I-02. Section: Urological and Renal Care P&P: Foley Catheter Insertion and Care Sterile Technique

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1 Policy: 1. Nurses may insert an indwelling foley catheter into the urethra and bladder of a client with the order of a physician or an RN(EC). The order must specify if the catheter is to be in an out or indwelling. If the order specifies the type of catheter, the size of catheter or the frequency of changing the catheter the nurse must follow these orders or obtain a new order. If the order does not specify the type of catheter, the size of catheter or the frequency of changing the catheter, then the nurse follows commonly accepted best practices. 2. Indwelling catheters must always be inserted using strict aseptic technique. In and out catheterization can be performed using aseptic technique or using clean technique (see Nursing P&P I-03). 3. Nurses may initiate inserting an indwelling or in and out catheter when a client is very near death and requires urinary catheterization as a comfort measure. 4. Nurse Continence Advisors may initiate in and out catheterization as part of an assessment for residual urine. 5. Nurses may insert Coudé tip catheters if a Coudé tip catheter is specifically ordered by the physician or RN(EC). 6. If a urine specimen is required from a client with an indwelling catheter, the nurse obtains the sample from the sample port using a syringe and needle; the system is not opened. 7. The catheter is always replaced when a client is started on antibiotics for a urinary tract infection. 8. Clients and caregivers are not taught to insert indwelling catheters; consult the Director of Professional Practice if an exception to this policy is required. Page 1 of 7

2 Background Information: Ten percent of all urinary catheterizations result in a bladder infection. Strict aseptic technique must be observed when catheterizing a client and indwelling catheters should be removed as soon as they are no longer needed; risk for infection increases with every day that a catheter remains in situ. When replacing a catheter, roll the catheter between your fingers. A crunching sound indicates a buildup of sediment and consideration should be given to changing the catheter more frequently. Generally, increasing the amount of water in the balloon or increasing the size of the catheter does not decrease bypassing of urine. It is no longer necessary to test the integrity of the balloon before inserting the catheter. The balloon should be inflated with the amount of sterile water indicated on the catheter package. Teaching the client and caregiver to care for an indwelling catheter is essential for the prevention of catheter related infections. See CarePartners Client Handout : Caring for your Urinary Catheter at Home Equipment: Sterile catheterization tray Sterile indwelling catheter (usually a 14F or 16F for adult females and 16F-18F for adult males. A 10 cc balloon is used for most adults.) 2-10cc syringes Incontinence pad or towel Sterile gloves Antiseptic solution Sterile 2x2 s Sterile lubricant (water soluble) New drainage tubing and collection bag Tape Page 2 of 7

3 Garbage bag Non-sterile gloves Sterile specimen container, if sample required Procedure Female: 1) Explain procedure to client and caregiver. 2) Perform hand hygiene. 3) Assemble equipment. Ensure that there is adequate lighting. Open new drainage bag and ensure all clamps are closed. 4) Assist client to a supine position with knees flexed. Have client relax thighs so as to externally rotate the hip joints. Legs may be supported with pillows to reduce muscle tension OR position in a side-lying position with upper leg flexed at knee and hip. (The side lying position is associated with a higher risk for infection so use only if necessary). 5) Place incontinence pad or towel under client. 6) Drape client for privacy. 7) Don gloves and wash perineal area with soap and water; rinse and dry. 8) If the client has a catheter already in situ, using an extra syringe slowly remove the water from the catheter balloon and gently remove the catheter. Discard in waste receptacle. 9) Remove gloves and perform hand hygiene. 10) Open catheter tray, using sterile technique. 11) Open the sterile wrap to provide a sterile field. 12) Grasp the sterile absorbent pad on the edges and place it under the client s buttocks, plastic side down being careful to maintain the sterility of the centre of the pad. 13) Don sterile gloves. 14) Drape client with fenestrated towel from catheter tray. 15) Open antiseptic solution and pour over cotton balls. 16) Lubricate 2.5 to 5 cm of the tip of the catheter. Page 3 of 7

4 17) Put the catheter tray with the catheter on the sterile drape between the client s legs. 18) With your non-dominant hand, separate the labia to expose the urethral meatus. Maintain this position throughout the procedure. 19) With your dominant hand, pick up a cotton ball with forceps and cleanse the perineal area, starting at the clitoris and progressing downward past the vagina. 20) Use a clean cotton ball for each stroke and then discard. Cleanse directly over the urethral meatus with the last cotton ball. 21) Instruct the client to breathe deeply to relax the perineal muscles and to overcome resistance to entry.with your dominant hand, gently insert the catheter tip into the urethral meatus until urine flows, and then advance the catheter approximately 2.5 to 5 cm further. 22) Release the labia and hold the catheter securely with non-dominant hand. Obtain urine sample, if needed. 23) Attach a syringe to the sideport lumen of the catheter and slowly inject the appropriate amount of sterile water to inflate the balloon. (use the volume of solution recommended by the manufacturer). If the client complains of sudden pain, aspirate back the solution and advance catheter further. 24) Gently pull the catheter to be sure the balloon is inflated and will hold the catheter in place. 25) Connect the end of the catheter to the drainage tubing and the urinary collection bag. Be careful not to contaminate the end of the catheter or the end of the drainage tubing. 26) Secure the catheter and drainage tubing to prevent tugging. Tape catheter tubing to the inner thigh. Allow for slack so movement does not create tension on the catheter. 27) Discard disposable items as per policy. Page 4 of 7

5 28) Remove gloves and perform hand hygiene. 29) Be sure there are no obstructions or kinks in the tubing, and instruct client in ways to lie in bed with the catheter. 30) Document the following on the client Flow Sheet: The procedure and client response Size and type of catheter inserted Amount of sterile water instilled into the catheter balloon Color, odor, amount and characteristics of client s urine Any unusual outcome such as pain, blood in urine Collection of urine sample, if appropriate Client/caregiver teaching Procedure Male: Note: To reduce the discomfort of catheterization for males the physician or RN(EC) may order lidocaine gel 2%. This is usually provided as a preloaded syringe with an opening appropriate for insertion into the meatus (no needle). To instill, hold the penis firmly and extended, place the tip of the syringe in the meatus, and apply gentle but continuous pressure on the plunger. A gloved finger should be placed at the urethral tip and held for a couple of minutes to allow the anesthetic to take effect. Catheterization Procedure: 1) Explain procedure to client/caregiver. 2) Perform hand hygiene. 3) Assemble equipment. 4) Assist the client to a supine position with knees flexed and separated. Place a towel under client s buttocks. 5) Don non-sterile gloves. Page 5 of 7

6 6) Wash the penis with soap and water. If the client is uncircumcised, retract the foreskin and clean the meatus. Rinse and dry. Drape client for privacy. 7) Remove gloves and perform hand hygiene. 8) Open catheter tray, using sterile technique. 9) Open the sterile wrap to provide a sterile field. 10) Place sterile towel (plastic side down) from the catheter tray under the penis, over the scrotum and thighs. 11) Don sterile gloves. 12) Open antiseptic solution and pour over cotton balls. 13) Liberally lubricate 12.5 to 17.5 cm of the tip of the catheter. 14) Place the catheter tray with the catheter on the sterile drape between the client s legs. 15) With your non-dominant hand, hold the penis upright at approximately a 90 angle to the client s body. Retract the foreskin if the client is not circumcised, and expose the meatus. Maintain this position throughout the procedure. 16) With your dominant hand, pick up a cotton ball with forceps and cleanse the glans with antiseptic solution from the meatus outward. Use a clean cotton ball for each stroke. 17) With your dominant hand, gently insert the catheter tip into the urethral meatus all the way to the bifurcation in the catheter. 18) Some resistance may be felt as the catheter tip meets the external sphincter. Instruct the client to breathe deeply to relax the perineal muscles and to overcome resistance to the entry. Slightly twisting the catheter from side to side while advancing it may help the catheter pass beyond this point; or it may be necessary to withdraw the catheter a short distance and attempt to re-advance it slowly. Insert the catheter as far as possible, right to the bifurcation in the catheter. 19) Obtain urine sample, if needed. Page 6 of 7

7 20) Attach a syringe to the sideport lumen of the catheter and slowly inject the appropriate amount of sterile water to inflate the balloon (follow manufacturer s instructions to determine the correct volume). (Only inflate the balloon if urine is flowing). If the client complains of sudden pain, aspirate back the solution and advance catheter further. 21) Gently pull the catheter to be sure the balloon is inflated. 22) If the client is uncircumcised, place the foreskin back to its previous position to prevent swelling. 23) Connect the end of the catheter to the drainage tubing and the urinary collection bag. Be careful not to contaminate the end of the catheter or the end of the drainage tubing. 24) Secure the catheter and drainage tubing to prevent tugging. Tape the catheter tubing to the top of the thigh or if the client is bedridden, tape to the lower abdomen (with penis directed toward the chest). Allow for slack so movement does not create tension on the catheter. 25) Discard disposable items as per policy. 26) Remove gloves perform hand hygiene. 27) Be sure there are no obstructions or kinks in the tubing, and instruct client in ways to lie in bed with the catheter. 28) Document the following on the client Flow Sheet: The procedure and client response Size and type of catheter Amount of sterile water instilled into the catheter balloon Color, odor, amount and characteristics of client s urine Any unusual outcomes such as pain, blood in urine Collection of urine sample, if appropriate Client/caregiver teaching Page 7 of 7

8 Care of Catheter Drainage Bags Night drainage bags and leg bags may be used for 4 weeks at a time before being replaced. When a night drainage bag is disconnected so that a leg bag can be attached, the end of the tubing should be protected with a cap or sterile gauze. The end of the catheter and the end of the tubing should always be cleaned with alcohol prior to reconnecting the tubing and catheter. It is important to keep the system closed if at all possible to reduce the risk of infection. The caregiver can assume the care of the drainage bags. Teach them to: a. Clean the bag with soap and water. b. Rinse the bag with one part vinegar to five parts water. c. Allow to air dry. Patient Safety Alert: The urethra can be injured if the balloon is inflated in the urethra. Urine return is not a reliable indicator that the balloon is in the bladder. For males, before inflating the balloon, always advance the catheter right to the point where the catheter widens (called the bifurcation). If the client complains of discomfort during inflation of the balloon, stop the procedure immediately and deflate the balloon.and advance the catheter further. Page 8 of 7