Uploaded by Mark Geli

Urinary Catheterization 2020

College of Nursing
Performance Evaluation Tool
INSTRUCTION: Rate the student’s performance utilizing the scale below:
3-Demonstrated procedure accurately, correctly stated rationale.
2-Demonstrated procedure accurately, incomplete rationale stated.
1-Demonstrated procedure inaccurately, incorrect/no rationale stated.
0-Not Demonstrated
1. States the purpose of the procedure.
2. Checks the Physician’s order.
3. Greets the client and introduces self.
4. Identifies client using two identifiers.
5. Explains the procedure to the client.
6. Performs hand hygiene.
7. Provides for client privacy.
8. Assessment:
8.1 Determines the most appropriate
method of catheterization based on
the purpose.
9. Preparation:
9.1 If using catheterization kit, reads the
label carefully to ensure that all
necessary items are included.
9.2 Dons cleans gloves and performs
routine perineal care.
9.3 Locates the urinary meatus relative to
surrounding structures (for women).
9.3 Removes and discard gloves.
9.4. Performs hand hygiene.
10. Places the client in the appropriate
position and drape all areas except the
3 2 1 0
To monitor urinary function,prevent or
relieve bladder distention and provide a
means for irrigating the bladder with fluids
or medication.
Prevents potential errors.
To gain trust of the client.
Which facilitates the procedure and is
more comfortable for client.
Information facilitates acceptance and
compliance in the therapy.
Prevents transmission of microorganism.
Preserves the client’s dignity.
Allows you to clarify misunderstandings
and promotes patient cooperation.
The materials in the kit are arranged in
sequence of use.
Reduces microorganisms near urethral
meatus and allows further opportunity to
visualize perineum and landmarks.
Allows for visualization of the urinary
Prevents transmission of microorganisms.
To reduce the number of microorganisms.
The drape provides a large sterile field.
Female: Supine with knees flexed, feet
about 2 feet apart, and hips slightly
externally rotated, if possible.
Male: Supine, thighs slightly abducted or
11. Establishes adequate lighting. Stands on
the client’s right if right-handed, on the
client’s left left-handed.
Adequate lighting and correct positioning
are crucial for clear visualization of the
urinary meatus.
12. Opens the drainage package and places
the end of the tubing within reach.
13. If agency policy permits, dons gloves and
inject 10-15mL of Xylocaine gel into the
urethra of the male client. Wipe the
underside of the penile shaft to distribute
the gel up to the urethra and wait at least
5 minutes for the gel to take effect before
inserting the catheter.
14. Removes and discards gloves.
14.1 Performs hand hygiene.
15. Opens catheterization kit observing
sterile technique.
16. Places a waterproof drape under the
buttocks for female and under penis for male
without contaminating the center of the drape
with your hands
17. Dons sterile gloves.
18. Organizes the remaining supplies:
18.1Removes specimen container and
place it nearby with the lid loosely
on top.
18.2 Opens lubricant package.
18.3. Soaks cotton balls with antiseptic
19. Attaches prefilled syringe to the
indwelling catheter hub and pretest the
20. Lubricates the catheter 2.5cm-5cm for
females, 15cm-17.5cm for males, and
place it with the drainage end inside the
collection container.
21. Places the fenestrated drape over the
perineum, exposing the urinary meatus.
22. Cleanses the meatus:
22.1 Female:
22.1a. Uses non-dominant hand to
spread the labia to expose meatus.
22.1b. Establishes firm but gentle
pressure on the labia.
22.1c. Holds a cleansing ball with the
forceps in your dominant hand.
22.1d. Wipes side of the labia majora
one at a time with different cleansing
ball in an anteroposterior
direction. Repeats for the labia minora.
22.1e Uses the last cleansing ball to
cleanse directly over the meatus.
22.2 Male
Prepares system for eventual connection
with catheter.
Xylocaine Jelly are used to stop pain and
used to ease pain from skin irritations.
To prevent transmission of micro
To reduce number of microorganisms.
To create environment to prevent the
transfer of microorganisms during sterile
Maintains aseptic techniques during
To prevent transmission of
Retains sterility of inside of container and
prevents spillage of urine.
Maintains principles of surgical asepsis
and organizes work area.
Note: Pretesting of balloon is no longer
recommended because catheters are
pretested during manufacturing and
inflation may distort the balloon leading to
increased trauma(Smith, 2006)
Makes insertion of the catheter by
decreasing friction.
Avoids unnecessary exposure of body
parts and maintains patient’s comfort.
Full retraction prevents contamination of
urethral meatus during cleansing.
Maintain position of non dominant hand
throughout procedure.
Cleansing reduces number of
microorganisms at urethral meatus.
Cleansing for each of the three areas
proceeds from area of least contamination
to that most contamination.
Use of single cotton for each wipe prevents
transfer of microorganisms.
22.2a. Uses non-dominant hand to grasp
the penis just below the glans.
22.2b. Holds the penis firmly upright
with slight tension.
22.2c. Holds a cleansing ball with the
forceps in dominant hand.
22.2d. Wipes from the center of the
meatus in the circular motion
around the glans. Uses a new
cleansing ball and repeat three
more times.
23. Inserts the catheter:
23.1. Grasps the catheter firmly 5cm7.5cm from the tip. Asks the client
to take a slow deep breath and
insert the catheter as the client
exhales. Slight resistance is
expected as the catheter passes
through the sphincter.
22.2 Advances the catheter 5cm farther
after the urine begins to flow
through it.
24. Holds the catheter with the nondominant hand.
25. Inflates the retention balloon with the
designated volume.
25.1Without releasing the catheter holds
the inflation valve between two
fingers of non-dominant hand while
attaching the syringe.
25.2 Inflates with dominant hand. If the
client complains discomfort,
immediately withdraw the instilled
fluid, advance the catheter farther,
and attempt to inflate the balloon
25.3 Pulls gently on the catheter until
resistance is felt to ensure that the
balloon has inflated and to place it
in the trigone of the bladder.
26. Collects urine specimen if needed.
 Straight catheter. Allow 20-30mL. to
flow into the bottle without touching the
catheter to the bottle. Allows the
remaining urine to continue draining
into the urine receptacle. In some cases,
only 750-1,000mL. of urine are to be
drained from the bladder at one time.
Removes the straight catheter when
urine flow stops.
 Indwelling catheter. Pre-attached to a
drainage bag, a specimen may be taken
from the bag this initial time only.
Straightens urethral canal to ease catheter
Relaxation of urethral sphincter and pelvic
floor aids in insertion of catheter.
Cleansing reduces number of
microorganisms at urethral canal.
Cleansing for each of the three areas
proceeds from area of least contamination
to that most contamination.
Relaxation of urethral sphincter and pelvic
floor aids in insertion of catheter
Appearance of urine indicates that the
catheter tip is in bladder or lower
urethra.Further advancement of catheter
ensures bladder placement.
Catheter may be expelled accidentally by
bladder or sphincter contraction.
Inflation of balloon anchors the catheter tip
in place above the bladder outlet to
prevent the catheter’s removal.
If resistance is felt, the catheter balloon is
properly inflated in the bladder.
As always, you should monitor the client’s
condition; if the vital signs change or
bleeding occurs, temporarily stop the flow
of urine and continue when the client’s
condition warrants
Allows sterile specimen to be obtained for
culture analysis.
27. Attaches the drainage end of an
indwelling catheter to the collecting
tubing and bag.
28. Examines and measures the urine.
29. Secures the catheter tubing to the thigh
for female clients or to the upper thigh
or lower abdomen for male clients to
prevent movement on the urethra or
excessive tension or pulling on the
retention balloon.
30. Hangs the bag below the below the level
of the bladder. No tubing should fall
below the top of the bag.
31. Wipes any remaining antiseptic or
lubricant from the perineal area. Replaces
the foreskin if retracted earlier.
32. Places the client to a comfortable
position. Instruct the client on positioning
and moving with catheter in place.
33. Discards all used supplies in appropriate
34. Removes and discard gloves.
35. Performs hand hygiene.
36. Documents the catheterization procedure
including size and relevant findings.
Clinical Instructor
Attaching to the bed frame prevents
accidental pulling of the catheter.
It might contain infectious organisms.
Anchoring catheter to lower abdomen
reduces pressure on urethra, thus
reducing possibility of tissue injury.
In-dwelling catheters the bladder by
Cleaning protects the area from
Provides for client comfort.
Reduces transmission of microorganisms.
Reduces transmission of microorganisms.
Reduces transmission of microorganisms.
Maintains legal record and communicates
with members of health care team
Student’s Signature