What is the first step in the proper placement of an indwelling urinary catheter for a male client?

• 1 Explanation and Consent
• 2 Preparation
• 3 Procedure
• 4 Aftercare

In urethral catheterisation, a flexible tube is inserted into the bladder via the urethra. Urine can then drain freely from the bladder for collection. There are various indications for urethral catheterisation, such as the treatment of acute urinary retention, preoperative bladder emptying prior to urological or pelvic surgery, and the monitoring of urine output.

The process of urinary catheterisation can be divided into four steps; explanation and consent, preparation, procedure and aftercare. The procedure itself is different in men and women – due to the differing pelvic anatomy.

Explanation and Consent

• Confirm the patients identification
  • Check full name, DOB, and hospital number
  • Confirm against patients wristband
• Explain rationale for the procedure
  • Describe the procedure
  • State the importance of the procedure
• Explain the risks of the procedure to the patient
  • Inability to pass the catheter into the bladder
  • Trauma to the urethra or bladder neck
  • Infection (can be minimised by sterile equipment and aseptic non-touch technique)
  • Paraphimosis, from failure to replace the prepuce
  • Bladder spasm (due to presence of catheter balloon)
• Ask about relevant past medical history
  • Previous urethral trauma, urethral strictures, or lower urinary tract surgery
  • Blood clotting disorders or medication that affects blood clotting (e.g. warfarin)
  • Recent haematuria, penile discharge, or urinary tract infection

Check that the patient is happy to go ahead with the procedure. Ask the patient if they would like a chaperone present. Preferably, the patient has washed their genitals beforehand or has had assistance to do so

Preparation

Chose the correct catheter size, based upon sex of the patient, length of time of insertion, and any allergies to latex

• Catheter size (diameter measured in Ch) should be the smallest as possible to drain urine
• Patients with urine debris or clots may require a larger diameter catheter

When in the treatment room, prepare your equipment on an appropriate equipment trolley.

• Decontaminate your hands
• Clean your trolley and plastic tray with appropriate aseptic agent (e.g. Chlor-clean), allowing to dry fully. Decontaminate your hands
• Gather the equipment into the plastic tray on the trolley and move to the patients bedside
  • Equipment required catheter pack, catheter, drainage bag, instillagel, saline vial, chlorhexidine wipe, sterile forceps, 2x pairs sterile gloves, apron, and inco pad
  • Catheter pack should contain J-tray, sterile swabs, cotton wool balls, plastic pot, and sterile drape

Once at the patient’s bedside

• Re-confirm the patients identification
• Expose the patient from the waist down
  • Throughout the procedure, ensure the patients dignity is maintained

Prepare your sterile field next to the patient’s bedside

• Open the outer packaging of the catheter pack onto the trolley and decontaminate your hands
• Carefully open the catheter pack, touching only the outside border, and arrange the contents of the catheter pack using the sterile forceps. Place the cotton wool balls in the plastic pot. Discard the forceps once used.
• Clean the top of the saline vial with the chlorhexidine wipe, open the vial, and pour the saline onto the cotton wool balls
• Open the sterile gloves package onto the sterile field

Procedure

• Put the sterile gloves on
• Take the sterile drape and tear a hole in the centre, draping over the penis
  • A sling may be made from sterile gauze, placed around the patient penis, to aid mobility of the penis during the procedure
• Using at least 5 cotton wool balls, clean the glans of the penis and penile shaft from tip to base
  • Best practice is to use one hand to pick the cotton wool balls and hold the sling whilst using the other to clean the penis
• Hold the penis erect and inject 11ml instillagel into the urethra and gently squeeze the tip to prevent leakage
• Remove your gloves and decontaminate your hands

• Carefully open the catheter and syringe onto your sterile field
• Open another sterile gloves package
• Decontaminate your hands
• Put the sterile gloves on and open up the syringe
• Place the J-tray between the patients legs

• Carefully open the catheter from its sterile packaging, exposing only the catheter tip
• Without touching the catheter directly, insert the catheter along the urethra into the bladder
  • If any resistance is felt, ask the patient to cough to ease insertion
• Once the urine begins to flow, advance the catheter a further 5cm
• Inject the contents of the syringe into the catheter to inflate the balloon in the catheter
  • Monitor the patient for any signs of discomfort
  • Gently withdraw the catheter to ensure the balloon is secure against the bladder neck
• Attach the catheter to the drainage bag
  • Attach the drainage bag to the patients leg, patients bed, or catheter stand
• Replace the foreskin

• Discard all waste into the correction disposal bins and ensure the patient is comfortable
• Remove your gloves and decontaminate your hands

Aftercare

Instruct the patient to:

• Regularly wash with warm soapy water at least twice a day, washing in a direction away from the urethra
• Do not pull on the catheter
• Inform the nursing staff if any pain or discomfort

Thank the patient and leave the patient’s bedside. Ensure the correct catheterisation documentation is filled out completely and placed in the patients notes.

An indwelling catheter is also called a foley catheter or "Foley.” It can be used in males or females. A Foley is usually left in the bladder and drains the bladder continuously.

Foley Catheter: Step by Step Process

1. Gather the Supplies

• Indwelling Foley Catheter Tray with a 10 cc balloon (size 16fr is a common size used for adults.) The tray comes with all the needed supplies
• Syringe to deflate the balloon of the existing catheter (if there is one already in the bladder)
• Soapy wash cloth and wet wash cloth

2. Wash hands with soap and water

3. Prepare all needed supplies

4. Lie flat on back with legs flat

5. If there is already a catheter in place, remove it by deflating the balloon.

• Attach the syringe to the end of the "Y" pigtail (side port).
• Withdraw the plunger of the syringe. This will deflate the balloon on the catheter inside the bladder.
• You will know it is completely deflated when you are unable to pull anymore water into the syringe.

6. Gently pull the catheter out from the bladder. 

Wash with the soapy cloth and rinse with the wet cloth. Dry well.

8. Wash hands again.

9. Open the Indwelling Catheter Tray carefully. Set up the supplies.

• Place paper pad under hips.
• Put on the gloves if this is not a self catheterization.
• Pour the Betadine onto the cotton balls
• Remove the plastic cover from the catheter (be careful not to touch the catheter tube) & squirt the lubricating jelly onto the catheter.
• Remove the rubber cap from the syringe with the water in it.
• Connect the end of the catheter to the drainage bag

10. Choose your "clean" and "dirty" hand.

Whatever hand comes in contact with the body, the one that holds the penis, is dirty. The one that touches the catheter supplies is clean. Never mix clean and dirty hands in regard to the catheter supplies. It is important that this procedure stay "super clean" so as not to allow germs to enter the bladder.

11. Hold the penis.

Remember, the hand touching the body will now be the dirty hand.

12. Clean urinary opening on penis

• Use clean hand to touch items in the kit
• Clean penis with the cotton balls soaked in Betadine.
• Use 1 cotton ball per wipe.
• Always wipe from the tip of the penis toward the shaft of the penis.
• Never re-use a cotton ball.

14. See the urine flow into the catheter

Continue to insert the catheter until the "Y" pigtail section of the catheter becomes very close to the end of the penis.

While holding the catheter in place, attach the pre-filled syringe in the kit to the "Y" pigtail port and insert all of the water from the syringe. 

If it is easier, you can attach the syringe before you insert the catheter so it is ready when you need it. Do not blow up the balloon until the catheter is in and you see urine flowing.

Below is a picture of a catheter with an inflated balloon...this is what it would look like inside the bladder

16. Wash off the extra Betadine from the penis.

17. Always hang/attach the drainage bag to chair/bed frame below the level of the penis.

This will allow for the best drainage.

18. Consider wearing a leg strap.

The leg strap attaches the catheter to the inner thigh. It helps to keep the catheter secure.

19. If wearing a leg bag, always wear it below the knee.

Real Questions from Real People

1. How often does the catheter need to be changed?

Catheters can stay in for about a month as long as it is not leaking or having crusty areas around it near the urethral opening. You should wash the urinary opening at least twice a day while the catheter is in place. Change the catheter by the schedule given to you by your doctor.

2. Should I save anything from the catheter kit incase problems arise with the catheter?

Yes. Save the syringe so you can deflate the balloon when the catheter needs to be removed.

3. What if touch the catheter with my dirty hand or I drop the catheter on the floor before I have it safely inserted?

Stop and get another catheter or kit. It is important that germs do not enter the bladder during this procedure.

4. What if I have spasms while the catheter is being inserted?

Stop and wait for the spasm to pass; then continue with the insertion.

5. What if the catheter will not go in easily or I feel like I meet resistance when inserting it?

Do not force the catheter in. Call the doctor for further advice.

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