Scope of Practice: Registered Nurse
Guideline: Discontinuing An Indwelling Urinary Catheter
1. Prompt/encourage the patient to void at least every 3-4 hours during waking hours
2. Measure the voided volume and record
3. Assess the patient for palpable bladder distention and for signs and symptoms of bladder
distention
4. Immediately check the post void residual, preferably with a bladder scan (3EC RN 4130).
5. In and out sterile catheterization, if the residual volume is greater than 250 cc on bladder
scan. Measure the amount of urine and record.
6. If bladder scan is not available, do an in and out sterile catheterization to assess the post
void residual volume
7. Continue to assess post void residuals for 3 days post removal of the catheter
8. Documentation:
Intermittent Catheterization Record C587
Reorder # 415154.
References:
Nursing For Continence, 2nd Edition, Professor Christine Norton PhD, RGN. (1996)
Urinary Incontinence in Adults: Acute and Chronic Management
Clinical Practice Guideline Number 2 (1996 Update)
AHCPR Publication No. 96-0682: March 1996
Appropriate Indications for Chronic Indwelling Catheters
 Urinary retention which is characterized by the following:
 Causes persistent overflow incontinence, symptomatic infections, or renal
dysfunction
 Cannot be corrected surgically or medically
 Cannot or patient prefers not to be managed with intermittent catheterization
Guideline: Discontinuing An Indwelling Urinary Catheter
Reviewed by Dr Radzinski, Urologist
Barbara G. Cassel, RN, BScN, MN, GNC(C), NCA
Advanced Practice Nurse, Respirology
Professional Practice Portfolio
May 14, 2003
 Skin wounds, pressure sores, or irritations that are being contaminated by incontinent urine
 Care of terminally ill or severely impaired for whom bed and clothing changes are
uncomfortable or disruptive
 Preference of patient when patient has not responded to more specific treatments
Excerpted from AMDA's Clinical Practice Guideline: Urinary Incontinence. © 1996 American
Medical Directors Association. All rights reserved.
Guideline: Discontinuing An Indwelling Urinary Catheter
Reviewed by Dr Radzinski, Urologist
Barbara G. Cassel, RN, BScN, MN, GNC(C), NCA
Advanced Practice Nurse, Respirology
Professional Practice Portfolio
May 14, 2003