Policy & Procedure
Shiawassee County Medical Care Facility
Approved by Social Services Board
Date: 12/31/99
Revised: 3/11/2011
Catheter (Indwelling), Insertion and Removal of
(Female and Male)
Basic Responsibility: Licensed Nurse
If performed by individuals other than those listed in Basic Responsibility, check all that apply.
Procedure Performed by: CENA LPN RN
Purpose
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To provide continuous drainage of the urinary bladder.
To prevent contact of urine with open areas on the body.
To obtain accurate measurement of urinary output.
To obtain sterile specimen for diagnostic purposes.
To instill medication into the bladder.
General Resident Rights Guidelines
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If resident is in his/her room, knock on the door, wait for a response and identify yourself.
Identify resident and explain reason for procedure.
Explain benefits of the procedure to the resident.
Explain safety measures of the procedure to the resident.
Explain the adverse effects and/or complications of the procedure to the resident.
Place call light within reach and instruct resident to call for assistance, if needed.
Screen and drape resident for maximum privacy.
Include resident’s family and surrogate health care decision-makers in care planning
when possible.
General Guidelines for Assessment may include, but are not limited to:
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Level of mobility.
Color, consistency, amount of urine.
Condition of skin.
Any pain, burning, discomfort.
Level of activity.
Nutritional intake.
Hydration and fluid balance status.
General Infection Control Guidelines
1. Observe (standard) universal precautions or other infection control standards as
approved by appropriate facility committee.
2. Wash your hands before and after all procedures.
3. Gather equipment, maintaining sterility and cleanliness.
4. Dry skin well after procedure.
5. Dispose of disposable equipment appropriately.
6. Thoroughly clean all equipment used and return to appropriate storage area.
7. Dispose of soiled linen appropriately.
Insertion of Indwelling Catheter
Equipment
1. Sterile, disposable indwelling catheterization tray.
2. Sterile, indwelling (Foley) catheter in the size ordered by the physician.
3. Protective bed pad.
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Policy & Procedure
4.
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Catheter strap.
Medication if ordered.
Sterile specimen container and label as indicated.
Urinary drainage bag.
Connecting tubing, if not supplied with urinary drainage bag.
Procedure
1. Assist resident to dorsal recumbent position and drape to expose perineum only.
2. Lift sterile tray from plastic cover (DO NOT CONTAMINATE) and place on dry, working
surface.
3. Open sterile wrap.
4. If catheter is packaged separately, open and place on sterile field.
5. Position protective bed pad.
6. Put on sterile gloves.
7. Open antiseptic solution and pour over cotton balls.
8. Follow procedure for insertion of straight catheter for male or female resident.
9. Advance catheter one to one and one-half inches beyond the point of free flow of urine.
10. Check size of balloon; draw up sterile water to this amount. (If not using prefilled syringe)
attach the syringe to the balloon port on the catheter.
11. Note: A three-way irrigation catheter may be used. If so, check markings on ends of ports
to determine balloon port and irrigation port.
12. Do not force water into balloon. If resistance is encountered or the resident complains of
pain, deflate balloon, advance farther into the bladder and inflate.
13. Tug gently on catheter until you feel resistance. Secure to leg with catheter strap. Allow
sufficient slack for adequate movement.
14. At no time should the tubing be placed above the level of the bladder to allow back flow
of urine into the bladder.
15. Secure urinary drainage bag below the level of the bladder and keep off the floor at all
times. Coil extra tubing and secure with catheter strap.
16. Wash and dry the resident well and leave in comfortable position with call light within
reach.
17. If specimen is required, complete laboratory request form. Label bottle with resident’s
name, hospital number, date and physician.
18. Place specimen in proper refrigerator and record proper information in laboratory log.
Notify laboratory that the specimen is ready for pick up.
19. Dispose of equipment properly.
Removal of Indwelling Catheter
Equipment
1. Disposable gloves.
2. Syringe (same capacity as balloon of catheter).
3. Emesis basin.
Procedure
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Check physician’s order for discontinuance of catheter.
Collect equipment and bring to bedside.
Identify resident and explain procedure; screen for privacy.
Assist resident to dorsal recumbent position and drape to expose perineum only.
Place protective bed pad beneath resident’s buttocks.
Remove catheter strap.
Put on disposable gloves.
Attach syringe to balloon port of catheter and aspirate entire amount of sterile water in
balloon.
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Policy & Procedure
9. Pinch catheter and withdraw gently and slowly and place in emesis basin.
10. Give peri-care and leave resident clean and comfortable with call light in reach.
11. If specimen is required, collect in sterile container directly from the end of the catheter
prior to removal (NOT THE DRAINAGE BAG) and complete laboratory request form.
Label bottle with resident’s name, hospital number, date and physician.
12. Place specimen in proper refrigerator and record proper information in laboratory log.
Notify laboratory that the specimen is ready for pick up.
Possible Related Minimum Data Set Triggers
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ADL function/rehabilitation potential.
Urinary incontinence and indwelling catheter.
Psychosocial well-being.
Dehydration/fluid maintenance.
General Documentation Guidelines
1. Date, time, procedure, amount of urine obtained, color, consistency, odor, and presence
of blood, pus or anything unusual.
2. How well resident tolerated procedure.
3. Signature and title.
General Resident Care Plan Documentation Guidelines
Enter the catheter insertion/instillation as an approach under the appropriate underlying problem
on the resident’s care plan.
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