FOLEY CATHETERIZATION RET.DEM

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Republic of the Philippines
NUEVA ECIJA UNIVERSITY OF SCIENCE AND TECHNOLOGY
General Tinio, Cabanatuan City, Nueva Ecija
Clinical Learning Skills Laboratory
CARE OF MOTHER, CHILD, AND ADOLESCENT (NCM 107)
CHECKLIST:
FOLEY CATHETER INSERTION
Name: ______________________________________________________________ Score:
Block: ________________________ Date:____________________________
PROCEDURE
Performed Comments
YES NO
ASSESSMENT
1. Assess:
 Determine the most appropriate method of
catheterization based on the purpose and size of
catheter to be used.
 Assess the client’s overall condition.
 Determine when the client last voided or was last
catheterized.
2. Determine:
 If catheterizationisbeingperformedbecausethe client
has been unable to void, when possible, complete a
bladder scan to assess the amount of urine present in
the bladder.
PLANNING
1.  Allow adequate time to perform the catheterization.
 Some clients may feel uncomfortable being
catheterizedbynursesof the opposite gender.If thisis
the case, obtain the client’s permission. Also consider
whetheragencypolicy requiresorencourageshavinga
person of the client’s same gender present for the
procedure.
Equipment:
■ Sterile catheter of appropriate size
• Sterile gloves
• Waterproof drape(s)
• Antiseptic solution
• Cleansing balls
• Forceps
• Water-soluble lubricant
• Urine receptacle
• Specimen container
■ For an indwelling catheter:
• Syringe prefilled with sterile water in amount specified by
catheter manufacturer (10cc Syringe)
• Collection bag and tubing
■ 5–10 mL 2% Xylocaine gel orwater-soluble lubricantformale
urethral injection (if agency permits)
■ Clean gloves

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■ Supplies for performing perineal cleansing
■ Bath blanket or sheet for draping the client
■ Adequate lighting(Obtain a flashlight or lamp if necessary.)
IMPLEMENTATION
1. Priorto performingthe procedure,introduce self andverify
the client’sidentityusingagencyprotocol.Explaintothe client
whatyou are goingto do,whyit isnecessary,andhow he or
she can participate.
2. Performhand hygiene andobserve appropriate infection
control procedures
3. Provide forclientprivacy
4. Place the clientin the appropriate positionand drape all
areas exceptthe perineum.
a. Female:supine withkneesflexed,feetabout2feetapart,
and hipsslightlyexternallyrotated,if possible
b. Male:supine,thighsslightlyabductedorapart
5. Establishadequate lighting. Standon the client’srightif you
are right-handed, onthe client’sleftif youare left-handed.
6. Applysterile gloves
7. Attach the prefilledsyringe tothe indwellingcatheterinflation
hub.Applyagencypolicyregardingpretestingof the balloon.
8. Lubricate the catheter2.5 to 5 cm (1 to 2 in.) forfemales,15to
17.5 cm (6 to 7 in.) formales,andplace itwiththe drainage
endinside the collectioncontainer.
9. If desired,place the fenestrateddrape overthe perineum,
exposingthe urinary meatus.
10 Cleanse the meatus.
Note:The nondominanthandisconsideredcontaminated
once it touchesthe client’sskin.
11. Insert the catheter.
• Grasp the catheterfirmly5 to 7.5 cm (2 to 3 in.) fromthe tip.
Askthe clientto take a slowdeepbreathandinsertthe
catheteras the clientexhales.Slightresistance isexpectedas
the catheterpassesthroughthe sphincter.If necessary,twist
the catheteror holdpressure onthe catheteruntil the
sphincterrelaxes.
• Advance the catheter5 cm (2 in.) fartherafterthe urine
beginstoflowthroughit.
12. Holdthe catheterwiththe nondominanthand.
13. For an indwellingcatheter,inflate the retentionballoonwith
the designatedvolume.
• Withoutreleasingthe catheter(and,forfemales,without
releasingthe labia),holdthe inflationvalve betweentwo
fingersof yournondominanthandwhileyouattach the
syringe (if notleftattachedearlier) andinflate withyour
dominanthand.If the clientcomplainsof discomfort,
immediatelywithdrawthe instilledfluid,advance the catheter
farther,andattemptto inflate the balloonagain.

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Remarks:
_________________________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
RatingScale:
Excellent : 96 – 100%
Very Satisfactory : 90 – 95%
Very Good : 85 – 89%
Good : 80 – 84%
Fair : 75 – 79%
Poor : 74 and below
__________________________________________________
Student’sPrintedName and Signature
______________________________________
SkillsLaboratoryInstructor
PrintedName and Signature
• Pull gentlyonthe catheteruntil resistance isfelttoensure
that the balloonhasinflatedandtoplace itin the trigone of
the bladder
14. Wipe anyremainingantisepticorlubricantfromthe perineal
area.Replace the foreskinif retractedearlier.Returnthe client
to a comfortable position.Instructthe clientonpositioning
and movingwiththe catheterinplace.
15. Discard all usedsuppliesinappropriate receptacles.
16. Remove anddiscardgloves.Performhandhygiene.
EVALUATION AND DOCUMENTATION
17. Documentthe catheterizationprocedure includingcatheter
size andresultsinthe clientrecordusingformsor checklists
supplementedbynarrative noteswhenappropriate.
18. Notifythe primarycare providerof the catheterizationresults.
19. Performa detailedfollow-upbasedonfindingsthatdeviated
fromexpectedornormal forthe client.
20. Teach the clienthowtocare for the indwellingcatheter,to
drinkmore fluids,andprovide otherappropriateinstructions.
TOTAL