CATHETERIZATION

DEFINITION:
The introduction of a catheter into the bladder through the urinary meatus and urethral canal.

PURPOSES:
1. To relieve bladder distention.
2. To obtain sterile urine specimen.
3. To empty the bladder before the surgery where general and spinal anesthesia are used.
4. To check and or remove residual urine.
5. To prevent voiding when there are wounds in the genitor-urinary tract or other condition which make it
important that the area be kept clean and dry.

POINTS TO REMEMBER:
1. Never catheterized without a written order by the physician.
2. Exhaust all nursing measures to induce voiding before resorting to catheterization.
3. Rigid aseptic technique should be practiced.
4. Never use glycerine, it is irritant.
5. If the bladder is greatly distended, do not withdraw over 800 cc, at one time.
6. Usually 8 hours is the maximum length of time a patient should wait before voiding. Following pelvic operations
it is very important that the bladder nit become over distended.

EQUIPMENTS:
Sterile catheterization tray
KY jelly/water soluble
Syringe
Sterile water
Collection bag
Sterile pair of gloves
2 rubber catheters Fr. 14 and Fr. 16 for women/Fr. 18 and Fr. 20 for male
Pitcher with sterile solution
Perineal tray
Bedpan with cover
Flashlight/penlight

STEPS RATIONALE
1. Check physician’s order. - Catheterization is dependent nursing
action.
2. Inform the client. - To elicit cooperation.
3. Wash hands and observe other - Handwashing deters the spread of
appropriate infection control procedures. microorganisms.
4. Provide for client privacy. - Lessens embarrassment.
5. Place the client in the appropriate position - So the patient be relaxed and convenient
and drape all areas except the perineum. while doing the procedure and avoid
interruption.
6. Establish adequate lighting. Stand on the
client’s right if you are right-handed, on
the client’s left if you are left-handed.
7. Arrange equipments to provide - Placing equipment in order of use increase
convenience and to avoid having to reach speed of performance. Reaching over
over sterile field. sterile items increase risk of
contamination.
8. Don sterile gloves. - Sterile equipment can be handled without
contamination when sterile gloves are
worn.
9. Lubricate catheter for about ½ inch, being - Lubricant reduces friction and facilitates
careful not to plug eye of catheter. easy insertion of catheter.
10. Female - Stretching tissue straighten labia fold
Place thumb and index finger between makes meatus visible for any insertion of
labia minora, spread and then pull catheter. Touching labia contaminates
upward, gloved hand separating labia is gloves hands.
now considered contaminated.
11. Cleanse exposed area of meatus - Moving from area where there is likely to
thoroughly. Move cotton ball from above be less contamination to an area where
meatus down toward rectum. there is more contamination prevent
spread of organism. Thoroughly cleansing
helps reduce possibility of introducing
organism into the bladder.
12. Male
Use your non-dominant hand to grasp the - Lifting the penis in this manner helps
penis just below the glans. If necessary, straighten the urethra.
retract the foreskin. Hold the penis firmly
upright, with slight tension.
13. Pick up a cleansing ball with the forceps in - Moving from area where there is likely to
your dominant hand and wipe from the be less contamination to an area where
center of the meatus in a circular motion there is more contamination prevent
around the glans. spread of organism. Thoroughly cleansing
helps reduce possibility of introducing
organism into the bladder.
14. Use a new ball and repeat three more
times.
15. Insert the catheter.
Grasp the catheter firmly 2-3 inches from - Slight resistance is expected as the
the tip. Ask the client to take a slow deep catheter passes through the sphincter.
breath, and insert the catheter as the
client exhales.
16. Advance the catheter 2 inches further - To be sure that the catheter is fully in the
after the urine begins to flow through it. bladder.
17. For an indwelling catheter, inflate the -
retention balloon with the designated
volume.
18. Hold catheter securely while bladder - Withdrawal and reinsertion of catheter
empties. Avoid pushing and pulling creates friction thus provide discomfort to
catheter in and out.If necessary, attached the patient.
the drainage end of an indwelling catheter
to the collecting tubing and bag.
19. Examine and measure the urine. In some - Removing more than 750-1000ml of urine
cases, only 750-1000 ml of urine are to be at one time causes bladder damage and
drained from the bladder at one time. shock.
20. Care of equipment and urine specimen as
required and record results.
INTRAVENOUS PUSH

DEFINITION:
An IV Push (bolus) is the intravenous administration of a medication into the body through intravenous line in a
short time.

PURPOSE:
 Administer a medication intravenously for immediate effect or rapid therapeutic effect.
 Administer a medication that cannot be given by any other route.
 A patient may receive nothing by mouth.
 An irritating drug would cause pain and tissue damage if given intramuscular or subcutaneously.

Critical Elements of Administering Medication by IV Push:

EQUIPMENT:

 For IV port:
Physician’s order or the Medication Card
IV Medication Tray
Antiseptic swabs
Medication in a vial or ampule
Sterile syringes 3-5ml (to prepare medication)
Watch with a second hand

 For Heparin-Lock Device:

STEPS RATIONALE
IV Medication Push through the IV port
1. Check the physician’s order carefully for the
medication, dosage, route, and rate of
administration.
2. Observe the 10 R’s when preparing and
administering medication.
3. Explain the procedure. - To reassure patient and significant others. Elicit
cooperation.
4. Do handwashing before and after the - Handwashing deters the spread of
procedure. microorganisms.
5. Identify the patient.
6. Check patency. Assess IV site for inflammation
or infiltration.
7. Identify an injection port nearest to the
patient. Clean port with the antiseptic swab.
8. Stop the IV flow by closing the roller clamp.
9. Insert the needle into the port and inject the
medication at the ordered rate or per
manufacturer’s recommendation.
10. Using same syringe, aspirate 1-2cc of IVF to
flush the medicine given.
11. Regulate rate of IV fluid as prescribed.
12. Disposal of equipment according to hospital
policy.
13. Wash hands.
14. Observe patient closely for adverse reactions. - To timely address any life threatening situation.
15. Document the procedure and all relevant
information.
IV Medication Push through the Heparin-Lock Device
1. Gather Equipment.
2. Check the physician’s order carefully for the
medication, dosage, route, and rate of
administration.
3. Do handwashing before and after the - Handwashing deters the spread of
procedure. microorganisms.
4. Observe the 10 R’s when preparing and
administering medication.
5. Explain the procedure. - To reassure patient and significant others. Elicit
cooperation.
6. Prepare the medication.
7. Prepare Flushing with saline: Two syringes with
1ml of normal saline solution each.
8. Clean the injection port with the antiseptic
swab.
9. Check patency, open the IV line and inject NSS.
10. Remove saline syringe and insert medication
syringe into the port. Give IV push 5-10minutes
for IV potent drug. For 2-3 IV medications, give at
least 30 minutes to 1 hour interval.
11. After each drug administered via IV push,
flush it with 2-3cc of saline solution.
12. Observe patient closely for any adverse - For timely intervention.
reactions.
13. Discard waste according to agency’s policy.
14. Document the procedure and all relevant
information.
IV Medication Incorporation into Volumetric Chamber
1. Check the physician’s order carefully for the
medication, dosage, route, and rate of
administration.
2. Gather Equipment.
3. Observe the 10 R’s when preparing and
administering medication.
4. Explain procedure to patient. - To reassure patient and significant others. Elicit
cooperation.
5. Assess Iv site.
6. Verify for skin test of the drug before IV
incorporation.
7. Do handwashing. - Handwashing deters the spread of
microorganisms.
8. Prepare the medication. Aspirate prepared
right drug with correct dose.
9. Add desired IVF diluents into volumetric
chamber by opening the sliding clamp from the
bottle then close the clamp.
10. Check to make sure that the air vent on the
volumetric chamber is open.
11. Disinfect rubber injection port of the
volumetric chamber and incorporate the drug.
Mix gently.
12. Attach medication label to the volumetric
chamber.
13. Disinfect the access port bellow the roller
clamp on the primary IV infusion tubing, usually
the port closest to the IV site.
14. Connect the secondary infusion to the
primary infusion at the cleansed port.
15. Regulate flow rate of the secondary infusion
set accordingly.
16. Observe/ monitor patient closely. - For timely intervention.
17. Discard waste according to hospital policy.
18. Document all pertinent data accurately.