lOMoARcPSD|8491600

lOMoARcP

CATHERIZATION BVC

1. HAND HYGIENE (15-30)

2. DOCTOR’S ORDER (My client’s name is Clarke, Thomas, ID#125 2569, DOB:
march25,1987, Doctor’s ORDER include: Insert Foley catheter
3. GATHER SUPPLIES (I will be needing)
a. Catheter (plus extra)
b. Catheter tray
c. Blue pad
d. Tape
e. Extra sterile gloves
f. Drainage bag
g. Clean gloves
h. Bath blanket
4. Hand hygiene before going to my client’s room
5. (knock) Good morning Mr. Clark, my name is---I am your student nurse today . First can I see
your ID band.. Can you state your full name and your birth date.
6. Procedure and consent: Your doctor has ordered for insertion of catheter. Is this your
first procedure or you have had catheter before; okay so,I am going to insert a catheter
that will go through your urethra and into your bladder that allow continuous flow of
urine into a drainage bag is that okay with you.
7. Before I begin, let me do Safety checks for the bed breaks, I will close the curtain for
your privacy, I will adjust the bed to my working height and adjust the table to my
waist or working height too.
8. Hand hygiene, clean gloves on. I will put this towel Drape on your chest for your
privacy.
9. I will position you into supine position. Mr.Clarke, can you lift up your bump as I will put
on the blue pad underneath. I will extend your legs and thigh slightly open.
I will do Peri care then after.. I will do my 3 assessment
10. ASSESSMENT:
First: Are you experiencing any pain at all today.
c- can you describe the pain, is it sharp or
dull o-when does it start
l- can you tell me exactly where you feel the pain,
point it d-how long does it last, minutes or seconds
s-if you were to rate your pain on a scale of 0-10 with 0- being no pain and 10
being the worst pain you ever felt. how would you rate it.
p- is it the pain with movement or constant pain
a- Any associated feactors like nausea or vomiting.

How does affect your daily life

How do you cope with the pain.

Downloaded by Faith Iyere (faithiyere@gmail.com)

 lOMoARcPSD|8491600

2nd I will assess your lower abdomen for bladder distention. I will put a gentle pressure on
your abdomen. I noticed that your bladder is distended. When was the last time that
you went to the washroom.
3rd I will assess the Skin integrity: (coca)I can see that your skin is intact. I didn’t notice
any rednes , swelling, or unusual odor. No discharge noted.
11. Ungloves-HAND HYSGIENE
12. Put the tapes to the table
13. Open catheter bags and within reached, I will make sure that is close.
14. Open the catheter and tape well outside package on the table.
15. Open catheter tray kit. Make sure not across
16. HAND HYGIENE x 15-30 secs
17. REMOVE THE GLOVES from tray THEn PUT ON (PUT THE COVER PAPER ON BEDSIDE), put
the drapes under the patient, 2nd drape on top of abdomen.
18. ASSEMBLE Equipment (open the3 sterile swab, open the gel, grab the catheter then
attached to 10 cc syringe, then carefully return to tray without touching the sides of the
tray!)
19. MAINTAIN VISION AND STERILITY
20. Bring tray, place close to the patient
21. Non-dominant hand to expose urethra, position the penis into perpendicular, retract the skin
the clean with 3 swabs. 1st to urethral meatus, 2nd to sides and 3rd to glands area
underneath.
22. Move the tray closer to patient
23. Insert the catheter (now I’m going to insert the catheter, take a deep breath if you feel
mild discomfort) about 17.5cm- 22.5cm until urine return then Advance 2.5 to 5cm further.
I’m going to inflate balloon with 10cc of sterile water in the syringe. (gentle tug) with
right hand.
24. Remove the syringe then Attach the urine bag.Secure catheter with tape to the lower thigh,
then attached urine bag under the bed below the bladder.
25. Doff gloves(palm to palm skin to skin)
26. HAND HYGIENE
27. Clean gloves on
28. I will inspect the characteristics and note the amount of urine. Discard urine and dispose
these garbage to biohazard container.
29. Doff gloves
30. HAND HYGIENE. Drapes the patient.
31. 3 teachings while lowering the bed and safety breaks, ensure patient comfort. open
the curtain.
*Mr. Clark, are you now comfortable. I highly recommend you to drink plenty of fluids to
produce large amount of urine that flushes the bladder that keeps tubing free of
sediments.
*Drainage bag always below the bladder to prevent back flow of urine into the bladder
that may cause infection.
* don’t tug the catheter tube and report any severe pain.
Do you have any questions for me.
Thank you for your cooperation Mr. Clark, I will do my charting now , if you have any
concern, here is your call bell and you can reached me.

33.Hand hygiene before leaving the room

Downloaded by Faith Iyere (faithiyere@gmail.com)

 lOMoARcPSD|8491600

34. Document

a. Date and time of procedure

b. catheter size and balloon size

c. colour and character of urine returned (COCA)

d. education

2017-Sept-28 2030 nursing Catheter Insertion

D: Patient has no urine output since 2400. Reported pain with scale of 6\10. Slightly distended
bladder upon palpation. Skin is intack with no redness, no swelling, no odor and no discharge.

A: Inserted F14 foley catheter. Inflated balloon with 10cc sterile water. Urine output of 600 ml, orange
in color, no foul odor. Patient teaching like increase water intake, urine bags below the bladder level,
and instructed to call using call bell if any concern.

R: Patient tolerated the procedure.

P: Will come back after 1 hour to check the good flow of urine, then continue monitoring
input and output for my entire shift.

Downloaded by Faith Iyere (faithiyere@gmail.com)