Skill 12-7

Catheterizing the Urinary Bladder of a Patient With Female Genitalia

Skill Variation: Intermittent Urethral Catheterization of a Patient With Female Genitalia

Urinary catheterization is the introduction of a catheter (tube) through the urethra into the bladder for the purpose of withdrawing urine. Catheter-associated urinary tract infections (CAUTIs) remain one of the most common causes of health care-associated infections in the United States (Knill et al., 2018). The best way to prevent a CAUTI is to use urinary catheters only when absolutely necessary (ANA, n.d.; Panchisin, 2016). The CDC provides parameters to guide the decision to insert an indwelling urinary catheter (Gould et al., 2019). When use of a urinary catheter is deemed necessary, it should be performed using strict aseptic technique, left in place only as long as needed, and removed as soon as possible (ANA, 2014; Gould et al., 2019; Gyesi-Appiah et al., 2020; SUNA, 2015).

If a catheter is to remain in place for continuous drainage, an indwelling urethral catheter is used. Indwelling catheters are also called retention or Foley catheters. The indwelling urethral catheter is designed so that it does not slip out of the bladder. A balloon is inflated to ensure that the catheter remains in the bladder once it is inserted (Figure 1A).

Intermittent urethral catheters (straight catheters) are used to drain the bladder for shorter periods (Figure 1B). Intermittent catheterization should be considered as an alternative to short- or long-term indwelling urethral catheterization to reduce CAUTIs (Gould et al., 2019). Intermittent catheterization is the preferred bladder management method for patients with urinary retention and bladder-emptying dysfunctions and following surgical interventions (Beauchemin et al., 2018; Gould et al., 2019). Certain advantages to intermittent catheterization, including the lower risks of CAUTI and complications, may make it a more desirable and safer option than indwelling catheterization (Panchisin, 2016; Wilson, 2015).

Some facilities have adopted a two-person urinary catheter insertion protocol, in which one nurse catheterizes the patient and one observes to ensure that the nurse inserting the catheter follows sterile technique and performs the procedure correctly (Belizario, 2015; Rhone et al., 2017). Implementation of the two-person urinary catheter insertion protocol has been shown to decrease CAUTI (Belizario, 2015; Fletcher-Gutowski & Cecil, 2019; Rhone et al., 2017).

The following procedure reviews insertion of an indwelling catheter. The procedure for an intermittent catheter follows as a Skill Variation. Guidelines for caring for a patient with an indwelling catheter are summarized in Box 12-1.

Delegation Considerations

The catheterization of the urinary bladder is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, catheterization of the urinary bladder may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Sterile catheter kit that contains:
- Sterile gloves
- Sterile drapes (one of which is fenestrated )
- Sterile catheter (use the smallest appropriate-sized catheter that will allow effective drainage; a 14F with a 5- to 10-mL balloon is usually appropriate, unless another size is prescribed [ANA, 2014; SUNA 2021b; Yates, 2017a])
- Antiseptic cleansing solution and cotton balls or gauze squares; antiseptic swabs (based on facility policy)
- Lubricant
- Forceps
- Prefilled syringe with sterile water (sufficient to inflate indwelling catheter balloon)
- Sterile specimen container (if specimen is required)
- Anesthetic gel, as prescribed or indicated (see Assessments below)
Flashlight or lamp
Waterproof, disposable pad
Sterile, disposable urine collection bag and drainage tubing (may be connected to catheter in catheter kit)
Catheter-securing device
Disposable gloves
Additional PPE, as indicated
Washcloth, skin cleanser, and warm water to perform perineal hygiene before and after catheterization

Assessment

Assess the patient's usual elimination habits. Assess the patient's degree of limitations and ability to help with activity. Assess for health problems, such as hip surgery or spinal injury, which would contraindicate certain actions by the patient. Assess for the presence of any other conditions that may interfere with passage of the catheter or contraindicate insertion of the catheter, such as urethral strictures or bladder cancer. Check for the presence of drains, dressings, intravenous fluid infusion sites/equipment, traction, or any other devices that could interfere with the patient's ability to help with the procedure or that could become dislodged. Assess bladder fullness before performing the procedure, either by palpation or with a handheld bladder ultrasound device. Question the patient about any allergies, especially to latex or iodine. Ask the patient if they have ever been catheterized. If they had an indwelling catheter previously, ask why and for how long it was used. The patient may have urethral strictures, which may make catheter insertion more difficult. Assess for the need to use anesthetic gel; the use of anesthetic gel is usually not necessary for patients with female anatomy but should be considered if it is the patient's first catheterization or if a difficulty catheterization is anticipated (SUNA, 2021a). Assess the characteristics of the urine and the patient's skin.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Urinary retention
Infection risk
Total urinary incontinence

Outcome Identification and Planning

The expected outcomes to achieve when catheterizing the urinary bladder is that the catheter is successfully inserted without adverse effect, the patient's urinary elimination is maintained, and the patient's bladder is not distended. Other appropriate outcomes may include that the patient's skin remains clean, dry, intact, and without evidence of irritation or breakdown, and the patient verbalizes an understanding of the purpose for and care of the catheter, as appropriate.

Implementation

Action	Rationale
1. Review the patient's health record for any limitations in physical activity. Confirm the prescribed intervention for indwelling catheter insertion.	Physical limitations may require adaptations in performing the skill. Verifying the prescribed intervention ensures that the correct intervention is administered to the right patient.
2. Gather equipment. Obtain assistance from another staff member, if necessary or based on facility policy.	Assembling equipment provides for an organized approach to the task. Assistance from another person may be required to perform the intervention safely.
3. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the spread of microorganisms. PPE is required based on transmission precautions.
4. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
5. Close the curtains around the bed and close the door to the room, if possible. Discuss the procedure with the patient and assess the patient's ability to assist with the procedure. Ask the patient if they have any allergies, especially to latex or iodine.	This ensures the patient's privacy. Discussion promotes reassurance and provides knowledge about the procedure. Dialogue encourages patient participation and allows for individualized nursing care. Some catheters and gloves in kits are made of latex. Some antiseptic solutions contain iodine.
6. Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach.	Good lighting is necessary to see the meatus clearly. A readily available trash receptacle allows for prompt disposal of used supplies and reduces the risk of contaminating the sterile field.
7. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and prevents unnecessary stretching and twisting of muscles on the part of the nurse.
8. Adjust the bed to a comfortable working height (VHACEOSH, 2016). Stand on the patient's right side if you are right-handed or on the patient's left side if you are left-handed.	Having the bed at the proper height prevents back and muscle strain. Positioning allows for ease of use of your dominant hand for catheter insertion.
9. Assist the patient to a dorsal recumbent position with their knees flexed, feet about 2 ft apart, and legs abducted. Drape the patient (Figure 2). Alternatively, the Sims', or lateral, position can be used. Place the patient's buttocks near the edge of the bed with their shoulders at the opposite edge and their knees drawn toward the chest (Figure 3). Allow the patient to lie on either side, depending on which position is easiest for the nurse and best for the patient's comfort. Slide a waterproof pad under the patient.	Proper positioning allows adequate visualization of the urinary meatus. Patients with female genitalia should lie with their knees bent and legs spread apart (SUNA, 2021a; Yates, 2017b). Embarrassment, chilliness, and tension can interfere with catheter insertion; draping the patient will promote comfort and relaxation. The Sims' position may allow better visualization and be more comfortable for the patient, especially if hip and knee movements are difficult. The smaller area of exposure is also less stressful for the patient. The waterproof pad will protect bed linens from moisture.
10. Put on clean gloves. Clean the perineal area with a washcloth, skin cleanser, and warm water, using a different corner of the washcloth with each stroke. Wipe from above the orifice downward toward the sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene again.	Gloves reduce the risk of exposure to blood and body fluids. Cleaning reduces microorganisms near the urethral meatus and provides an opportunity to visualize the perineum and landmarks before the procedure. Hand hygiene reduces the spread of microorganisms.
11. Prepare the urine drainage setup if a separate urine collection system is to be used. Secure it to the bed frame, according to the manufacturer's directions.	This facilitates connection of the catheter to the drainage system and provides for easy access.
12. Open the sterile catheterization tray on a clean overbed table using sterile technique.	Placement of equipment near the worksite increases efficiency. Sterile technique protects the patient and prevents transmission of microorganisms.
13. Put on sterile gloves. Grasp the upper corners of the drape and unfold the drape without touching nonsterile areas. Fold back a corner on each side to make a cuff over your gloved hands. Ask the patient to lift their buttocks and slide the sterile drape under them with your gloves protected by the cuff.	The drape provides a sterile field close to the meatus. Covering the gloved hands will help keep the gloves sterile while placing the drape.
14. Based on facility policy, position the fenestrated sterile drape. Place a fenestrated sterile drape over the perineal area, exposing the labia (Figure 4). (Note: The fenestrated drape is not shown in the remaining illustrations in order to provide a clear view of the procedure.)	The drape expands the sterile field and protects against contamination. Use of a fenestrated drape may limit visualization and is considered optional by some health care providers and/or facility policies.
15. Place the sterile tray on the drape between the patient's thighs. If the patient is in the side-lying position, place the sterile tray near the patient's legs close to the sterile drape.	The sterile setup should be arranged so that the nurse's back is not turned to it, nor should it be out of the nurse's range of vision. This provides easy access to supplies.
16. Open all the supplies. Remove the cap from the prefilled sterile saline syringe and attach it to the balloon inflation port on the catheter. Open the package of antiseptic swabs. Alternatively, fluff cotton balls in a tray before pouring antiseptic solution over them. Open the specimen container if a specimen is to be obtained. If using anesthetic gel, remove the cap from the prefilled syringe. Open and squirt lubricant in the tray.	It is necessary to open all supplies and prepare for the procedure while both hands are sterile.
17. Remove the cover from the catheter and lubricate 1 to 2 inches of the catheter tip (SUNA, 2021b).	Lubrication facilitates catheter insertion and reduces tissue trauma (SUNA, 2021a).
18. With the thumb and one finger of your nondominant hand, spread the labia and identify the meatus (Figure 5). Be prepared to maintain separation of the labia with one hand until the catheter is inserted and urine is flowing well and continuously. If the patient is in the side-lying position, lift the upper buttock and labia to expose the urinary meatus (Figure 6).	Smoothing the area immediately surrounding the meatus helps to make it visible. Allowing the labia to drop back into position may contaminate the area around the meatus as well as the catheter. The nondominant hand is now contaminated.
19. Use your dominant hand to pick up an antiseptic swab, or use forceps to pick up a cotton ball. Clean one labial fold, top to bottom (from above the meatus down toward the rectum), then discard the swab/cotton ball (Figure 7). Using a new swab/cotton ball for each stroke, continue to clean the other labial fold, then use a third to clean directly over the meatus. Discard each swab/cotton ball after one use.	Moving from an area where there is likely to be less contamination to an area where there is more contamination helps prevent the spread of microorganisms. Cleaning the meatus last helps reduce the possibility of introducing microorganisms into the bladder.
20. If using anesthetic gel, with your noncontaminated, dominant hand, pick up the anesthetic syringe. Gently place nozzle of gel near the urethral orifice and apply some gel (SUNA, 2021b). Gently place nozzle at the meatus and slowly squeeze at least 5 mL of gel into the urethra (SUNA, 2021b). Allow the gel to dwell for approximately 3 to 5 minutes before starting the catheter insertion (SUNA, 2021b). Additional lubrication with a water-based lubricant may not be needed.	The use of anesthetic gel is usually not necessary for patients with female anatomy but should be considered if it is the patient's first catheterization or if a difficulty catheterization is anticipated (SUNA, 2021a).
21. With your noncontaminated, dominant hand, place the drainage end of the catheter in a receptacle. If the catheter is pre-attached to the sterile tubing and drainage container (closed drainage system), position the catheter and setup within easy reach on the sterile field. Ensure that the clamp on the drainage bag is closed.	This facilitates drainage of urine and minimizes risk of contaminating sterile equipment.
22. Using your dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra (Figure 8). Advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]). Once urine drains, advance the catheter another 2 to 3 inches (4.8 to 7.2 cm). Do not force the catheter through the urethra into the bladder. Ask the patient to breathe deeply, and rotate the catheter gently if slight resistance is met as the catheter reaches the external sphincter.	The female urethra is about 1.5 to 2.5 inches (3.6 to 6.0 cm) long. Applying force on the catheter is likely to injure mucous membranes. The sphincter relaxes and the catheter can enter the bladder easily when the patient relaxes. Advancing an indwelling catheter an additional 2 to 3 inches (4.8 to 7.2 cm) ensures placement in the bladder and facilitates inflation of the balloon without damaging the urethra.
23. Hold the catheter securely at the meatus with your nondominant hand. Use your dominant hand to inflate the catheter balloon (Figure 9). Inject the entire volume of sterile water supplied in a prefilled syringe. Remove the syringe from the port.	Bladder or sphincter contraction could push the catheter out. The balloon anchors the catheter in place in the bladder. The manufacturer provides the appropriate amount of sterile water for the size of the catheter in the kit; as a result, use the entire syringe provided in the kit. Removal of the syringe from the injection port prevents the sterile water from pushing back into the syringe and resulting balloon deflation.
24. Pull gently on the catheter after the balloon is inflated to feel resistance.	Improper inflation can cause patient discomfort and malpositioning of the catheter.
25. Attach the catheter to the drainage system if not already pre-attached (Figure 10).	The closed drainage system minimizes the risk for microorganisms being introduced into the bladder (Gould et al., 2019).
26. Remove equipment and dispose of it according to facility policy. Discard the syringe in a sharps container. Wash and dry the perineal area, as needed.	Proper disposal prevents the spread of microorganisms. Placing the syringe in a sharps container prevents reuse. Cleaning promotes comfort and appropriate personal hygiene.
27. Remove gloves. Perform hand hygiene. Secure the catheter tubing to the patient's inner thigh with a catheter-securing device (Figure 11). Leave some slack in the catheter for leg movement.	Proper securement prevents tension on the catheter; reduces risk for catheter displacement, expulsion, migration, and trauma; and increases patient comfort (Holroyd, 2019). Hand hygiene prevents the spread of microorganisms. Whether to secure the drainage tubing over or under the leg depends on gravity flow, the patient's mobility, and the patient's comfort.
28. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.	Positioning and covering provides warmth and promotes comfort.
29. Secure the drainage bag below the level of the bladder. Check that the drainage tubing is not kinked and that movement of side rails does not interfere with the catheter or drainage bag.	This facilitates drainage of urine and prevents the backflow of urine (ANA, 2014; Gould et al., 2019).
30. Put on gloves. Obtain a urine specimen immediately, if needed, from the drainage bag. Label the specimen. Send the urine specimen to the laboratory promptly or refrigerate it.	The catheter system is sterile. Obtaining a specimen immediately allows access to the sterile system. Keeping the urine at room temperature may cause microorganisms, if present, to grow and distort laboratory findings.
31. Remove gloves and additional PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene prevents the spread of microorganisms.

Evaluation

The expected outcomes have been met when the catheter has been inserted without adverse effect, the patient's urinary elimination has been maintained, and the patient's bladder has not distended. Other outcomes have been met when the patient's skin has remained clean, dry, intact, and without evidence of irritation or breakdown, and the patient has verbalized an understanding of the purpose for and care of the catheter, as appropriate.

Documentation

Guidelines

Document the type and size of catheter and balloon inserted, as well as the amount of fluid used to inflate the balloon. Document the patient's tolerance of the activity. Record the amount of urine obtained through the catheter and any specimen obtained. Document any other assessments, such as unusual urine characteristics or alterations in the patient's skin. Record urine amount on intake and output record, if appropriate.

Sample Documentation

Practice documenting catheterization of the female urinary bladder in Lippincott DocuCare.

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

No urine flow is obtained, and you note that the catheter is in the vaginal orifice: Leave the catheter in place as a marker. Obtain new sterile gloves and catheter kit. Start the procedure over and attempt to place the new catheter directly above the misplaced catheter. Once the new catheter is correctly in place, remove the catheter in the vaginal orifice. Because of the risk of cross-infection, never remove a catheter from the vagina and insert it into the urethra.
Patient moves legs during procedure: If no supplies have been contaminated, ask the patient to hold still and continue with the procedure. If supplies have been contaminated, stop the procedure and start over. If necessary, get an assistant to remind the patient to hold still.
Urine flow is initially well established, and urine is clear, but after several hours flow dwindles: Check the tubing for kinking. If patient has changed position, the tubing and drainage bag may need to be moved to facilitate drainage of urine.
Urine leaks out of the meatus around the catheter: Do not increase the size of the indwelling catheter. Make sure the smallest-sized catheter with a 10-mL balloon is used. Large catheters cause bladder and urethral irritation and trauma. Large balloon-fill volumes occupy more space inside the bladder and put added weight on the base of the bladder. Irritation of the bladder wall and detrusor muscle can cause leakage. If leakage persists, consider an evaluation for urinary tract infection. Ensure that the correct amount of solution was used to inflate the balloon. Underfilling the balloon can cause the catheter to dislodge into the urethra, causing urethral spasm, pain, and discomfort. If you suspect underfill, do not attempt to push the catheter farther into the bladder. Remove the catheter and replace with a new catheter. Assess the patient for constipation. A bowel full of stool can cause pressure on the catheter lumen and prevent the drainage of urine. Implement interventions to prevent/treat constipation.

Special Considerations

General Considerations

Some facilities have adopted a two-person urinary catheter insertion protocol, in which one nurse catheterizes the patient and one observes to ensure that the nurse inserting the catheter follows sterile technique and performs the procedure correctly (Belizario, 2015; Rhone et al., 2017). Implementation of the two-person urinary catheter insertion protocol has been shown to decrease CAUTI (Belizario, 2015; Fletcher-Gutowski & Cecil, 2019; Rhone et al., 2017).
The use of anesthetic gel is usually not necessary for patients with female anatomy but should be considered if it is the patient's first catheterization or if a difficulty catheterization is anticipated (SUNA, 2021a).
Check for patient allergy before use of anesthetic gel. Anesthetic gel instilled into the patient's urethra should be administered at 3 to 5 minutes before catheterization to ensure sufficient anesthetic effect (SUNA, 2021b).
Be familiar with facility policy and/or primary health care provider guidelines for the maximum amount of urine to remove from the bladder at the time of insertion.
If the patient is unable to lift their buttocks or maintain the required position for the procedure, the assistance of another staff member may be necessary to place the drape under the patient and to help the patient maintain the required position.
Supplies can be opened and prepared on the overbed table, moving the tray onto the bed just before cleansing the patient.
If there is not an immediate flow of urine after the catheter has been inserted, several measures may prove helpful:
- Have the patient take a deep breath, which helps to relax the perineal and abdominal muscles.
- Rotate the catheter slightly, because a drainage hole may be resting against the bladder wall.
- Raise the head of the patient's bed to increase pressure in the bladder area.
- Assess the patient's intake to ensure adequate fluid intake for urine production.
- Assess the catheter and drainage tubing for kinks and occlusion.
If the catheter cannot be advanced, have the patient take several deep breaths. Rotate the catheter half a turn and try to advance it. If you are still unable to advance, remove the catheter. Notify the health care team.
Some catheter kits do not contain the catheter. This allows you to select a catheter and balloon size separately.
Maintain a constant downward flow of urine. Check tubing frequently to ensure kinks and dependent loops (low points) are not present in the tubing (ANA, 2014; Gould et al., 2019; Wuthier et al., 2016). Check to see that the patient is not lying on the drainage tubing and compressing it.
Keep the catheter drainage bag below the level of the bladder at all times (ANA, 2014; Gould et al., 2019).
Keep the drainage bag off the floor at all times to reduce the risk of infection (ANA, 2014; Gould et al., 2019). The floor is grossly contaminated.

Infant and Child Considerations

Size 6F to 8F is used for infants and young children (Kyle & Carman, 2021). Size 8F to 12F catheters are commonly used for older children (Kyle & Carman, 2021).
Distraction, such as blowing bubbles, deep breathing, or singing a song, can help the child relax.
Consider use of lidocaine jelly to anesthetize and lubricate the area before insertion of the catheter, decreasing the child's discomfort and anxiety. Refer to facility policy regarding prescribing requirements and use.

Community-Based Care Considerations

Intermittent catheterization, performed by the patient or a caregiver in the home, may be necessary for patients with spinal cord injuries or other neurologic conditions. Although the risk for UTI is always present, practice guidelines support the use of clean, rather than sterile, technique in the home environment (Bardsley, 2015a; Beauchemin et al., 2018; Gould et al., 2019; Wilson, 2015a). The procedure for self-intermittent catheterization is essentially the same as that used by the nurse to catheterize a patient, using clean, nonsterile technique (Collins, 2019; Leach, 2018). Box 12-2 outlines important information related to patient intermittent self-catheterization (ISC).
Single-use catheters and no-touch catheters are options for use for ISC in the home setting (Beauchemin et al., 2018). The past practice of catheter reuse in community settings, instructing patients to wash and reuse the same catheter for multiple catheterizations, is not recommended; no evidence-based guidelines on cleaning or disposing of a reused catheter are available (Beauchemin et al., 2018; Newman, 2019b).

Intermittent Urethral Catheterization of a Patient With Female Genitalia

Check the health record for the prescribed intervention of intermittent urethral catheterization. Review the patient's health record for any limitations in physical activity. Gather equipment. Obtain assistance from another staff member, if necessary.
Perform hand hygiene. Put on PPE, as indicated.
Identify the patient. Discuss the procedure with the patient and assess the patient's ability to assist with the procedure. Ask the patient if they have any allergies, especially to latex or iodine.
Close the curtains around the bed and close the door to the room, if possible.
Provide good lighting. Artificial light is recommended (use of a flashlight requires an assistant to hold and position it). Place a trash receptacle within easy reach.
Assemble equipment on the overbed table or other surface within reach.
Raise the bed to a comfortable working height. Stand on the patient's right side if you are right-handed, or the patient's left side if you are left-handed.
Put on gloves. Assist the patient to the dorsal recumbent position with their knees flexed, feet about 2 ft apart, and legs abducted. Drape the patient. Alternatively, use the Sims', or lateral, position. Place the patient's buttocks near the edge of the bed with their shoulders at the opposite edge and their knees drawn toward her chest. Slide a waterproof drape under the patient.
Clean the perineal area with a washcloth, skin cleanser, and warm water, using a different corner of the washcloth with each stroke. Wipe from above the orifice downward toward the sacrum (front to back). Rinse and dry. Remove gloves. Perform hand hygiene.
Open the sterile catheterization tray on a clean overbed table using sterile technique.
Put on sterile gloves. Grasp the upper corners of the drape and unfold the drape without touching nonsterile areas. Fold back a corner on each side to make a cuff over your gloved hands. Ask the patient to lift their buttocks and slide the sterile drape under them with your gloves protected by the cuff.
Place a fenestrated sterile drape over the perineal area, exposing the labia, if appropriate.
Place the sterile tray on the drape between the patient's thighs.
Open all the supplies. Open the package of antiseptic swabs. Alternatively, fluff cotton balls in a tray before pouring antiseptic solution over them. Open the specimen container if a specimen is to be obtained.
Lubricate 1 to 2 inches of the catheter tip.
With the thumb and one finger of your nondominant hand, spread the labia and identify the meatus. If the patient is in the side-lying position, lift the upper buttock and labia to expose the urinary meatus.Be prepared to maintain separation of the labia with one hand until the catheter is inserted and urine is flowing well and continuously.
Use your dominant hand to pick up an antiseptic swab/cotton ball.Clean one labial fold, top to bottom (from above the meatus down toward the rectum), then discard the swab/cotton ball. Using a new swab/cotton ball for each stroke, continue to clean the other labial fold, then directly over the meatus.
With your noncontaminated dominant hand, pick up the lubricant syringe. Gently insert the tip of the syringe with lubricant into the urethra and instill the 5 to 10 mL of lubricant.
With your noncontaminated, dominant hand, place the drainage end of the catheter in a receptacle. If a specimen is required, place the end into the specimen container in the receptacle.
Using your dominant hand, hold the catheter 2 to 3 inches from the tip and insert slowly into the urethra. Advance the catheter until there is a return of urine (approximately 2 to 3 inches [4.8 to 7.2 cm]). Do not force the catheter through the urethra into the bladder.Ask the patient to breathe deeply, and rotate the catheter gently if slight resistance is met as the catheter reaches the external sphincter.
Hold the catheter securely at the meatus with the nondominant hand while the bladder empties. If a specimen is being collected, remove the drainage end of the tubing from the specimen container after the required amount is obtained, and allow urine to flow into the receptacle. Set the specimen container aside and place the lid on the container.
Allow the bladder to empty. Withdraw the catheter slowly and smoothly after urine has stopped flowing. Remove equipment and dispose of it according to facility policy. Discard the syringe in a sharps container to prevent reuse. Wash and dry the perineal area, as needed.
Remove gloves. Perform hand hygiene. Assist the patient to a comfortable position. Cover the patient with bed linens. Place the bed in the lowest position.
Put on gloves. Secure the container lid and label the specimen. Send the urine specimen to the laboratory promptly or refrigerate it.
Remove gloves and additional PPE, if used. Perform hand hygiene.

Note: Intermittent catheterization in the home is performed using clean technique (Collins, 2019; Leach, 2018). Single-use catheters and no-touch catheters are options for use for intermittent self-catheterization (ISC) in the home setting (Beauchemin et al., 2018). The past practice of catheter reuse in community settings, instructing patients to wash and reuse the same catheter for multiple catheterizations, is not recommended; no evidence-based guidelines on cleaning or disposing of a reused catheter are available (Beauchemin et al., 2018; Newman, 2019b).

Box 12-2 outlines information related to patient ISC.

EVIDENCE FOR PRACTICE

Prevention of Catheter-Associated Infections

Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & the Healthcare Infection Control Practices Advisory Committee (HICPAC). (2019 [update]). Guideline for prevention of catheter-associated urinary tract infections 2009. Centers for Disease Control and Prevention, 31(4). https://www.cdc.gov/infectioncontrol/pdf/guidelines/cauti-guidelines-H.pdf

These guidelines provide evidence-based recommendations to guide care for patients requiring catheterization of the urinary bladder to prevent CAUTI.

EVIDENCE FOR PRACTICE

Antimicrobials for Meatal Cleaning

Guidelines for catheter insertion and control of CAUTIs in hospitalized patients include the recommended practice of cleaning of the urethral meatus prior to catheterization to reduce the risk of introducing bacteria during catheter insertion (Mitchell & Hill, 2018). Is the use of an antimicrobial for meatal cleaning effective?

Related Research

Fasugba, O., Cheng, A. S., Gregory, V., Graves, N., Koerner, J., Collignon, P., Gardner, A., & Mitchell, B. G. (2019). Chlorhexidine for meatal cleaning in reducing catheter-associated urinary tract infections: A multicentre stepped-wedge randomised controlled trial. Lancet Infectious Diseases, 19(6), 611-619. https://doi.org/10.1016/S1473-3099(18)30736-9

The purpose of this randomized-controlled trial was to evaluate the efficacy of using chlorhexidine compared with normal saline for meatal cleaning before catheter insertion in reducing the incidence of catheter-associated asymptomatic bacteriuria and urinary tract infection. Participants included patients requiring a urinary catheter at three public and private hospitals in Australia with an intensive care unit and more than 30,000 admissions per year. Hospitals were randomly assigned to an intervention crossover date using a computer-generated randomization system every 8 weeks. During the first 8 weeks of the study, no hospitals were exposed to the intervention (control phase), after which each hospital sequentially crossed over from the control to the intervention every 8 weeks. The intervention consisted of the use of 0.1% chlorhexidine solution for meatal cleaning before urinary catheterization; 0.9% normal saline was used for meatal cleaning before urinary catheterization during the control phase. The total number of participants in all three hospitals was 1,642, with 697 (42%), in the control phase and 945 (58%) in the intervention period. The number of cases of catheter-associated asymptomatic bacteriuria and urinary tract infection were assessed within 7 days of catheter insertion. In the control period, there were 13 catheter-associated urinary tract infections and 29 catheter-associated asymptomatic bacteriuria events. During the intervention period, there were 4 catheter-associated urinary tract infections and 16 catheter-associated asymptomatic bacteriuria cases. The intervention was associated with a 74% reduction in the incidence of catheter-associated asymptomatic bacteriuria (p = .026) and a 94% decrease in the incidence of catheter-associated urinary tract infection (p = .00080). The researchers concluded the use of chlorhexidine solution for meatal cleaning before urinary catheter insertion is associated with improved patient outcomes related to decreased incidence of catheter-associated asymptomatic bacteriuria and urinary tract infection and has the potential to improve patient safety.

Relevance to Nursing Practice

Nurses are an integral part of the committees involved in the development of policy and procedures for health care organizations. Nurses have a responsibility to use interventions to improve patient outcomes, in this case, in reducing the risk for CAUTI in patients with indwelling urinary catheters. Integration of the best evidence is an integral part of providing evidence-based practice, and nurses should consider this and other evidence to ensure the best patient outcomes related to use of indwelling urinary catheters.

Refer to Skill 12-8 for additional evidence related to urinary catheterization.

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Skill 12-7

EVIDENCE FOR PRACTICE

EVIDENCE FOR PRACTICE