NUR 102
Fundamentals of Nursing
Inserting an Indwelling Catheter
Name ______________________________________ Date _______________
Instructor _____________________________________ Results S
Step
1. Review physician’s orders, I & O flow sheet
2. Assess for needed equipment and supplies.
3. Assess status of client (mobility, impairments,
knowledge, etc.),
4. Wash hands, close curtain, turn overbed light on, raise
side rails
5. Raise bed to working height
6. If right handed, stand on left side of bed, face client
7. Lower side rail on working side
8. Clean/clear bedside table, adjust to working heath,
place towards foot of bed, arrange equipment
9. Place waterproof pad/towel under client’s hips
10. Position client. Female: in dorsal recumbent; Male:
supine
11. Fold spread off, place on clean surface
12. Drape client. Female: Place top sheet diamond
fashion over client, with one corner at client’s neck; wrap
side corners over each foot; center corner over perineum.
Male: untuck top sheet from bottom of bed, and fanfold to
perineal area. Cover each leg with a towel.
13. Don disposable gloves, perform perineal care as
needed, remove gloves
14. Raise both top side rails, remove used equipment,
wash hands.
15. Utilize an assistant to manage flash light if necessary.
16. Position sterile catheter kit either at foot of bed
between client’s feet, or on bedside table that is place
across foot of bed. Lower side rail on working side.
Expose perineum.
17. Remove catheter kit from plastic wrap. Fold down top
of plastic wrapper, place appropriately to use for
discarded items.
18. While grasping outside folds of sterile catheter kit,
open flap away from you first; then open two side flaps;
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flap closes to you is opened last. Avoid touching inside of
sterile wrap. One inch all around will be considered
contaminated.
19. If sterile glove package is on top, carefully lift from kit,
place on overbed table or on client’s chest. Avoid
touching inside of kit
20. Grasp underpad by edges only. Place plastic side
down under female client’s hip; place over male client’s
legs just below penis.
21. Don sterile gloves. Don’t’ turn your back on sterile
field.
22. Organize equipment on sterile field. Lift top plastic
tray. Place on sterile field closest to client’ perineum.
Remove cleansing swabs from package, place eon tray.
Squeeze lubricant onto tray. Drop discarded items in
plastic outer wrapper. Don’t contaminate hands.
23. Remove rubber tip from prefilled syringe. Carefully
coil catheter in our hand. Attach syringe to balloon port;
test patency of balloon. Pull water back into syringe,
leave syringe attached to balloon port.
24. Carefully remove outer plastic from catheter.
Lubricate catheter,; avoid occluding draining opening.
Female lubricate 1 -2 inches, male lubricate 5 – 7 inches.
Place catheter in box on top of attached drainage tubing
and GU bag or in tray.
25. Move plastic tray conveniently for cleansing urethral
meatus. Female: With nondominant hand, carefully
retract labia minora, to fully expose urethral meatus.
Maintain position of nondominant hand throughout
procedure. Use a new swab for each cleansing stroke,
discarding each appropriately. First cleanse from clitoris
toward anus, along the far inner labial fold. Next cleanse
down near inner labial fold; and last cleanse directly over
center of urethral meatus. Male; with nondominant hand,
retract foreskin if client is not circumcised. Maintain
position of nondominant hand throughout procedure.
Cleanse in a circular motion from urethral meatus down to
base of glans. Repeat with each swab, discard each
swab.
26. With dominant hand, place box containing catheter on
top of plastic tray, and convenient for catheter insertion.
27. Wit h gloved dominant hand, grasp catheter 3 – 4
inches from catheter tip.
Step
28. Ask client to bear down gently as if to void. Slowly
insert catheter through urethral meatus. Female:
Advance catheter 2 – 3 inches; when urine flow, advance
catheter another 1 -2 inches. Males: Lift penis
perpendicular to client’s body. Insert catheter 7 – 9
inches. When urine flow, advance catheter to Y of
catheter.
29. With nondominant had, grasp catheter at urethral
meatus and hold in place. Don’t allow catheter to slip from
bladder.
30. Using dominate hand, inflate balloon with attach
prefilled syringe. Hold plunger down to prevent water
escaping from balloon. While maintaining pressure on
plunger, twist syringe from balloon port.
31. Gently retract catheter to feel resistance then move
catheter slightly back into bladder. Remove gloves.
32. Anchor catheter to client’s thigh. Female: Lower
client’s leg. Place a wide piece of nonallergenic tape to
inner thigh. Allowing for slack in catheter, place three
strips of narrow tape around catheter, and secure to wide
tape. Male: Anchor connective tubing in a similar fashion
top of thigh, or lower abdomen.
33. Coil excess drainage tubing on edge of mattress, and
clip to bottom sheet. Attach drainage bag to bedframe,
with tubing running in a straight line from mattress.
34. Don clean gloves, perform perineal care. Remove
gloves assess client comfort. Replace top sheet/spread.
Raise both top side rails, lower bed; replace call signal
Wash hands.
35. Remove equipment
36. Document/report to team leader.
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