1. Urinary Catheterization
PREPARED BY:
Laurence Soriano
Haena rose Tamayo
Sandeep Kaur
Pamela Galang

2. REVIEW OF URINARY SYSTEM

3. Urinary elimination depends on the function of the kidneys, ureters, bladder, and urethra
KIDNEYS remove wastes from the blood to form urine.
URETERS transport urine from the kidneys to the bladder.
The BLADDER holds urine until the urge to urinate develops.
Urine leaves the body through the URETHRA.

4. BLADDER - 600 mL of sterile urine.
Feel the urge (150 to 200 mL in an adult and 50 to 100 mL in a child).
2200–2700 mL in 24 hours.
30 mL per hour
clear, straw-coloured, and slightly acidic.
The urethra and bladder are the primary structures involved during insertion of a urinary catheter.

5. Factors Influencing Urinary Elimination
Age
Muscle tone
Surgical
Sociocultural
Fluid intake
Medications
Psychological
Disease
conditions
Diagnostics

6. CATHETERIZATION
Involves introducing a narrow tube through the urethra into the bladder to allow continuous flow of urine into a drainage receptacle.
may be short term (2 weeks or less) or long term (more than 1 month)

7. INDICATIONS OF CATHETERIZATION
TYPE OF CATHETERIZATION
REASON
INTERMITTENT STRAIGHT CATHETERIZATION
Relief of discomfort from acute bladder distention
To obtain a sterile urine specimen
Assessment of post-void residual when a bladder scanner is unavailable. Long-term management of patients with chronic urinary retention from spinal cord injuries, neuromuscular degeneration, or incompetent bladders
Sometimes used to instill a medication

8. TYPE OF CATHETERIZATION
REASON
SHORT-TERM INDWELLING
Relief of urinary obstruction; for example, by enlarged prostate
Perioperatively or postoperatively
Prevention of urethral obstruction caused by blood clots; continuous or intermittent bladder irrigation
Accurate monitoring of urinary output in critically ill patients

9. TYPE OF CATHETERIZATION
REASON
LONG-TERM INDWELLING
Severe urinary retention
Presence of stage III and IV pressure ulcers that cannot heal because of continual incontinence
Terminal illness when bed linen changes are painful for the patient

10. TYPES OF CATHETERIZATION
INTERMITTENT
A straight, single-use
catheter
5 to 10 mins.
Single-lumen
catheters

11. TYPES OF CATHETERIZATION
INDWELLING
remains in place
until a patient is able to
void voluntarily and completely, or as long as accurate measurements are needed.
Double- lumen Catheters,
Triple- lumen Catheters

12. TYPES OF CATHETERIZATION
COUDE
Has a curved tip
Is used for males with
enlarged prostates that partly
obstruct urethra
Less traumatic
Stiffer and easier
to control

13. GUIDELINES FOR APPROPRIATE CATHETER SELECTION

14. Catheter Size based on age
Age(Yr)
Catheter Size (French)
5-8 FR
<5
8-10 FR
5-10
10 FR
10-14
10-16 FR
>14

15. GUIDELINES FOR APPROPRIATE CATHETER SELECTION
adults with an indwelling catheter: 14–16 Fr
5–6 Fr for infants; 8–10 Fr for children; and 12–16 FR for adults or young girls.
Larger catheter diameters increase the risk for urethral trauma
Larger catheters are usually used for urological surgery or in the presence of gross hematuria.
Factors such as latex allergy, history of catheter encrustation, and susceptibility to infection.
Latex catheters with special coatings reduce urethral irritation
Silicone catheters have a larger internal diameter, helpful in frequent catheter changes due to encrustation

16. Indwelling -balloon sizes from 3 mL, for a child, to 30 mL, for continuous bladder irrigation (CBI).
Recommended: adult is a 5-mL balloon
Long-term use of larger balloons (30 mL) has been associated with -increased patient discomfort
- irritation and trauma
-increased risk of catheter expulsion
-incomplete emptying of the bladder
ONLY STERILE WATER -inflate the balloon
LEAKAGE= change in lumen size or use of antispasmodic medication may be warranted.
Catheters should be changed for leaking, blockage, and before obtaining a sterile specimen

17. WAYS TO PREVENT INFECTION IN CATHETERIZED PATIENTS
Hand
Good hand hygiene techniques.
Never
Never allow the spigot on the drainage system to touch a contaminated surface.
Use
Use only sterile technique to collect specimens from a catheter.
Refrain
If the drainage tube becomes disconnected, refrain from touching the ends of the catheter or tubing. Instead, wipe the ends of the tubing or catheter with an antimicrobial solution before reconnecting.
WAYS TO PREVENT INFECTION IN CATHETERIZED PATIENTS

18. Ensure that each patient has a separate receptacle for measuring urine.
Prevent pooling of urine in the tubing and reflux of urine into the bladder.
Avoid raising the drainage bag above the level of the bladder.
If it becomes necessary to raise the bag during transfer of the patient to a bed or stretcher, clamp the tubing or empty the tubing contents into the drainage bag first.
Positioning the tubing above the drainage bag.
Drain all urine from the tubing into the drainage bag

19. Avoid prolonged kinking or clamping of the tubing, which prevents bladder emptying.
Empty the drainage bag at least every eight hours. Encourage fluid intake unless contraindicated.
Tape or secure the catheter appropriately for the patient.
Perform routine perineal hygiene

20. DELEGATION AND COLLABORATION
Inserting a STRAIGHT OR INDWELLING urinary
catheter CANNOT be delegated to unregulated care providers
(UCPs). The nurse directs the UCP to do the following:
Position the patient
Focus lighting for the procedure
Maintain privacy
Aid in the patient's comfort during the procedure

21. DELEGATION AND COLLABORATION
Monitor the patient's intake and output, emptying urine from
the collection bag
Assist with perineal care after catheter insertion
Report abnormal colour, odour, and amount and report if the catheter is leaking or causes pain
Report any patient complaints of discomfort or pressure
Report any fever

22. Catheter kit containing the following sterile items:
Sterile gloves
Prefilled syringe with sterile water for balloon inflation
Antiseptic cleansing solution
Sterile drainage tubing with collection bag
Waterproof drapes (one fenestrated–has an opening in centre of drape)
Lubricant
Forceps
Cotton Balls

23. Catheter kit containing the following sterile items:
Clean gloves, basin with warm water, soap, washcloth, and towel for perineal care
Multipurpose tube holder or tape.
Receptacle or basin (
Specimen container
Sterile drainage tubing and bag (if not included in the kit)
Bath blanket
Waterproof absorbent pad

24. Expected Outcomes: Patient’s bladder is not palpable.
Patient verbalizes absence of abdominal discomfort or bladder pressure or fullness.
urine output of at least 30 mL/hr of urine
less than 30 mL per hour could indicate the following:
The catheter has slipped out of the bladder or is occluded.
Severe dehydration has occurred.
There is a decrease in renal perfusion.
Patient verbalizes the purpose and expectations for the procedure.

25. Evaluation After urinary catheterization, evaluate the following:
Palpate bladder for distention or use bladder scan.
Ask patient to determine patient's level of comfort.
Indwelling catheter:
Observe character and amount of urine in drainage system
Ensure that there is no urine leaking from catheter or tubing connections

26. ASSESSMENT
1. Review patient's medical record, including health care provider's order and nurses' notes
2. Close bedside curtain or door.
3. Assess status of patients:
a. Ask patient when he/she last voided
b. Level of awareness or developmental stage
c. Mobility and physical limitations of patients
d. Patient gender and age
e. Distended bladder
f. Perform hand hygiene. Apply clean gloves. Inspect perineum.
g. Note any pathologic condition that may impair passage of catheter.
h. Allergies

27. ASSESSMENT
4. Assess patients knowledge of the purpose for catheterization.
5. Explain procedure to patient
6. Arrange for extra nursing personnel to assist as necessary.
7. Perform hand hygiene
8. Raise the bed
9. Arrange equipment.
10. Raise the side rail on the opposite side of the bed, and put the side rail down on the working side.
11. Place a waterproof pad under the client.

28. 12. Position the client.
A. Female client:
(1) dorsal recumbent; relax her thighs so that the hips can be rotated externally.
(2) side-lying (Sims’) position with the upper leg flexed at the hip if the client is unable to assume the dorsal recumbent position.
B. Male client:
Assist the client to a supine position with thighs slightly abducted.
13. Drape client.
14. Wearing disposable gloves, provide perineal care.
15. Hand hygiene

29. 16. Open the catheterization kit according to directions, keeping the bottom of the container sterile. 17. Place the plastic bag within reach in which used supplies can be disposed. 18. Put on sterile gloves. 19. Organize supplies on a sterile field. 20. Before inserting an in-dwelling catheter, test the balloon by injecting fluid from the prefilled syringe into the balloon port.

30. 21 Lubricate 2. 5–5 cm of the catheter for female clients and 12. 5–17
21 Lubricate 2.5–5 cm of the catheter for female clients and 12.5–17.5 cm for male clients.
Apply the sterile drape:
A. Female client:
(1) Allow the top edge of the drape to form a cuff over both gloved hands. Place the drape on the bed between the client’s thighs. Slip the cuffed edge just under the client’s buttocks, taking care not to touch the contaminated surface with gloves.
(2) Pick up the fenestrated sterile drape and allow it to unfold without touching any unsterile objects. Apply over the client’s perineum, exposing labia, taking care not to touch the contaminated surface with gloves.

31. B. Male client: First method: -over the thighs and under the penis without completely opening fenestrated drape. Second method: -over the thighs just below the penis. Pick up the fenestrated sterile drape, allow it to unfold without touching any unsterile objects, and drape it over the penis, with the fenestrated slit resting over the penis.

32. 23. Cleanse the urethral meatus. A
23. Cleanse the urethral meatus. A. Female client: - Holding forceps in your sterile dominant hand, pick up a cotton ball saturated with antiseptic solution - Wiping from clitoris toward anus (front to back). Using a new cotton ball for each area B. Male client: - Use forceps to pick up a cotton ball saturated with antiseptic solution, and clean the penis. -circular motion from the urethral meatus down to the base of the glans. - repeat three more times, using a clean cotton ball each .

33. 24. Pick up the catheter with your gloved dominant hand, 7
24. Pick up the catheter with your gloved dominant hand, 7.5–10 cm from the catheter tip. Hold the end of the catheter loosely coiled in the palm of your dominant hand. 25. Insert the catheter. A. Female client: (1) Ask the client to bear down gently as if to void urine, and slowly insert through the urethral meatus. (2) Advance the catheter a total of 5–7.5 cm in an adult or until urine flows out the catheter’s end. When urine appears, advance the catheter another 2.5–5 cm. DO NOT USE FORCE AGAINST RESISTANCE. (3) Slowly inflate the balloon if the indwelling catheter is being used.

34. B. Male client: (1) Lift the client’s penis to position perpendicular to the client’s body, and apply light traction. (2) Ask the client to bear down gently as if to void urine, and slowly insert the catheter through the urethral meatus. (3) Advance the catheter 17–22.5 cm (7–9 inches) in an adult or until urine flows out the catheter’s end. If resistance is felt, withdraw the catheter When urine appears, advance the catheter another 2.5–5 cm. DO NOT USE FORCE AGAINST RESISTANCE. (4) Place the end of the catheter in the urine tray. Inflate the balloon if an in-dwelling catheter is being used. (5) Reduce (or reposition) the foreskin.

35. 26. Collect the urine specimen as needed
26. Collect the urine specimen as needed. Fill the specimen cup or jar to the desired level (20–30 mL) by holding the end of the catheter over the cup with your dominant hand. 27. Allow the client’s bladder to empty fully (about 800–1000 mL) unless institution policy restricts the maximal volume. 28. After inflating the baloon, pull gently. 29. The drainage bag must be below the level of the bladder. Attach the bag to the bed frame; DO NOT PLACE THE BAG ON THE BED’S SIDE RAILS. 30. Anchor the catheter.

36. A. Female client:
(1) inner thigh or abdomen with a strip of non allergenic tape (or multipurpose tube holders with a Velcro strap).
B. Male client:
thigh or lower abdomen (with the penis directed toward the chest).
31. Assist the client to a comfortable position. Perineal care if needed.
32. Remove gloves and dispose of equipment, drapes, and urine in proper receptacles.

37. 33. Perform hand hygiene. 34. Palpate the client’s bladder. 35
33. Perform hand hygiene. 34. Palpate the client’s bladder. 35. Ask whether the client is comfortable Observe the character and amount of urine in the drainage system. 37. Ensure that no urine is leaking from the catheter or tubing connections. 38. Record and report catheterization 39. Initiate intake and output records.

38. Video Catheterization

39. SAFETY CONSIDERATIONS
Regularly assess patient's functional status.
Evaluate a patient's normal pattern of micturition. Consider age.
Patients that need assistance with elimination should have a call bell within easy reach and the offer for assistance made at regular intervals
Explain the importance of Adequate oral intake especially if the patient has an indwelling urinary catheter.

40. SAFETY CONSIDERATIONS
Evaluate urinary output.
Know the average output range for a patient.
Know the signs of dehydration and fluid overload.
Assess a patient's most recent serum electrolyte measurements.
Weigh the patient to determine fluid status. Ask the patient to empty their bladder.
Maintain aseptic (sterile) technique when catheterizing a patient

41. Unexpected Outcomes and Interventions

44. APPLYING CONDOM CATHETER
Condom catheter or penile sheath, is a soft, pliable condomlike sheath
Safe and non-invasive
Soft silicone that reduces friction
Held in place by
adhesive coating of the internal lining of the sheath,
a double-sided self-adhesive strip
a brush-on adhesive applied to the penile shaft
an external strap.
suitable for incontinent patients who have complete
and spontaneous bladder emptying.
associated with less risk for UTI

45. DELEGATION AND COLLABORATION
Applying a condom catheter CAN
BE DELEGATED to a UCP. The nurse directs
the UCP to do the following:
Follow the manufacturer’s directions
for applying the condom catheter and
securing the device
Monitor urine output and record I&O,
if applicable.
Immediately report any redness, swelling,
or skin irritation or breakdown of the glans
penis or penile shaft.

46. •Patient's normal urinary pattern
ASSESSMENT
•Patient's normal urinary pattern
•Patient's ability to voluntarily urinate and degree of continence
•Patient's mental status and functional ability to self-apply device
•Condition of the skin on and surrounding the penis. Use the manufacturer's measuring guide to measure the diameter of penis in a flaccid state. The penile shaft should be at least 2 cm in length to ensure successful application.
•The patient's level of understanding as to the purpose of the condom catheter.
• ALLERGIES to:
Latex or rubber products (or both)
Antiseptic solutions (Betadine),

47. PLANNING-EQUIPMENT Condom catheter kit:
Condom sheath of appropriate size
Skin preparation to protect skin (per manufacturer’s directions)
Securing device
Basin with warm water and soap
Towels and washcloth(s)
Bath blanket
Clean gloves
Hair guard, or scissors and paper towel

48. EXPECTED OUTCOMES EVALUATION
Patient’s skin is free from urine wetness.
Glans and penile shaft are free of skin irritation or breakdown.
Patient explains the purpose of the procedure and what to expect.
EVALUATION
Observe urinary drainage.
Inspect penis with condom catheter in place within 15–30 minutes of application. Assess for swelling and discoloration of the penis, and ask patient if there is any discomfort.
Inspect skin on penile shaft for signs of breakdown or irritation at least daily, when performing hygiene, and before reapplying condom.

49. Unexpected Outcomes and Interventions

52. SPECIMEN COLLECTION Urine samples can be clean or sterile
Strict aseptic technique
A urine specimen can be collected
only from a new sterile urine bag
when an indwelling catheter
is first inserted and connected to the bag.
Always refer to facility policy and manufacturer's recommendations

53. DELEGATION AND COLLABORATION
Sterile urine sample (indwelling catheter ) MAY BE DELEGATED to unregulated care providers (UCPs) familiar with aseptic technique.
Sterile urine sample (straight catheter insertion) is INAPPROPRIATE TO DELEGATE to a UCP.
The nurse informs the UCP about the following:
Proper technique for obtaining the urine sample
When to obtain the specimen
How to appropriately handle and transport the specimen to the laboratory
Reporting to the nurse if the urine is not clear
DELEGATION AND COLLABORATION

54. ASSESSMENT
Assess the patient's or family members' understanding of the need to collect urine. 
Assess for signs and symptoms of urinary tract infection:
Frequency
Urgency
Dysuria
Changes in urine colour and odour
Hematuria (blood in urine)
Flank pain
Fever
Indwelling catheter-
Luer-Lok port- no needle is used; urine is removed with a Luer-Lok syringe.
If it is a self-sealing port, a needle can be used.
For straight catheterization, assess for latex allergy.

55. PLANNING—EQUIPMENT Obtaining a urine specimen from a urinary catheter:
Clean gloves (indwelling catheter); sterile gloves if urine is obtained during straight catheterization
A 3-mL Luer-Lok syringe for needle-free port for culture (indwelling catheters only)
A 20-mL Luer-Lok syringe for routine urinalysis (indwelling catheters only)
Alcohol, chlorhexidine, or other disinfectant swab (indwelling catheters only)
Specimen container
Nonsterile for routine urinalysis
Sterile culture container
A completed identification label with appropriate patient identifiers
A completed laboratory requisition including patient identification, date, time, name of test, and source of culture
Small plastic biohazard bag for delivery of specimen to laboratory (or container specified by facility)

56. PLANNING—EXPECTED OUTCOMES
A urine specimen is obtained from the catheter without contamination.
Patient’s comfort
The urinary catheter and drainage system remain intact.
EVALUATION
Evaluate your patient and the urine itself.
The urine colour, characteristics, and amount
Any discomfort
Compare the results of the patient's laboratory report with normal laboratory values and report any abnormalities to the health care provider.
Indwelling catheter
Observe the urinary drainage system

57. UNEXPECTED OUTCOMES & INTERVENTIONS
Related Interventions
Urine specimen is contaminated during procedure
Obtain a new specimen
Urine does not collect in drainage tube
Offer fluids if permitted to enhance urine production
Urine culture reveals bacterial growth (determined by colony count of more than 10,000 organisms per millilitre)
Report findings to health care provider
Administer medications as ordered
Monitor patient for fever and dysuria
Lumen leading to balloon that holds catheter in bladder is punctured
Notify health care provider
Prepare for removal and insertion of new catheter
Collect specimen

58. Care and Removal of the Indwelling Catheter
Delegation and Collaboration
CARE AND REMOVAL INDWELLING CATHETER- Can be delegated to unregulated care providers (UCPs)
However, the nurse must first assess
patient's status, verify the order, and validate that the UCP is allowed to do so as indicated by facility policy.
The nurse directs the UCP to do the following:
Check size of balloon and syringe needed to deflate balloon
Report: Characteristics of the urine
condition of patient's genital area
bleeding after removal
time and amount of first voiding after removal
Signs of infection (CAUTI)
Signs of UTI after removal

59. ASSESSMENT Observe urinary output and characteristics.
Assess for history or presence of bowel incontinence. 
Observe for any discharge, redness, bleeding, or presence of tissue trauma around the urethral meatus.
Assess patient’s knowledge of catheter care. 
Catheter removal:
Review patient’s medical record, including health care provider’s order and nurses’ notes.
Determine size of catheter inflation balloon by looking at balloon inflation valve. 

60. PLANNING—EQUIPMENT CATHETER CARE
• Clean gloves (needed for care and removal)
Waterproof pad
Bath blanket
Soap, washcloth, basin, and water For removing a catheter, you need the following:
10-mL or larger syringe without needle.
Graduated cylinder to measure urine
Toilet, bedside commode, urine "hat," urinal, or bedpan
Bladder scanner (if indicated)
Washcloth and warm water

61. Genital area is free of secretions, fecal matter, and irritation.
EXPECTED OUTCOMES
CATHETER CARE:
Genital area is free of secretions, fecal matter, and irritation.
Patient will verbalize a feeling of comfort.
CATHETER REMOVAL:
Patient voids at least 150 mL with each voiding, no more than SIX TO EIGHT HOURS after removal.
Patient’ S feeling of complete bladder emptying and absence of discomfort.
Patient will identify signs and symptoms of UTI.

62. Evaluate for signs and symptoms of a UTI.
EVALUATION
 Inspect the catheter and genital area for soiling, irritation, and skin breakdown.
Observe time, and measure the amount of first voiding after catheter removal.
The time of removal and the due-to-void time should be recorded and reported
Evaluate for signs and symptoms of a UTI.

63. UNEXPECTED OUTCOME & INTERVENTIONS
Water from inflation balloon does not return into syringe.
Reposition patient; ensure that catheter is not pinched or kinked.
Remove syringe. Attach new syringe and allow enough time for passive emptying.
Attempt to empty balloon by gently pulling back on the syringe plunger.
If a catheter balloon does not deflate, do not cut balloon inflation valve to drain the water. Notify the health care provider.
Patient has one or a combination of fever, chills, burning, flank pain, back pain, hematuria, painful urination, urgency, frequency, lower abdominal pain, change in mental status, and/or lethargy
Assess for bladder distention and tenderness.
Monitor vital signs and urine output.
Report findings to health care provider; signs and symptoms may indicate a urinary tract infection.

64. UNEXPECTED OUTCOME & INTERVENTIONS
Patient is unable to void after catheter removal, has a sensation of not emptying, strains to void, or experiences small voiding amounts with increasing frequency.
Assess for bladder distention. Ensure adequate intake and privacy, and facilitate urination by relaxation. Assist to normal position to void.
Perform bladder ultrasound scan to assess for excessive urine volume in bladder.
If patient is unable to void within six to eight hours of catheter removal or experiences abdominal pain, notify health care provider.

65. REFERENCES
Potter and Perry (2014) Suction Techniques Retrieved from Elsevier, Canada (2014) Canadian Fundamentals of Nursing Fifth Edition: Urinary Catheterization