RETDEM

INSERTING A FOLEY CATHETER ON A FEMALE PATIENT

1. Introduce yourself, verify patient’s name and DOB and explain the procedure that you will be doing to
your patient
2. Perform hand hygiene and observe infection control procedures.
3. Provide patient’s privacy
4. Prepare the patient into the proper position
- Roll the blanket down
- Bend the knees and open hips
5. Establish adequate lighting. Stand on the right side of the patient, if you are right handed dominant or
left if you are left handed dominant.
6. Prepare your equipment.
- If a collection bag is not included in the catheterization kit, open the drainage package and
place the end of the tubing within reach.
7. Open the catheterization kit. Place a waterproof drape under the buttocks without contaminating the
center of the drape.
8. Put on your sterile gloves. Organize remaining supplies.
- Prepare the swabs
- Open the lubricant package
9. Attach the sterile water solution or prefilled syringe to the indwelling catheter inflation hub.
- Test the balloon if instructed (rationale: to test if it is intact)
10. Lubricate the catheter and place it in with the drainage end inside the collection container.
11. Cleanse the meatus.
- Use your non dominant hand to open the labia
- Pick up a cotton swab, and wipe one side of the labia majora in an anteroposterior direction.
- Use a new swab for the other side.
- Repeat for the labia minora.
- Use the last swab to cleanse directly over the meatus.
12. Start inserting the tube
- Grasp the catheter 2-3 inches from the tip.
- Ask the patient to take a deep breath before inserting, and insert while they are exhaling.
- Assure the resident that it won’t hurt; they’ll just feel uncomfortable
- Advance the catheter an additional 2 inches and stop when you see a urinary return.
- If the catheter has been inserted in vagina, it is considered contaminated and a new set of
catheter must be used. The contaminated catheter can be left inside to prevent the same
error. Remove the contaminated catheter after the new catheter has been correctly inserted.
13. Inflate the balloon with the designated amount of fluid.
- If the client is feeling discomfort, deflate the balloon and advance the catheter a little further,
and attempt reinflation.
- Tug the catheter gently until resistance is felt. (rationale: to make sure it’s in place)
14. Secure the catheter tubing in the inner thighs, with enough slack to allow movement.
15. Hook the collecting tube in an immovable part of the bed below the patient’s waist.
- Below the level of the bladder but no tubbing should go below the top of the bag.
16. Wipe the perineal area of any remaining antiseptic or lubricant, and return the patient into a
comfortable position.
17. Discard all supplies in appropriate receptacles, and perform hand hygiene.
18. Document the catheterization procedure including the catheter size and results in client record.
DISCONTINUATION OF THE CATHETER
1. Perform hand hygiene
2. Introduce yourself, verify patient’s name and DOB and explain the procedure that you will be doing to
your patient
3. Provide privacy
4. Prepare clean gloves, empty syringe and washcloth
5. Prepare the patient
6. Put on the clean gloves
7. Insert the empty syringe in the port
- Deflate the balloon
8. Take the wash cloth covering the perineal area then pull out the catheter
- Instruct the patient to take a deep breath before pulling out
9. Discard the catheter
10. Perform or assist the patient for perineal care
11. Perform hand hygiene
12. Document the procedure

INSERTING A TRANSURETHRAL CATHETER (MALE)

1. Hand hygiene.
2. Provide privacy.
3. Verify patient identity.
4. Explain the procedure. Prepare the patient.
5. Position the patient, slightly bend the knees or spread the legs.
6. Assemble equipment. Observe aseptic technique when handling the equipment.
- Don gloves.
- Using a non-dominant hand, set up materials such as sterile drapes (shiny side down) and the cover
for the genital.
- Prepare Betadine swabs
- Put lubricant on the tray.
- Attach the syringe to the catheter (may or may not test the balloon).
7. Using a non-dominant hand, point the penis upward. Using the dominant hand, wipe the glans of the
penis with the betadine swab in one circular motion. Discard swab. Repeat.
Note: if the patient is uncircumcised, retract the foreskin before cleaning with swab.
8. Insertion of catheter. Dip the tip of the catheter to the lubricant. Instruct the patient to take a deep
breath and inform that there should not be any pain but may be slightly uncomfortable.
9. Slowly insert the catheter until urine flows the tube (continue with caution when resistance is
encountered until flow of urine is evident).
10. Inflate the balloon with 5 mL saline.
11. Tape the tube above the leg of the patient.
12. Hook the urine bag to the bed frame that is NOT movable below the level of the hips of the patient.
13. Document (esp. the size of the catheter used and the mL used for the balloon).

DISCONTINUATION OF TRANSURETHRAL CATHETER (MALE)

 1. Hand hygiene.
2. Provide privacy.
3. Verify patient identity.
4. Explain the procedure. Prepare the patient.
5. Assemble materials:
- Clean gloves
- Washcloth
- syringe
6. Don gloves.
7. Deflate the balloon using syringe. Note: check the amount of injected saline in documentation.
8. Instruct the patient to take a deep breath and carefully pull out the catheter tube. Cover the end of the
tube with washcloth.
9. Remove tape on the leg and discard the catheter.
10. Perform or assist perineal care.
11. Document.

CENTRAL VENOUS CATHETER (CVC)

● type of access for hemodialysis patients
● For emergency HD access
● Similar to an IV, but MUCH larger and needs to be surgically inserted in a central vein
● It is used to administer medications or fluids, obtain blood samples and invasive monitoring of
central venous pressure
● 2 types of CVC
➔ Dual lumen catheter
➔ Triple lumen catheter
● 3 most common veins of choice:
➔ Intrajugular (Neck, usually the first choice)
➔ Subclavian (Chest, underneath your collar bone, least common of the three)
➔ Femoral (Groin – the dirtiest site of the three in my opinion, very prone to infection)
● Pros:
❏ Can be inserted fairly quickly (as little as an hour, maybe even less) and used right away
❏ Easy to remove for healing
● Cons:
❏ Easily removed/dislodged, costs money to have it inserted/replaced
❏ Prone to infection, bleeding, clotting (because kids, remember that its in a CENTRAL vein)
Your role as a nurse:
● Proper Maintenance is key
● Inspect the site for signs of infection (rubor, callor, tumor, dolor or redness, heat, swelling,
and pain) or bleeding
➔ Try to minimize unnecessary handling the CVC (for infection control), but if needed
ensure sterile/aseptic handling of the CVC
➔ Regularly check for patency – assess for presence of backflow. If none, patency
may be compromised - inform your doctor as the access may need to be
replaced/reevaluated
➔ Ensure that the access remains patent – aseptic intermittent flushing with NSS can
help prolong the life of your CVC by preventing clotting of blood
➔ Health education (if your patient is conscious and ambulatory) – educate them on
the importance of maintaining sterility of the site and to avoid accidentally
pulling the CVC out

Central Venous Catheter Care (https://www.youtube.com/watch?v=OT1DQ8SvC0s)

1. PREPARE EQUIPMENT
❖ A clean trolley containing:
➢ Sterile dressing pack, Sterile paper draper, 2% Chlorhexidine swab stick,
Transparent/Mepore dressing, Tegaderm dressing with Chlorhexidine gluconate,
Sterile gloves, 5 mL sterile syringes, 10 mL Sterile syringes, 10 mL.9% Saline
ampules, Heparinized saline ampules, Needleless IV catheter hub, Kidney tray and
Alcohol hand rub
2. IDENTIFY PATIENT + EXPLAIN THE PROCEDURE TO THE PATIENT/FAMILY
3. Provide PRIVACY for the patient + Perform Hand hygiene PRIOR to procedure
4. Clean the working surface area with disinfectant wipes
5. Open the dressing pack ASEPTICALLY. Open all items needed and drop into the sterile field.
6. Place patient in SUPINE POSITION with head turned away from CVC line
7. Do hand hygiene + Wear MASK and sterile gloves
8. REMOVE the old dressing gently, touching only the TIP. Secure the catheter well
9. Discard dressing into the prepared YELLOW plastic bag
10. Inspect INSERTION SITE for signs of infection, leakage or other mechanical problems
● Signs of infection (rubor, callor, tumor or bleeding)
11. Check the surrounding skin for any signs of REDNESS, RASHES and IRRITATION
12. Check level of the Catheter
● To check the catheter in the original position
13. Cover catheter site with STERILE GAUZE
14. Remove gloves. Repeat Hand hygiene. Wear sterile gloves.
15. Clean the wound with 2% Chlorhexidine working from the INSIDE to the OUTSIDE of the area and
dealing with the CLEANEST parts of the wounds first
16. Apply appropriate dressing: Mepore dressing
● If EXIT site is with DISCHARGE
● TRANSPARENT Dressing — If exit site is DRY
● Tegaderm with Chlorhexidine — either for clean or infected sites
17. Mepore and transparent to change after 72 hours. Tegaderm with Chlorhexidine Gluconate
(CHG) to change after 7 days.
18. Remove gloves and Repeat Hand hygiene
19. Keep SALINE and HEPARINIZED SALINE in separate syringes
20. Clean the CVC lumens with 2% chlorhexidine
21. Spread the sterile drape on the patient’s chest longitudinally and place the catheter lumens into the
drape
22. Clamp catheter. Remove USED sterile gloves. SWITCH OFF IV Infusion Pump
23. Wash hands and Apply new sterile gloves
24. Disconnect the old needles catheter hub. If there is any blood clean the lumen port with 2%
chlorhexidine in 70% alcohol three times
25. Connect a new needles catheter hub open clamp flush with saline followed by heparinized saline
using push force technique — to maintain a patent catheter for intermittent use and prevent
rupture of the catheter
26. Label the dressing with the date of dressing changed — to ensure dressing will be changed at the
appropriate dates
27. Discard supplies as per waste disposal policy perform hand hygiene after the procedure
28. Document the procedure performed in the EPR
❖ Aseptic technique must be observed at all times during the procedure 10 ml
syringe must be used for flushing CVC to avoid rupture. Flushing must be done
with the SASH METHOD (Saline flush, Administer, Saline flush, Heparin using the
Push-Pause technique). When about 0.5 ml of the Saline left in the syringe clamp the
lumen to create positive pressure and to prevent backflow of the blood.
 ❖ If Central Venous Catheter will not be used for more than 10 hrs or if patient is
discharged, FLUSH catheter with 400 units of HEPARIN

How to Flush CVC : (https://www.youtube.com/watch?v=HB4T4cXw4Kg)

1. Gather supplies
- prefilled 10 milliliter syringe with
- normal saline one alcohol pad and one
- disinfection cap for each lumen of your CVC
- pair of non-sterile gloves
2. Clean your hands
- wet your hands, apply soap, rub them for 15 to 20 seconds then rinse dry your
hands with a paper towel and use that same towel to turn the faucet off
- if you're using alcohol-based hand sanitizer be sure to cover your hands with it
rubbing them together until they're dry
3. Put on the gloves
4. Pick up the prefilled syringe and release the air bubbles by pointing the syringe up and gently tapping
the side loosen but don't take off the cap
5. Press the plunger on the syringe until the air is pushed out then retighten the cap
6. Pick up one lumen and unclamp
a. it if it has a disinfection cap take the cap off
b. if it doesn't have a disinfection cap scrub the end of the needleless connector with an alcohol
pad for 15 seconds then let it dry for 15 seconds
7. Take the cap off the syringe and throw it away
8. Make sure nothing touches the clean end of the needleless connector while you're doing this
9. Push the syringe into the needleless connector and twist it clockwise to the right until the connection
feels secure
10. To do this, Inject one third of the Saline then pause inject another third of the Saline then pause
inject the last third of the Saline then pause (to loosen any clots that may have formed at the end of
the catheter)
a. If you can't inject the Saline
i. Stop and check to make sure the lumen isn't twisted blocked or clamped then try
again
ii. If you still can't inject the Saline don't push harder
iii. Remove the syringe re-clamp the lumen and call your healthcare provider
11. Once the syringe is empty
a. Re-clamp the lumen untwist the syringe from the needleless connector and throw it away
12. Put a disinfection cap on the end of the needleless connector then check to make sure the clamp is
closed repeat these steps for each lumen
13. Once you flushed all the lumens, secure your catheter so it's comfortable and won't be pulled
14. Your healthcare team will show you how
15. Then throw away your gloves and wash your hands

REMEMBER!
❏ Call the health care provider right away if patient have:
- Redness swelling or drainage around the exit side of your catheter
- Fever of 100 point 4 degrees F or 38 degrees C or higher
 - Have chills
- If he/she can't flush catheter
- Needleless connector falls off
- Catheter is broken or leaking
- Dressing is damaged, dirty, wet or peeling off
- If patient have any questions

Assessment for AVF (gabbie)

1. Post operatively
a. Regularly inspect the site post-operatively for signs of infection/bleeding
b. Monitor progress of healing
c. Keep site clean/sterile
2. Long term
a. Same as above minus the “progress of healing”
b. Assess for patency by auscultating for presence of bruit or palpating for a thrill (vibration, not
pleasure)
c. Observe arm precautions! Avoid anything that can constrict/alter blood flow in the fistulated arm
(bracelets, tight clothing, BP monitoring, venipuncture)
d. Assess for pulses distal to vascular access, note capillary refill, signs of poor blood flow (mottling of
skin, etc)
3. REMEMBER: (N)
● Fistula is soft, compressible, and palpable thrill (indicates good flow of blood)
● Thrill and bruit have the highest intensity or sound at the site of anastomosis
● (-) Hyper Pulsatility = no venous stenosis
● Three Tests:
○ Pulse Augmentation
○ Arm Elevation Test (n/a for AVG)
○ Sequential Occlusion Test - looks at accessory veins

PERITONEAL DIALYSIS
Equipments:
- A catheter placed in the peritoneum
- Dialysate
- Bag for drainage
- Gloves
2 types of PD
- The type of peritoneal dialysis you choose will depend on your lifestyle and your preference. You can
have one of the two types or have a combination.
CAPD (Continuous Ambulatory Peritoneal Dialysis)
- Prepare materials: dialysate, empty bag for drainage, gloves
- Verify the doctor's order about the procedure, the prescribed fluid, and for how many hours it will sit
in the peritoneum.
- Introduce self + explain procedure + verify patient's name and birthdate
- Provide privacy.
- Do hand hygiene. Wear your gloves.
- Remember: In, Sit, Out.
- In. Connect a catheter to a special tube that allows a cleansing fluid (dialysate) to flow into the belly.
 - It takes about 10 minutes for the dialysate to fill the peritoneum.
- Once that's done, the catheter is capped so that it doesn't leak.
- Sit. The lining in the peritoneum acts as a natural filter. It lets the waste products and extra fluid in
your blood pass through it going into the dialysate. At the same time it holds back the important
things (i.e. RBC and other nutrients) that the body needs.
- The dialysate must stay in the peritoneum for several hours. Depending on the patient's body size
and how much waste has to be removed.
- Out. Drain the dialysate from the body into an empty bag and properly dispose of it.
- Remove gloves. And perform hand hygiene.
- Document.
- Repeat the procedure 3-6 times a day
CCPD (Continuous Cycling Peritoneal Dialysis)
- Prepare the materials: dialysate, empty bag for drainage
- Do hand hygiene.
- Connect the catheter into the cycler at night before going to sleep. Since the exchanges will not be
done by oneself during the day. Instead the cycler will automatically fill the belly with fresh solution
and automatically drain them.

Nursing considerations:

1. Regular monitoring of the stoma for signs of infection/bleeding

2. Proper and daily wound care/cleansing (remember, aseptic is key)

3. Timely weighing of patient before and after the procedure

4. Proper head-to-toe assessment pre, intra, and post PD

- Level of consciousness
- Diagnostic results
- Fluid intake and output
- Vital signs
- Weight. Before and after dialysis.

5. Health education for the patient and family on the above listed topics, to help facilitate for discharge.

Catheter Care for PD:

1. Prepare equipments
- Hand disinfectant
- Antibacterial cream
- Sterile gauze
- Dressing
- Micropore tape
- Alcohol wipe
- Iodine swab sticks
- Garbage bag
- Gloves
2. Check the equipment. Ensure correct material, check expiry date, and if the package is intact.
3. Introduce self + explain the procedure + verify patient's name and birthdate.
4. Provide privacy.
5. Perform hand hygiene.
 6. Clean the work area with an alcohol wipe.
7. Open the dressing supplies.
8. Remove the old dressing.
9. Wear gloves.
10. Inspect the exit site for signs of infection (rubor, calor, dolor, tumor, discharge)
11. Clean site with iodine swab sticks. Clean in a circular motion. From the inside to outside. Repeat the
procedure, each time with a new swab stick. Wait for it to dry.
12. Dry the exit site with sterile gauze until the excess iodine is cleaned off.
13. Apply antibacterial cream as prescribed by the doctor using a sterile gauze swab.
14. Cover the exit site with a new dressing. Secure the PD catheter with micropore tape.
15. Some patients have a PD catheter belt wherein they can place the catheter extension into the PD belt
and clean up. For patients who do not have a belt, coil the catheter and use a micropore tape to secure
it in place on your belly.
If the patient would shower:
1. Coil the catheter extension.
2. Secure it with micropore tape.
3. Cover the site dressing with waterproof plastic.
4. Secure it with micropore tape.

4 Ws and 1 H for cystoclysis

● WHO - Cystoclysis is performed by a doctor
● WHAT - Cystoclysis is a procedure where the bladder continuously flushed with normal saline using a
three-way/triple lumen catheter
● WHEN - usually done after TURP or if the patient has medical conditions that leads to bleeding in the
bladder.
● WHY - Cystoclysis is done to prevent or treat clot formation so that urine can freely flow and maintain
a patent IDC
● HOW
1. Prepare Equipments (urine bag, three-way catheter, syringe, IV infusion set, saline solution,
swabs, lubricant, and sterile gloves.)
2. Introduce yourself, verify patient’s name and DOB and explain the procedure that you will be
doing to your patient
3. Perform hand hygiene and observe infection control procedures.
4. Provide patient’s privacy
5. ENSURE STERILE TECHNIQUE THROUGHOUT THE PROCEDURE
6. Infuse your saline solution using the IV infusion set
- Make sure all clamps are closed
7. Prime the tubing
8. Lubricate the catheter and place it in with the drainage end inside the collection container.
9. Using a non-dominant hand, point the penis upward. Using the dominant hand, wipe the
glans of the penis with the betadine swab in one circular motion. Discard swab. Repeat.
(Note: if the patient is uncircumcised, retract the foreskin before cleaning with a swab.)
10. Insertion of catheter. Dip the tip of the catheter to the lubricant. Instruct the patient to take a
deep breath and inform that there should not be any pain but may be slightly uncomfortable.
11. Slowly insert the catheter until urine flows the tube (continue with caution when resistance
is encountered until flow of urine is evident).
12. Inflate the balloon with 10cc of saline solution.
 - If the client is feeling discomfort, deflate the balloon and advance the catheter a little
further, and attempt reinflation.
- Tug the catheter gently until resistance is felt. (rationale: to make sure it’s in place)
13. Connect the catheter with the IV tubing
14. Connect the urine bag to one of the ports of the catheter
15. After connecting the IV and the urine bag to the catheter, start infusing the IV set as the
doctors orders.
16. Tape the tube above the leg of the patient.
17. Hook the urine bag to the bed frame that is NOT movable below the level of the hips of the
patient.
18. Assess patency of catheter and tubing
19. Document (esp. the size of the catheter used and the mL used for the balloon).