Nursing Procedure 8.5
Assessment should focus on the following:
Nursing diagnoses may include the following:
Outcome Identification and Planning
Sample desired outcomes include the following:
Special Considerations in Planning and Implementation
Never force a catheter if it does not pass through the urethral canal smoothly. If the catheter still does not pass smoothly, discontinue the procedure and notify the doctor. Forcing the catheter may result in damage to the urethra and surrounding structures.
The bladder is higher and more anterior in an infant and small child than that in an adult. Common catheter sizes are 8 and 10 French. Catheterization is a very threatening and anxiety-provoking experience for children, so they need explanations, support, and understanding.
A common pathologic feature in elderly men is enlargement of the prostate gland, which often makes inserting a catheter difficult.
Because indwelling catheterization is used on a long-term basis for the homebound client, the potential for infection is high. Be alert for early signs and symptoms of infection and adhere to a strict schedule for changing catheters. Explore the possibility of an external catheter as an alternative to the indwelling catheter. If the client uses intermittent self-catheterization, store sterilized catheters in sterilized jars.
When replacing a Foley catheter, note the size of the previous catheter to avoid waste from inserting too small a catheter. This occurs frequently with clients on long-term catheterization.
In some agencies, catheterization may be delegated to specially trained unlicensed personnel. Note agency policies concerning delegation of this procedure (e.g., what level of personnel).
| Action | Rationale | |
|---|---|---|
| 1 | Perform hand hygiene. | Reduces microorganism transfer |
| 2 | Explain procedure to client. | Reduces anxiety; promotes cooperation |
| 3 | Determine if client is allergic to iodine-based antiseptics and use alternative, if indicated. | Avoids allergic reactions |
| 4 | Provide privacy. | Decreases embarrassment |
| 5 | Don nonsterile gloves. | Prevents contamination of hands; prevents exposure to body secretions |
| 6 | If catheterization is being done for residual urine, ask client to void in urinal, and measure and record the amount voided; empty urinal. | Determines amount of urine client is able to void without catheterization |
| 7 | Lower side rails, assist client into a supine position, and place linen saver under client’s buttocks. | Facilitates comfort for client and access to penis; avoids soiling linens |
| 8 | Wash genital area with warm, soapy water, rinse, and pat dry with towel. | Decreases microorganisms around urethral opening |
| 9 | Discard gloves, bath water, washcloth, and towel; perform hand hygiene. | Decreases clutter; reduces microorganism transfer |
| 10 | Drape client so that only penis is exposed. | Provides privacy; reduces embarrassment |
| 11 | Set up work field: | |
| Removes kit without opening inner folds | |
| Provides waste bag | |
| Places items within easy reach | |
| Relaxes pelvic muscles | |
| Provides sterile field | |
| Promotes establishment of sterile closed catheter system | |
| 12 | Don sterile gloves. | Avoids contaminating other items in kit |
| 13 | Prepare items in kit for use during insertion as follows: | |
| Prepares cotton balls for cleaning | |
| Promotes easy manipulation | |
| Prevents use of damaged catheter; avoids irritation of meatus during catheter insertion; promotes ease of insertion | |
| Connects the syringe needed to inflate balloon to balloon port | |
| Tests balloon for defects | |
| Prevents catheter from dislodging after insertion | |
| Leaves syringe within reach | |
| Facilitates organization while maintaining sterility | |
| Prevents soiling of sterile field and loss of urine before measurement | |
| Places container within easy reach for specimen collection | |
| 14 | Remove fenestrated drape from kit and place penis through hole in drape with nondominant hand. KEEP DOMINANT HAND STERILE. | Expands sterile field |
| 15 | Use nondominant hand to hold penis up at a 90-degree angle to client’s supine body. | Straightens urethra |
| 16 | Gently grasp glans (tip) of penis; retract foreskin, if necessary. | Exposes penis for cleansing; prevents contamination of sterile field later |
| 17 | With forceps in dominant hand, cleanse meatus and glans of penis with cotton balls, beginning at urethral opening and moving toward shaft of penis; make one complete circle around penis with each cotton ball, discarding cotton ball after each wipe (Fig. 8.6). | Cleanses meatus without cross-contaminating or contaminating sterile hand |
| 18 | After all cotton balls have been used, discard forceps. | Prevents contamination of sterile field |
| 19 | With thumb and first finger of dominant hand, pick catheter up about 1.5–2 in. from tip. | Gives nurse good control of catheter tip (which easily bends) |
| 20 | Carefully gather additional tubing in hand. | Gives nurse good control of full catheter length |
| 21 | Ask client to bear down as if voiding and to take slow, deep breaths; encourage him to continue to breathe deeply until catheter is fully inserted. | Opens sphincter; relaxes sphincter muscles of bladder and urethra |
| 22 | Insert tip of catheter slowly through urethral opening 7–9 in. (or until urine returns). | Inserts catheter |
| 23 | If resistance is met: | |
| Allows sphincters to relax and reduces anxiety | |
| Promotes relaxation of the client and sphincter muscles | |
| Prevents injury to prostate, urethra, and surrounding structures | |
| 24 | If no resistance is noted, lower penis to about a 45-degree angle after catheter is inserted about halfway and hold open end of catheter over collection container (if it is not connected to a drainage bag). | Places penis in position for urine to be released into collection container so that accurate amount is measured |
| 25 | After catheter has been advanced an appropriate distance to obtain urine, advance catheter another 1–1.5 in. | Ensures that catheter is advanced far enough not to be dislodged and for safe inflation of catheter retention balloon |
| 26 | For straight catheterization: | |
| Obtains sterile specimen | |
| Empties bladder; obtains residual urine amount | |
| 27 | For an indwelling catheter, inflate balloon with attached syringe and gently pull back on catheter until it stops (catches). Secure catheter loosely | Secures catheter placement |
| 28 | Secure catheter loosely with tape to lower abdomen on side from which drainage bag will be hanging (preferably away from door); using tape or catheter tube holder to secure additional tubing to thigh; make certain that tubing is not caught on railing locks and is not obstructed. | Stabilizes catheter; prevents accidental dislodgment |
| 29 | Clear bed of all equipment. | Removes waste from bed |
| 30 | Reposition client for comfort, and replace linens for warmth and privacy. | Promotes general comfort |
| 31 | Raise side rails and place call light within reach. | Promotes safety; facilitates communication |
| 32 | Measure amount of urine in collection container or drainage bag and discard urine and disposable supplies. | Provides urine drainage amounts for assessment data |
| 33 | Gather and discard or restore all additional equipment. | Promotes clean environment |
| 34 | Remove and discard gloves and perform hand hygiene. | Reduces microorganism transfer |
Were desired outcomes achieved? Examples of evaluation include:
The following should be noted on the client's record:
Cost-Cutting Tip