Purposes

• To relieve discomfort due to bladder

distention or to provide gradual
decompression of a distended
• To assess the amount of residual urine if
the bladder empties incompletely
• To obtain a sterile urine specimen
• To empty the bladder completely prior to
surgery.
• To facilitate accurate measurement of urinary
output for critically ill clients whose output
needs to be monitored hourly
• To provide for intermittent or continuous
bladder drainage and/ or irrigation
• To prevent urine from contacting an incision
after perineal surgery
1. Introduce self and verify the client’s identity
using agency protocol. Explain to the client
what you are going to do, why it is necessary,
and how she or she can participate.
RATIONALE: TO ENSURE THAT YOU ARE
DEALING WITH THE CORRECT PATIENT AND
TO GET HIS OR HER FULL PARTICIPATION
2. Perform hand hygiene and observe other
appropriate infection prevention procedures.
RATIONALE: TO REDUCE OR PREVENT
CROSS CONTAMINATION AMONG THE CLIENT

3. Provide for client privacy.

RATIONALE: TO REDUCE CLIENT’S ANXIETY
4. If using a catheterization kit, read the label
carefully
- to ensure that all necessary items are included.
5. APPLY CLEAN GLOVES AND PERFORM
ROUTINE PERINEAL CARE TO CLEANSE
CROSS CONTAMINATION. FOR WOMEN, USE
THIS TO LOCATE URINARY MEATUS RELATIVE
TO SURROUNDING STRUCTURES.
TO AVOID THE SPREAD OF INFECTION AND
TO PREVENT THE CROSS CONTAMINATION.
PERINEAL CLEANING
MALE
• If not circumcised, hold shaft of penis and gently retract
foreskin.
• Using circular motion, wash tip of penis (if using soap, avoid
getting it into meatus.)
• Repeat cleaning using the diff. sections of the cloth from
meatus outward until clean; if needed, return foreskin to
natural position.
• Wash shaft and testicles. Pay attention to folds and groin area.
• Rinse ( if soap used) and pat thoroughly dry (Note: pre-
moistened wipes preferable.)
• Using separate cloth, wash lower abdomen
or any other areas that may have been
exposed to urine or feces.
• Reposition resident to side-lying position,
cleanse anal and buttocks area with toilet
tissue if excess fecal matter.
• Rinse (if soap used) and pat dry.
6. REMOVE AND DISCARD GLOVES.
PERFORM HAND HYGIENE.
TO PREVENT THE SPREAD OF INFECTION
7. Place the client in the appropriate position and
drape all areas except the perineum.
RATIONALE: TO FACILITATE PRIVACY AND
COMFORT TO THE PATIENT

Females: supine with knees flexed, feet about two

feet apart, and hips slightly externally rotated if
possible.
Male: supine, thighs slightly abducted or apart.
8. Establish adequate lighting, stand on the client’s
right if you are right handed and left, if you are left
handed.

RATIONALE: TO FACILITATE A CLEARER

VISION UPON DOING THE CATHETERIZATION
AND FOR THE NURSE TO BE COMFORTABLE
WITH HER/HIS POSITION
9. Open the drainage package of the collecting
bag and place the end of the tubing within reach.

RATIONALE: Because one hand is needed to hold

the catheter once it is in place, open the package
while two hands are still available.
11.Place a waterproof drape under the buttocks
(female) or penis (male) without contaminating the
center of the drape with your hands.
RATIONALE: helping maintain the sterile field in
by creating a barrier to protect the patient from his
own flora as well as bacteria in the room's air.
12. Organize the remaining supplies.
RATIONALE: TO SAVE TIME AND TO
MAINTAIN THE STERILITY OF THE
EQUIPMENT
13.Saturate the cleansing balls with the
antiseptic solution
-FOR ANTI SEPTING PREPARATION
14.Open the lubricant package.
-FOR EASILY ACCESS WHEN INSERTION
STARTS
15. Remove the specimen container and place it
nearby with the lid loosely on top.
-FOR EASY ACCESS AND TO MAKE SURE
THAT WE ARE PREVENTING CONSUMING
TIME.
16. Attach prefilled syringe to the indwelling catheter
inflation hub. Apply agency policy and/or
manufacturer recommendation regarding retesting of
the balloon.
RATIONALE: There is little research regarding
pretesting of the balloon; however, some balloons
(e.g., silicone) may form a cuff on deflation that can
irritate the urethra on insertion.
17. Apply sterile gloves.
-TO PREVENT SPREAD OF INFECTION
18.Lubricate the catheter 2.5-5cm for
females, and 15-17.5cm for males and
place it with the drainage inside the
collection container.
-THIS IS TO PROVIDE COMFORT AND
MINIMIZE THE DISCOMFORT AND
TRAUMA DURING THE PROCEDURE.
19.If desired, we should place the fenestrated
drape over the perineum, exposing the urinary
meatus.
-TO PROVIDE COMFORTABLE ACCESS
WHEN DOING THE PROCEDURE SINCE
THE ONLY PART THAT WILL BE EXPOSED
IS THE URINARY MEATUS
20.Cleanse the meatus.
- Use your nondominant hand to grasp
the penis just below the glans. If
necessary, retract the foreskin.
For better access when inserting the
catherization. Retracting the skin can help
you to have an easy and speed insertion
without wasting time.
Male:
- Hold the penis firmly upright with
slight tension.
- Pick up a cleansing ball with
forceps in your dominant hand and
wipe the center of the meatus in a
circular motion around the glans.
- Use great care that wiping the client
does not contaminate the sterile hand.
- Use a new ball and repeat three more
times. The antiseptic may make the
tissues slippery but the foreskin must
not be allowed to return over the
cleaned meatus nor the penis be
dropped.
21. Insert the catheter. Grasp the
catheter firmly from the tip.
TO START THE INSERTION, GRASP
THE CATHETER FIRMLY TO EASILY
INSERT THE CATHERIZATION TIP.
22. Ask the client to take a slow, deep
breath and insert the catheter as the
client exhales. Slight resistance is
expected as the catheter passes
through the sphincter.
THIS IS TO MAKE SURE THAT WE
VARY THE FEAR OF OUR CLIENT
AND THEY MAY AWARE OF THE
PROCEDURE.
23.If necessary, twist the catheter or
hold pressure on the catheter until the
sphincter relaxes.
THIS CAN MAKE SURE THAT WE
ARE PROVIDING COMFORT.
24.Advance the catheter 5cm farther
after the urine begins to flow through
it.
TO ENSURE THAT THE CATHETER
IS FULLY IN THE BLADDER.
25.If the catheter accidentally contacts the labia
or slips into the vagina, it is considered
contaminated and a new sterile catheter must
be used. The contaminated catheter may be left
in the vagina until the new catheter is inserted
to help avoid mistaking the vaginal opening for
the urethral meatus.
TO AVOID THE MISTAKING THE VAGINAL
OPENING.
26.Hold the catheter with the nondominant
hand.
TO STEADY THE CATHETER IN EASILY
INSERTION.
27.For an indwelling catheter, inflate the
retention balloon with the designated
volume.
TO CHECK THE PATENCY OF
CATHETER WHEN INFLATING THE
RETENTIONBALLOON.
28.Without releasing the catheter (and for
females, without releasing the labia), hold
the inflation valve between the two fingers
of your nondominant hand while you attach
the syringe (if not left attached earlier) and
inflate with your dominant hand.
TO MAKE SURE THAT THE CATHETER
IS
STEADY AND AVOID THE
DISLODGEMENT.
29.If the client complains of discomfort, immediately withdraw the instilled fluid, advance the catheter farther and attempt to inflate the balloon again.
THIS IS TO MAKE SURE THAT WE AVOID OF
PRESSURE IN THE BLADDER NECK.
30.Pull gently on the catheter until resistance
is felt to ensure that the balloon has inflated
and to place it in the trigon of the bladder.
TO ENSURE THAT IT HAS INFLATEDAND
PROPERLY PLACED IN THE TRIGON OF
BLADDER.
31.Collect all urine specimen if needed.
FOR FURTHER MONITORING AND
EXAMINATION.
32. What I have is an indwelling catheter, so we will just move on from the straight one.
For an indwelling catheter preattached to a drainage bag, a specimen may be taken from the bag this initial time only.
TO AVOID THE SPREAD OF INFECTION
33. Attach the drainage of an
indwelling catheter to the collecting
tubing and bag.
FOR MAKING SURE THAT THE
DRAINAGE IS PROPERLY
ATTACHED IN THE COLLECTING
TUBING AND BAG.
34.Examine and measure the urine.
In some cases, only 750 to 1,000 mL
of urine are to be drained from the
bladder at one time. Check agency
policy for further instructions if this
should occur.
TO KNOW THE TEXTURE AND
AMOUNT OF URINE IN DRAINING.
35. For an indwelling catheter, secure
the catheter tubing to the lower abdomen
for male clients to prevent movement on
the urethra or excessive tension.
SECURING THE CATHETER CAN
AVOID DISLODGEMENT AND
DISCOMFORT.
36. Hang the bag below the level of the
bladder. No tubing should fall below the
top of the bag
TO PREVENT LEAKING AND OVER
FLOWING OF URINE.
37.Wipe any remaining antiseptic or lubricant
from the perineal area. Replace the foreskin if
retracted earlier. Return the client to a
comfortable position. Instruct the client on
positioning and moving with the catheter in
place
THIS IS TO MAKE SURE THAT WE
PREVENTING ACCIDENT PREVENT THE
SPREAD OF INFECTION AND PROVIDING
THE CLIENT COMFORT.
38.Discard all used supplies in appropriate
receptacles.
THIS IS TO MAKE SURE THAT WERE
PREVENTING HAZARDOUS AND
TRANSMISSION OF DISEASES.
39.Remove and discard gloves. Perform hand
hygiene.
TO PREVENT THE TRANSMISSION OF
MICROORGANISMS
40. Document the catheterization
procedure including the catheter size
and results in the client record using
forms or checklists supplemented by
narrative notes when appropriate .
THIS CAN BE SERVED AS OUR
BASELINE FOR FURTHER
ASSESSMENT.