Name: Inclusive Date of duty: March 11, 2022

Year Level: BSN- 2A Clinical Area Assigned: OB

Assigned Clinical Instructor: Milky Adajar-Escober RN, MN

INDWELLING URINARY CATHETERIZATION

Definition:
Also known as a Foley catheter, an indwelling urinary catheter remains in the bladder to provide
continuous urine drainage. A balloon inflated at the catheter’s distal end prevents it from slipping
out of the bladder after insertion.
Objectives:
1. To withdraw urine and monitor urinary output
2. To provide relief of discomfort from bladder distention or urinary retention / decompression of
the bladder
3. To empty the bladder before and during surgery where general or spinal anesthesia is used and
before certain diagnostic examinations
Materials/Equipment to Use:

INSERTION REMOVAL
1. Double-Lumen Catheter 1. Dressing pack containing paper
2. Drapes towel, swabs and gallipot;
2. Kidney dish to receive the
3. Lubricant catheter;
4. Cleansing solution incorporated in an 3. Syringe for deflating the balloon
applicator or to be added to cotton balls (forceps to (usually a 10ml syringe);
pick up cotton balls) 4. Disposable gloves and apron
5. Prefilled syringe with sterile water for balloon 5. Cleansing solution, for example
inflation 0.9% sodium chloride.
6. Sterile drainage tubing bag
7. Sterile gloves
8. Specimen Container

PROCEDURE RATIONALE
1. Check physician’s order for catheter Catheterization is a dependent nursing action.
insertion.
2. Check patient’s identification band. Explain To ensure that the patient understands the
the procedure and obtain consent. process and gives informed consent..

Provide opportunity to ask questions To elicit cooperation.

3. Palpate for bladder fullness and pain. A full bladder causes a voiding urge and/or
pain.
Check current medications and any known Assess the patient to prevent medication
allergies. reaction.

4. Perform hand hygiene To reduce the transmission of microorganism.

5. Arrange equipment to provide convenience Placing equipment in order of use increase
and to avoid having to reach over sterile speed of performance. Reaching over sterile
 field. items increases the risk of contamination.
6. Provide privacy by closing the curtains or To prevent feeling of embarrassment and
doors discomfort.
Ask patient to remove underwear.

7. Raise bed to appropriate working height. Promotes body mechanics and patient
If side rails in use: safety.
• Lower the working side
• Close the opposite side
8. Place waterproof pad under patient. Prevents soiling of bed linen.
9. Positioning the patient depends on gender. For the comfort of patient, with perineum or
penis exposed, to ensure accessibility,
For female patient: On back with knees dignity, and comfort.
flexed and thighs relaxed so that hips rotate
to expose perineal area.

For male patient: Supine position with legs

extended and slightly apart.

10. Place a blanket or sheet to cover patient This step helps protect patient dignity.
and expose only required anatomical areas.
11. Provide perineal hygiene if needed (apply Hygiene before catheter insertion removes
clean gloves, complete cleansing, discard secretions, urine, and feces that could
gloves and perform hand hygiene). contaminate the sterile field and increase
risk for catheter-associated urinary tract
infection (CAUTI).
12. Ensure adequate lighting. Adequate lighting helps with accuracy and
speed of catheter insertion.
13. If using indwelling catheter and closed Urinary bag should be closed to prevent
drainage system, attach urinary bag to the urine drainage leaving bag.
bed and ensure that the clamp is closed.
The outer 2.5 cm is considered non-sterile
14. Drape patient with catheterization kit drape,
on a sterile drape.
only touching the outer edges. Strictly avoid
touching non-sterile surfaces with sterile
supplies or gloves. Drape to expose
patient's perineum or penis.
To reduce the transmission of
15. Perform hand hygiene then apply sterile
microorganism.
gloves using sterile technique.
16. Check balloon inflation using a sterile
This maintains sterility of catheter.
syringe.
17. Place sterile tray with catheter between Once catheter tip is in bladder, sterile tray
patient’s legs. collects urine.

18. Clean perineal area as follows. This reduces the transmission of

Female patient: Separate labia with fingers of microorganisms.
non-dominant hand (now contaminated and
no longer sterile). Using sterile technique The urethral meatus can be seen clearly.
and dominant hand, clean labia and urethral Front-to-back cleaning cleans from least
 meatus from clitoris to anus, and from contaminated to most contaminated. Gloved
outside labia to inner labial folds and dominant hand remains sterile.
urethral meatus. Cleanse with sterile
forceps and a new cotton swab.
Penis at 90-degree angle to patient
Male patient: With non-dominant hand, straightens male urethra and promotes entry.
gently grasp penis shaft and hold it at right Circular washing follows medical asepsis
angles to the body (now contaminated and principles.
no longer sterile). Clean the urethral meatus
in a circular motion working outward from
meatus with sterile technique and dominant
hand. Cleanse with sterile forceps and a
new cotton swab.

19. Pick up catheter with sterile dominant hand Holding catheter closer to the tip will help to
7.5 to 10 cm below the tip of the catheter. control and manipulate it during insertion.

20. Lubricate catheter about 1-2 inches from tip. Lubrication minimizes urethral trauma and
discomfort during procedure.

21. Insert catheter as follows.

Female patient: This process helps visualize urethral meatus
 Ask patient to gently bear down to and relax external urinary sphincter.
expose urethral meatus
 • Advance catheter 5–7.5 cm until urine
flows, then advance 5 cm.
Male patient:
 Hold penis perpendicular to body and
pull up slightly on shaft.
 Ask patient to bear down gently (as if to
void) and slowly insert catheter through
urethral meatus.
 Advance catheter 17 to 22.5 cm or until
urine flows from catheter.

22. Place catheter in sterile tray and collect urine Urine specimen may be required for
specimen if required. analysis. Collect as per agency policy.

23. Slowly inflate balloon for indwelling catheters The size of balloon is marked on the catheter
according to catheter size, using prefilled port.
syringe.
24. After balloon is inflated, pull gently on Moving catheter back into bladder will avoid
catheter until resistance is felt and then placing pressure on bladder neck.
advance the catheter again.
25. Connect urinary bag to catheter using sterile Keep urinary bag below level of patient’s
technique. bladder.

26. Secure catheter to patient’s leg using Securing catheter reduces risk of CAUTI,
securement device at tubing just above urethral erosion, and accidental catheter
catheter bifurcation. removal.
Female patient: Secure catheter to inner thigh,
allowing enough slack to prevent tension.

Male patient: Secure catheter to upper thigh For male patients, leaving the foreskin
 (with penis directed downward) or abdomen retracted can cause pain and edema.
(with penis directed toward chest), allowing
enough slack to prevent tension. Ensure
foreskin is not retracted.
27. Dispose of supplies following agency policy. This reduces the transmission of
microorganisms.

28. Remove gloves and perform hand hygiene. This reduces the transmission of
microorganisms.

29. Document process, patient tolerance, Timely and accurate documentation

unexpected outcomes, and urine output per promotes patient safety.
agency policy.

REMOVAL OF INDWELLING FOLEY CATHETER

1. Review medical order for removal of Premature removal of catheter inpatients who
catheter. Obtaining an order is important in have undergone GU surgery could injure
cases of genitourinary surgery. patient.

2. Perform hand hygiene, put on clean gloves, Procedure requires use of medical asepsis.
and provide privacy

3. Prepare the patient:

(a) Provide an explanation of procedure. Prepares patient to minimize anxiety.

(b) Position patient with waterproof pad Shows respect for patient dignity by only
under buttocks, cover with bath blanket, exposing genital area and catheter.
and expose only the genital area and
catheter. Females are positioned in
recumbent and males in supine.

(c) Remove catheter securement device

and free drainage tubing.

4. Provide hygiene of genital are with soap and Antiseptic cleaners have not been proven to
water if needed. decrease risk for CAUTI.

5. Move syringe plunger up and down to loosen Partially inflated balloon can traumatize
then withdraw plunger to 0.5 mL. Insert hub urethral wall during removal.
of syringe into inflation valve (balloon port).
Allow fluid to drain into syringe by gravity. Passive drainage of catheter balloon prevents
Compare removed amount to volume formation of ridges in balloon. Ridges can
needed for inflation to make sure the entire cause discomfort or trauma during removal.
amount of fluid is removed.

6. Pull catheter out smoothly and slowly. Promotes patient comfort and safety.
Examine to ensure it is whole. Catheter
should slide out easily. Don’t use force.
Repeat step 5 to remove remaining water if
resistance is noted. Notify health care
 provider if balloon does not deflate
completely.

7. Wrap contaminated catheter in waterproof Prevents transmission of microorganisms.

pad. Unhook urine bag and drainage tubing
from bed.

8. Reposition patient. Provide hygiene. Lower Prevent possible infections.

level of bed and position side rails
accordingly.

9. Empty, measure and record urine in the Records urinary output.

drainage bag. Discard properly. Remove and Reduces transmission of microorganisms.
discard gloves. Perform hand hygiene.

10. Encourage patient to increase or maintain To normalize urine output.

fluid intake.

11. Initiate voiding record or bladder diary. Evaluates bladder function.

Instruct patient to report when urge to void
occurs and measure the urine. Make sure
that patient understands how to use
collection container.

12. Ensure easy access to toilet, bedpan, or

urinal. Place urine “hat” on toilet seat if
patient is using toilet. Place call bell within
easy reach.