COLLEGE OF HEALTH SCIENCES

NCM 116 (RLE)

MODULE ON URINARY CATHETERIZATION

Learning Outcomes:
At the end of the topic, the student will be able to:
1. discuss the principles of catheterization
2. demonstrate how to perform male and female catheterization
3. demonstrate how to remove a catheter
4. formulate a nursing care plan for a patient with catheter
Rationale
▪ Urinary catheterization is the insertion of a specially designed tube
into the bladder through the urethra using aseptic technique
Purposes:
▪ draining/withdrawing urine
▪ removal of clots/debris
▪ instillation of medication.
Risks:
▪ can cause trauma to the patient
▪ impacts body image
▪ a primary source of UTI – it should be inserted only when deemed
necessary and left in palace for the shortest time
Indications:
• To empty the contents of the bladder, i.e. before or after abdominal,
pelvic or rectal surgery, before certain investigations and before
childbirth, if thought necessary.
• To determine residual urine.
• To allow irrigation of the bladder.
• To bypass an obstruction.
• To relieve retention of urine.
• To enable bladder function tests to be performed.
• To measure urinary output accurately i.e. patient who is in shock,
undergoing bone marrow transplantation or receiving high-dose
chemotherapy.
• To relieve incontinence when no other means is practicable.
• To avoid complications during the insertion of radioactive material

Catheter Types
Type Material Use
Indwelling Urethral Latex, PTFE- coated • for continuous
catheter (Retention or latex, silicone bladder drainage
Foley catheter) elastomer coated, (short, medium or
• a balloon is in 100% silicone, long term)
place (inflated) hydrogel coated • To provide
to keep the continuous
catheter in place irrigation (i.e
• can be 3-way or after
2-way channel prostatectomy)
Intermittent urethral PVC and other plastics • to drain the
catheter (Straight) bladder for
• one channel only shorter periods
(5-10 minutes)

COMPLICATIONS OF CATHETERIZATION

Problem Cause Nursing responsibility

Inability to Urethral mucosal remove the catheter and seek an
tolerate irritation, alternative means of urine drainage
indwelling Psychological trauma Explain the need for and the
catheter Unstable bladder functioning of the catheter
Radiation cystitis

Inadequate Incorrect placement of Resite the catheter

drainage of a catheter Kinked Inspect the system and straighten
urine drainage tubing any kinks
Blocked tubing, for If a three-way catheter, such as a
example pus, urates, Foley, is in place, irrigate it. If an
phosphates, blood ordinary catheter is in use, milk the
clots tubing in an attempt to dislodge the
debris, then attempt a gentle bladder
washout. Failing this, the catheter
will need to be replaced; a three-way
catheter should be used if the
obstruction is being caused by clots
and associated hematuria

Fistula Pressure on the Ensure that correct strapping is used

formation penoscrotal angle

Penile pain on Not allowing enough Ensure that an adequate length is

erection length of catheter to available to accommodate penile
accommodate penile erection
erection
Formation of Increased urethral Correct catheter toilet
crusts around secretions collect at
the urethral the meatus and form
meatus crusts, due to irritation
of urothelium by the
catheter

Unable to Valve expansion or Check the non-return valve on the

deflate balloon displacement inflation/ deflation channel. If
Channel obstruction jammed, use a syringe and needle to
aspirate by means of the inflation
arm above the valve
Obstruction by a foreign body can
sometimes be relieved by the
introduction of a guidewire through
the inflation channel
Inject 3.5 mL of dilute ether solution
(diluted 50/50 with sterile water or
0.9% sodium chloride) into the
inflation arm
Alternatively, the balloon can be
punctured suprapubically using a
needle under ultrasound
visualization
Following catheter removal, the
balloon should be inspected to
ensure it has not disintegrated
Note: steps above should be
attempted by or under the directions
of a urologist. The patient may
require cystoscopy following balloon
deflation to remove any balloon
fragments and to wash the bladder
out

Leakage of Incorrect size of Replace with the correct size, usually

urine around catheter 2 ch smaller
catheter Incorrect balloon size Select catheter with 10 mL balloon
Bladder Use Roberts tipped catheter
hyperirritability As a last resort, bladder
hyperirritability can be reduced by
giving diazepam or anticholinergic
drugs
Dysuria Inflammation of the Ensure a fluid intake of 2–3 litres per
urethral mucosa day. Advise the patient that dysuria
is common but will usually be
resolved once micturition has
occurred at least three times. Inform
medical staff if the problem persists

Retention of May be psychological Encourage the patient to increase

urine fluid intake. Offer the patient a warm
bath. Inform medical staff if the
problem persists
Guidelines for caring of a patient with an indwelling catheter
1. Use an indwelling catheter only when necessary and refer to evidence
based references and clinical facility guidelines in the use of catheter.
2. Use the smallest appropriate-size catheter
-Urethral catheters are measured in charrières (ch) which is the outer
circumference of the catheter in millimeters and is equivalent to three
times the diameter.
Ex. A 12-ch catheter has a diameter of 4 mm. The bigger the catheter,
the more the urethra is dilated
3. Observe aseptic techniques when inserting a catheter.
4. Keep the drainage bag below the level of the patient’s bladder to
maintain drainage of urine and prevent the backflow of urine into the
patient’s bladder that can cause infection
5. Don’t let drainage bag touch the ground and maintain a closed
system. Obtain urine samples using aseptic technique via a closed
system when taking urine samples.
6. Keep catheter tube patent and avoid irrigation, unless necessary to
relieve or prevent obstruction.
7. Empty the drainage bag when one half to two thirds full or every 3 to
6 hours
8. Do not use powders and lotions after cleaning. Do not use antibiotic
or other antimicrobial cleaners or betadine at the urethral meatus.
9. Document properly any observations and procedure done on the
patient’s medical record.
10. Inflating the balloon
• Underinflation of balloon
- may cause dislodgement or occlusion of one or more of the
drainage eyes
• Overinflation
- risk for rupturing the balloon and leaving fragments of it inside
the bladder.
Nursing considerations (when inflating the balloon)
a) Catheter balloons should only be inflated
b) Use sterile water only when filling.
▪ Tap water and 0.9% sodium chloride should not be used as salt
crystals and debris may block the inflation channel
▪ Any micro-organisms which may be present in tap water can
pass through the balloon into the bladder

PROCEDURES IN CATHETERIZATION

1. FEMALE CATHETERIZATION

Equipment in catheterization
• Sterile gloves
• Sterile drapes (one of which is fenestrated)
• Sterile catheter (Use the smallest appropriate-size catheter, usually a
14F to 16F catheter with a 5- to 10- mL balloon
• Antiseptic cleansing solution and cotton balls or gauze squares;
antiseptic swabs
• Lubricant
• Forceps
• Prefilled syringe with sterile water (sufficient to inflate indwelling
catheter balloon)
• Sterile specimen container (if specimen is required)
• Flashlight or lamp
• Waterproof, disposable pad
Sterile, disposable urine collection bag and drainage tubing (may be
connected to catheter in catheter kit) Catheter-securing device
• Disposable gloves
• Additional PPE, as indicated
• Washcloth, skin cleanser, and warm water to perform perineal
hygiene before and after catheterization

Procedure Rationale
1. Review the patient’s chart for any To ensure correct intervention is
limitations in physical activity. implemented
Confirm the medical order for
indwelling catheter insertion.
2. Perform hand hygiene and put on To prevent spread of microorganisms
PPE, if indicated. Gather equipment. Check equipment are complete
3. Identify the patient. To ensure it is the right patient
4. Close curtains around bed and close To provide privacy
the door to the room, if possible.
Discuss the procedure with the
patient and assess the patient’s
ability to assist with the procedure.
Ask the patient if she has any
allergies, especially to latex or iodine.
5. Provide good lighting. Artificial light To see the meatus clearly
is recommended (use of a flashlight
requires an assistant to hold and
position it). Place a trash receptacle
within easy reach.
6. Assemble all equipment within reach For easy accessibility and
convinience
7. Adjust the bed to a comfortable Prevents muscle and back strain of
working height, usually elbow height the nurse
of the Stand on the patient’s right
side if you are right- handed,
patient’s left side if you are left-
handed.
8. Assist the patient to a dorsal
recumbent position with knees
flexed, feet about 2 feet apart, with
her legs abducted. Drape patient.
Alternately, the Sims’, or lateral,
position can be used. Place the
 patient’s buttocks near the edge of
the bed with her shoulders at the
opposite edge and her knees drawn
toward her chest. Allow the patient
to lie on either side, depending on
which position is easiest for the
nurse and best for the patient’s
comfort. Slide waterproof pad under
patient.

Proper positioning allows adequate

visualization of the urinary meatus
and pad prevents wetting the bed
linens

9. Put on clean gloves. Clean the To prevent spread of microorganisms

perineal area with washcloth, skin
cleanser, and warm water, using a
different corner of the washcloth
with each stroke. Wipe from above
orifice downward toward sacrum
(front to back). Rinse and dry.
Remove gloves. Perform hand
hygiene again.
10. Prepare urine drainage setup if a Facilitates connection of the catheter
separate urine collection system is to to the drainage and for easy access
be used. Secure to bed frame
according to manufacturer’s
directions.
11. Open sterile catheterization tray on Prevents transmission of infection
a clean overbed table using sterile
technique.
12. Put on sterile gloves. Grasp upper Drape provides a sterile field close to
corners of drape and unfold drape the meatus.
without touching unsterile areas.
Fold back a corner on each side to
make a cuff over gloved hands. Ask
patient to lift her buttocks and slide
sterile drape under her with gloves
protected by cuff.
13. Based on facility policy, position The drape expands the sterile field
the fenestrated sterile drape. Place a and protects against contamination
fenestrated sterile drape over the
perineal area, exposing the labia.
Place sterile tray on drape between
patient’s thighs.
14. Open all the supplies. Fluff cotton It is necessary to open all supplies
balls in tray before pouring while both hands are sterile
antiseptic solution over them.
Alternately, open package of
antiseptic swabs. Open specimen
container if specimen is to be
obtained.
15. Lubricate 1 to 2 inches of catheter Facilitates easier insertion
tip.
16. With thumb and one finger of
nondominant hand, spread labia and Separating prevents contamination
identify meatus. Be prepared to and easier visualization of meatus
maintain separation of labia with one Nondominant hand is already
hand until catheter is inserted and contaminated at this point
urine is flowing well and
continuously. If the patient is in the
side-lying position, lift the upper
buttock and labia to expose the
urinary meatus.

17. Use the dominant hand to pick up To prevent introducing

a cotton ball or antiseptic swab. microorganisms into the bladder
Clean one labial fold, top to bottom
(from above the meatus down toward
the rectum), then discard the cotton
ball. Using a new cotton ball/swab
for each stroke, continue to clean the
other labial fold, then directly over
the meatus.
18. With your uncontaminated, To facilitate drainage of urine and
dominant hand, place the drainage minimize contamination of sterile
end of the catheter in receptacle. If equipment
the catheter is preattached to sterile
tubing and drainage container
(closed drainage system), position
catheter and setup within easy reach
on sterile field. Ensure that clamp on
drainage bag is closed.
19. Using your dominant hand, hold Applying force on the urethra may
the catheter 2 to 3 inches from the injure mucus membrane the
tip and insert slowly into the sphincter relaxes and can enter the
urethra. Advance the catheter until bladder easily when patient relaxes.
there is a return of urine Advancing the catheter facilitates
(approximately 2 to 3 inches [4.8 to inflation of the balloon without
7.2 cm]). Once urine drains, advance damaging the urethra
catheter another 2 to 3 inches (4.8 to
 7.2 cm). Do not force catheter
through urethra into bladder. Ask
patient to breathe deeply, and rotate
catheter gently if slight resistance is
met as catheter reaches external
sphincter.

20. Hold the catheter securely at the The balloon anchors the catheter in
meatus with your nondominant place in the bladder to prevent
hand. Use your dominant hand to getting dislodged
inflate the catheter balloon. Inject
entire volume of sterile water
supplied in prefilled syringe.

21. Pull gently on catheter after To check positioning and comfort of

balloon is inflated to feel resistance. the patient
22. Attach catheter to drainage system To minimize risk of microorganisms
if not already preattached.

23. Remove equipment and dispose of Proper disposal prevents spread of

it according to facility policy. Discard microorganisms
syringe in sharps container. Wash
and dry the perineal area, as needed.
24. Remove gloves. Secure catheter To prevent trauma to the urethra
tubing to the patient’s inner thigh and meatus from tension on the
with Velcro leg strap or tape. Leave tubing
some slack in catheter for leg
movement.
 25. Assist the patient to a comfortable To promote comfort
position. Cover the patient with bed
linens. Place the bed in the lowest
position.
26. Secure drainage bag below the level Facilitates drainage and prevent
of the bladder. Check that drainage urine backflow
tubing is not kinked and that
movement of side rails does not
interfere with catheter or drainage
bag.
27. Put on clean gloves. Obtain urine To keep specimen sterile
specimen immediately, if needed,
from drainage bag. Label specimen.
Send urine specimen to the
laboratory promptly or refrigerate it.
28. Remove gloves and additional PPE, To prevent transmission of infection
if used. Perform hand hygiene.

2. MALE CATHETERIZATION
Fig. 2.1

Procedure Rationale
1. Review chart for any limitations in To ensure correct intervention is
physical activity. Confirm the implemented
medical order for indwelling
catheter insertion.
2. Perform hand hygiene and put on To prevent spread of
PPE, if indicated. Gather equipment microorganisms
Check equipment are complete
3. Identify the patient. To ensure it is the right patient
4. Close curtains around bed and To provide privacy
close the door to the room, if
possible. Discuss the procedure
with the patient and assess
patient’s ability to assist with the
procedure. Ask the patient if he has
any allergies, especially to latex or
iodine.
5. Provide good lighting. Artificial light To see the meatus clearly
is recommended (use of a flashlight
requires an assistant to hold and
position it). Place a trash receptacle
within easy reach.
6. Assemble equipment within reach For easy accessibility and
convinience
7. Adjust the bed to a comfortable Prevents muscle and back strain
working height, usually elbow of the nurse
height of the caregiver Stand on the
patient’s right side if you are right-
handed, patient’s left side if you are
left-handed.
8. Position the patient on his back Proper positioning allows
with thighs slightly apart. Drape the adequate visualization of the
patient so that only the area around urinary meatus and pad prevents
the penis is exposed. Slide wetting the bed linens
waterproof pad under patient.
9. Put on clean gloves. Clean the To prevent spread of
genital area with washcloth, skin microorganisms
cleanser, and warm water. Clean
the tip of the penis first, moving the
washcloth in a circular motion from
the meatus outward. Wash the
shaft of the penis using down- ward
strokes toward the pubic area.
Rinse and dry. Remove gloves.
Perform hand hygiene again.
10. Prepare urine drainage setup if a For easy access and ensure
separate urine collection system is connection of catheter to
to be used. Secure to bed frame drainage system
according to manufacturer’s
directions.
11. Open sterile catheterization tray Increase efficiency and prevent
on a clean overbed table, using spread of microorganisms
sterile technique.
12. Put on sterile gloves. Open sterile To maintain a sterile area
drape and place on patient’s thighs.
Place fenestrated drape with
 opening over penis. Place catheter
set on or next to patient’s legs on
sterile drape.

13. Open all the supplies. Remove cap Open supplies while both hands
from prefilled sterile saline syringe are sterile
and attach to the balloon inflation
port of the catheter. Open package
of antiseptic swabs Alternately, fluff
cotton balls in tray before pouring
antiseptic solution over them..
Open specimen container if
specimen is to be obtained. Remove
cap from syringe pre- filled with
lubricant.
14. Place drainage end of catheter in prevent spread of
receptacle. If the catheter is microorganisms, lubrication
preattached to sterile tubing and facilitates easier insertion
drainage container (closed drainage
system), position catheter and
setup within easy reach on sterile
field. Ensure that clamp on
drainage bag is closed. Lubricate 1-
2 inches of catheter tip
15. Lift penis with nondominant prevent spread of
hand. Retract foreskin in microorganisms.
uncircumcised patient. Be prepared
to keep this hand in this position Hand touching the penis
until catheter is inserted and urine becomes contaminated
is flowing well and continuously.
Using the dominant hand and the
forceps, pick up a cotton ball or
antiseptic swab. Using a circular
motion, clean the penis, moving
from the meatus down the glans of
the penis. Repeat this cleansing
motion two more times, using a new
cotton ball/swab each time.
Discard each cotton ball/swab after
one use.

16. Hold penis with slight upward To prevent trauma to the meatus
tension and perpendicular to
patient’s body. Use the dominant
hand to pick up
 the lubricant syringe. Gently
insert tip of syringe with
lubricant into urethra and instill
the 10 mL of lubricant
17. Use the dominant hand to pick up Applying force on the urethra
the catheter and hold it an inch or may injure mucus membrane the
two from the tip. Ask the patient to sphincter relaxes and can enter
bear down as if voiding. Insert the bladder easily when patient
catheter tip into meatus. Ask the relaxes. Advancing the catheter
patient to take deep breaths. facilitates inflation of the balloon
Advance the catheter to the without damaging the urethra
bifurcation or “Y” level of the ports.
Do not use force to introduce the
catheter. If the catheter resists
entry, ask patient to breathe deeply
and rotate catheter slightly.

18. Hold the catheter securely at the The balloon anchors the catheter
meatus with your nondominant in place in the bladder to prevent
hand. Use your dominant hand to getting dislodged
inflate the catheter balloon. Inject
the entire volume of sterile water
supplied in the prefilled syringe.
Once the balloon is inflated, the
catheter may be gently pulled back
into place. Replace foreskin over
catheter. Lower penis.
19. Pull gently on catheter after To check positioning and comfort
balloon is inflated to feel resistance. of the patient
Attach catheter to drainage system,
if necessary.
22. Remove equipment and dispose of To prevent spread of
it according to facility policy. microorganisms
Discard syringe in sharps
container. Wash and dry the
perineal area as needed.
23. Remove gloves. Secure catheter To prevent trauma to the urethra
tubing to the patient’s inner thigh and meatus from tension on the
or lower abdomen (with the penis tubing
directed toward the patient’s chest)
with Velcro leg strap or tape. Leave
some slack in catheter for leg
movement.
 24. Assist the patient to a comfortable To promote comfort
position. Cover the patient with bed
linens. Place the bed in the lowest
position.
25. Secure drainage bag below the Facilitates drainage and prevent
level of the bladder. Check that urine backflow
drainage tubing is not kinked and
that movement of side rails does
not interfere with catheter or

drainage bag.
26. Put on clean gloves. Obtain urine To keep specimen sterile
specimen immediately, if needed,
from drainage bag. Label specimen.
Send urine specimen to the
laboratory promptly or refrigerate it.
27. Remove gloves and additional To prevent transmission of
PPE, if used. Perform hand hygiene. infection

Nursing Considerations
a. Be familiar with facility policy on catheterization
b. Ask for assistance from another staff if the patient is unable to secure
desired position for the procedure.
c. If there is no immediate flow of urine after the insertion, try the following:
• Have the patient take a deep breath, which helps to relax the
perineal and abdominal muscles.
• Rotate the catheter slightly, because a drainage hole may be
resting against the bladder wall.
• Raise the head of the patient’s bed to increase pressure in the
bladder area.
• Assess the patient’s intake to check for adequate fluid intake
• Check for catheter and drainage tubing kinks and occlusion.
d. If the catheter cannot be advanced, have the patient take several deep
breaths. Rotate the catheter half a turn and try to advance it. If these
fails, remove the catheter and inform the physician.
e. Lubricant may occlude the catheter lumen. If urine flow does not occur
within a minute of catheter insertion, irrigate the catheter to free the
lumen of lubricant

3. REMOVAL OF CATHETER
• Catheters are usually removed early in the morning so that any
retention problems can be dealt with during the day.
Equipment
• Dressing pack containing sterile towel, gallipot, swab or non-linting gauze
• Needle and syringe for urine specimen, specimen container
• Disposable gloves and apron
• Syringe for deflating balloon
Procedure Rationale
1. Explain procedure to the patient So that patient knows what to expect,
and inform them of potential post- and can plan daily activity.
catheter symptoms, such as
urgency, frequency and
discomfort, which are often
caused by irritation of the urethra
by the catheter
2. Perform hand hygiene and wear To reduce risk of cross-infection
PPE if indicated. Assemble all For easier access of equipment
equipment.
3. If a specimen is required, clamp To obtain an adequate urine sample
below the sampling port until and to assess whether post catheter
sufficient urine collects. Take a antibiotic therapy is needed
catheter specimen of urine using
the sampling port.
4. Wearing gloves, use saline-soaked To reduce risk of infection
gauze to clean the meatus and To help reduce the risk of bacteria
catheter, always swabbing away from the vagina and perineum
from the urethral opening. contaminating the urethra
Note: in women, never clean from the
perineum/vagina towards the
urethra.
5. Release leg support For easier removal of catheter
6. Having checked volume of water in To confirm how much water is in the
balloon use syringe to deflate balloon. To ensure balloon Is
balloon completely deflated before removing
catheter.
7. Ask patient to breathe in and then Male patients should be warned of
out; as patient exhales, gently (but discomfort as the deflated balloon
firmly with continuous traction) passes through the prostate gland
remove catheter To relax pelvic floor muscles
It is advisable to extend the penis as
per the process for insertion to aid
removal
8. Male: clean meatus and make the To maintain patient comfort and
patient comfortable. dignity.
Female: clean area around the
genitalia and make the patient
comfortable.
9. Encourage patient to exercise and To prevent urinary tract infections
to drink 2–3 litres of fluid per day.
10. Dispose of equipment including To prevent environmental
apron and gloves in a clinical contamination
waste bag
11. Wash hands thoroughly with To reduce risk of infection
bactericidal soap and water.
12. Record information in relevant To provide a point of reference or
documents; this should include: comparison in the event of later
• reasons for catheterization queries
• date and time of catheterization
• catheter type, length and size
• amount of water instilled into
the balloon
• batch number and
manufacturer
• any problems negotiated during
the procedure
• a review date to assess the
need for continued
catheterization or date of
change of catheter.

4. BLADDER IRRIGATION
▪ Bladder irrigation is the continuous washing out of the bladder with
sterile fluid, usually 0.9% normal saline using three- way catheters

Fig. 4.1
Indications:
▪ to prevent the formation and retention of blood clots (example
following prostatic surgery (TURBT) or (TURP).
▪ irrigation for the delivery of pharmacological agents
▪ irrigation for candida cystitis
▪ prevention of hematuria following chemotherapy or surgical procedure
Principles of care
▪ patient activity and mobility (catheter positioning, catheter kinking)
▪ diet and fluid intake
▪ standards of patient hygiene
▪ patient’s and/or carer’s ability to care for the catheter

References:
Lynn, P. (2019). Taylor’s Clinical Nursing Skills: A Nursing Process Approach,
5th Edition, Wolters Kluwer

Prepared by:

Marichu N. Guyguyon