
1. Checked patient’s plan for care for
size and type of catheter, used
smallest size posible.
2. Performed hand hygiene.
3. Provided privacy.
4. Raised bed to appropriate height,
raised side rail on opposite side,
lowered side rail on working side.
5. Placed waterproof pad under
patient.
6. Applied clean gloves; cleaned,
rinsed, and dried perineal area,
examined patient and identified
urinary meatus, removed and
discarded gloves, performed hand
hygiene.
7. Positioned patient
appropriately.
8. Draped patient appropriately.
9. Positioned light to illuminate
genitals or had assistant hold
light.
10. Opened outer wrapping of
catheterisation kit, planed inner
wrapped kit on appropriate clean
surface.
11. Opened inner sterile wrap using
sterile technique.
12. Applied sterile gloves.
13. Draped perineum, kept gloves sterile:
a. Draped female patient:
1) Unfolded square drape without touching unsterile
surfaces, allowed top edge to form cuff over both
hands, placed drape shiny side down between
patient’s thighs, asked patients to lift hips, slipped
cuffed edge just under buttocks, applied new gloves
if old gloves are contaminated.
2) Unfolded fenestrated sterile drape without touching
unsterile surfaces, allowed top edge to form cuff over
both hands, draped over perineum, exposed labia.
13. Draped perineum, kept gloves
sterile:
b. Draped male patient:
1) Unfolded square drape without
touching unsterile surfaces, placed
over thighs just below penis, placed
fenestrated drape with opening
centered over penis.
14. Arranged supplies on sterile field, maintained sterility of
gloves, placed loaded sterile tray on sterile drape:
a. Poured antiseptic solution over cotton balls if
necessary.
b. Opened sterile specimen container if specimen was to
be obtained
c. Opened inner sterile wrapper of catheter, attached
drainage bag if part of a closed system, ensured clamp
on drainage port of bag was closed, attached catheter
to drainage tubing if part of sterile tray.
d. Opened lubricant, squeezed onto sterile field,
lubricated catheter in gel appropriately.
15. Ceansed urethral meatus:
a. For female patient:
1) Seperated labia with fingers of
nondominant hand.
2) Maintained position of nondominant
hand throughout procedure.
3) Cleansed labia with one cotton ball
using forceps, cleaned labia and
urinary meatus appropriately.
15. Ceansed urethral meatus:
b. For male patient:
1) Retracted foreskin if present with
nondominant hand, held penis
appropriately.
2) Used uncontaminated hand to
appropriately cleanse meatus.
3) Repeated cleaning 3 times using clean
cotton ball each time.
16.Held catheter properly
away from catheter tip with
catheter coiled in hand,
positioned urine tray
appropriately if necessary.
17. Inserted catheter, explained to patient
that feeling for burning or pressure is
normal and will go away:
a. For Female patient:
1) Asked patient to bear down, inserted catheter slowly
through urethral meatus.
2) Advanced catheter appropriately or until urine flows
out end.
3) Released labia, held catheter securely with
nondominant hand.
17. Inserted catheter, explained to patient
that feeling for burning or pressure is
normal and will go away:
b. For male patient:
1) Applied upward traction to penis as it was held at 90-degree angle
from body.
2) Asked patient to bear down, slowly inserted catheter through
urethral meatus.
3) Advanced catheter appropriately or until urine flows out end.
4) When urine appears in indwelling catheter, advances to
bifurcation.
5) Lowered penis, held catheter securely.
18. Allowed bladder to empty fully unless
volume was restricted.
19. Collected urine specimen as needed,
labeled and bagged specimen in front of
patient according to agency policy, sent to
laboratory as soon as possible.
20. If straight catheterization, withdrew
catheter slowly until removed.
21. Inflated catheter ballon with designated
amount of fluid;
a. Continued to hold catheter with nondominant hand.
b. Connected prefilled syringe to injection port with
free dominant hand.
c. Injected total amount of solution.
d. Released catheter after inflating ballon, pulled
catheter gently until resistance was felt, advanced
catheter slightly.
e. Connected drainage tubing to catheter if not
preconnected.
22. Secured indwelling catheter with
securement device, left enough slack to
allow leg movement arrow attached device
just at the catheter bifurcation:
a. For female patient, secured tubing to inner thigh,
allowed enough slack.
b. For male patient, secured catheter tubing to upper
thigh or lower abdomen, allowed enough slack,
replaced foreskin if retracted.
23. Clipped drainage tubing to edge of
mattress, positioned bag lower than
bladder, did not attach side rails of bed.
24. Ensured there was no obstruction to urine
flow, coiled excess tubing on bed, fastened
to bottom sheet with securement device.
25. Provided hygiene as needed, assisted
patient to comfortable position.
26.Disposed of supplies in
appropriate receptacles.
27.Measured urine and recorded
the amount.
28.Removed gloves, performed
hand hygiene.
1. Palpated bladder for distention or used bladder
scan.
2. Asked patient to describe level of comfort
3. Observed character and amount of urine in
drainage system for indwelling catheter.
4. Ensured there was no urine leaking from catheter
or tubing connections for indwelling catheter.
5. Asked patient to describe how to keep urine
flowing out of catheter.
6. dentified unexpected outcomes
1. Recorded and reported all pertinent
information in the appropriate log.
2. Recorded amount of urine on I&O flow
sheet record.
3. Reported persistent catheter-related
pain, inadequate urine output, and
discomfort to health care provider.
1. Identified patient using two identifiers.
2. Performed hand hygiene
3. Assessed need for catheter care:
a. Observed urinary output and urine characteristics.
b. Assessed for history or presence of bowel
incontinence.
c. Observed fro any discharge, redness, bleeding, or
presence of tissue trauma around urethral meatus.
d. Assessed patient’s knowledge of catheter care.
4. Assessed need for catheter removal:
a. Reviewed patient’s medical record, noted
length of time catheter was in place.
b. Assessed patient’s knowledge and prior
experience with catheter removal.
c. Assessed urine color, clarity, odor, and amount;
noted urethral discharge, irritation or trauma.
d. Determined size of catheter inflation balloon
by looking at valve.
1. Identified expected outcomes
following catheter care.
2. Identified expected outcomes
following catheter removal.
3. Explained procedure to patient,
discussed signs and symptoms of UTI,
taught patient how to perform
catheter hygiene.
1. Provided privacy.
2. Performed hand hygiene.
3. Raised bed to appropriate working
height, lowered side rails on working
side.
4. Organized equipment for perineal
care and/ or removal of catheter.
5. Positioned patient with watereproof
pad under buttocks, covered with
bath blanket, exposed genital area
and catheter only.
6. Applied gloves.
7. Removed catheter securement
device while maintaining connection
with drainage tubing.
8. Performed catheter care:
a. Seperated labia or retracted foreskin expose meatus,
maintained position throughout procedure.
b. Grasped catheter with two fingers to stabilise it.
c. Assessed urethral meatus and surrounding tissues for
inflammation, swelling, discharge or tissue trauma;
asked patient if burning or discomfort was present.
d. Provided perineal hygiene with soap and water.
e. Reapplied catheter securement device, allowed slack in
catheter.
9. Checked drainage tubing and bag routinely for proper
securement and positioning.
10. Performed catheter removal:
a. Loosened syringe, withdrew plunger, inserted hub of
syringe into inflation valve, allowed balloon fluid to
drain into syringe, ensured entire amount of fluid was
removed.
b. Pulled catheter appropriately , ensured catheter was
whole, did not use force.
c. Wrapped contaminated catheter in waterproof pad,
unhooked bag and drainage tubing from bed.
d. Emptied, measured, and recorded urine present in
drainage bag.
10. Performed catheter removal:
a. Encouraged patient to maintain or increase fluid intake.
b. Initiated voiding record or bladder diary, instructed
patient to tell you when need to empty bladder
occurred and that all urine was measured, ensured
patient knew how to use collection container.
c. Explained that many patients experience mild burning,
discomfort, or small-volume Voiding, which will
subside.
d. Informed patient to report signs of UTI.
e. Ensured easy access to toilet or bedpan, placed urine
“hat” on toilet seat, placed call bell within easy reach.
11. Repositioned patient, provided
hygiene, lowered bed and
positioned side rails.
12. Disposed of all contaminated
supplies in appropriate receptacle,
performed hand hygiene.
1. Inspected catheter and genital area for soiling,
irritation, and skin breakdown; asked patient
about discomfort.
2. Observed time and measured amount of first
voiding after catheter removal.
3. Evaluated patient for signs and symptoms of UTI.
4. Asked patient to describe preventive measures
against UTIs.
5. Identified unexpected outcomes.
1. Recorded time for catheter care and appearance of urine,
described condition of meatus and catheter.
2. Recorded and reported time of catheter removal;
amount of water removed from balloon; condition of
urethral meatus and catheter; and time, amount, and
characteristics of first voided urine.
3. Recorded teaching related to catheter care, catheter
removal, and fluid intake.
4. Reported hematuria, dysuria, inability or difficulty
voiding, or any new incontinence after catheter removal.
5. Reported signs of UTI to health care provider.