Republic of the Philippines

PAMANTASAN NG LUNGSOD NG MAYNILA

(University of the City of Manila)
General Luna Street corner Muralla Street
Intramuros, Manila

COLLEGE OF NURSING
(Dalubhasaan ng Narsing)

Medical Surgical I – RGUT SKILLS LABORATORY CHECKLIST #7

Removing of an Indwelling Catheter

Name: _____________________________ Date: ______________________________

Year Level & Block: ________________ Clinical Instructor: ___________________

Rating Scale:

3 - Performed correctly, systematically according to standard with correct rationale

2 - Performed correctly, systematically according to standard but with inadequate/
incorrect rationale
1 - Perfomed correctly not systematically with inadequate/incorrect rationale
0 - Performed incorrectly/not done

Purpose of the Procedure:

 Terminates urinary catheterization

 Permits return of client-controlled voiding

Special Considerations in Planning and Implementation:

 General: If swelling is noted around the catheter entry site, consult doctor before removing
catheter.
 Delegation: Unlicensed assistive personnel can remove catheters. The nurse should
observe perineal area and urinary output and assess that client voids within 4 hours of
catheter removal.

Reference-Source: Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to Clinical Procedures 6th Edition
(Wolter Kluwers / Lippincott Williams and Wilkins)

Prepared by: Dr. Jennifer P. Reyes

AY-1st Semester 2020-2021

Removing an Indwelling Catheter

 Preparation Performance Remarks/Suggestion Demerit
3 2 1 0
1. Assessment should
focus on the following:

 Length of time catheter

has been in place and
agency policy regarding
maximum length of
time before catheter
removal or change.
 Order for catheter
removal and parameters
for removal (e.g., after
specimen obtained,
when client is
ambulatory).
 Client’s knowledge of
catheter removal
procedure.
 Size of catheter and
balloon.
 Characteristics of urine
(e.g., color, clarity, odor,
amount)
 Amount of urine output
 Distention, pain, or
tenderness of lower
abdomen

2. Equipment/Materials
needed:

 Syringe (appropriate size

to remove water from
balloon on catheter
 Graduated container
 Non-sterile gloves
 Basin of warm water
 Towel
 Soap
 Washcloth
 Linen saver
 Pen

Reference-Source: Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to Clinical Procedures 6th Edition
(Wolter Kluwers / Lippincott Williams and Wilkins)

Prepared by: Dr. Jennifer P. Reyes

AY-1st Semester 2020-2021

Implementation of the Procedures:

 ACTION / STEPS of the Performance Remarks/Suggestion Demerit
Procedure 3 2 1 0
1. Perform Hand Hygiene.

2. Prepare the equipment/materials

needed.

3. Introduce self and Verify client’s

identity.

4. Explained procedure to client.

5. Provide Privacy.

6. Determine if client is allergic to

iodine-based antiseptics and use
alternative, if indicated.
7. Don nonsterile gloves.

8. Lower side rails, place client in

supine or lateral position, and
place linen saver under client’s
buttocks.
9. Obtain urine specimen if ordered.

10. Insert syringe into balloon port

inflation valve.

11. Aspirate total amount of fluid that

was used to inflate the balloon. If
unsure balloon is fully deflated,
cut the inflation port and allow
water to drain.
12. Remove tape or remove tubing
from holder.

13. Instruct client to relax and take

slow deep breaths. Slowly and
smoothly pull catheter out of
urethra onto towel.
14. Hold catheter up until urine has
drained into bag.

15. Clear bed all equipment.

Reference-Source: Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to Clinical Procedures 6th Edition
(Wolter Kluwers / Lippincott Williams and Wilkins)

Prepared by: Dr. Jennifer P. Reyes

AY-1st Semester 2020-2021

16. Reposition client for comfort, and

replace linens for warmth and
privacy.
17. Raise side rails and place call
light within reach.
18. Remove and discard gloves and
perform hand hygiene.
19. Instruct client to notify nurse of
next voiding and save urine.
 20. Documentation:
The following should be noted on the
client’s record:

 Assessment of lower abdomen

before removal of catheter.
 Assessment of genetalia, if
abnormalities noted.
 Size of catheter.
 Amount, color, and
consistency of urine draining
from catheter.
 Any difficulties encountered
when removing catheter.
 Reports of unsual discomfort
during removal.
 Status of catheter.
 Time and amount of first
voiding.
 Specimen obtained (catheter
tip is sent to lab., if
applicable).

Reference-Source: Jean Smith-Temple and Joyce Young Johnson. Nurses’ Guide to Clinical Procedures 6th Edition
(Wolter Kluwers / Lippincott Williams and Wilkins)

Prepared by: Dr. Jennifer P. Reyes

AY-1st Semester 2020-2021

Total Deduction or Demerit: ________ Total score: ____________________

I fully understand how I was graded for this particular skill and it was properly explained to me.

__________________________________________________ Date: ____________________

Student’s Full Name & Signature

I have explained and discussed how I have graded my students for this particular skill.

__________________________________________________ Date: ____________________

Clinical Instructor’s Full Name & Signature