foleycathernursingprocedure

Urinary catheters are devices that are used to promote elimination on patients who can otherwise void normally without a diagnosed health problem. These devices are usually made up of silicone material and are introduced to the urinary bladder by inserting it through the urethra. Usually, urinary catheters stay in place until it is no longer needed for the patient to have them in place.

Patients with problems in urinary elimination are faced with challenges in one of the most basic bodily functions. Their ability to eliminate body wastes via the urinary tract is often compromised by illnesses, surgical procedures, and other health problems, whether acute or chronic. In some cases, patients are prescribed to be inserted with a urinary catheter when they experience one or more of the following:

  • Urinary retention
  • A need to thoroughly monitor fluid intake and urine output
  • As part of preoperative management
  • For patients who are incontinent or on prolonged bed rest
  • Patients with sacral or perineal wounds
  • Bedridden patients
  • Those who are at the end-of-life care

Other purposes of inserting urinary catheters include:

  • Obtaining sterile urine specimens from patients
  • Measuring the amount of residual urine in the bladder
  • Complete bladder emptying, especially prior to diagnostic or surgical procedures
  • To serve as irrigation route for patients needing bladder irrigation

The Intermittent and Indwelling Catheters

Inserting a urinary catheter into the bladder is considered part of routine nursing interventions and is not necessarily a complex skill. However, it can also be a difficult skill for the nurse to master as both male and female patients presents the nurse with challenges in inserting the catheter.

It is important to ensure adequate lighting to help visualization of the urethra, especially among female patients. Positioning the patient properly is also important, taking into consideration of the patient’s condition and any contraindications for certain positions (i.e., female in the last trimester of pregnancy in the supine lithotomy position).

There are two major types of catheterization normally used for patients needing them: intermittent and indwelling. 

Intermittent catheterization is done using a single-lumen catheter and is normally used for patients needing:

  1. Immediate relief from urinary retention, 
  2. Long-term management of an incompetent bladder; 
  3. Obtaining a sterile urine specimen for diagnostic tests; and
  4. Assessment of the urinary bladder for residual urine after voiding.

An indwelling catheter, on the other hand, may use a double or triple lumen catheter and is used for:

  • Promotion of normal urinary elimination patterns
  • Measuring the accurate amounts of urine output
  • Prevention of skin breakdown
  • Helps facilitate wound management
  • In helping surgical sites such as the urethra, bladder and surrounding structures heal after surgery
  • Instillation of irrigation fluids and/or medications
  • Assessment of persistent abdominal or pelvic pain
  • Assisting in the diagnosis of conditions involving the genitourinary system

The lumens of the indwelling catheters have their distinct uses. In the double-lumen catheter, one of the lumens is used mainly for draining urine into a collection bag, while the other lumen is used as a port for the liquid used in inflating the balloon to keep it in place. In the triple-lumen set-up, the third lumen is usually used to instill medication and/or irrigating solution into the bladder. The catheter is also attached to a collection bag hanged lower than the catheter so that the flow of urine remains unrestricted.

Catheters inserted into the bladder are also used based on the French (Fr) scale sizes. This scale is used to denote the diameter of the tubes.

Recommended Fr sizes for female patients range from 12 to 16, while male patients normally use Fr 14 to Fr 16.

Insertion of the Catheter

Prior to the actual insertion of the catheter, the nurse must remember to check and verify the order and refer to the protocols implemented in the facility regarding the procedure. An informed consent for catheterization is also required to be signed prior to the actual procedure and may be signed by the patient or an authorized guardian if he is unable to give consent.

Prior to Insertion

Prior to inserting the catheter, the nurse must prepare the following materials to be used in the procedure: sterile gloves, catheterization kit, cleaning solution, water-based lubricant (if not included in the kit), prefilled syringe for balloon inflation based on catheter size, foley catheter and urine bag. The following tips should also be remembered:

  1. Perform hand washing to reduce the risk of transferring infections.
  2. Assess the patients’ room/environment thoroughly to determine appropriate lighting, need for privacy and other additional precautions.
  3. Confirm the patient’s identity and explain to the patient the procedure and how he can cooperate with the process.
  4. Prepare the necessary materials for easier access during the insertion of the catheter.
  5. Inflate the balloon using a syringe prior to use to determine the patency of the balloon. Aspirate the fluid back into the syringe and set it aside.
  6. Prepare the necessary materials to be used in a sterile field.

During Insertion

The table below presents the steps to be followed in catheter insertion with the rationale for each action.

Procedure Rationale
Determine the size of the catheter to be used. If possible, choose the smallest size for the patient. Large catheter sizes increases the risk of urethral trauma and may cause pain during insertion.
Place a waterproof pad under the patient’s perineal area. This helps protect the linens from soiling during the procedure.
Position the patient appropriately.  

Positioning the patient appropriately helps to visualize the insertion site, making it easier for the nurse to perform the procedure safely.

Female patient: On back with knees flexed and thighs relaxed so that hips rotate to expose perineal area. Alternatively, if patient cannot abduct leg at the hip, patient can be side-lying with upper leg flexed at knee and hip, supported by pillows.
Male patient: Supine with legs extended and slightly apart.
Draw curtains around the bed and place a blanket or sheet to cover patient and expose only required anatomical areas. This helps provide privacy to the patient, maintaining his dignity and modesty.
Apply clean gloves and wash perineal area with warm water and soap or perineal cleanser according to agency policy. Cleaning removes any secretions, urine, and feces, and reduces risk of CAUTI (catheter-acquired urinary tract infection).
Ensure that there is adequate lighting near the insertion site. This helps the nurse to visualize the site better, thereby ensuring accuracy and speed of the insertion.
Add supplies and cleaning solution to catheterization kit, and according to agency policy. Placing supplies in a kit ensures organization during the procedure and limits the need of the nurse to stop midway into the procedure to get additional supplies.
If using indwelling catheter and closed drainage system, attach urinary bag to the bed and ensure that the clamp is closed. Urinary bag should be closed to prevent urine drainage leaving bag.
Apply sterile gloves using sterile technique This step is necessary to observe the aseptic technique and reduce the risk of infections
Drape patient with drape found in catheterization kit, either using sterile gloves or using ungloved hands and only touching the outer edges of the drape. Ensure that any sterile supplies touch only the middle of the sterile drape (not the edges), and that sterile gloves do not touch non-sterile surfaces. Drape patient to expose perineum or penis. The outer edges (2.5 cm) of the drape is considered to be unsterile. Touching this part would render the entire field unsterile, which may increase the risk of infections.
Lubricate tip of catheter using sterile lubricant included in tray, or add lubricant using sterile technique. Applying lubricants to the tip of the catheter ensures easier and more effortless insertion, decreasing urethral trauma and discomfort.
Check balloon inflation using a sterile syringe. This maintains sterility of catheter and helps determine its patency.
Place sterile tray with catheter between patient’s legs. Sterile tray will collect urine once catheter tip is inserted into bladder.
Clean perineal area as follows.  

Perineal care helps in reducing the introduction of microorganisms into the urethra, thereby reducing infections.

Female patient: Separate labia with fingers of non-dominant hand (now contaminated and no longer sterile). Using sterile technique and dominant hand, clean labia and urethral meatus from clitoris to anus, and from outside labia to inner labial folds and urethral meatus. Use sterile forceps and a new cotton swab with each cleansing stroke.
Male patient: Gently grasp penis at shaft and hold it at right angle to the body throughout procedure with non-dominant hand (now contaminated and no longer sterile). Using sterile technique and dominant hand, clean urethral meatus in a circular motion working outward from meatus. Use sterile forceps and a new cotton swab with each cleansing stroke.
Pick up catheter with sterile dominant hand 7.5 to 10 cm below the tip of the catheter. Holding catheter closer to the tip will help to control and manipulate catheter during insertion.
Insert catheter as follows. This process helps visualize urethral meatus and relax external urinary sphincter.

 

Note: If catheter does not advance in a male patient, do not use force. Ask patient to take deep breaths and try again. If catheter still does not advance, stop procedure and inform physician. Patient may have an enlarged prostate or urethral obstruction.

 

Note: If urine does not appear in a female patient, the catheter may be in the patient’s vagina. You may leave catheter in vagina as a landmark, and insert another sterile catheter.

Female patient:
  • Ask patient to bear down gently (as if to void) to help expose urethral meatus.
  • Advance catheter 5 to 7.5 cm until urine flows from catheter, then advance an additional 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.
Slowly inflate balloon for indwelling catheters according to catheter size, using prefilled syringe. The inflated balloon will help keep the catheter in place and reduce the risk of it accidentally being pulled out.
After balloon is inflated, pull gently on catheter until resistance is felt and then advance the catheter again. Moving catheter back into bladder will avoid placing pressure on bladder neck.
Connect urinary bag to catheter using sterile technique. The urinary bag will ensure that urine will be collected and output monitored appropriately.
Secure catheter to patient’s leg using securement device at tubing just above catheter bifurcation.  

 

Securing catheter reduces risk of CAUTI, urethral erosion, and accidental catheter removal.

 

Female patient: Secure catheter to inner thigh, allowing enough slack to prevent tension.
Male patient: Secure catheter to upper thigh (with penis directed downward) or abdomen (with penis directed toward chest), allowing enough slack to prevent tension. Ensure foreskin is not retracted.
Dispose of used materials according to infection control procedure. Remove gloves and perform hand hygiene. This reduces the transfer of microorganisms and reduces the risk o infections.
Document procedure according to agency policy, including patient tolerance of procedure, any unexpected outcomes, and urine output. Timely and accurate documentation promotes patient safety.

After Insertion

Ensure that the patient’s response to the procedure is appropriately monitored and that urine output is documented. Ensure also that the urine bag and insertion sites are free from obstructions, and if there is a need to replace any part of the system.

Once the goal of the catheterization is met, its removal is expected to be ordered since prolonged use of the catheter may place the patient at an increased risk of developing infections. Preferably, catheters should be removed within 24 hours.

Patients require an order to have an indwelling catheter removed. Although the order is required, the health care provider’s responsibility is to evaluate if the indwelling catheter is necessary for the patient’s recovery. Removal of the catheter should be done after assessing whether the patient’s bladder function has returned and any untoward responses to the therapy should be reported to the physician. These symptoms include:

  • Hematuria
  • Inability or difficulty in voiding
  • Incontinence after catheter removal
  • Signs of infection such as pain upon urination, fever and chills

Moreover, the nurse should also include in the patient education the expected symptoms after catheter removal, such as mild burning sensation immediately after removal. Also, patients should receive the following instructions while on catheter:

  • Increase fluid intake to at least 3000ml per day unless contraindicated
  • Bladder training, if needed: instruct the patient to void when he can do so and to make sure that he empties his bladder within 6 hours of catheter removal
  • Take note of the first voided urine characteristics and report these to the health care provider: color, volume, sensation upon urination, and any abnormality in smell and transparency.
  • Report any pain, burning sensation or blood tinged-urine
  • Inform the nurse or other members of the health team of any signs indicating catheter-acquired urinary tract infection

Removing the Catheter

The table below presents the steps to be followed in insertion of the catheter with the rationale for each action.

Procedure Rationale
Verify the order for the removal of the catheter. Once verified, prepare necessary materials for removal. This ensures that the order for the removal of the catheter is made correctly.
Ensure that the patient is properly identified and necessary measures to protect privacy are instituted. Providing privacy helps protect the dignity of the patient and increases his trust in the health care provider.
Provide patient teaching on the symptoms he may feel after the removal of the catheter and what he can do to alleviate them. This helps to make sure that the patient knows what symptoms to report, what to expect and how to manage them.
Perform hand hygiene and don non-sterile gloves. Performing hand hygiene prior to preparing the materials also helps break the chain of infection.
Measure, empty, and record contents of catheter bag. Remove gloves, perform hand hygiene, and apply new non-sterile gloves.

 

Documentation is a vital aspect of caring for patients with impaired urinary function, while use of sterile gloves reduces the risk of transferring pathogens to the patient.
Remove catheter securement/anchor device. To make it easier for the nurse to pullout and remove the catheter later on.
Perform catheter care with warm water and soap or according to agency protocol. This reduces the transfer of microorganisms into the urethra.
Insert syringe in balloon port and drain fluid from balloon. Verify balloon size on catheter to ensure all fluid is removed from balloon. A partially deflated balloon will cause trauma to the urethra wall and pain.
Pull catheter out slowly and smoothly. Catheter should slide out slowly and smoothly.

Note: If resistance is felt, stop removal and reattempt to remove the fluid from the balloon. Attempt removal again. If unable to remove the catheter, stop and notify physician.

This reduces trauma to the urinary tract and reduces the discomfort the patient may feel during the removal.
Wrap used catheter in waterproof pad or gloves. Unhook catheter tube from urinary bag. Discard equipment and supplies according to agency policy. This prevents accidental spilling of urine from the catheter.
Provide perineal care as required and reposition patient to a comfortable position. This promotes patient comfort.
Review post-catheter care, fluid intake, and expected and unexpected outcomes with patient.

Ensure patient has access to toilet, commode, bedpan, or urinal. Place call bell within reach. Ensure first void (urine output) is measured as per agency policy.

Encourage patient to maintain or increase fluid intake to maintain normal urine output (unless contraindicated).

These measures ensure that the patient would have lower risks of having CAUTI and would be able to achieve normal voiding patterns after catheterization.
Lower bed to safe position, remove gloves, and perform hand hygiene. Lowering the bed helps prevent falls. Hand hygiene prevents the transmission of microorganisms from patient to health care provider.
Document procedure according to agency policy. Document time of catheter removal, condition of urethra, and any teaching related to post-catheter care and fluid intake.

Document time, amount, and characteristics of first void after catheter removal.

References

  1. Basavanthappa, B., (2015). Medical Surgical Nursing. New Delhi: Jaypee Brothers Medical Publishers.
  2. Billings, D. and Hensel, D., 2019. Lippincott Q & A Review For NCLEX-RN. 13th ed. St. Louis, MO., USA.: Wolters Kluwer Medical.
  3. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
  4. Morton, P., & Fontaine, D. (2018). Critical Care Nursing. Wolters Kluwer.
  5. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing Practice (9th ed.). St. Louis: Elsevier.
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