EMILIAO AGUINALDO COLLEGE

1113-1117 San Marcelino St. Paco, Manila

College of Nursing

EVALUATION TOOL

Name: _______________________________ Date: ________________

Procedure: Foley Catheter Insertion Female

PREPARATION

LEGEND:

5 Gather correct and complete supplies and equipment.

4 Collect 1 appropriate supply and equipment/ or lacks 1 supply and equipment
3 Collect 1 appropriate supply and equipment/ or lacks 2 supply and equipment
2 Collect 1 appropriate supply and equipment/ or lacks 3 supply and equipment
1 Fails to gather correct and complete supplies/equipment

PREPARATION 5 4 3 2 1 Remarks

1. Equipment
 Moisture proof absorbent pad
 Bath blanket
 Bedpan or commode
 Enema set containing:
- Container to hold the solution
- Tubing
- Clamp
- Rectal tube of the correct size
- Lubricant
- Disposable gloves
- Disposable towel
- Soap suds enema solution

LEGEND:
 4 Very Satisfactory Performed
3 Satisfactory performed
2 Fairly Performed
1 Poorly Performed

PROCEDURE 4 3 2 1 Remarks
1. Gather equipment
2. Explain procedure to the patient what you are going to do, why
is it necessary, and how the client can cooperate
3. Wash hands and observe other appropriate infection control
procedures
4. Provide client privacy
5. Assist the adult client to a left lateral position, with the right
leg as acutely flexed as possible, with the linen under the buttocks.
6. Place the waterproof pad under the client’s buttocks to protect
the bed linen, and drape the client with the bath linen
7. Prepare the equipment
 Lubricate about 5 cm (2 in) of the rectal tube: Lubrication
facilitates insertion through the sphincter and minimizes
trauma.
 Open the clamp, and run some solution through the
connecting tubing and the rectal tube to expel any air in
the tubing; then close clamp

8. Don gloves, and insert the rectal tube

 For clients in the left lateral position, lift the upper buttock
to ensure good visualization of the anus
 Insert the tube smoothly and slowly into the rectum,
directing it towards the umbilicus The angle follows the
normal contour of the rectum. Slow insertion prevents
spasm of the sphincter.
 Insert the tube 7-10 cm (3-4 in) Because the anal canal is
about 2.5 to 5 cm (1 to 2 in.) long in the adult, insertion
to this point places the tip of the tube beyond the anal
sphincter into the rectum.
 If resistance is encountered at the internal sphincter, ask
the client to take a deep breath, then run a small amount of
solution through the tube. This relaxes the internal anal
sphincter
 Never force tube entry. If resistance persists, withdraw the
tube, and report the resistance to the nurse in charge
9. Slowly administer the enema solution
  Raise the solution container, and open the clamp to allow
fluid flow or compress a pliable container by hand
 During most adults low enemas hold the solution no
higher than 30 cm (12 in) above the rectum The higher the
solution container is held above the rectum, the faster the
flow and the greater the force (pressure) in the rectum.
For children, lower the height of the solution container
appropriately for the age of the child
 Administer the fluid slowly. If client complains of fullness
or pain, use clamp to stop the flow for 30 seconds, and
then restart the flow at a slower rate Administering the
enema slowly and stopping the flow momentarily
decreases the likelihood of intestinal spasm and
premature ejection of the solution
 After all of the solution has been instilled or when the
client cannot hold anymore and wants to defecate, close
the clamp, and remove the rectal tube from the anus
 Place the rectal tube in a disposable towel as you withdraw
it
10. Encourage the client to retain the enema.
 Ask the client to remain lying down. It is easier for the
client to retain the enema when lying down than when
sitting or standing, because gravity promotes drainage
and peristalsis.
 Request that the client retain the solution for the
appropriate amount of time, for example, 5 to 10 minutes
for a cleansing enema or at least 30 minutes for a retention
enema.
11. Assist the client to defecate.
 Assist the client to a sitting position on the bedpan,
commode, or toilet. A sitting position facilitates the act of
defecation.
 Ask the client who is using the toilet not to flush it. The
nurse needs to observe the feces.
 If a specimen of feces is required, ask the client to use a
bedpan or commode.
 Remove and discard gloves.
 Perform hand hygiene.

12. Document the type and volume, if appropriate, of enema

given. Describe the results.

GRADING SYSTEM
 Performance Score ___________ x 90%= ___________

Punctuality and Grooming ___________ x 10%= ___________

Total=___________

Evaluated by: Conformed by:

___________________________ _____________________________
Signature over printed name Signature over printed name