Indwelling

Urinary (Foley) Catheterization Female: Barrier, Catheterization Tray, Penlight, 2 Pairs of Clean Gloves, Tape, Towel, Bath Blanket (Optional) 1. Check chart for MD order 2. Knock on door, enter, close door and privacy curtain. 3. Address client, state your name, job title, and skill about to perform. Ask for consent 4. Go to bathroom and wash your hands. 5. Return to room, provide adequate lighting and check ID band (Name, DOB, Allergies latex & betadine) and brakes on bed. 6. Gather equipment and set up on barrier on bedside table. Apply gloves. 7. Explain Procedure. Raise bed to comfort level (warn client so as not to startle) and place client in Supine position. Ask client to tell you if they have any pain currently or experience pain during the procedure. 8. Assist client into dorsal recumbent position being sure to spread legs apart. 9. Lift clients gown (warn client before you expose them) and using penlight visualize urinary meatus, state if perineal area were dirty, you would clean the area from front to back (actually clean if dirty). Place towel and bath blanket under and over client. 10. Remove gloves. Wash hands. 11. Remove catheterization kit from bag, place bag inside out at foot of bed, place kit on bedside table on barrier. 12. Open catheterization kit, grab drape, provide proper placement for drape maintaining sterility (use corners shiny side down, dont touch clients leg, do not reach over sterile field). 13. Don sterile gloves (fix drape placement if necessary), maintain sterility 14. Place catheterization tray between clients legs 15. Prepare tray: a. Open betadine swabs b. Open lube c. Check catheter balloon patency i. Can test in sleeve ii. Roll sleeve onto fingers to maintain control of catheter iii. Can leave catheter in box (sterile) until right before insertion iv. Leave syringe attached, place catheter tip in oil lubricate well 16. Using non-dominant hand, position client to gain access to urinary meatus (warn client you are about to touch them) 17. Clean urinary meatus from front to back three times side away from you, side toward you, down middle. (Warn client betadine will be very cold; upon removing betadine swab from meatus make certain not to go over sterile field so as not to contaminate catheter tip) 18. Maintain sterility of dominant hand. Ask client to take a deep breath or bear down. Insert lubed catheter (upon entering meatus immediately back off hand, insert until urine return in tube, go 1-2 inches more)

Manatee Technical Institute Nursing Skills 2013-2014

19. Hold catheter securely with non-dominant hand, inflate with 5mL of sterile water, ask patient if they feel any discomfort. 20. Remove syringe promptly after inflation (disconnect to prevent syringe refilling, and balloon deflation). Slightly tug catheter to check to ensure proper balloon and catheter placement. 21. Do dirty/dirty clean/clean: Discard dirty linen and equipment. Discard dirty gloves. Apply clean gloves. 22. Cover patient. Secure catheter to inside leg with tape leaving slack for catheter. Reposition client. Educate client: a. Increase fluids, if not contraindicated b. Keep foley bag below waist at all times c. Make sure there are no coils or kinks in tubing allows free flow and proper drainage d. If urge to void felt, just go foley catheter securely in place and will drain urine 23. C.A.B. patient: Call light, Ask if okay, Bed down/Brakes. 24. Tidy work area, pull curtain open, and wash your hands.