WELCOME TO THE CLINICAL SKILLS TRAINING PROGRAM NURSEZONE REVIEW CENTER

NAME: ___________________________________________ SCHOOL: _____________________________ RATING: ______________________________

NURSE STAFF: __________________________
PROCEDURE FOR INDWELLING FOLEY CATHETERIZATION
Equipment
 Catheterization set: - Thumb forceps or pick-up forceps - Safety pin and rubber band or plastic
- Sterile catheter - Cleansing solution clamp
- Sterile wrapper - Syringe prefilled with sterile water - Drainage tubing and collection bag
- Sterile gloves - Water-soluble lubricant for lubricating the - Tape
- Sterile drapes catheter  Light source
- Sterile cleansing swabs - Specimen container and label (if  Bath blanket or sheet for draping
necessary)
Name of Participant: Good Satisfactory Excellent Comments
1. Check the Doctor’s order and identify the patient.
2. Determine if the procedure is to be a straight or indwelling catheterization
3. Assess need for collection of a specimen
4. Explain the procedure to the patient. Answer any questions
5. Collect appropriate equipments
6. Wash your hands for universal precaution.
7. Do hand gloving.
8. Provide privacy.
9. Place the client in the appropriate position and cover the patient with fenestrated drape.
a. Pediatric patient or confused patient- seek an assistant
b. Female patient in dorsal recumbent position, with knees flexed, or in Sim’s position
c. Male patient in supine position.
10. Set up the equipment
a. Arrange the lamp
b. Open catheterization set and arrange the sterile field
c. Set up receptacle for soiled cleansing swabs
d. If drainage bag is in separate package, open it and attach to bed
e. If sterile drape is on top of set, grasp drape by side that is to be non-sterile and place under
patient. Then put on sterile gloves
f. If sterile gloves (not drape) are on top of set, put them on. Then grasp drape by side that is to be
sterile and place under patient, protecting your gloves
g. Place second drape to enlarge sterile field
h. Open cleansing solution and pour over swabs

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 WELCOME TO THE CLINICAL SKILLS TRAINING PROGRAM NURSEZONE REVIEW CENTER

i. Open lubricant and place it on end of catheter

j. For an indwelling catheter, attach syringe and test balloon by instilling all of the sterile water and
then deflating balloon by withdrawing water. Leave syringe attached
k. Set the specimen container and its cap upside down
l. If drainage bag is in set, connect distal end of catheter to drainage tubing
11. Catheterize the patient
a. Use non-dominant hand to expose the meatus.
b. After meatus is identified, cleanse the area surrounding the meatus, using swabs held in forceps.
Use circular motion on males. Swab from anterior to posterior on females. Discard swabs away
from sterile field.
c. Use sterile hand to move tray containing catheter close to patient, and to pick up catheter.
d. Insert catheter 2-3 inches into female or 6-9 inches into male, holding the penis at a 45 degree
angle, until urine returns.
12. If using a straight catheter, obtain a specimen and drain the bladder
13. If using an indwelling catheter, inflate the balloon
14. Connect the bag to the catheter
15. Obtain specimen by aspirating the urine in the port of the indwelling catheter.
16. Tape the catheter to the patient – for a male, to the lower abdomen; for a female, to the thigh or loosely
over the leg without taping
17. Gather and discard disposable equipment. Clean non-disposable equipment
18. Wipe perineal area of any remaining antiseptic or lubricant.
19. Evaluate using the following criteria:
a. Indwelling catheter draining properly or straight catheter inserted and removed without
discomfort
b. Patient comfortable
c. Wash your hands
20. Document the following
a. Date and time
b. Type and size of catheter

c. Whether a specimen was obtained

d. Amount of urine
e. Description of urine
f. Patient’s response to procedure

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 WELCOME TO THE CLINICAL SKILLS TRAINING PROGRAM NURSEZONE REVIEW CENTER

CARING FOR A PATIENT WITH AN INDWELLING FOLEY CATHETER

1.
2. Place the patient on intake and output 7. Keep tubing coiled by patient’s side
3. Encourage increased fluid intake 8. Keep drainage bag off the floor
4. Maintain closed system 9. Tape catheter to prevent pulling
5. Maintain external cleanliness around catheter 10. Observe for irritation at meatus
6. Keep catheter drainage bag below level of bladder 11. Empty bag at regular intervals

PROCEDURE FOR REMOVING AN INDWELLING FOLEY CATHETER

Equipment
 Paper towels  A small container to catch urine
 A syringe to remove the fluid from balloon  Clean gloves
Needs More
Name of Participant: Satisfactory Excellent Comments
Practice
1. Verify the Doctor’s order and identify the patient
2. Determine whether a urine specimen is needed
3. Explain that catheter is to be removed and what to expect to the patient.
4. Wash your hands
5. Obtain necessary equipment
6. Prepare patient by proper draping. Put on clean gloves
7. Withdraw the catheter
a. Place paper towels under catheter
b. Use syringe to remove fluid from balloon

c. Pinch catheter and pull it out smoothly

d. Wrap catheter in paper towel
e. Hold end of catheter up to allow urine to drain from tubing
8. Assist patient to comfortable position
9. Measure urine output
10. Dispose of the equipment
11. Remove gloves and wash your hands
12. Evaluate using the following criteria:
a. Catheter removed without difficulty
b. Patient voiding adequate amounts (250 mL) at regular intervals
c. Patient is continuing to increase fluid intake
13. Document time of catheter removal, urine output, and patient’s response

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