COLLEGE OF NURSING

PERFORMANCE EVALUATION TOOL

NCM 109 – CARE OF MOTHER AND CHILD AT RISK OR WITH PROBLEMS (ACUTE AND
CHRONIC)

PROCEDURE: URINARY CATHETERIZATION AND COLLECTION

NAME OF STUDENT :______________________________________ Score:

Block :______ Date:______________

DIRECTIONS:
● The evaluation tool will be discussed by the clinical instructor/s.

● During the discussion, the instructor/s may demonstrate the procedures or may use video viewing for students’
orientation.
● The students should be given sufficient time to prepare for the return demonstration.

● The students will do the return demonstration based on the checklist given.

● The following rating scale shall be used in grading student’s performance:

DONE- able to perform
Perform the procedure safely and accurately in a very consistent and independent manner without
supportive assistance from the instructors.
Perform a difficult action quickly and skillfully
Spends minimal time on task
Focuses on the client while giving care
NOT DONE - unable to perform
Unable to perform the procedure even under close supervision of guidance
Require continuous, supportive, and directive cues
Takes a longer time to complete the procedure.
Performs in an unskilled manner
● At the end of each laboratory session, the instructor/s will give remarks based on the student’s performance per
the procedures indicated.

DONE NOT DONE

1. Checks doctor’s order for the purpose of the procedure (urine

specimen collection, straight catheterization, or indwelling
catheterization).

2. Informs client and explains the procedure and get the consent
before the prep and ask the client if they are aware of the doctors
orders

3. Wash hands.

4. Prepares necessary equipment and supplies:

A. sterile urethral catheter (fr. 16 2-way), sterile or clean kidney
basin and enamel cup, sterile gloves, lubricant, sterile gauze,
betadine, cotton balls, sterile forceps or pick up forceps soaked in
sterile solution, bed protector, flash light or floor lamp, clean
tissue paper.

B. for specimen collection include sterile receptacle bottle.

C. for indwelling catheterization include: adhesive plaster, pair of

scissors urinary drainage bag, sterile syringe (10 cc) with sterile

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water

5. Provides privacy. Closes bed curtains or room curtains.

6. Asks/assists patient to remove underwear or open diaper. Proper

lifting should be done

7. Positions patient: A. female patient in dorsal recumbent position.

8. Places bed protector under the perianal area (Perineal pad)

9. Drapes patient: A. female client: placed blanket in diamond

fashion over client, one corner at client’s neck, side corners over
each side and secured around each thigh, last corner over
perineum.

10. Positions lamp to illuminate perineal area for female patients.

11. Perineal Care

Puts on sterile gloves. (In the absence of a sterile forceps, cleans

the genitalia using the pickup forceps soaked in sterile solution
and cotton balls with betadine before putting on sterile gloves.)

12. Unwraps the sterile pack being careful not to contaminate the
inner surface.

13. Don sterile gloves

14. Prepares lubricant by dropping a few amount on the sterile gauze

(or on the thumb side of the sterile glove of the nondominant
hand.)

15. Attaches syringe and tests balloon by inflating then deflating the
balloon using sterile water. Filled sterile syringe with 10cc sterile
water (ask assistance for sterile water)

16. Exposes the urinary meatus using the non dominant hand.

17. Cleans the area surrounding the meatus using cotton balls with
betadine held in sterile forceps (circular motion for males; rule of
seven for females). Uses one cotton ball per stroke and discards
used cotton balls away from the sterile field.

18. Lubricates the tip of the catheter 2-3 inches being careful not to
plug the opening

19. Instructs client to bear down during initial insertion and to breathe
through the mouth while the catheter is being threaded in

20. Inserts the catheter 2-3 inches into females; 6-9 inches into males
holding the penis at a 45-degree angle until urine flow is noted

21. Performs the following:

For indwelling catheterization: inflates balloon and connects tip of

catheter to the hospicare bag. Secures tubings and hospicare bag

22. For specimen collection: let a few cc passed out first on the kidney
basin, pinches catheter then drains required amount of urine into

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sterile bottle. Re-pinches catheter then drains remaining urine on
the kidney basin.

23. For intermittent catheterization: drains urine continuously on the

kidney basin or enamel cup until bladder is relieved of distention.
May apply pressure over the lower abdomen

24. For removal of catheter:

A. Deflates the balloon (for indwelling catheter).

25. B.Pinches/folds the catheter

26. C. Instructs the client to breathe through the mouth as catheter is

gently pulled out of the meatus.

27. D. Provides clean tissue paper to wipe the genital area.

28. E. Assists client to put on underwear or diaper.

29. Removes bed protector. Removes gloves.

30. Assists client to comfortable position.

31. Discards disposable equipment. Cleanses non disposable

equipment. Washes hands.

32. Documents the following: date, time, procedure done, purpose of

obtaining urine specimen (urinalysis, urine CS), amount, and
characteristic of urine, size and type of catheter used.

TOTAL=32 POINTS

REMARKS:_
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________

EXPECTED LEVEL OF PERFORMANCE

8 to 13 items done: PASS

8 items below done: Repeat the procedure to PASS

Student’s Signature:_______________
Date:__________

Instructor’ Signature:________________
Date:__________

GEN-FM-019 Rev 2 Effective Date 24 July 2023