URINARY

ELIMINATION AND
CATHETERIZATION

Davey, 2019
Copyright © 2018, Elsevier Inc. All rights reserved for content from Perry + Potter, Ostendorf 9th Edition of Clinical Nursing Skills & Techniques
 Urinary • Urinary elimination support
Elimination – Helping a patient to a
toilet or a bedside
commode
– Assisting with a urinal
Minimize
Assist
Risk – Performing
catheterization
• Implement measures to
minimize risk for infection

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Principles for • Adequate oral intake is
Practice essential for bladder health
• Evaluate urinary input:
– Know the average output range
2200-2700 in for a patient
24 hrs
– Know the signs of dehydration
and fluid overload
<30 ml/hr – Assess patient’s most recent
for 2 hrs serum electrolytes
– Weigh a patient to determine
fluid status

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 Patient Centered Care
• Understand values & preferences
Preferences
• Try to adapt procedures to
minimize the invasive nature of
catheterization & maintain a
Dignity
patient’s dignity and respect
• Many cultures have specific
Culture
beliefs & practices related to
elimination, privacy, & gender-
specific care

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 Evidence Based Practice
• Catheter-associated urinary tract infection (CAUTI)
prevention practices
Aseptically inserting catheters
Limiting use of indwelling catheters
Using smallest catheter & remove ASAP
Secure indwelling catheters
Maintaining closed drainage system
Maintaining free flow of urine
Perform routine perineal care daily, after soiling

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 Safety Guidelines
Remember
Regularly assess and determine functional status.
Evaluate a patient’s normal pattern of micturition.
Consider age when assessing voiding habits.
Patients who need assistance with elimination should
have a call bell within easy reach and the offer for
assistance at regular intervals.
Maintain aseptic technique when catheterizing a patient to
prevent CAUTI.

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 Applying a Condom-Type
External Catheter

• External urinary catheters

– Available in silicone or latex
– Held in place with adhesive or an external strap
– May be used with a small- or large-volume bag
– Associated with less risk of UTI than indwelling catheters

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 Recording and Reporting

Record condom
application;
condition of
penis, skin, and
scrotum; urinary
output, voiding
pattern in nurses’
notes in the
(EHR) or chart
Report penile
erythema,
rashes, and/or
skin breakdown

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 Special Considerations
• Teaching
– Explain signs of skin breakdown/trauma
– Advise to keep kink-free and below level of bladder
– Assess leg straps for tightness
• Gerontological
– Evaluate for neuropathy before applying
– Not recommended with prostatic obstruction
• Home care
– Explain use and care of equipment
– Teach appropriate assessments
– Loose-fitting clothing may be required

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Insertion of a • Straight catheter = single use
Straight or (long enough to drain bladder
• In community patients may wash
Indwelling and re-use (clean technique)
Urinary • Hospital = sterile
Catheter • Coude: curved tip, used for males
with obstructions

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Insertion of a Straight or Indwelling Urinary
Catheter

Insertion of a
narrow tube
through the
urethra into the
bladder to allow
for the continuous
flow of urine.

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 Insertion of a Straight or Indwelling
Urinary Catheter
• Styles
– Single-lumen
– Double-lumen
– Triple-lumen
• Materials
– Latex
– Silicone

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 Insertion of a Straight or Indwelling
Urinary Catheter

• Sizing
– Internal catheter size
– Balloon size
• Changing
– Individualized, not
routine

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ASSESSMENT Basic Steps
1. Review record, note previous catheterization; any
pathological condition that may impair passage of catheter.
2. Hand hygiene, check for allergies.
3. Assess weight, LOC, developmental level, ability to
cooperate, and mobility.
4. Assess gender and age.
5. Assess knowledge, prior experience with catheterization,
and feelings about procedure.
6. Assess for pain and bladder fullness.
7. Hand hygiene, apply gloves, inspect perineal region, remove 14
gloves, Hand hygiene.
 Basic Steps

PLANNING
1. Explain procedure to patient.
2. Arrange for extra personnel to assist as
necessary, organize supplies at bedside.

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 Basic Steps
IMPLEMENTATION
1. Check Physician’s Order
2. Check plan of care for size and type of
catheter, (smallest size possible).
3. Hand hygiene.
4. Privacy.
5. Bed to appropriate height, side rails.
6. Place waterproof pad under patient. 16
 Basic Steps
IMPLEMENTATION
1. Apply clean gloves; clean, rinse, & dry
perineal area, examine to identify urinary
meatus, remove & discard gloves, hand
hygiene.
2. Position patient appropriately (Female -
dorsal recumbent, Male - supine with legs
extended and thighs slightly abducted).
3. Drape patient appropriately for privacy
(diamond).
4. Position light to illuminate genitals or have 17

assistant hold light.

 Basic Steps
IMPLEMENTATION
10.Open outer wrapping of catheterization kit, place
inner wrapped kit on appropriate clean surface
(Use the outer wrapping-plastic bag as your
garbage bag).
11. Open inner sterile wrap using sterile technique.
12.Apply sterile gloves.
13. Drape perineal area, keeping gloves sterile.

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 Basic Steps
IMPLEMENTATION
10.Arrange supplies on sterile field, maintain sterility
of gloves, placed loaded sterile tray on sterile
drape:
– Pour antiseptic solution over cotton balls if
necessary.
– Open sterile specimen container if specimen is
to be obtained.
– Open lubricant, squeeze onto sterile field,
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lubricate catheter in gel.
IMPLEMENTATION Basic Steps
15. Clean urethral meatus:
Female patient:
– Separate labia with fingers of nondominant
hand.
– Maintain position of nondominant hand.
– Clean labia with one cotton ball using forceps,
clean labia & urinary meatus.

Male patient:
– Retract foreskin if present with nondominant
hand, hold penis.
– Use uncontaminated hand to cleanse meatus.
– Repeat cleaning 3 times with new cotton ball
each time.
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IMPLEMENTATION Basic Steps
16.Hold catheter away from catheter tip with catheter
coiled in hand, position urine tray appropriately.
17. Insert catheter, explain to patient that feeling for
burning or pressure is normal and will go away:
Female patient:
– Ask patient to bear down, insert catheter slowly
through urethral meatus.
– Advance catheter until urine flows out end.
– Release labia, hold catheter securely with
nondominant hand. 21
IMPLEMENTATION Basic Steps
Male patient:
– Apply upward traction to penis - hold at 90-degree
angle from body.
– Ask patient to bear down, slowly insert catheter
through urethral meatus.
– Advance catheter appropriately or until urine flows
out end.
– When urine appears in indwelling catheter, advance
to bifurcation.
– Lower penis, hold catheter. Allow bladder to empty
unless volume is restricted. 22
Location

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IMPLEMENTATION Basic Steps
18. Collect urine specimen as needed.
19. If straight catheterization, withdraw
catheter slowly until removed.
20. Inflate foley catheter balloon with
fluid using prefilled syringe:
– Continue to hold catheter with
nondominant hand.
– Connect prefilled syringe to injection port
with free dominant hand.
– Inject total amount of solution.
– Release catheter after inflating balloon,
pull catheter gently until resistance is felt,
advance catheter slightly. 24
– Connect drainage tubing to catheter .
 Basic Steps
IMPLEMENTATION
21. Secure indwelling catheter with securement device, leave
enough slack to allow leg movement, attach device just at the
catheter bifurcation:
– Female patient, secure tubing to inner thigh, allow enough
slack.
– Male patient, secure catheter tubing to upper thigh or lower
abdomen, allow enough slack, replace foreskin if retracted.
22. Clip drainage tubing to edge of mattress, position bag lower
than bladder, do not attach side rails of bed.
23. Ensure there was no obstruction to urine flow, coil excess
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tubing on bed, fasten to sheet with securement device.
 Basic Steps
IMPLEMENTATION
24. Provide hygiene as needed, assist patient to
comfortable position.
25.Dispose of supplies in appropriate receptacles.
26. Measure urine and record the amount.
27. Remove gloves, perform hand hygiene.
28. Document

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 Recording and Reporting
• Record and report the reason for catheterization, type
and size of catheter inserted, amount of fluid used to
inflate balloon, specimen collection (if applicable),
characteristics and amount of urine, patient’s
response to procedure, and any teaching in nurses’
notes in the electronic health record (EHR) or chart

• Record amount of urine on intake and output (I&O)

flow sheet record
• Report persistent catheter-related pain, inadequate
urine output, and discomfort.

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 Special Considerations
• Teaching
– Explain routine care
– Explain that adequate fluid intake helps prevent blockage
• Pediatric
– Teach young children to blow into a straw or a pinwheel to
aid in relaxing pelvic muscles
• Gerontological
– Age-related physical changes, urinary tract infection (UTI)
risks, decreased mobility, increased mortality
• Home care
– Care and use of catheter system, signs of UTI, supplies

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 Care and Removal of an Indwelling
Catheter
• Ensure that catheter balloon is fully deflated before
removal
• Procedure for monitoring the patient after removal
of the catheter (monitor for 24-48 hours, voiding
record – time, amount, incontinence)
• Use a bladder scan to monitor function (residual
volume)
• Watch for symptoms of UTI even after catheter
removal
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 Recording and Reporting
• Record time for catheter care and appearance of urine;
describe condition of meatus and catheter
• Record and report time of catheter removal; amount of
water removed from balloon; condition of urethral
meatus and catheter; and the time, amount, and
characteristics of first voided urine
• Record teaching related to catheter care, catheter
removal, and fluid intake
• Report hematuria, dysuria, inability or difficulty voiding,
and any new incontinence after a catheter is removed

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 Special Considerations
• Teaching
– Proper hydration, ambulating with bag, not
disconnecting bag
• Pediatric
– During removal, do not force catheter out of bladder if
you meet resistance
• Gerontological
– Older adults may exhibit atypical S & S of CAUTI
• Home care
– Assess patient/caregiver for ability/motivation to
participate in catheter care

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 Bladder Scan and Catheterization to Determine Residual
Urine

• Bladder scanner
– Assesses bladder volume

• Postvoid residual (PVR)

– Perform measurement
within 5 to 15 minutes of
voiding

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 Performing Catheter Irrigation

• Irrigation may be
intermittent or
continuous

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 Performing Catheter Irrigation

• Irrigation may be
intermittent or
continuous

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 Recording and Reporting
• Record irrigation method, amount of and type of
irrigation solution, amount returned as drainage,
characteristics of output, urine output, and patient
tolerance to procedure in nurses’ notes in the
electronic health record (EHR) or chart
• Report catheter occlusion, sudden bleeding, infection,
or increased pain to health care provider
• Record I&O on appropriate flow sheet

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 Special Considerations
• Teaching
– Teach patients to observe urine and maintain adequate
oral intake
• Home care
– Teach patients to perform catheter irrigation, observe
urine, and watch for signs of catheter obstruction/UTI
– Arrange for home delivery of supplies

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 Suprapubic Catheter Care

• Suprapubic catheter
– Surgically inserted
– May be sutured to
skin, secured with
adhesive, or retained
with fluid-filled
balloon

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 Recording and Reporting

• Record and report character of urine and type of

dressing change, including assessments of
insertion site and patient’s comfort level with the
catheter and dressing change in nurses’ notes in
the electronic health record (EHR) or chart
• Record urine output on I&O flow sheet.

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 Special Considerations
• Teaching
– Encourage adequate fluid intake
– Keep bag lower than bladder and keep tubing kink-free
• Home care
– Teach how to clean and apply dressing
– Explain use and care of equipment
– Arrange for home delivery of supplies
– Explain UTI, obstruction, signs of infection

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 Principles of Surgical Asepsis
1. All items used within a sterile filed must be sterile.
2. A sterile barrier that has been permeated by punctures, tears or moisture must be considered
contaminated.
3. Once a sterile package is opened, a 2.5 cm (1 inch) border around the edges is considered unsterile.
4. Tables draped as part of a sterile field are considered sterile only at table level.
5. If there is any question or doubt about the sterility of an item, the item is considered to be
unsterile.
6. Sterile people or items contact only sterile areas; unsterile people or items contact only unsterile
areas.
7. Movement around and in the sterile field must not compromise or contaminate the field.
8. A sterile object or field out of the range of vision or an object held below a person’s waist is
contaminated.
9. A sterile object or field becomes contaminated by prolonged exposure to air; stay organized and
complete any procedure as soon as possible. 40
 References
Perry Clinical Nursing Skills & Techniques Mosby 9th Edition
Potter Canadian Fundamentals of Nursing Mosby 5th Edition

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