Nursing Procedure 8.6
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 urethra 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 urethra hooks around the symphysis in a C shape in baby girls. Common catheter size is 8 or 10 French. Catheterization is a very threatening and anxiety-producing experience, so they need explanations, support, and understanding.
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. If the client uses intermittent self-catheterization, store sterilized catheters in sterilized jars.
For female clients, time and money may be saved by using clean gloves to locate the meatus before opening the sterile kit. This minimizes the chance of sterile glove contamination. If replacing a Foley catheter, note the size of the previous catheter to avoid waste from insertion of 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, emphasizing need to maintain sterile field. | 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 bedpan, and measure and record the amount voided; empty bedpan. | Determines amount of urine client is able to void without catheterization |
| 7 | Lower side rails, assist client into a supine or side-lying position, and place linen saver under client’s buttocks. | Facilitates comfort for client and access to urethra; avoids soiling linens |
| 8 | Place light to enhance visualization. | Promotes clear identification of anatomical parts |
| 9 | Separate labia to expose urethral opening: | Allows nurse to identify urethral opening clearly before area is cleansed |
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| 10 | Wash genital area with warm, soapy water, washing from front to back. Rinse and pat dry with a towel. | Decreases microorganisms around urethral opening |
| 11 | Discard bath water, washcloth, and towel. | Decreases clutter; reduces microorganism transfer |
| 12 | If inserting an indwelling catheter in which the drainage apparatus is separate from the catheter (not preconnected): | Places drainage tubing within immediate and easy reach, decreasing chance of catheter contamination once inserted |
| Prevents soiling with urine when tubing is inserted | |
| Stabilizes collection container to prevent tension on urinary catheter tubing | |
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| Avoids accidental dislodging of catheter | |
| 13 | Position client in dorsal recumbent or side-lying position with knees flexed (Figs. 8.7A, B); in side-lying position, slide client’s hips toward edge of bed. | Exposes labia |
| 14 | Drape client so that only perineum is exposed. | Provides privacy; reduces embarrassment |
| 15 | Remove and discard gloves and perform hand hygiene; lift side rails and cover client before leaving bedside. | Reduces microorganism transfer; promotes safety; reduces embarrassment |
| 16 | Set up sterile field: | |
| Removes kit without opening inner folds | |
| Provides waste bag | |
| Places items within easy reach | |
| Provides sterile field | |
| Promotes establishment of sterile closed catheter system | |
| 17 | Don sterile gloves. | Avoids contaminating other items in kit |
| 18 | Prepare items in kit for use during insertion as follows: | |
| Prepares cotton balls for cleaning | |
| Promotes easy manipulation | |
| Prevents use of damaged catheter; avoids local irritation of meatus during catheter insertion; promotes insertion | |
| Connects the syringe needed to inflate balloon to balloon port | |
| Tests balloon for defects | |
| Prevents catheter from becoming dislodged 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 | |
| 19 | Remove fenestrated drape from kit and place on perineum such that only labia are exposed (or discard the drape if you prefer). | Expands sterile field |
| 20 | Separate labia minora with nondominant hand in same manner as in Step 9 and hold this position until catheter is inserted (dominant hand is the only hand sterile now; contaminated hand continues to separate labia). | Exposes urethral opening |
| 21 | With forceps in dominant hand, cleanse meatus with cotton balls: | Cleanses meatus without cross-contaminating or contaminating sterile hand |
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| 22 | After all cotton balls have been used, discard forceps. | Prevents contamination of sterile field |
| 23 | Move cleaning tray to end of sterile field and move collection container and catheter closer to client. | Facilitates organization; prevents accidental contamination of system |
| 24 | 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) |
| 25 | Carefully gather additional tubing in hand. | Gives nurse good control of full catheter length |
| 26 | Ask client to bear down as if voiding and to take slow, deep breaths; encourage her to continue to breathe deeply until catheter is fully inserted. | Opens sphincter; relaxes sphincter muscles of bladder and urethra |
| 27 | Insert tip of catheter slowly through urethral opening 3–4 in. (or until urine returns), releasing tubing from hand as insertion continues; direct open end of catheter into collection container. If resistance is met, verify position, and if unable to insert past resistance, withdraw catheter and notify doctor. | Inserts catheter |
| 28 | After catheter has been advanced an appropriate distance (3–4 in. or until urine returns), advance another 1–1.5 in. | Ensures that catheter is advanced far enough not to be dislodged and for safe inflation of catheter retention balloon |
| 29 | Grasp catheter with thumb and first finger of nondominant hand and hold steadily (for indwelling catheter proceed to Step 31). | Keeps catheter from being forced out by sphincter muscles; avoids contamination of distal portion of catheter |
| 30 | For straight catheterization: | |
| Obtains sterile specimen | |
| Empties bladder; obtains residual urine amount; prevents fluid volume shifts and potential hypovolemic state | |
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| 31 | For an indwelling catheter, inflate balloon with attached syringe and gently pull back on catheter until it stops (catches). | Secures catheter placement |
| 32 | If the indwelling catheter is separate from bag and tubing, remove protective cap from end of tubing and attach drainage tubing to end of catheter. | Converts system to closed system |
| 33 | Secure catheter loosely to thigh with tape or with commercial tube holder. Position tubing on thigh on the side from which drainage bag will be hanging (preferably away from door); make certain that tubing is not caught on railing locks or obstructed. | Stabilizes catheter; prevents accidental dislodgment |
| 34 | Clear bed of all equipment. | Removes waste from bed |
| 35 | Reposition client for comfort, and replace linens for warmth and privacy. | Promotes general comfort |
| 36 | Raise side rails and place call light within reach. | Promotes safety; facilitates communication |
| 37 | Measure amount of urine in collection container or drainage bag and discard urine and disposable supplies. | Provides urine drainage amounts for assessment data |
| 38 | Gather and discard or restore all additional equipment. | Promotes clean environment |
| 39 | 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