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.
FEMALE
• Pour water over perineum.
Reason: To wash off the discharge from the perineal area.
• Clean the perineum using the wet swabs.
Reason: To prevent the entrance of bacteria from the colon
into urinary tract.
• Clean the perineum using the wet swabs.
Reason: To prevent the entrance of bacteria from the colon
into urinary tract.
• Hold the swabs with forceps and clean from above.
• Use one swab for one swabbing.
• Clean perineum from the midline outward in
following order
a. The vulva
b. The labia
c. Inside of labia on both sides.
d. Outside of labia on both sides.
• Clean the perineal region and anus thoroughly.
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.
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.
10. Remove and discard gloves. Perform hand
hygiene.
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.
Female:
- Use your nondominant hand to spread the
labia so that the meatus is visible. Establish
firm but gentle pressure on the labia.
(FOR MAKING SURE THAT THE MEATUS IS
VISIBLE AND TO HAVE AN EASY ACCESS.)
- The antiseptic may make the tissues
slippery but the labia must not be allowed
to return over the cleaned meatus.
THIS IS TO MAKE SURE THAT WE ARE
PREVENTING THE CONTAMINATION AND
PREVENTING THE MICROORGANISM TO
TRANFERED.
- Use great care that wiping the client
does not contaminate the sterile
hand. Use a new ball for the opposite
side. Repeat for the labia minora.
(TO ENSURE THAT WE MAINTAIN THE
STERILE TECHNIQUE.)
- Use the last ball to cleanse directly over the
meatus.
(USING THE LAST BALL TO CLENSE DIRECTLY
OVER THE MEATUS IS A WAY TO MAKE SURE
THAT WE PREVENT THE SPREAD OF
MICROORGANISM BY CLEANING THE LEAST
TO MOST CONTAMINATION.)
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 pre-attached 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 thigh for female
clients or the upper thigh 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