NURSING PRACTICE & SKILL

Urinary Catheter, Indwelling (Foley): Insertion in the Female Pediatric Patient

What is an Indwelling Foley Urinary Catheter Insertion in the Female Pediatric Patient?
A urinary catheter is a tube inserted into the bladder via the urethra, called transurethral catheterization. Because the catheter permits urine to drain freely, a collection unit is typically attached to the distal end of the catheter if the catheter is to remain within the patient (indwelling). The most commonly used indwelling urinary catheter in pediatric patients is a straight (Foley) catheter (FC), which is the topic of this paper. See the series of Nursing Practice & Skill papers for information regarding condom catheters, Coud (i.e., curved at the tip) catheters, catheter insertion for male adult patients, male and female adult patients, intermittent (straight) catheterization, and care of the suprapubic catheter. What: An FC is a relatively short (~ 40 cm/15.7 inches), double-lumen tube constructed of flexible latex, silicone, or polyurethane (Figure 1). The sizes most commonly used for pediatric patients range from 4 Fr to 14 Fr. The proximal end of the primary lumen includes several drainage holes to permit urine to flow from the bladder through the tube. The second, smaller lumen includes a valve on the distal end and a balloon, commonly made of silicone or natural rubber, near the proximal end. Immediately following insertion, the balloon is inflated with sterile water which serves to anchor the catheter within the bladder. Note: Some clinicians have found that inflating the balloon with normal saline (NS; i.e., 0.9% sodium chloride in sterile water) to inflate the balloon is associated with crystal formation within the balloon and impedes removal

ICD-9
57.94

Author
Kathleen Walsh, RN, MSN, CCRN Cinahl Information Systems, Glendale, CA

Figure 1: Foley catheter 10 Fr with balloon inflated. Copyright2013, EBSCO Publishing Inc. How: Transurethral catheterization involves the use of aseptic technique and involves insertion of a catheter into the urethra until the tip extends into the bladder. The catheter is secured in place by inflating the balloon. A drainage bag is attached to the distal end of the drainage lumen and positioned at a level below the bladder, which permits drainage by gravity. The procedure is moderately invasive and can be painful to patients with inflamed urinary tissue or who have urethral strictures or other obstructions Note: Transurethral catheterization differs from suprapubic catheterization, which is a surgical procedure that requires anesthesia. Suprapubic catheterization involves insertion of a catheter through an incision in the abdominal wall into the bladder and is indicated when placement of a transurethral catheter is contraindicated or is not possible Where: Transurethral catheterization is commonly performed in inpatient, outpatient, and homecare settings Who: Transurethral catheterization can be performed by registered nurses, physicians, nurse practitioners, and physician assistants. Patients can learn to self-perform intermittent catheterization at home when indicated for certain medical conditions and ordered by the treating clinician. These tasks should not be delegated to assistive healthcare staff. Because of privacy concerns and the need to maintain asepsis, it is usually not appropriate for visitors to be present during the urinary catheter insertion. Exceptions may be made in the case of young

Reviewers
Carita Caple, RN, BSN, MSHS Cinahl Information Systems, Glendale, CA Nursing Practice Council Glendale Adventist Medical Center, Glendale, CA

Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems, Glendale, CA

November 30, 2012

Published by Cinahl Information Systems, a division of EBSCO Publishing. Copyright2013, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206

What is the Desired Outcome of Inserting an Indwelling Foley Urinary Catheter?

The desired outcome of inserting an indwelling urinary catheter is to permit urine drainage from the bladder Placement of a urinary catheter may be indicated following urinary tract surgery, for relief of urinary retention, to obtain a sterile urine specimen for laboratory testing, or to facilitate urine collection in patients who are incapacitated or who have dysfunctional urinary systems

children because the presence of a parent or other supportive adult known to the child will reduce the childs anxiety and promote cooperation with the procedure

Why is Insertion of an Indwelling Urinary Foley Catheter Important?

Insertion and use of an indwelling urinary catheter is important for monitoring and treatment of numerous medical conditions, such as obtaining the precise measurement of urinary output in postoperative, injured, or critically ill patients or for measuring residual bladder volume in patients with a voiding dysfunction. Precise measurement of urinary output is crucial to monitor for fluid volume alteration, which can lead to a deterioration in clinical status for diagnostic studies, such as collection of sterile urine specimenintermittent catheterization is used if sterile specimen collection is the only goal imaging study of the lower urinary tract requiring instillation of fluid into the bladder for a diagnostic procedure (e.g., pelvic ultrasound, cystoscopy) delivery of medication to the bladder for therapeutic purposes treatment of urinary retention and to decompress the bladder when overdistended due to acute or chronic obstruction or neurogenic bladder. Urinary retention can result in hydronephrosis (i.e., distention and dilation of the renal pelvis and calyces due to urine backing up into the kidney), inflammation, and renal failure due to the risk of hydronephrosis, extreme caution should be used when clamping the catheter or tubing and it should be done for a brief period of time only - Note: Typically, an intermittent catheter is used to treat nerve-related bladder dysfunction; however, an indwelling catheter can be used in the immediate acute phase of treatment urethral obstruction. Insertion can be difficult in these cases and early urological consultation is advisable incontinence when other methods have proven unsuccessful and when it is essential to keep the perineal area clean of urine (e.g., for a patient at risk for a pressure ulcer or with an existing pressure ulcer) for irrigation

Facts and Figures

It is estimated that 420% of residents of long-term care facilities and 4% of homecare patients have indwelling urinary catheters. Among long-term users of catheters, the most common complication is bacteriuria, followed by catheter blockage due to bladder stones and candiduria (i.e., the presence of candida organisms in the urine); (Hagen et al., 2010) Although bladder stones can develop in individuals without indwelling catheterswhen the minerals from concentrated urine in the bladder combine to form stones, a condition that is more common in patients with an enlarged prostate or a urinary tract infection (UTI)bladder stones in patients with indwelling urinary catheters can develop due to a combination of the following two processes (Linsenmeyer et al., 2006): Encrustation on the catheter that develops as a result of microorganism adherence to the external and internal surface (i.e., lumen), which secretes an extracellular matrix of bacterial proteins that form a layer of biofilm The presence of urease-producing bacteria (e.g., Proteus mirabilis), which alkalinize the urine and promote the development of crystals Among hospitalized patients in Europe, 1525% have an indwelling urinary catheter in place at some point during their hospital stay. Investigators report that a patients cumulative risk for a UTI increases 36% each day that the catheter remains in place (Theofanidis et al., 2011) Researchers who conducted a randomized study comparing the rates of bacteriuria and UTI among 60 women who, prior to catheter insertion, received a periurethral cleansing with either sterile water or a povidone-iodine solution found no significant differences in the rate of bacteriuria or UTIs between the two groups. Although the subject group was small, these findings suggest that periurethral cleansing with sterile water may be as effective as cleansing with povidone-iodine in preventing UTI. If so, advantages of using sterile water for periurethral cleansing include cost savings and a reduction in exposure to iodine, which can trigger allergic reactions in some patients (Nasiriani et al., 2009) Researchers who conducted a randomized, controlled study comparing the use of various types of catheters (e.g., standard polyvinyl chloride, hydrophilic, and gel-lubricated catheters) in 10 patients with spinal cord injury reported that the use of hydrophilic and gel-lubricated catheters was associated with reduced trauma to the urethral surfaces and increased rates of patient satisfaction; there were no significant differences in rates of UTI between the 3 catheter types (Sarica et al., 2010) The Foley catheter was designed in the 1930s by Frederic Foley, a Massachusetts surgeon (Foley, 1937)

What You Need to Know Before Inserting an Indwelling Foley Urinary Catheter in the Female Pediatric Patient
The American Academy of Pediatrics (AAP) has issued guidelines that recommend urine specimens be obtained via bladder catheterization or suprapubic aspiration to minimize contamination and that the gold standard for pediatric urine specimen is suprapubic needle aspiration. The sterile bag method (i.e., use of a bag secured to the perineal area of the patient) is associated with a higher rate of bacterial contaminationfalse-positive rate of 8599% (AAP, 1999; National Guideline Clearinghouse, 2009) Prior to inserting an FC, the clinician should be familiar with the following: Anatomy and physiology of the female urinary system, especially the developmental changes that occur in pediatric patients (Figures 2, 3) The kidneys perform the primary filtering function of the urinary system. The two bean-shaped organs are primarily retroperitoneal (i.e., located behind the peritoneum that lines the abdominal cavity). They are held against the posterior abdominal wall and are partially protected by the lower ribs A ureter drains from the renal pelvis of each kidney into the bladder. Urine moves to the bladder via peristaltic wave-like motion of the smooth muscle walls

 The bladder is a hollow muscular reservoir. Adult bladder capacity of 500 mL is reached at ~ 1418 years of age. Prior to that time, bladder capacity in children is calculated using the childs age (Kaefer et al., 1997): - For children 2 years of age, multiply the childs age in years by 2 and add 2. For example, the bladder capacity of a 2 year old child should be 4 ounces or ~ 120 mL: ([2x2)]+2=4) - For children > 2 years of age, the general rule is the childs age in years, divided by 2, and then add 6. For example, the bladder capacity of a 6 year old child is 9 ounces or 266 mL: ([6/2]+6=9) The urethra extends from the neck of the bladder through the pelvic diaphragm to the external urethral orifice. In a functioning pediatric bladder, when urine volume in the bladder reaches a certain level (depending on the age of the child), impulses cause a reflex contraction of the bladder and the urethral sphincter relaxes to permit urine flow - The female urethra lengthens throughout physical development (see table, below). It is embedded in the anterior wall of the vagina and extends from the bladder to the external urethral orifice. A sphincter that controls urine flow is located near the bladder. Unlike the male urethra, which functions for both the urinary and reproductive systems, the female urethra functions only as an outlet for the urinary system . Age of Patient Neonate Infant to 3 years of age Child, 48 years of age Child, 8 years to adolescence Adolescent girls . 5 5 56 68 68 Average length of pediatric female urethra (cm)

Figure 2: Urinary system. This image is copied from Wikimedia Commons pursuant to a Creative Commons Attribution-Share Alike 3.0 Unported License, the GNU Free Documentation License

Figure 3: Transverse view of female pelvis. Wikimedia. This image is in the public domain

 Anatomy of the female perineal area (Figure 4) Labial folds (labia majora [outer folds] and labia minora [inner folds]) surround the female external genitalia - During the first eight weeks of life, maternal estrogen affects the genitalia of the female infant. The labia majora and labia minora are enlarged, which makes visualization of the clitoris and external urethral orifice more difficult - The decrease in estrogen levels through age eight to nine years causes the genital tissues to appear thinner and more atrophic and often do not cover the vaginal opening. The external urethral orifice is very small in the prepubertal female patient, but may appear distended and bright pink A protective hood of skin covers the clitoris, which is a small mass of erectile tissue located at the anterior tip of the genital area The external urethral orifice is located slightly below and posterior to the clitoris The vaginal opening is located slightly below and posterior to the external urethral orifice

Figure 4: Comparison of female adult and pediatric external genitalia. This image is copied from Wikimedia Commons pursuant to a Creative Commons Attribution-Share Alike 3.0 Unported License, the GNU Free Documentation License Standard precautions and demonstrated competence in adherence to aseptic technique to prevent bacterial contamination of the urinary tract The definition of aseptic technique varies somewhat depending on the clinical situation and is generally distinguished as either surgical aseptic technique or general aseptic non-touch technique (ANTT; i.e., the skin should not be touched after it has been prepared with antiseptic cleanser and any item introduced into the patient is sterile prior to insertion) - Surgical aseptic technique is practiced in the operating room (OR) under strict conditions and may be adapted for use outside the OR for situations that require similarly strict application of aseptic technique (e.g., intravascular procedures, including insertion of a central venous catheter; wound care) - General ANTT is used for simpler and less invasive procedures and refers to a variety of precautions, but primarily to the use of nonsterile gloves coupled with a no-touch technique so that sterile items and equipment are used and the sterile part of the item/equipment does not come into contact with anything that is not sterile Type of urinary catheter to be used for insertion (e.g., Foley, triple-lumen [typically used when continuous closed bladder irrigation is needed], silver alloy, antibiotic-impregnated). Note: Although feeding tubes are used for catheterization in young children, increasing evidence underscores the risk in using these tubes because, compared with urinary catheters, they are longer, more flexible, and more prone to coiling and knotting within the bladder (Kilbane, 2009) The following table can be used as a general guide to catheter selection: . Age of Child Neonate and infant < 6 months of age Children > 6 months of age to 12 years Children 8 years to adolescence Adolescent girls . 46 Fr 58 Fr 1012 Fr 1214 Fr Intermittent Catheterization Indwelling Catheters 68 Fr with 3 mL retention balloon 68 Fr with 35 mL retention balloon 812 Fr with 35 mL retention balloon 1214 Fr with 5 mL retention balloon

Indications for insertion of indwelling urinary catheter (see Why is Insertion of an Indwelling Foley Urinary Catheter Important?, above) Contraindications for insertion of indwelling urinary catheter, e.g., traumatic injury to the lower urinary tract (e.g., urethral tear) Note: Suspected extraperitoneal bladder injury is not a contraindication to urinary catheter insertion. Intraperitoneal bladder injuries typically require surgical repair Potential complications of catheter insertion (for details, see Red Flags , below) Topical anesthesia (e.g., 2% lidocaine gel) can be applied via a gel applicator inserted into the urinary meatus prior to FC insertion. Note: The use of urethral anesthetic in female patients is controversial and should be used only if the patient consents (Tanabe et al., 2004). Also, a 2005 randomized control trial indicated that 2% lidocaine gel demonstrated no statistically significant difference in pain (as measured by the Face Legs Arms Cry Consolability Pain Scale [FLACC]) between patients who received 2% lidocaine gel and a nonanesthetic lubricant (Vaughan et al., 2005) Preliminary steps to be taken before inserting an FC include the following:

 Review the facility/unit specific protocol for FC insertion, if one is available Protocols may dictate that a chaperone of the patients gender be present when the patient and clinician are different genders Be aware that due to sociocultural background, religious beliefs, or personal reasons, some patients and/or parents of pediatric patients may prefer that a clinician of the same gender perform the procedure Review the treating clinicians order for inserting the FC Note the type and size of the FC to be inserted and the purpose for which it has been ordered (e.g., urine drainage, diagnostic testing, administration of medication or other agents) Familiarize yourself with the manufacturers instructions for the type of FC to be inserted Verify completion of facility informed consent documents, if appropriate. Typically, the general consent for treatment that is executed by parents/guardians at the outset of admission to a healthcare facility includes standard provisions that encompass insertion of an FC Review the patients medical record for history of any renal-related injury, surgery, or medical condition any allergies (e.g., to latex, medications, or other substances); use alternative materials if appropriate. If the patient is allergic to iodine, select an alternative antiseptic to the commercially available povidone-iodine found in most commercially prepared kits - The 2011 guidelines for skin preparation issued by the Centers for Disease Control and Prevention (CDC) and the Healthcare Infection Control Practices Advisory Committee (HICPAC) recommend that clean skin be prepared with an antiseptic, such as 70% alcohol; tincture of iodine; an iodophor; or an alcohol-based chlorhexidine gluconate solution and that skin be allowed to air dry (OGrady et al., 2011) laboratory test results to check for coagulopathies or blood dyscrasias (e.g., CBC, PTT if the patient is receiving heparin, or PT if the patient is using warfarin) - Advise the treating clinician if the laboratory test results indicate the patient is at increased risk for bleeding Gather the supplies necessary for inserting the FC, which typically include (Figure 5): Sterile gloves and non-sterile gloves. Other personal protective equipment (PPE; e.g., eye protection, gown, and mask) may be necessary if exposure to body fluids is anticipated. Note: Many commercially prepared insertion kits include sterile gloves FC of the appropriate size Bath blanket or clean sheet. This can be placed over the patient, above the pelvis, to keep the patient warm and to promote privacy Penlight, optional. Note: Some clinicians prefer to use a gooseneck-style lamp Topical anesthesia (2% lidocaine) with gel applicator, if prescribed Patient label and biohazard bag if urine specimen is required Graduated container to collect urine, optional Pinwheel or blow toy (for younger children) or video/DVD for older children, optional The following items are usually found in a commercially available kit but may be gathered separately: Sterile gloves Waterproof absorbent underpad Fenestrated drape (i.e., drape with an opening in the center) Facility-approved antiseptic solution. Note: The most commonly used antiseptic solution for invasive procedures is povidone-iodine; however, check with your facility to confirm the type of antiseptic solution to be used (e.g., chlorhexidine gluconate) Sterile swabs or plastic forceps and cotton balls Water-soluble lubricating gel Specimen container (if urinary sample is required for laboratory analysis) 10 mL syringe, prefilled with sterile water Drainage collection bag and facility-approved securement device. Note: A commercial tube holder (e.g., Velcro-type strap) is the preferred method to secure the drainage tube to the patients leg.- Alternatively, hydrocolloidal dressing (e.g., Duoderm) and hypoallergenic tape can be used

Figure 5: Supplies required to insert an indwelling Foley urinary catheter in the pediatric patient. Copyright2013, EBSCO Publishing Inc.

How to Insert an Indwelling Foley Urinary Catheter in the Female Pediatric Patient
Verify that good lighting is available

Perform hand hygiene Identify the patient according to facility protocol Establish privacy by closing the door to the patients room and/or drawing the curtain surrounding the patients bed As age appropriate, introduce yourself to the patient and parents/guardians and explain your clinical role. Depending on the age and comprehension of the patient, assess the coping ability of the patient and family and for knowledge deficits and anxiety regarding insertion of the FC Determine if the patient/family requires special considerations regarding communication (e.g., due to illiteracy, language barriers, or deafness); make arrangements to meet these needs if they are present Use professional certified medical interpreters, either in person or via phone, when language barriers exist Explain the procedure and its purpose; answer any questions and provide emotional support as needed. Depending on the age and comprehension level of the child, explain to the patient that you will ask her to cough when catheter is immediately inserted, an action that provides for an easier catheter passage. Some clinicians give younger patients a pinwheel or toy that requires blowing to help them relax during the procedure. Older children can be taught to press their hips against the bed or examination able, an action the aids in relaxing the pelvic muscles tell the patient that she will probably feel the need to urinate teach that it is important for the insertion site to remain untouched during the procedure and she will need to keep her legs apart until the procedure is complete advise the patient that she may feel some discomfort as the tube is inserted, but indicate the tube will be lubricated to ease its passage tell the patient you will not force the FC, but that some pressure is necessary. Ask the patient to communicate with you if she wants to stop briefly during the insertion As appropriate, request family members and other visitors to leave the patients room in order to promote privacy Observe general ANTT throughout the procedure Assess the patient to determine if the patient meets the criteria for FC placement (see What You Need to Know Before Inserting an Indwelling Foley Urinary Catheter, above). Also percuss the bladder for distention to provide baseline information. Recall that a dull (flat) sound without echoes is indicative of fluid, a tympanic (higher pitch sound) reflects the presence of air. Because it is usually not possible to percuss the bladder unless it is distended above the symphysis pubis, note how high the bladder rises above the symphysis pubis assess for mental status (Will the patient be able to cooperate with the FC placement?). If the patient will not be able to cooperate, it may be necessary to request assistance from staff members Because you will use your dominant hand to insert the catheter, stand on the patients right side if you are right-handed or on the patients left side if you are left-handed Obtain the patients verbal consent prior to beginning the procedure Lower the side rail on the side of the bed where the procedure will be performed and raise the bed to a comfortable working height. Position and drape the patient for privacy and accessibility It is important to provide developmentally appropriate explanations and instructions throughout the procedure Assist the patient into the preferred position: the dorsal recumbent position (i.e., supine with knees apart and flexed)many clinicians prefer to have the patient in a frog-leg position with the legs apart, knees flexed, and feet together. A parent can be asked to lean over the childs torso to provide a firm hug (blocking the patients view of the procedure may reduce anxiety) while another clinician holds the knees apart. Although it is not optimal to depend on a parents assistance, it may be necessary to request the parents assistance if the child is overly anxious. For example, it may calm the child if the parent holds the child on her lap in a frog-leg position or to sit on the bed/examination table in a semi-recumbent position holding the child with the childs legs over her thighs. Some children are comfortable with the knee-chest position to expose the genitals while lying on their backs or sides. Use pillows or rolled blankets to support the patient in the side-lying position Cover the areas (e.g., the upper torso) that do not need to be exposed for the procedure with a bath blanket or a clean sheet Place a waterproof pad beneath the patient to prevent the bed linen from becoming soiled Don non-sterile gloves and wash the perineum with warm soapy water and rinse thoroughly Open the outer wrapping of the catheter kit. If not using a catheter kit, using sterile technique, unwrap all items and place onto a sterile field within easy reach Place the inner wrapped box on the bed nearby for easy access (some clinicians place the inner wrapped container between the patients legs); set the outer wrapper near the end of the bed for waste disposal upon completion of the procedure Using sterile technique, fold back the flaps on the sterile wrap so that the catheter kit supplies are accessible and the tray rests within a sterile field Touching the edges of each drape, remove the sterile drapes from the tray and position the square drape under the patients buttocks, then position the fenestrated drape over the perineum to expose the labial folds Remove and dispose of the nonsterile gloves; perform hand hygiene Apply sterile gloves using sterile technique Remove supplies from the catheter tray and organize them within the sterile field (Figure 6) If a urine sample is to be collected, loosen the lid on the collection container Apply antiseptic solution over cotton balls or open the packages of pre-moistened antiseptic swabs Open lubricant and spread it into a small area of the sterile tray

 If topical anesthesia is ordered, open the prefilled applicator

Figure 6: Supplies prepared for insertion of indwelling urinary catheter. Copyright2013, EBSCO Publishing Inc. If the catheter has a cover, remove it Check the condition of the FC for obvious defects (e.g., intact, rough edges) Attach the prefilled syringe to the inflation valve of the appropriate lumen and slowly instill the appropriate volume of sterile water into the catheter to inflate the balloon to confirm it is functionalalways verify the maximum volume of fluid for inflation which is usually printed on the valve at the distal end of the balloon lumen. Do not overinflate the balloon due to risk of rupture. Aspirate the fluid but leave the filled syringe attached to the catheter Pretesting balloons on silicone catheters is discouraged because the deflation can cause a crease that is associated with urethral trauma during insertion A protocol developed by Nationwide Childrens Hospital in Columbus, Ohio included the prohibition of inflating catheter balloons prior to insertion. The rationale for the prohibition was that inflating the balloon increased the size of the balloon and the risk of trauma to urethral tissue, which predisposed a patient to catheter-associated urinary tract infection (CAUTI); (UTIs decreased with these steps, 2011) Note: Some manufacturers discourage pre-inflation of the balloon due to increased risk of infectionalways review the manufacturers recommendations prior to use of supplies and equipment Verify the distal end of the catheter is attached to a drainage collection bag because any urine in the bladder will drain from the catheter once it is inserted. Note: If a urine specimen is needed, do not attach the drainage bag at this time but place the specimen container within reach Set the catheter aside on the sterile field Maintaining general ANTT, cleanse the external urethral orifice. Although HICPAC did not issue a recommendation in favor of antiseptic solutions vs. sterile water or saline for periurethral cleaning prior to FC insertion in its most recent guidelines (Gould et al., 2009), most clinicians use antiseptic solution as follows (Figure 7): Using the non-dominant hand, expose the meatus by spreading the labial folds to expose the urinary meatus. In preadolescent girls, it may help visualize the external urinary orifice to gently grasp the labia and pull it toward you instead of separating the labia. The urinary meatus is slightly superior to the vaginal opening (which is usually easier to locate) and appears as a pinpoint-sized opening or dimple Once the external urinary orifice is exposed do not allow it to close, especially after the antiseptic cleansing agent has been applied. If the labia closes after cleaning, the skin is considered contaminated and must be recleaned Keep the non-dominant hand in this position for the remainder of the procedurethis hand is now unsterile. It may be helpful if an assistant illuminates the meatus with a penlight Using the dominant hand, use forceps to apply antiseptic-soaked cotton balls or the antiseptic swabs from anterior to posterior Cleanse the right side of the vulva and perineal area using one swipe beginning to the right of the clitoris, cleansing along the labia majora, labia minora, and adipose tissue and ending before the perianal area; discard the cotton ball or swab Cleanse the left side of the vulva and perianal area using one swipe beginning to the left of the clitoris, cleansing along the labia majora, labia minora, and adipose tissue and ending before the perianal area; discard the cotton ball or swab Cleanse the center of the vulva using one swipe beginning above the clitoris, wiping directly over the urethral meatus and ending before the perianal area; discard the cotton ball or swab

 Do not reuse cotton balls or swabs

Figure 7: Use a separate antiseptic-soaked swab for each downward swipe. This image is copied from Wikimedia Commons pursuant to a Creative Commons Attribution-Share Alike 3.0 Unported License, the GNU Free Documentation License If prescribed, insert the catheter tip of the syringe containing the 2% lidocaine into the external urinary orifice and inject the prescribed amount of the gel; allow for the topical anesthetic to take effect before proceeding with the insertion Be aware that a rapid instillation of the entire amount of prescribed lidocaine can cause a burning sensation and tissue irritation. Some clinicians prefer to place a small amount of lidocaine on a cotton ball and hold it against the tissue for 12 minutes, and then inject the remaining medication into the external urinary orifice. Although the male urethra is longer than the female urethra, the total amount of medication instilled is the same for both males and females (e.g., infant [0.51.5 mL], toddler [1.52.5 mL], school-aged [2.55 mL], adolescent [35 mL]) Generously lubricate the proximal tip of the catheter; some clinicians use the remaining lidocaine to lubricate the catheter tip Using the dominant hand, grasp the catheter from its insertion tip and coil the remainder of the catheter in the palm Insert the catheter Ask the patient to cough or blow out as the catheter is inserted, and then slowly advance the catheter in a slightly downward direction (to track the slight curve of the urethra) through the external urethral orifice toward the bladder until urine begins to flow. You may feel a slight resistance as the FC passes the urethral sphincter. Once urine appears, continue to advance the catheter an additional 2.55.1 cm/12 inches to make certain that the catheter tip rests within the bladder Never force the catheterencourage the patient to breathe deeply to try to relax or press the hips downward to reduce the incidence of spasm or stricture, but contact the treating clinician if undue obstruction remains If a urine specimen has been ordered, allow the urine to drain into the specimen container; pinch the FC to briefly stop the flow of urine. Note: Some clinicians prefer to collect the urine in a graduated container and then attach the FC to the drainage bag Attach the drainage bag to the FC and place the drainage bag below the level of the bladder to allow urine to flow out of the bladder by gravity Do not attach the drainage bag to the bed rails because the bag and catheter can be pulled when the rails are adjusted Secure the catheter within the bladder as follows: Using the dominant hand, slowly instill the sterile water into the catheter to inflate the balloon never instill more than the recommended volume shown on the inflation valve . If the patient complains of pain during balloon inflation, the balloon is most probably in the urethra, withdraw the fluid, advance the catheter, and slowly re-instill the fluid. After the fluid has been instilled, apply gentle traction to the catheter until resistance is met to verify that the balloon is adequately inflated and the indwelling catheter will not be expelled The balloon should be slowly inflated to ascertain if it is within the urethra. Urethral tearing can occur if the balloon is inflated within the urethra Clean the excess antiseptic and lubricant from the patients genital area. Completely clean the perineal area because it reduces the risk of skin irritation due to iodine sensitivity. Be aware that children and family members can mistake iodine-based antiseptic for blood Secure the catheter and tubing to prevent movement and traction against the urethra that could damage urethral tissue. Typically the catheter is strapped to the patients inner thigh using a commercial tube holder and the drainage tubing is clipped to the mattress or to the bed frameavoid any dependent loops or kinks to permit unobstructed urine drainage. Allow for enough slack in the drainage tubing so the patient can move his thigh without pulling the catheter If commercial securement device is unavailable, utilize one of following methods: Apply a piece of hydrocolloidal dressing (e.g., DuoDerm) to the skinhold the hydrocolloid material against the skin for a brief period to allow the gel to mold to the skin, place the FC tubing over the dressing, and use tape/occlusive bandage to secure the tube to the dressing (Figure 8) Create a reverse gutter with tape to reduce tubing tension against the skin. The reverse gutter technique can be prepared with three pieces of tape as follows: - Center one piece of tape over the catheter/drainage bag tubing and pinch the edges together to create a short tab, and then extend the ends of the tape over the patients thigh. The reverse gutter created by elevating the catheter/tubing above the thigh with tape reduces traction against the skin and the urethra

- Place the two remaining pieces of tape over the tape on the patients skin

Figure 8: Secure the Foley catheter and drainage tube to the patients leg with hydrocolloidal dressing and occlusive bandage. Copyright2013, EBSCO Publishing Inc. Reassess the patients bladder to verify the distention has resolved Remove the underpads and assist the patient into a comfortable position; raise the bed rail and lower the bed to a safe position Arrange for transport of the labeled urine specimen to the laboratory in a biohazard bag Discard all soiled materials appropriately; perform hand hygiene Update the patients plan of care and document the following information in the patients medical record: Date and time of FC insertion Type and size of FC inserted; volume of sterile water instilled into the balloon Administration of topical anesthetic, if applicable Volume and characteristics of urine drainage (e.g., color, clarity, odor, presence of sediment/clots); record all output in the Input/Output section of the patients medical record Specimen forwarded to laboratory for analysis, if applicable Patient assessment information including any change in bladder distention and the patients tolerance of the procedure Any unexpected patient events or outcomes, interventions performed, and whether or not the treating clinician was notified Patient/family education and response to the teaching

Other Tests, Treatments, or Procedures That May Be Necessary Before or After Inserting an Indwelling Foley Urinary Catheter
Routine catheter care will be performed to confirm that the system is intact and to prevent proliferation of bacteria, which can lead to UTI. For more information, see Nursing Practice & SkillUrinary Catheter: Care Bacterial culture and antibiotic sensitivity testing will be performed on urine specimen if UTI is suspected; antibiotics will be prescribed if UTI is diagnosed If the catheter becomes blocked or the area around the insertion site becomes painful, the catheter may need to be replaced Urinary specimens should be transported promptly to the laboratory for testing, and results reviewed for abnormalities when available Bladder irrigation may be ordered if urinary catheter obstruction occurs or following certain surgical procedures, if ordered by the treating clinician

What to Expect After Insertion of an Indwelling a Foley Urinary Catheter

The FC will be inserted using sterile technique and with minimal patient discomfort and no resulting complications The bladder will be completely emptied of urine The patient will remain free of complications, including UTI; alternatively, any signs or symptoms of UTI or other complications of urinary catheterization will be promptly identified and treated

Red Flags
Potential complications of catheter use include bladder stones due to accumulation of urinary crystals, which can result in catheter blockage hematuria due to pulling on the catheter skin breakdown in the urethral meatus or lower extremities due to friction from the catheter or urinary drainage bag tubing urethral injury, which can occur during insertion or due to pulling on the catheter UTI/septicemia due to a break in sterile technique or insufficient or improper catheter care Prolonged use of indwelling catheters is linked to renal inflammation and pyelonephritis (i.e., kidney infection) and nephro-cysto-lithiasis (i.e., kidney and bladder stones)

 displacement of the catheter due to deflation of the catheter balloon, which is indicated by an increase in the length of the catheter that is visible outside the urethral meatus Fever, abdominal pain, foul-smelling urine, and/or hematuria may be indicative of a UTI. In patients with UTI, bacteria can ascend rapidly through the ureters to the kidneys, potentially causing damage to the kidneys and, in some cases, septicemia . Signs and symptoms of UTI should be reported promptly to the treating clinician Prophylactic antibiotics are commonly ordered for patients with an artificial urethral sphincter or with a prosthetic heart valve

What Do I Need to Tell the Patient/Patients Family?

Provide positive reinforcement throughout the procedure and thank the child for her cooperation. Educate the child, depending on her level of understanding, and the family regarding indications for catheter placement, details regarding the procedure, risks and benefits of the procedure, and any discomfort the patient may experience If laboratory testing or other diagnostic procedures are ordered, explain how these procedures are performed and when the results will likely become available Educate about clinical signs and symptoms that may indicate infection (for details, see Red Flags , above) or other complications, and emphasize the importance of reporting these signs and symptoms promptly to the home health nurse or the treating clinician

References
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