University of Colorado Hospital Policy and Procedure
Insertion, Removal and Care of an Indwelling Urinary Catheter
Related Policies and Procedures:
Hand Hygiene – Outside the Surgical Setting
Approved by:
Professional Practice, Policy and Procedure Committee
Effective: 9/04
Revised: 12/12
Description:
This policy provides the procedure to ensure the safe, sterile placement and
removal of the indwelling urinary catheter (IUC). It also provides guidelines for catheter care
and specimen collection from the catheter.
Accountability:
The prescribing provider (e.g. physician, physician assistant, nurse
practitioner) is responsible for writing the order for placement of the IUC. Only properly trained
persons (registered nurse, licensed practical nurse, advanced care partner, emergency medical
technician or paramedic) who know the correct technique of aseptic catheter insertion and
maintenance is responsible for placing an IUC. The above personnel must have demonstrated the
knowledge and skills to perform this procedure as evidenced by verification on a competency
checklist.


Insert IUC only for appropriate indications and leave in place only as long as needed
(HICPAC/CDC Guidelines) (see Appendix A)
Consider using alternatives to IUC as appropriate (e.g. commodes, external catheters for
males, urinals, incontinence pads)
Table of Contents:
A. Policies/Procedures: ................................................................................................................ 2
B. General Insertion Procedures .................................................................................................. 2
C. Female Insertion Procedure .................................................................................................... 2
D. Male Insertion Procedures ...................................................................................................... 3
F. Directions for Removal ........................................................................................................... 4
G. Fill and Pull ............................................................................................................................. 4
H. Bladder Scanning: ................................................................................................................... 4
I. Patient Care and Considerations ............................................................................................. 5
J. Infection Control Considerations ............................................................................................ 5
K. MRI Procedures for Temperature Sensing IUC...................................................................... 6
References: ...................................................................................................................................... 6
Appendix A ..................................................................................................................................... 9
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Insertion, Removal and Care of an Indwelling Urinary Catheter
A. Policies/Procedures:
1. Identify the patient using the required two patient identifiers.
2. Verify that the patient is not allergic to latex, iodine or betadine. If the patient is sensitive
or allergic to latex, replace the catheter in the kit with a silicone catheter. If the patient is
allergic to iodine or betadine, use an alternate cleanser such as chlorhexidine.
3. Gather equipment: IUC kit (use non-latex for patients with latex allergies).
a. Use the smallest size catheter that is appropriate.
b. If temperature sensing IUC is clinically indicated, it should be utilized in the
Operating Room, Emergency Department and Critical Care Units only.
4. Explain the procedure to the patient and maintain the patient’s privacy and dignity.
5. Perform hand hygiene immediately before and after insertion or with any manipulation of
the IUC.
6. Documentation of placement of the foley can be done in the EHR by creating a new
LDA and documenting placement date and time.
B. General Insertion Procedures
1. Visually inspect the product for any imperfections or surface deterioration prior to use. If
any damage is noted or the package has been opened, do not use.
2. Don protective eye wear.
3. Wash the patient’s genital area before the procedure if visibly soiled. Don non-sterile
gloves, wash patient’s genital area with foam body cleanser (4:1 body cleanser), or Ready
cleanse™ wipes. Remove gloves and perform hand hygiene.
4. Using aseptic technique, open the outer plastic wrap to form a sterile field and place the
underpad beneath the patient, plastic side down.
5. Apply non-sterile gloves and cleans genital area with soap provided in IUC kit. Remove
gloves. Perform hand hygiene.
6. Don Sterile gloves
7. Position the sterile fenestrated drape around the patient’s genitalia.
8. Use aseptic technique and sterile equipment for the IUC insertion.
9. Before insertion, dispense the lubricating gel into the kit tray. Remove the plastic sleeve
from the catheter and lock the sterile water syringe into the port. DO NOT PREINFLATE THE BALLOON PRIOR TO INSERTION.
10. Open the antiseptic swab sticks. Use each swab stick for one swipe only in cleansing
genital area.
11. Using the dominant, sterile hand to handle the catheter, cover the tip of the catheter with
lubricant. Insert the IUC through the urethra into the bladder.
a. Instruct the patient to inform the nurse if any discomfort is felt with inflation of the
balloon. If discomfort is felt, the catheter is probably in the urethra and will need to
be deflated and advanced. Inflate the balloon slowly, using the entire 10 mL of sterile
water. Withdraw the catheter slowly to the point of resistance at the bladder neck.
C. Female Insertion Procedure
1. Position female patient into a frog-leg pose.
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2. Separate the labia using the non-dominant hand and visualize the meatus. Cleans with
antiseptic swab sticks, cleanse one side of the labia from top to bottom and discard swab
stick away from the sterile field. Repeat on the opposite side and then wipe down the
middle using the third swab stick.
3. Insert the catheter approximately three inches, wait to see if urine flows, then advance
another 2 inches before inflating balloon.
4. For unconscious female patients or those with decreased sensation (i.e. paralyzed), insert
the catheter slightly further than three inches, to make certain the catheter is in the
bladder.
D. Male Insertion Procedures
1. Position male patients into a supine pose.
2. Retract the foreskin, if present, and hold the shaft of the penis with the non-dominant
hand. Grasp one antiseptic swab stick and using a circular motion, wipe the glans from
the meatus outward. Discard the swab stick away from the sterile field. Repeat with two
more swab sticks. Grasp the penis in an upright position and insert the lubricated catheter
firmly into the meatus, advancing the catheter to the bifurcation at the ‘Y’ of the catheter.
A slight lean toward the umbilicus may be necessary if resistance in advancing the
catheter is met at the prostate.
3. The return of urine does not assure that the catheter is placed correctly in males, since
there is residual urine in the penis. Inserting the catheter to the bifurcation of the Y is the
standard for assurance of proper placement.
4. If the foreskin was retracted, reposition it after placement.
5. If catheter placement is in question (i.e. no urine return or unable to fully insert the
catheter), do not inflate the balloon and contact the physician.
6. If resistance is met, do not attempt forceful catheter insertion; apply continuous gentle
pressure and ask the patient to take slow deep breaths to help relax or instruct the patient
to try to void to open the sphincter and allow the catheter to pass.
E. Complete the Procedure
1. Secure the catheter to the patient’s thigh with hospital-approved catheter securement
device (ie: Stat Lock) to prevent movement, urethral traction, and irritation. To improve
urine flow, some men may need to have the catheter secured slightly upward. For males
with long-term catheters, the catheter should be secured to the abdomen to prevent
damage to the inferior urethra.
2. Position the collection bag to avoid urine reflux into the bladder, kinking, or gross
contamination of the bag. For inpatient setting, position the bag hanger on the bed rail
near the foot of the bed using the clip to secure the drainage tube to the sheet. Keep the
bag below the level of the bladder at all times to prevent the backflow of urine and
decrease the risk for infection. Never leave the catheter hanging to be pulled by the
weight of the bag. Do not leave the bag laying on the floor unless necessary due to patient
positioning (i.e. Trendelenberg position in the Operating Room).
3. Periodic observations of the system should be made to ensure that urine is flowing freely.
If a standing column of urine is observed, check for correct positioning of the bag and
then for a physical obstruction, such as a kink in the tubing.
4. If correct positioning of the bag or removal of physical obstruction does not allow free
flow, the bag may have to be changed.
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Insertion, Removal and Care of an Indwelling Urinary Catheter
F. Directions for Removal
1. Deflate the catheter balloon by negative pressure. Exercise the plunger of a luer-tipped 10
ml syringe by moving up and down within the syringe barrel. Pull back 0.5 ml air in the
syringe to prevent adherence of the plunger to the end of the syringe barrel, then insert
the syringe into the balloon port. (This allows for automatic flow of instilled liquid and
balloon deflation via negative pressure in the syringe.) Never use more force than is
required to make the syringe “stick” in the valve. Use gentle aspiration, only if needed, to
encourage deflation.
2. Allow the pressure within the balloon to push the plunger back and fill the syringe with
water.
3. NEVER FORCE THE WATER INTO THE SYRINGE. Vigorous aspiration may
collapse the inflation lumen, preventing balloon deflation. Allow 30 seconds for the
balloon to deflate.
4. If there is slow or no deflation, re-seat the syringe gently.
5. If the retention balloon still does not deflate, reposition the patient to ensure catheter is
not in traction or compressed within the bladder.
6. If this fails, contact the prescribing provider.
7. Consider alternatives for elimination (e.g. bedside commode, urinals, external catheters,
incontinence pads, nursing rounds to offer elimination options) if the patient is not fully
ambulatory.
G. Fill and Pull
1. Fill and Pull is a procedure ordered by the prescribing provider prior to IUC removal only
for patients who have had surgery around the outlet of their bladder or are experiencing
urethral swelling.
2. Prescribing provider order is required.
3. Using aseptic technique disconnect plastic drainage tube from the indwelling urinary
catheter (IUC).
4. Insert a Toomey tip syringe into the end of the (IUC). Fill bladder with up to 250 mL of
sterile normal saline unless patient complains of pain or discomfort. Notify prescribing
provider if unable to instill 250 mL.
5. Passively deflate the balloon on IUC using a 10 mL syringe; ensure all fluid is removed
from balloon (some catheters are filled with more than 10 mL).
6. Gently remove the IUC.
7. Wait for the patient to void.
8. Immediately after patient urinates, check post void residual (PVR) using bladder scanner.
9. Contact prescribing provider with PVR and voided amount to determine if the patient
needs replacement of IUC catheter or any other interventions (If PVR is more than150
mL, IUC may need to be replaced).
H. Bladder Scanning:
1. If the patient does not void within 4-6 hours of removing the IUC, a bedside bladder scan
ultrasound should be performed.
2. If the bladder volume is less than 500 mL, encourage the patient to void by using
techniques to stimulate bladder reflex (cold water to abdomen, stroke inner thigh, run
water, flush toilet). Continue to assess the patient and repeat the bladder scan in 2 hours
if the patient has not voided.
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3. If the bladder volume is greater than 500 mL, catheterize for residual urine volume rather
than place an IUC.
I. Patient Care and Considerations
1. Always use aseptic technique and sterile equipment when inserting a IUC Document the
following:
a. Indication for IUC insertion
b. Date and time of IUC insertion
c. Name and credentials of who inserted IUC if other than person documenting
procedure.
d. Procedure, including the size of the catheter placed, the color, amount, and clarity of
urine returned after the initial placement, and patient response.
e. Catheter removal.
f. Use of the bladder scanner, amount of residual volume, need for intermittent
catheterization.
2. Record urine output as ordered.
3. Assess the patient for pain during and after procedure. Provide pain relief measures as
indicated and document response.
J. Infection Control Considerations
1. Perform hand hygiene immediately before and after any manipulation of the catheter site
or drainage bag.
2. Clean the perineal area and catheter tubing in a proximal to distal motion, with foam
body cleanser (4:1 body cleanser) or Ready cleanse™ wipes daily and after every bowel
movement. The periurethral area should not be aggressively cleansed with antiseptic
solutions as this can lead to aggravation and increase the likelihood of infection. The
nurse should provide daily reminders to the prescribing provider recommending the
removal of the IUC (unless the IUC is still indicated). See Appendix A for indications for
continued IUC usage. Provide patient and family education regarding the benefits of
removing the IUC. Encourage use of the bedside commode or bathroom within 4-6 hours
after IUC removal.
3. For daily care and maintenance, use a chlorhexidine gluconate wipe (CHG) wipe to clean
the perineum and wipe down the catheter. If the patient has gross contamination with
stool or other body fluids, first cleanse the perineum with 4:1 foam cleanser, followed by
CHG wipes. All CHG clothes should be disposed of in the trash, never flushed. When
applying lotion, only use CHG compatible products such as dimethicone skin protectant,
or calazime ointment. Never microwave CHG cloths, as this will deactivate the CHG.If
redness or broken skin such as IAD or burns are present, discontinue use of CHG wipes,
as this can further irritate skin. Documentation of use CHG wipes can be done in two
places in the EHR. Under the interventions tab in the Hygiene section or under the LDA
tab for urethral catheter care.
4. To obtain a urine specimen, clean the sample port with alcohol and aspirate urine using a
10 mL syringe.
5. A sterile, continuously closed drainage system should be maintained. If the catheter must
be disconnected from the tubing, disinfect the catheter-tubing junction before separating.
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6. Empty the collection bag at least every 8 hours, when the drainage bag is 2/3 full to avoid
traction on the catheter from the weight of the drainage bag and prior to
transporting/ambulating patient to prevent infection. Take care not to contaminate the
drainage port by touching the collection container or floor when emptying.
7. When transporting patient, maintain position of drainage bag below the level of the
patient’s bladder, to prevent reflux of contaminated urine from the bag to the bladder.
Transport personnel should be instructed to wash their hands prior to transporting a
patient with an IUC. The catheter bag should be empty prior to transport to prevent
reflux.
8. If possible, do not place more than one patient with a urinary catheter in the same room to
prevent cross contamination.
9. If IUC is to remain indwelling for greater than 30 days, obtain an order for IUC and bag
change at 30 day intervals.
10. Do not irrigate an IUC unless indicated for post urology /genitourinary trauma, surgery,
or to relieve obstruction.
K. MRI Procedures for Temperature Sensing IUC
1. Bard Latex Free Temp Sensing IUCs and the Latex Temp Sensing IUC are MRI
compatible.
a. The IUC with temperature sensor should not be connected to the temperature
monitoring equipment during the MRI procedure.
2. If the IUC with temperature sensor has a removable catheter connector cable, it should be
disconnected prior to the MRI procedure.
3. Electrically conductive material that must remain in the bore of the MRI system should
be prevented from contacting the patient through the appropriate use of thermal and /or
electrical insulation between the material and the patient.
4. The catheter should be positioned in a straight configuration down the center of the
patient table to prevent cross points and conductive loops or coils.
5. The wire and connector of the catheter should be positioned so that it is not in contact
with the patient during the MRI procedure.
6. To prevent excessive movement of the clamp located on the outlet tube, the clamp should
be fixed in position using appropriate means (e.g. tape).
7. MRI technologists will refer to Conditions 5 and 6 referenced in the current edition of the
Reference Manual for Magnetic Resonance Safety, Implants, and Devices by Frank G.
Shellock, Ph.D., regarding the Temp Sensing Catheters.
References:
1. Ackley, B.J., Ladwig, G.B., Swan, B.A. & Tucker, S.J. (2008). Evidence-Based Nursing
Care Guidelines: Medical Surgical Interventions. St. Louis: Mosby Elsevier. (LOE VI)
2. Apisarnthanarak, A., et al. (2006). Effectiveness of multifaceted hospital wide quality
improvement programs featuring an intervention to remove unnecessary urinary catheters at
a tertiary care center in Thailand. Infection Control and Hospital Epidemiology, 28 (7), 791798. (LOE V)
3. BARD Instructional Video. Preventing UTI: Care and Catheterization Techniques. 2010.
(LOE VI).
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4. Boccola A. Mark, Sharma, Anant et al. The Infusion Method Trial of Void vs. Standard
Catheter Removal in the Outpatient Setting: A Prospective Randomized Trial. 2011 BJUI
Supplements 3, 43-46 (LOE II)
5. Ingber M, Sandip V, Moore C, et al. Force of Stream after Sling Therapy and Efficacy of
Rapid Discharge Care Pathway Based on Subjective Patient Report. 2011 The Journal of
Urology 185,
993-997 (LOE IV)
6. Johnson D, Lineweaver L, Maze L.M. (2009) Patients’ bath basins as potential sources of
infection: A multicenter sampling study. AJCC 18(1); 31-40 (LOE III)
7. Kleeman S, Goldwasser S, et al. Predicting Postoperative Voiding Efficiency After Operation
for Incontinence and Prolapse. 2002 Division of Urogynecology and Reconstructive Pelvic
Surgery 187 (1) 49-52 (LOE IV)
8. Lee, Y. Y., Tsay, W. L., Lou, M. F., & Dai, Y. T. (2006). The effectiveness of implementing
a bladder ultrasound program in non-surgical units. Journal of Advanced Nursing, 57 (2),
192-200. (LOE III)
9. Lo, E., et al. (2008). Strategies to prevent catheter-associated urinary tract infections in acute
care hospitals. Infection Control and Hospital Epidemiology, 29 (supplement 1), S41-S50.
(LOE I)
10. Makic M.B, VonRueden K.T., Rauen C.A., Chadwick J. (2011) Evidence-based practice
habits: Putting more sacred cows out to pasture. Critical Care Nurse 31(2); 38-62 (LOE VI)
11. Powers J, Peed J, Burns L, et al. (2012) Chlorhexidine bathing and microbial contamination
in patients’ bath basins. AJCC 21(5); 339-342 (LOE IV)
12. Robinson, S. et al. (2007). Development of an evidence-based protocol for reduction of
indwelling urinary catheter usage. MedSurg Nursing, 16 (3), 157-161. (LOE VI)
13. Society of Urologic Nurses and Associates (SUNA) Clinical Practice Guidelines Task Force.
(2006). Care of the patient with an indwelling catheter. Urologic Nursing, 26(10): 80-81.
(LOE VI)
14. Shellock, Frank G. (2011). Reference Manual for Magnetic Resonance Safety, Implants, and
Devices: 2011 Edition, pp 267-272, p 407. Biometical Research Publishing Group, Los
Angeles, CA . (LOE VI)
15. Sievert D, Armola R, Halm M.A. (2011) Chlorhexidine gluconate bathing: does it decrease
hospital-acquired infections? AJCC 20(2); 166-170 (LOE I)
16. Gould CV, Umscheid CA, Agarwal RK, Kuntz G, Pegues DA. Guideline for Prevention of
Catheter-Associated Urinary Tract Infections: Healthcare Infection Control Practices
Advisory
Committee
(HICPAC).
2009
pp
1-67.
Available
at:
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf (LOE V)
17. Hooten TM, Bradley SF, Cardenas DD, Colgan R, Geerlings SE, Rice JC, et al. Diagnosis,
prevention, and treatment of catheter-associated urinary tract infection in adults: 2009
international clinical practice guidelines from the Infectious Diseases Society of America.
Clinical Infectious Diseases 2010;50:625-663. (LOE V)
18. Gray M. Reducing catheter-associated urinary tract infection in the critical care unit. AACN
Advanced Critical Care, 2010;21(2):247-257. (LOE V)
19. Parker D, Callan L, Harwood J, Thompson DL, Wilde M, Gray M. Nursing interventions to
reduce the risk of catheter-associated urinary tract infection: Part 1: Catheter selection. J
Wound Ostomy Continence Nurs.2009;36(1):23-34. (LOE V)
20. Willson M, Wilde M, Webb ML, Thompson DL, Parker D, Harwood J, Callan L, Gray M.
Nursing interventions to deduce the risk of catheter-associated urinary tract infection: Part 2:
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Staff education, monitoring, and care techniques J Wound Ostomy Continence Nurs.
2009;36(2):137-154. (LOE V)
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Appendix A
Algorithm for Appropriate Insertions of Indwelling Urinary Catheters
Admission/Shift change assessment of Urine Output Management
Is there a need for an indwelling urinary catheter?
Please read the following criteria for appropriate use of Foley catheter and
check your reason for ordering the Foley catheter for this patient.
Drainage:
 Urinary obstruction (distal urinary tract)
 Urinary retention (not managed with intermittent
catheterization)
Monitoring:
 Alteration in the blood pressure or volume status
(unstable patient) requiring urine volume measurement.
 Accurate monitoring of intake and output in a patient
unable to cooperate with urine collection by other means.
Peri-procedure:  Preoperative insertion for emergency surgery
 Major trauma patients
 Placement by urology for procedure or surgery
Therapy:
 Continuous bladder irrigation
 Management of urinary incontinence with stage 3 or
greater pressure ulcerations
 Comfort care for the terminally ill
YES, the reason appears above.
NO, the reason does not appear
Insert catheter
above. (A catheter may not be
indicated for this patient.)
Consider:
Re-evaluate continued need
each shift.
Consider removal if indications
no longer met.
1.
2.
3.
4.
5.
6.
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Straight Catheterization (for
Sterile specimen if needed)
Commode
Urinal
Bed pan
Incontinence Pads
Toileting with assistance
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