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Urinary Catheterization

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By Paul Martin, BSN, R.N.

Urinary catheterization is a nursing procedure that is a common practice in various medical settings, including hospitals, outpatient clinics, and home care, and can be temporary or long-term depending on the patient’s condition. The procedure is performed for patients who cannot urinate independently due to surgery, illness, or injury, and it assists in maintaining urinary function and managing specific medical conditions.

Despite the normally sterile urinary tract, introducing microorganisms through this procedure poses a risk of catheter-associated urinary tract infections. Bacteria can ascend from the bladder to the kidneys via the ureters. Even post-catheterization, infection risk remains elevated as natural defense mechanisms, such as flushing microorganisms through voiding, are bypassed. Therefore, maintaining meticulous sterile technique during catheterization is imperative.

Table of Contents

What is Urinary Catheterization?

Urinary catheterization is a medical procedure that involves the insertion of a thin, flexible tube into the bladder through the urethra or a surgical opening in the abdomen. This catheter allows for the drainage of urine from the bladder when normal urine flow is obstructed or when accurate measurement of urine output is required.

Indications

Urinary catheterization is indicated in a variety of clinical situations, including but not limited to:

1. Acute or chronic urinary retention. Inability to empty the bladder naturally due to obstruction, neurological conditions, or weakened bladder muscles.

2. Monitoring urine output. Critical in managing patients in intensive care units or during major surgeries where accurate measurement of urine output is necessary.

3. Collecting sterile urine samples. Necessary when uncontaminated urine specimens are required for diagnostic tests.

4. Perioperative use. During and after surgical procedures, particularly those involving the urinary tract or prolonged surgeries where bladder control may be compromised.

5. Management of severe incontinence. When other treatments are ineffective or impractical, particularly in patients with mobility impairments or severe neurological conditions.

6. Facilitation of healing. In patients with severe open sacral pressure ulcers or perineal wounds to keep the area dry and promote healing.

7. Bladder irrigation. To prevent or manage blood clots or debris in the bladder, especially post-operatively.

Contraindication

Avoid catheterization for the following situations that will further cause injury or complications. These may include:

1. Known or suspected carcinoma of the bladder. Inserting a catheter can potentially cause trauma or bleeding in patients with bladder cancer.

2. Anticoagulation/Antiplatelet Treatment. Patients on anticoagulant or antiplatelet therapy have an increased risk of bleeding, which can lead to uncontrolled hemorrhage during catheter insertion.

3. Acute Prostatitis: Severe inflammation of the prostate gland, as catheterization can exacerbate the condition and cause additional complications.

4. Recent Urethral Surgery: Patients who have undergone recent urethral surgery or have urethral strictures, as catheterization can disrupt the surgical site or worsen the stricture.

5. Severe Urethral Stricture Disease: Narrowing of the urethra that makes catheter insertion difficult or impossible without causing trauma.

Types of Urinary Catheter

Urinary catheters vary in the number of lumens. Some are equipped with balloons to secure the indwelling catheter, while others feature a closed drainage system.

1. Single-Lumen (straight) Catheters: These catheters have one lumen (channel) and are typically used for short-term catheterization such as during surgical procedures or for obtaining a urine sample.

2. Double-Lumen (indwelling) Catheters: Designed for indwelling use, with one lumen for urinary drainage and a second lumen for inflating a balloon to keep the catheter in place.

3. Triple-Lumen Catheters: Used for continuous bladder irrigation or for instilling medications into the bladder. One lumen drains urine, the second inflates the balloon, and the third delivers irrigation fluid.

Supplies and Equipment

Proper urinary catheterization requires specific supplies and equipment to ensure safety and reduce the risk of infection. These include:

  • Sterile Catheters (For males, a urinary catheter size typically ranges from 12 to 16 French (Fr), while for females, it ranges from 10 to 14 French (Fr), selected based on individual anatomical considerations and clinical requirements.)
  • Sterile gloves
  • Antiseptic solution for periurethral cleaning
  • Sterile water-based lubricant
  • 10 mL syringes pre-filled with sterile water for inflating the catheter balloon.
  • Urine drainage bag connected to the catheter
  • Adhesive securement device or tape
  • Urine receptacle
  • Specimen container (if for urine culture)
  • Bath blanket or sheet for draping
  • Standing lamp or flashlight

Inserting Indwelling Foley Catheter

Master the procedure of Foley catheter insertion for males and females, key for accurate urine output monitoring and addressing urinary retention:

1. Explain the procedure to the patient.
Understanding the procedure can also help the patient remain calm and still, reducing the risk of complications.

2. Position the client in a supine position.
Proper positioning (bend the knees gently and promote external rotation of the thighs for female clients) or (extend the knees and hips while gently separating the legs for male clients) provides optimal access to the urethra and facilitates the insertion process.

3. Perform hand hygiene and don sterile gloves.
Maintaining hand hygiene and using sterile gloves are needed to prevent the invasion of pathogens into the urinary tract, thereby lowering the risk of infection, including catheter-associated urinary tract infection (CAUTI).

4. Gather all supplies.
Ensure all required supplies are opened and readily available for the sterile hand (catheter kit, gloves, antiseptic solution, sterile drapes, lubricant, drainage bag). This minimizes the risk of contamination and reduces the time the patient is exposed.

5. For male clients, drape the lower abdomen, leaving the genital area exposed. Secure the drape for accessibility. For females, drape the lower abdomen, exposing the urethral opening.
Draping during catheter insertion maintains sterility by covering non-essential areas, ensuring a clean field for the procedure. It also respects the client’s privacy and dignity by selectively exposing only the necessary anatomical structures.

6. Place the catheter kit on the sterile field; between the legs for female, and either on top of the thighs or between the legs for male.
Positioning the catheter kit in these specific locations facilitates ease of access during the procedure, ensuring efficiency and minimizing contamination risks.

7. Cleanse the urinary meatus:
a. Females: With the nondominant hand, spread the labia to expose the urinary meatus. Using forceps in the other hand, wipe from the pubis to the rectum along the far labia with an antiseptic-soaked cotton ball, then discard. Repeat along the near labia and down the middle with new cotton balls each time.
Clean from front to back, moving from the least contaminated area to the most contaminated, following medical asepsis principles.

b. Males: Using the non-dominant hand, hold the penis at the shaft below the glans, then clean the urethral meatus with circular motions using the dominant hand, starting from the center and moving outward.
Use antiseptic solution to cleanse the penis, focusing on the meatus. This reduces the bacterial load on the skin, minimizing the risk of introducing pathogens during catheter insertion.

8. Apply lubrication to the catheter, using 2.5 to 5 cm (1 to 2 in.) for females and 15 to 17.5 cm (6 to 7 in.) for males.
Females typically require a shorter length of lubrication (2.5 to 5 cm or 1 to 2 in.) because the female urethra is shorter and more accessible. In contrast, males need a longer length of lubrication (15 to 17.5 cm or 6 to 7 in.) due to the longer and more convoluted nature of the male urethra.

9. Hold the catheter 7.5 to 10 cm (3 to 4 inches) from the tip, loosely coiling the rest in palm of the hand. Make sure the urine bag is attached to the catheter.
Holding the catheter near the tip allows for easier manipulation during insertion. Coiling it in the palm prevents the distal end from touching a unsterile area.

10. Insert the catheter:
a. Females: Ask the client to take a slow deep breath; gently insert the catheter through the urethreal meatus as the client exhales. Then advance another 5 to 7.5 cm (2 to 3 inches) until urine flows then release the labia and use the nondominant hand to hold the catheter securely.
Inserting the catheter as the client exhales relaxes the urethral sphincter, making insertion easier. Advancing the catheter further ensures it reaches the bladder for proper urine flow.

b. Males: Hold the penis upward and insert the catheter 7.5 to 10 cm (3 to 4 inches) from its tip into the urethral meatus. Advance it 17 to 22.5 cm (7 to 9 inches) until urine flows. Avoid forcing catheter insertion if resistance is encountered. Lower the penis once the bladder is empty, and for uncircumcised patients, remember to replace the foreskin.
Gradual insertion prevents sudden movements that can cause urethral injury. Inform the client that a burning sensation is felt during catheter insertion into the urethra. Explain that this sensation is normal and will quickly subside.

11. Secure the catheter in position and inflate the balloon with the saline-filled syringe held in the other hand, attach the catheter to the urine drainage system, and secure it to the client’s inner thigh with adhesive tape.
These steps ensure the catheter remains securely in place, allows for free urine drainage, and reduces the risk of trauma while maintaining patient comfort.

12. In case of patient discomfort, deflate the balloon, move the catheter forward by 1 inch, and reinflate it to confirm correct urethral placement.
Securing and inflating the catheter balloon prevents accidental removal from the bladder. Discomfort may signal improper placement in the urethra, so deflating, adjusting, and reinflating the balloon ensures correct positioning, reducing discomfort and potential complications.

13. Hang the urine drainage bag below the level of the bladder by attaching to bed frame. Do not place it on the side rails or the floor. Check that drainage tubing is not kinked.
Keeping drainage bags below bladder level helps maintain urine flow and prevent contamination. Attaching bags to side rails increases the chance of urethral trauma from pulling or accidental dislodgment.

14. Return the client to a comfortable position. Document the amount and characteristics of urine and the client’s response to the procedure.
Returning the client to comfort post-IFC insertion prevents strain, while documenting urine characteristics and client response ensures accurate monitoring for complications like hematuria or discomfort, prompting timely intervention if needed.

Removing the Indwelling Foley Catheter

Explore the essential steps in Foley catheter removal, prioritizing patient comfort and facilitating a smooth transition to natural bladder function.

1. Explain the procedure to the client
Providing information about the catheter removal process helps alleviate patient anxiety and ensures their cooperation during the procedure.

2. Perform hand hygiene and don clean gloves
Proper hand hygiene and wearing clean gloves prevent the introduction of pathogens, reducing the risk of infection.

3. Position the client comfortably and place a waterproof pad under the buttocks.
Ensuring the patient is comfortably positioned, typically in a supine position (males) or dorsal recumbent postion (females), provides optimal access to the catheter and minimizes discomfort. A waterproof pad protects the bedding from potential urine leakage during catheter removal, maintaining cleanliness and patient dignity.

4. Attach a syringe to the balloon port. Deflate the balloon by slowly withdrawing all the sterile water.
Attaching a syringe to the balloon port allows for controlled deflation of the balloon, a key step in safely removing the catheter without causing trauma to the urethra. Slowly withdrawing the sterile water from the balloon ensures it deflates completely, preventing urethral injury during catheter removal.

5. Ask the client to take deep breaths and gently withdraw the catheter.
Encouraging deep breaths helps the patient relax, and gentle withdrawal minimizes discomfort and reduces the risk of urethral trauma.

6. Inspect the catheter for any signs of damage or residual balloon fluid.
Inspecting the catheter ensures that the entire device has been removed intact and that no part of the balloon remains in the bladder, which could cause complications.

7. Dispose of the catheter and gloves properly and perform hand hygiene again
Proper disposal of the used catheter and gloves prevents the spread of infection and maintains a clean environment.

8. Document the procedure in the client’s record.
Accurate documentation provides a record of the procedure, including any observations or complications, and ensures continuity of care.

9. Monitor the client for urinary output and any signs of discomfort or infection.
Monitoring the patient post-removal helps detect any immediate complications such as urinary retention or infection, allowing for prompt intervention if needed. The client may experience burning or irritation the first few times he or she voids after removal, due to urethral irritation.

References and Sources

Paul Martin R.N. brings his wealth of experience from five years as a medical-surgical nurse to his role as a nursing instructor and writer for Nurseslabs, where he shares his expertise in nursing management, emergency care, critical care, infection control, and public health to help students and nurses become the best version of themselves and elevate the nursing profession.

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