FOLEY CATHETER
DEFINITION
a thin, sterile tube inserted into the bladder to drain urine. Because it can be left
in place in the bladder for a period of time.
also called an indwelling catheter.
It is held in place with a balloon at the end, which is filled with sterile water to
prevent the catheter from being removed from the bladder.
The urine drains through the catheter tube into a bag, which is emptied when full.
TYPES OF CATHETER
Catheters are commonly made of rubber or plastics although they may be made
from latex, silicone, or polyvinyl chloride (PVC). They are sized by the diameter of the
lumen using the French (Fr) scale: the larger the number, the larger the lumen.
STRAIGHT CATHETER
The straight catheter also called an intermittent catheter is a single lumen tube
with a small eye or opening about 1.25cm from the insertion tip to pass urine from the
body. Straight catheters are usually made of plastic (PVC) and are only used one time
and then thrown away.
INDWELLING / RETENTION (FOLEY) CATHETER
The retention, or Foley, catheter is a double-lumen catheter. The outside end of
this two-way retention catheter is bifurcated; that is, it has two openings, one to drain
urine, the other to inflate balloon. The larger lumen drains urine from the bladder and
the second smaller lumen is used to inflate the balloon near the tip of the catheter to
hold the catheter in place within the bladder.
A variation of the indwelling catheter is the coudé (elbowed) catheter, which has
curved tip. This is sometimes used for men who have a hypertrophied prostate,
because its tip is somewhat stiffer than a regular catheter and thus it can be better
controlled during insertion, and passage is often less traumatic.
THREE-WAY FOLEY CATHETER
Clients who require continuous or intermittent bladder irrigation may have a
three-way Foley catheter. The three-way catheter has a third lumen through which
sterile irrigation fluid can flow into the bladder. The fluid exits the bladder through the
drainage lumen, along with the urine.
EXTERNAL CATHETERS
External catheters are condom-type sheaths applied (usually rolled) over the
penis and connected to a drainage bag. They are used primarily for urine collection in
men who experience urinary incontinence. The most popular external catheters are
disposable and must be changed every 24 to 48 hours.
SPECIFIC SIZES OF CATHETER
Catheter sizes are color-coded at the balloon inflation site for easy identification.
The relative size of a Foley catheter is described using French units (Fr). 1 Fr is
equivalent to 0.33 mm = .013" = 1/77" in diameter.
Larger Fr sizes (e.g., 20-24 Fr) are most commonly used for drainage of blood
clots.
The most commonly utilized indwelling transurethral and suprapubic catheters
range from 14 to 16Fr in both adult females and males.
A 14 or 16 Fr is also the standard catheter in most commercially available IUC
insertion kits or trays.
In adolescents, catheter size 14 Fr is often used but for younger children,
pediatric catheter sizes of 6-12 Fr are preferred.
INSERTION
The procedure to insert a catheter is called catheterization. Urinary
catheterization is the introduction of a catheter into the urinary bladder. This is
usually performed only when absolutely necessary, because the danger exists of
introducing microorganisms into the bladder.
FEMALE
ACTION RATIONALE
Check for doctor’s order Only done with medical order
Assess whether client is allergic to Povidone iodine often used to cleanse the
iodine/plaster vulva before catheterization
Wash your hands. Handwashing deters the spread of
microorganism.
Assemble equipment Organization promotes efficient time
management.
Identify and explain the procedure to the Ensures the right client and elicits
client cooperation
Provide a good light Good lighting is necessary to see the
meatus clearly
Provide for privacy by screening and Client has the right to be protected from
closing the door/windows being seen by others
Replace top sheet with bath blanket. These protect the bed linen from moisture
Place waterproof under pad under the
client
Place client on a dorsal recumbent Good visualization of the meatus is
position with feet apart and drape the important.
client
Do perineal flushing Cleansing the area with soap decreases
the possibility of introducing organisms
into the bladder
Prepare the urine receptacle and tubing if Tubbing facilitates connecting the
an indwelling catheter is to be inserted. catheter to the drainage system
Open the pack and bring it near the Placement of the equipment near the
perineal area. Observe aseptic technique work site increase efficiency. Sterile
technique protects and prevent the
spread of microorganisms
Squeeze a small amount of lubricant over Organization promotes efficient time
the sterile OS placed in the sterile field. management.
Place two (2) CBs with betadine on the
sterile field on top of several OS. Open
the covers of the specimen bottle.
Put on sterile gloves. Grasp the upper A drape provides a sterile field where the
corners of the fenestrated or eye drape equipment and hand will be placed.
and unfold it. Place the drape aseptically Prevents accidental contamination from
over the vulvar area exposing the labia. the adjacent area
Lubricate one (1) to two (2) inches of the Lubrication facilitates the insertion of the
catheter tip. Avoid clogging of lumen. catheter and reduces trauma to the
tissues.
With the thumb and forefingers of your Separating the labia helps exposure the
non-dominant hand, spread the labia and meatus so its location is visible.
identify the urinary meatus.
Holding the labia apart with non-dominant Cleans the area and minimizes the risk of
hand, pick a sterile working forceps in the urinary tract infection by removing surface
dominant hand. Disinfect the meatus pathogens.
twice using CB with betadine. Use one
downward stroke for each CB and
discard. Maintain the separation of the
labia until the catheter has been inserted.
Insert the tip of the catheter into the Female urethra is about 3.5cm to 6.5cm
dimple-like structure below the clitoris long. Applying force on the catheter is
which is the meatus about 2-3inches or likely to injure mucous membranes.
until urine flow.
Do not force the catheter through the Advancing an indwelling catheter an
urethra. additional 1/2inch to 1inch ensures
placement within the bladder and
facilitates inflation of the balloon without
damaging the urethra.
Ask the client to breath deeply and rotate The sphincter relaxes and the catheter
the catheter gently if slight resistance is can enter the bladder easily when the
met client relaxes
Hold the catheter securely with your non- Movement, even though it is slight,
dominant hand while the bladder empties. increases the risk of introducing
Collect a specimen, about 20-30ml if organisms within the urethra. In general,
required. Continue drainage according to no more then 750ml-1000ml of urine
hospital policy. should be removed at one time. Pelvic
floor blood vessels may become
engorged from the sudden release of
pressure leading to a possible
hypotensive episode.
Remove the catheter smoothly and slowly The catheter is only needed to drain
urine present in the bladder and is not
intended for continuous use.
If a foley catheter is used, introduce 5cc Creates a balloon to ensure catheter
(or follow manufacturer’s instruction) of retention. Maximizes continuous bladder
distilled water/air to secure the catheter. drainage. Proper attachment prevent
Gently pull the catheter until retention trauma to the urethra and meatus from
balloon is snuggled against the bladder tension on the tubing.
neck. Remove the drape
Attach catheter to urine bag below the Drainage is prevented when the urinary
level of the bladder. Tape catheter to the bag is placed above the abdomen.
inner thigh. Prevents urinary reflux which may cause
UTI.
Remove and clean the equipment and Urine kept at room temperature may
make client comfortable. Label the urine cause organisms, if present, to grow and
specimen and send to the laboratory. distort laboratory findings.
Wash your hands Handwashing deters the spread of
microorganisms
Record the time of the catheterization, the A careful record is important for
amount of the urine removes, a documenting data after the client’s care.
description of the urine, the client’s
reaction to the procedure and other Reporting and recording of information
observation. about the procedure must be accurate
and timely for continuity of care.
MALE
ACTION RATIONALE
Follow step #’s 1-6 of female
catheterization
Put up the siderails at the opposite side of Ensures client’s safety and provide
the bed. Assist the client to move away adequate space for opening of the sterile
from you. pack.
With the client supine and knees slightly Draping keeps the client warm and
apart, drape by fan folding the bedcovers reduces embarrassment.
down to the midthigh exposing the
perineal area. Use a bath blanket to cover
the trunk. Place the waterproof under pad
under the buttocks.
Don working gloves. Observe/assess Skin breakdown increase the risk of a
redness, irritation or skin breakdown or urinary tract infection. Foul odor is
foul odor. Do perineal care; remove and frequently related to poor hygiene unless
discard gloves properly. the client is suffering from an infection.
Wash hands Handwashing deters the spread of
microorganisms. Cleansing the area with
soap decreases the possibility of
introducing organisms into the bladder.
Place sterile pack on the bed at the level Placement of the equipment near the
of the hips. Open the pack observing the work site increase efficiency. Sterile
proper sterile technique. Bring the sterile technique protects the client.
kidney basin near the working area
Squeeze a small amount of lubricant over Organization promotes efficient time
the sterile OS placed in the sterile field. management.
Get 2 CBs with betadine from the jar and
place on the sterile field on top of the
several OS. Open the covers of the
specimen bottles.
Don sterile gloves. To protect nurse from infection.
Place the opening of the fenestrated Maintain sterility of the work surface.
drape over the penis and onto the
perineum without touching the upper to
surface.
Lubricate around 3-4inches of the Prevents undue trauma when inserting
catheter. Avoid clogging the lumen. the catheter into the urethra
With the non-dominant hand lift penis to Straighten urethral canal to ease catheter
position perpendicular to client’s body insertion
and cleanse the glans in a circular motion
moving outward from the meatus with the Disinfects the area and prevents the
use of CB with betadine. Discard and spread of microorganisms.
cleanse again with 2 more CBs in
betadine if necessary.
Maintaining the hold on the shaft, pick up Relaxation of eternal sphincter aids in
the catheter with the dominant hand. Pull insertion of catheter.
the penis gently upward and ask the
client to bear down as if to void. Slowly
insert the catheter in the meatus about 7-
9 using a rotating motion until urine flows
If resistance is felt, withdraw the catheter Forcing the entry of the catheter through
a little and ask the client to take a deep urethra may cause damage to the
breath again. If resistance persists and mucosa.
the catheter will not go further still,
remove it and notify the physician.
Gently push the catheter in 1-2inches Further advancement of ensures proper
more after urine starts to flow. Allow 30cc placement.
or more urine flow and collect the
specimen as ordered. Instruct client to
breathe deeply and remove catheter
gently
If foley catheter is used, inject the content Creates a balloon to ensure catheter
of the pre-filled syringe (or follow retention.
manufactures order) to secure the
catheter. Gently pull the catheter until the Maximizes continuous bladder drainage.
retention balloon is snuggled against the
bladder neck. (Resistance will be met) Proper attachment prevent trauma to the
Remove the drape. Tape catheter on the urethra and meatus tension on the tubing
anterior thigh or lower abdomen.
Attach the catheter to the urinary bag Proper placement of the urinary bag
below the level of the bladder. Coil facilitates drainage and prevents urinary
excess tubing on the mattress and secure reflux that may cause UTI.
it on the bed frame.
Remove and clean the equipment and Urine kept at room temperature may
make client comfortable. Label the urine cause organisms, if present, to grow and
specimen and send to the laboratory distort laboratory findings
promptly.
Wash your hands Handwashing deters the spread of
microorganisms
Record the time of the catheterization the It is important to documenting the data to
amount of the urine removed, color, odor monitor the urinary status.
and quality of the urine; and client’s
reaction on the procedure.
REMOVING OF INDWELLING CATHETER
ACTION RATIONALE
Check the order on the client’s chart. Prevents removing a catheter from the
wrong client.
Obtain 5-10ml syringe (depending on the The water in the balloon must be
size of the balloon of the catheter) and an withdrawn prior to removing the catheter
absorbent towel.
Wash your hands
With the ticket, call out client’s name, Correctly identifies the right client;
check the client’s identification band and reduces fear of unknown.
explain the procedure. Inform the client
that there may be a slight discomfort as
the catheter is removed.
Don gloves
Place the absorbent towel on the Protects the mattress. If a portion of the
mattress under the catheter and attach water/solution remains in the balloon, the
the syringe to the balloon port. inflated balloon will injure the urethral
Withdraw all the water or solution from canal.
the balloon.
Hold the absorbent towel in your non- Prevents soiling by spilling urine.
dominant hand in front of the perineum. The upward position of the catheter will
Pinch the catheter near the meatus with allow urine in the tubing to flow faster into
your dominant hand and pull it steadily the urine bag.
out onto the absorbent towel until the end
is retrieved. Hold the catheter at an
upward angle to the drainage tubing so
that any urine in it will drain into the
drainage bag.
Inspect the catheter to make certain it is Ensure that a piece of catheter is not left
intact. If not, notify the physician in the bladder
Measure the output in the drainage bag. Reduce transfer of microorganisms.
Record the output on the I&O sheet. To make an accurate record of I&O.
Empty the urine into the toilet bowl and
dispose the urine bag into the yellow bin.
Remove gloves, wash hands and make Remove transient microorganisms and
client comfortable. Instruct the client to risk of transmission to others. Extra fluids
drink extra fluid and warn that there may help to flush the bladder.
be mild burning with the first few voiding. Irritation of the mucosa in the urethra may
Remind the client of the expected voiding cause burning sensation with voiding.
time.
Document the time of removal and time Sets guidelines by which all nurses will
by which client should have next voiding know when to check to see if the client
time. has voided.
REFERENCE
Balena, S. [Link] (2012). Manual of Nursing Procedure (2012 ed.). San Pedro College.
Berman, A., Snyder, S., Frandsen, G. (2016). Kozier & Erb’s Fundamental of Nursing
Concepts, Process, and Practice Tenth Edition. Pearson
