Nursing Services Manual

URINARY (URETHRAL) CATHETERIZATION PROCEDURE / PROTOCOL

PURPOSE

SUPPORTIVE
DATA

To outline nursing responsibilities/management of Urinary Catheters.

Steps of Urethral Catheterization (male & female)................Page 2
Use/insertion of COUDE catheter.........................................Page 3
Obtaining Urine Specimen...Page 3
Intermittent Irrigation of Urinary Catheter...Page 4
Catheter Care..Page 4
Removal of Urinary (Urethral) Catheter..Page 4
Continuous Bladder Irrigation (CBI) set up/initiation............Page 5
Catheter Leg BagPage 6

Criteria/Indications for insertion of Urinary Catheters are: use only when necessaryurinary retention, pre/intra/post-operative drainage of urine, epidural catheter, clinical
need/trauma/unstable, medications, accurate/strict output, protect open sacral/perineal
wound if incontinent, provide comfort care in the terminally ill. Catheter Associated
Urinary Tract Infections (CAUTI) Risk Factors include prolonged catheterization, female
gender, inserting the catheter outside the operating room, diabetes, malnutrition, renal
insufficiency, abnormal creatinine level, older age, fecal incontinence, co-existing
infection, absence of antibiotics, faulty aseptic management of catheter, bacterial
colonization of collection bag. Non-Latex catheters are available.
Urinary catheters should be removed as soon as possible as longer indwelling time
leads to higher risk of biofilm (bacteria adhere to and multiply on catheter surfaces,
multiply quickly and advance in a retrograde fashion) formation leading to infection.
Preconnected closed systems with Cleanser Prep of 10% Povidone Iodine or 1-2%
Aqueous Chlorhexidine are recommended. No evidence exists to support routine
catheter changes.
Catheter size: Use smallest diameter that will prevent trauma and provide good
drainage (usually 14-18Fr) unless presence of blood clots or sediment that can occlude
lumen. For those with obstructions, closed continuous 3-way irrigation larger catheter
may be needed.
Balloon size: Typically 5ml balloon used (inflates with 10ml sterile water) for routine
catheterizations; 30ml balloon may be used with prostate surgery to provide traction to
surgical area or per physician preference.
A Coude-tipped catheter which has a firm, curved tip designed to negotiate the male
prostatic curve may be needed for difficult male catheterizations (with physician order).
Urinary catheters should be removed as soon as possible; Post-op by day 1 or 2
recommended. Evidence Based Practice indicates to identify patients daily with
indwelling urinary catheters, and check for removal. Daily documentation of day
number of indwelling time to be done.

EXPECTED
OUTCOME:

Patient will have catheter removed as soon as possible. CAUTI preventive measures
utilized. Patient will have no occurrance of CAUTI.

Urinary (Urethral) Catheterization Procedure / Protocol - Page 2 of 10

INSERTION OF URINARY (URETHRAL) CATHETER

Equipment
Anti-Infective preconnected closed system with infection control drainage bag and
microbiocidal outlet tube/bacteriostatic urine catch system (2000ml) with antireflux
chamber and uroprep tray inclusive in kit
Antiseptic wash (10% povidone iodine or 1%-2% aqueous chlorhexidine solution.
(Povidone Iodine Solution in kit)
With physician order: UROJET (Lidocaine 2% Jel) for lubrication/discomfort.
Catheter Securement device

1.
2.
3.

4.
5.

STEPS
Select catheter 14-18fr with 5ml
balloon unless otherwise ordered
Wash hands, apply gloves
Wash external genital area thoroughly
with soap and water-rinse well
FEMALE: Identify Urethra prior to
beginning sterile procedure
Open kit-apply sterile gloves, use strict
aseptic technique.
Drape and cleanse urethra/meatus
and surrounding area utilizing sterile
technique.
FEMALE: Open labia to cleanse-hold
open
MALE:
If uncircumcised, retract foreskin
and cleanse prepuce area.
Recommend use of 1-2%
Lidocaine Jelly (UROJET) with
physician order and no allergygently inject directly into urethra

6. Insert catheter gently:

FEMALE: Supine position-use
Lubricant
MALE: Gently insert catheter (with
penis upright pointing slightly
towards umbilicus) into urethraAdvance catheter almost to inflation
port (bifurcation or Y) before inflation of
balloon.
7. Obtain urine flow.
8. Inflate (gently) balloon with 10ml sterile
water (per manufacturer instructions),
then pull catheter gently to seat balloon
at bladder neck

KEY POINTS
Wash hands before/after each patient
Decreases risk of CAUTI

Sterile procedure/strict Aseptic technique

Use Povidone Iodine or 1-2%
Chlorhexadine for prep
Use good lighting and assistant as needed

Check for allergies. Provides lubrication

for entire length of urethra and some
anesthesia to prevent external sphincter
spasmwait 2-5 minutes before
continuing with procedure.
If catheter inadvertently placed in vagina,
leave in temporarily as a landmark-obtain
new catheter.
Have patient take slow deep breaths to
help in relaxation and allow easier catheter
passage.
Prevents balloon from inflating into urethra.
Do not use normal saline (can cause
crystal formation leading to problems with
deflation at removal) or air for balloon
inflation. Avoid under or overinflation-can
cause asymmetrical balloon which can
deflect catheter tip to one side

Urinary (Urethral) Catheterization Procedure / Protocol - Page 3 of 10

STEPS
9. MALE: If Uncircumcised-Reposition
forward (or reduce) foreskin
10. Catheter Securement:
FEMALE: secure to inner thigh
MEN: secure to upper thigh or lower
abdomen.

11. Position drainage bag lower than

bladder
12. Do not allow drainage tubing to fall
below the drainage bag

KEY POINTS
Prevents Paraphimosis (retraction and
constriction of foreskin behind glans penis
secondary to catheterization)
Use a catheter specific anchor that
prevents slipping in and out. Allow for
slack to prevent tension on catheter.
(unsecured catheters can lead to bleeding,
trauma, pressure sores around meatus,
and bladder spasms from pressure and
traction
Prevents retrograde flow of urine into
drainage tubing and migration into bladder.

INSERTION OF COUDE CATHETER (FOR DIFFICULT MALE INSERTIONS-WITH

PHYSICIAN ORDER)
Equipment
Coude Catheter with balloon port (has firm curved tip) of appropriate size.
Urethral Catheterization tray
Closed System Urinary Drainage Bag-2000ml size
With physician order: UROJET-1-2% Lidocaine Jelly
Catheter Securement device
STEPS
1. Wash hands
2. Prep for urethral catheterization-use
sterile technique
3. Follow urethral catheterization
Procedure
4. Insert Coude-tipped catheter with
tip pointed upward towards the
patients umbilicus
5. Advance to bifurcation/port
6. Continue per catheterization
procedure and secure.

KEY POINTS
Wash hands before and after

Coude-tipped catheter has a firm, curved

tip designed to negotiate the male prostatic
curve. Tip up and to the Hub

OBTAINING URINE SPECIMAN

Equipment
Sampling Port is on urinary catheter drainage tubing
Urine Speciman Container
STEPS
1. Kink Catheter approximately 3

KEY POINTS
Use Aseptic technique

Urinary (Urethral) Catheterization Procedure / Protocol - Page 4 of 10

2.
3.
4.

5.
6.
7.
8.

below sampling port

Swab port with antiseptic
Apply gloves
Using Aseptic technique, position
leurlock syringe in center of
sampling port (hold perpendicular)Lock into place onto port.
Aspirate urine sample into syringe.
Inject into Urine Speciman
container
Unkink urinary catheter
Label, attach printed order, send
Speciman to Lab in Biohazard Bag.

Using port maintains closed system

Urine for a C&S should be obtained from
newly inserted catheter and drainage bag
to avoid culturing the system rather than
the urine

INTERMITTENT IRRIGATION OF URINARY (URETHRAL) CATHETER (To be done

only if obstructedclots or mucous anticipated)
Equipment
60cc Piston Syringe with Irrigation Tray (Toomey)-sterile
0.9 Normal Saline (sterile) irrigation solution (or solution per order)
STEPS
1. Wipe outside of catheter/tubing
connection with antiseptic
2. Apply gloves
3. Disconnect catheter from tubing
4. Aspirate first to attempt
clot/obstruction removal-if no return
instill 30-60 ml irrigation solution into
catheter, aspirate gently. Repeat as
needed to clear catheter
5. Reattach catheter to system

KEY POINTS
Use Aseptic technique/sterile equipment
Breaking catheter drainage bag connection
(closed system) is a major point of
bacterial entry into system
Avoid vigorous irrigation-can be damaging
to delicate bladder mucosa

CATHETER CARE
Equipment
STEPS
1. Routine Perineal care BID-avoid
specific meatal cleansing or
ointments to meatus (unless
specifically ordered)

KEY POINTS
There is no evidence to support special
meatal cleansing or use of ointments or
creams to meatus. Avoid petroleum based
products to catheters. Avoid catheter
manipulation

REMOVAL OF URINARY (URETHRAL) CATHETER

Equipment
12 ml leurlock syringe
STEPS
1. Slide syringe plunger back and forth
in barrel to loosen

KEY POINTS

Urinary (Urethral) Catheterization Procedure / Protocol - Page 5 of 10

2. Compress plunger all the way then

pull back 0.5ml to prevent
adherence
3. Gently attach syringe to balloon
port, allow all of inflation fluid to
return to syringe by gravitydo not
aspirate.

4. Remove catheter-assure all is intact

5. Discard all in Biohazard Bag

Wait at least 30 seconds for deflation. If

water does not return, reposition patient,
ensure catheter not in traction verify urine
flowing freely in tubing. If balloon still fails
to deflate, apply gentle, slow aspiration.
Measure urine output. Assess for meatal
drainage

INITIATION OF CONTINUOUS BLADDER IRRIGATION (CBI)

Equipment (available in Urology Cart from 7N or Sterile Processing)
3-Way Urinary Catheter-(size per physician order)
Urinary (Urethral) Catheterization Tray
Cystoscopy/Irrigation Set (Single Irrigation Tubing)
2000ml or 3000ml Irrigation Solution (Sterile Water or Saline)-per order/need
Closed System Urinary Drainage Bag-4000 ml size
With physician order: UROJET - 1-2% Lidocaine Jelly
Catheter Securement device
STEPS
1. Wash hands
2. Spike irrigation bag with
Cystoscopy/Irrigation Set single
irrigation tubing. Flush tubing,
clearing of air. Maintain sterility of
end of tubing.
3. Apply Gloves
4. Prep for urinary (urethral)
catheterization-use sterile
technique.
5. Follow urethral catheterization
procedure
6. Insert foley catheter-advance to
bifurcation/port
7. Continue per catheterization
procedure and secure.
8. Attach Continuous Bladder
Irrigation tubing to Irrigation Port of
3-Way Catheter. Infuse at rate to
keep return solution and urine clear
9. MAINTAIN ACCURATE INTAKE
AND OUTPUT
-With each new added bag of 20003000ml irrigation solution, empty

KEY POINTS
NOTE: if patient received Post-op with (Y)
double infusion tubing/bag, recommend
switching to single set-up for easier
management. If rapid infusions
anticipated, use 3000ml bag, available
from storeroom

As each irrigation bag is infused, add new

bag and empty (and measure) outflow
drainage bag contents. Continue cycles to
maintain clear return
Output EXAMPLE: CBI-2000ml, FOLEY
(solution and urine)-2450ml, URINE450ml

Urinary (Urethral) Catheterization Procedure / Protocol - Page 6 of 10

urinary/solution drainage bag and

measure
USE OF LEG BAG
Equipment Leg Bag (Follow instructions on package)
STEPS:
Fits with fabric leg straps
Put flutter valve @ top, attaches to catheter
Size to fit/place below knee (maleuse extension tubing)
NURSING PROTOCOL
URINARY (URETHRAL) CATHETERIZATION
ASSESSMENT/INTERVENTIONS
o Assess readiness for catheter removal every day
o Assess continued need for catheter
o Assess for readiness for alternative method
o Assess day of dwell time

Assess for S/S UTI: pain, urine color, abdominal/flank discomfort,

temperature >38 degrees C

Assess for clots or mucous in urine

Assess for adequate urinary volume-> 250ml/shift

URINARY CATHETER TUBING/DRAINAGE SYSTEM

Assess tubing/drainage bag intact, patent, and free of kinks-CLOSED SYSTEM
maintained.
Assess tubing not kinked, not obstructed- urine flowing thru tubing
Suprapubic Catheters: Assess catheter securement and insertion site. Secure
to avoid enlargement of stoma tract and leakage.
Assess for signs of blockage or encrustation
Leg Bag: assess for circulatory impairement of extremity
Empty drainage bag at least every shift-do I&O
Maintain patent system at all times
Irrigate only if necessary (clots, mucous, or obstruction). Avoid vigorous bladder
irrigation to minimize mucosal irritation
CONTINUOUS BLADDER IRRIGATION (CBI)
Assess system patent and intact
Assess solution return color and clarity-clear or light pink, free from clots
Assess urine output/return
Assess for suprapubic pain and fullness (bladder spasms, clogged catheter)

Urinary (Urethral) Catheterization Procedure / Protocol - Page 7 of 10

Clogged catheter: turn off CBI, take apart and irrigate outflow tube manually to
remove clots/obstruction-maintain sterilityuse new kit with each occurrence,
resume CBI.
Bladder spasms: per physician approval, try removing water from balloon to
decrease irritation, treat with antispasmodics per order.

UNCIRCUMCISED MALE
Assess foreskin pulled forward over glans penis with no S&S of
Phimosis
MEATAL AREA
Assess for drainage, bleeding, leaking, or redness around urinary meatus or
catheter insertion site
Assess for leakage causes: bladder spasms, infection, fecal impaction or
constipation, occlusion, encrustation.
SKIN
Assess skin condition under external devices in contact with skin or around
urinary meatus or insertion site, S-P insertion site
FLUID BALANCE/I&O
Assess I&O q shift
Monitor fluid balance q shift and q 24 hours
S&S of CAUTI
Assess for new onset temperature, chills, flank or suprapubic pain
Assess for urinary urgency, changes in urine character
Assess Laboratory values, positive urine culture (colony count > 10 2-3cfu/ml)
Assess for altered mental status
BLADDER STATUS (use Ultrasound Bladder Scan as needed/approved)
If Bladder distention, reposition patient, check tubing for kinks or clots (especially
if decrease in urine output)-Irrigate only if necessary
Check bladder status-if output low, check volume with Utrasound Bladder Scan
Use Ultrasound Bladder Scan to check for discomfort
FLUID BALANCE/I&0
Routine every shift or per order
CATHETER REMOVAL
Use alternatives when possible (S-P or intermittent catheterizations)
Remove all water from balloon to avoid trauma
Check for orders/actions after removal
Assess patients ability to void post removal or within specified time as ordereduse Ultrasound Bladder Scan to evaluate amount of urine in bladder as needed
Check for bladder distention and/or residual
Notify physician if unable to void

Urinary (Urethral) Catheterization Procedure / Protocol - Page 8 of 10

TROUBLESHOOTING-SELECTED SITUATIONS
Leakage Management- Identify cause, change catheter if lumen occluded-per
order.
Bladder Distention/CO of pain: check for kinked catheter or drainage tubing,
check if patient lying on tubing, tubing twisted, occlusion of catheter, pressure on
catheter. Try changing positions, secure catheter, verify catheter positioned over
thigh, check/remove fecal impaction.
Blockage/Lumen Occluded: Causes: blood clots, sediment or mucous;
Solution/prevention: Aspirate/Irrigate only if necessary, consider 3-way CBI (per
order), increase catheter size (not balloon) with order, increase fluids if tolerated,
check/remove fecal impaction.
BLADDER SPASMS: Possible causes: involuntary bladder contraction,
under/overinflated balloon, large balloon. Solution/prevention: secure catheter
over thigh or lower abdomen (for men), hang drainage bag properly, empty when
-2/3 full. Per physician approval, remove water from balloon to decrease
frequency of spasms (ie: big balloon can cause spasms).
REPORTABLE CONDITIONS
Report to physician
Unable to insert/pass urinary catheterAbort procedure if resistance, bleeding,
severe pain.
Leaking around insertion site/new drainage from meatal area
Low or no urine output (verify with bladder scanner)
Color change of urine-cloudy, red
Obstruction/unable to irrigate
Call if unable to void after expected or ordered time frame
S&S of UTI: Fever > 38C or >100.4F, chills, new flank or S-P pain, changes in urine
character, altered mental status, positive urine culture
S&S/appearance of Phimosis-tightened foreskin compromising blood flow to glans
penis
EMERGENCY MEASURES
Paraphimisis in uncircumcised males with tight prepuce/foreskin-call physician (is a
Urological emergency)-patient may need surgical repair
Unable to pass catheter, patient obstructed.
Notify Physician, anticipate/prepare Bedside Flexible Cystoscopy or to Surgery.
SAFETY
Avoid/prevent pulling or tugging on catheter
Secure carefully with securement device that prevents in and out movement of
catheter-allow catheter slack
Use Coude with order for difficult male catheterizations
Avoid positioning drainage bag between legs or on abdomen-hang properly to
facilitate forward flow (keep tubing in straight line)
Empty CBI outflow bag before filled to decrease pressure on bladder
Empty bag when to 2/3 full to avoid traction on catheter
Avoid petroleum based creams/ointments (can degrade latex catheter)

Urinary (Urethral) Catheterization Procedure / Protocol - Page 9 of 10

Catheterization: ABORT procedure if resistance is met, bleeding is noted, patient

complains of severe pain

INFECTION CONTROL
CAUTI Preventive Measures:
Remove urinary catheter ASAP-recommend on Post-op day 1 or 2
Use aseptic technique with sterile equipment with insertion (Category I)
Maintain closed system (Category 1)do not irrigate unless absolutely necessary
(prevents bacterial entry)-wipe end of tubing and catheter with antimicrobial solution
prior to reconnecting system
Keep drainage bag below bladder (Category I)
Do not allow tubing to loop, dangle, fall below drainage bag, or kinkkeep patent.
Wash hands before and after, wear gloves with each urinary catheter bag emptying
Do not allow outflow drain spigot to touch measuring container (can be a source of
UTI from retrograde bacterial migration).
Do not place urinary drainage bag up between patients legs.
Do not let bag lay on floor
Anchor catheter with securement device to minimize in and out motion to urethra
Avoid catheter manipulation around meatal area-can contribute to bacterial migration
into bladder
Prior to exercise/ambulation or transfer, drain all urine from tubing into drainage bag
to prevent retrograde flow of urine into bladder
PATIENT/SO EDUCATION
Purpose of urinary catheter
Wash hands before and after working with catheter
CAUTI preventive measures (ie: maintain closed system, no looping, no bag below
bladder, avoid outlet touching floor or collection container, no bag on floor)
Avoid pulling on catheter
Notify if new pain, abdominal distention, or no urine return (validated)
Application/removal of Leg Bag-if to be used at home (Teaching Protocol-Indwelling
Urinary Catheter).
DOCUMENTATION (in Care Link)
Procedure with tolerance (include catheter size & inflation amount) in Renal, Urinary
intrv and intrv response, urine source, device type
Urine return (characteristics: color, clarity, amount) in Renal, urine source, & I&O
Catheter anchored with Cath Secure & location in Renal, urine source, urine Intrv
Date inserted in Renal, urine source
Day Number # of indwelling catheter (ie: Catheter Day #2) in: Renal, Catheter,
Insertion Date (document insertion date daily)
Assessment and need for ongoing catheterization every 24 hours/daily
MALE-Uncircumcised precautions foreskin positioning in Renal, Intervention,
Envelope or Reproduction, Foreskin
Maintenance/irrigations if necessary and results in Renal, Intrv, Envelope
Bladder Scan amount in Renal, Bladder Scan amt

Urinary (Urethral) Catheterization Procedure / Protocol - Page 10 of 10

Perineal Care Reproduction, Intrv

Catheter Removal in Renal, Catheter, Intervention
CBI Initiation in Renal, Urine Source #1, Device Type, CBI Status
CBI Intake & Output in I&O:
o Intake, Bladder Irrigtn (enter cumulative amount instilled)
o Output, Bladder Irrigtn (enter cumulative amount instilled-returned out)
o Output, Urine Cath, Amount of Urine (subtracted amt from total emptied)
Intake & Output in I&O
Leg Bag-Home with Urinary Catheter Teaching in Patient Education
Patient/Family teaching in Patient Education

REFERENCES:
-Centers for Disease Control and Prevention and Association of Practitioners in
Infection control Guidelines.
-Chettle,C.,RN,MS,MPH,CIC,COHN-S, Nurses Critical as Reimbursement Dries
Up for Catheter Associated UTIs, Nursing Spectrum, August, 2008, pp. 2429.
-Perry & potter, Fundamentals of Nursing, 2005, pp.1412-31.
-Reilly, L., RN,BSN,CCRN, et al;Reducing Foley Catheter Device Days in an ICU, Using
the Evidence to Change Practice, AACN Advanced Critical care, Vol. 17, #3, AACN
2006, pp. 272-83.
-Sanjay,S. MD,MPH, et al, Preventing Hospital-Acquired Urinary Tract Infection in the
United States: A national Study, Nosocomial UTI Preventive Practices, Clinical
Infectious Diseases, 2008:46 (15 January), pp. 243-49.
-Smith, JoAnn Mercer, BSN,RN,CWOCN, Indwelling Catheter Management: From
Habit-Based to Evidence-Based Practice, Ostomy Wound Management, 2003,
49(12), 34-45.
-Society of Urological Nurses & Associates (SUNA), Clinical Practice Guidelines, 2005.
-Staff Educator (EBP), Urinary Tract Infections with Practical Measures, Infection
Control, Prevent, Vol.4, #3, 3/08.
-Society of Urologic Nurses and Associates (SUNA), Clinical Practice Guidelines, 2005
-Nursing Standard