44-2_InsertingCatheter

8/13/2019 44-2_InsertingCatheter

1/3

483

Copyright 2010 Elsevier Canada, a division of Reed Elsevier Canada, Ltd.

STUDENT: ________________________________________________________________ DATE: _________________________

INSTRUCTOR: _____________________________________________________________ DATE: _________________________

Skill 442 Inserting a Straight or In-Dwelling Catheter

S U NP Comments 1. Review the clients medical record, including physicians order and

nurses notes.____ ____ ____ ____________________

2. Close bedside curtain or door. ____ ____ ____ ____________________ 3. Assess the status of the client: ____________________

A. Urinary status: Ask the client when he or she last voided, orcheck intake and output flow sheet, or palpate bladder

____ ____ ____ ____________________

B. Level of awareness or developmental stage ____ ____ ____ ____________________C. Mobility and physical limitations of the client ____ ____ ____ ____________________D. The clients gender and age ____ ____ ____ ____________________E. Bladder distension ____ ____ ____ ____________________F. Perineum, for erythema, drainage, and odour: Perform hand

hygiene, put on clean gloves, and inspect perineum____ ____ ____ ____________________

G. Any pathological condition that may impair passage of catheter(e.g., enlarged prostate in men)

____ ____ ____ ____________________

H. Allergies ____ ____ ____ ____________________ 4. Assess the clients knowledge of the purpose of catheterization. ____ ____ ____ ____________________

5. Explain the procedure to the client. ____ ____ ____ ____________________ 6. Arrange for extra nursing assistance if necessary. ____ ____ ____ ____________________ 7. Perform hand hygiene. ____ ____ ____ ____________________ 8. Raise the bed to an appropriate working height. ____ ____ ____ ____________________ 9. Facing the client, stand on the left side of the bed if you are right-

handed (on the right side if you are left-handed). Clear the bedsidetable, and arrange equipment.

____ ____ ____ ____________________

10. Raise the side rail on the opposite side of the bed, and put the siderail down on the working side.

____ ____ ____ ____________________

11. Place a waterproof pad under the client. ____ ____ ____ ____________________12. Position the client.

A. Female client:(1) Assist the client to the dorsal recumbent position. Ask the

client to relax her thighs so that the hips can be rotatedexternally.

____ ____ ____ ____________________

(2) Assist the client to a side-lying (Sims) position with theupper leg flexed at the hip if the client is unable to assume

the dorsal recumbent position. If this position is used, youmust take extra precautions to cover the rectal area with adrape to reduce chance of cross-contamination.

____ ____ ____ ____________________

B. Male client:(1) Assist the client to a supine position with thighs slightly

abducted.____ ____ ____ ____________________

13. Drape client.A. Female client:

(1) Drape with a bath blanket. Place the blanket in a diamondshape over the client, with one corner at the clientsmidsection, side corners over each thigh and the abdomen,and the last corner over the perineum.

____ ____ ____ ____________________

B. Male client:(1) Drape the clients upper trunk with a bath blanket and

cover the lower extremities with bedsheets so that onlygenitalia are exposed.

____ ____ ____ ____________________

14. Wearing disposable gloves, wash the perineal area with soap andwater as needed; dry thoroughly. Remove and discard gloves;perform hand hygiene.

____ ____ ____ ____________________

15. Position a lamp to illuminate the perineal area. (If you use aflashlight, have an assistant hold it.)

____ ____ ____ ____________________

16. Open the package containing the drainage system. Place thedrainage bag over the edge of the bottom bed frame, and bring thedrainage tube up between side rail and mattress.

____ ____ ____ ____________________

17. Open the catheterization kit according to directions, keeping thebottom of the container sterile.

____ ____ ____ ____________________

Continued


2/3

484


S U NP Comments18. Place the plastic bag that contained the kit within reach of the

work area to use as a waterproof bag in which used supplies can bedisposed.

____ ____ ____ ____________________

19. Put on sterile gloves. ____ ____ ____ ____________________20. Organize supplies on a sterile field. Open the inner sterile package

containing the catheter. Pour sterile antiseptic solution into thecorrect compartment containing sterile cotton balls. Open thepacket containing lubricant. Remove the specimen container (the

lid should be placed loosely on top) and the prefilled syringe fromthe collection compartment of the tray, and set them aside on thesterile field.

____ ____ ____ ____________________

21. Before inserting an in-dwelling catheter, test the balloon byinjecting fluid from the prefilled syringe into the balloon port.

____ ____ ____ ____________________

22. Lubricate 2.55 cm of the catheter for female clients and 12.517.5 cm for male clients.

____ ____ ____ ____________________

23. Apply the sterile drape:A. Female client:

(1) Allow the top edge of the drape to form a cuff over bothgloved hands. Place the drape on the bed between theclients thighs. Slip the cuffed edge just under the clientsbuttocks, taking care not to touch the contaminatedsurface with gloves.

____ ____ ____ ____________________

(2) Pick up the fenestrated sterile drape and allow it to unfoldwithout touching any unsterile objects. Apply the drapeover the clients perineum, exposing labia, taking care not

to touch the contaminated surface with gloves.

____ ____ ____ ____________________

B. Male client:(1) Two methods are used for draping, depending on

preference.____ ____ ____ ____________________

First method:Apply the drape over the thighs and under thepenis without completely opening fenestrated drape.Second method:Apply the drape over the thighs just belowthe penis. Pick up the fenestrated sterile drape, allow it tounfold without touching any unsterile objects, and drapeit over the penis, with the fenestrated slit resting over thepenis.

24. Place the sterile tray and contents on the sterile drape. Open thespecimen container.

____ ____ ____ ____________________

25. Cleanse the urethral meatus.A. Female client:

(1) With your nondominant hand, carefully retract the labia tofully expose the urethral meatus. Maintain position of yournondominant hand throughout the procedure.

____ ____ ____ ____________________

(2) Holding forceps in your sterile dominant hand, pick up acotton ball saturated with antiseptic solution and cleanthe clients perineal area, wiping from clitoris toward anus(front to back). Using a new cotton ball for each area, wipealong the far labial fold, the near labial fold, and directlyover the centre of the urethral meatus.

____ ____ ____ ____________________

B. Male client:(1) If the client is not circumcised, retract the foreskin with

your nondominant hand. Grasp the penis at the shaft, justbelow the glans. Retract the urethral meatus between yourthumb and forefinger. Maintain your nondominant handin this position throughout the procedure.

____ ____ ____ ____________________

(2) With your sterile dominant hand, use forceps to pick upa cotton ball saturated with antiseptic solution, and cleanthe penis. Move the cotton ball in circular motion from

the urethral meatus down to the base of the glans. Repeatcleansing three more times, using a clean cotton ball eachtime.

____ ____ ____ ____________________

26. Pick up the catheter with your gloved dominant hand, 7.510 cmfrom the catheter tip. Hold the end of the catheter loosely coiledin the palm of your dominant hand. (Optional: Grasp the catheterwith forceps.)

____ ____ ____ ____________________

27. Insert the catheter.A. Female client:

(1) Ask the client to bear down gently as if to void urine, andslowly insert the catheter through the urethral meatus.

____ ____ ____ ____________________

Continued


3/3

485


S U NP Comments(2) Advance the catheter a total of 57.5 cm in an adult or until

urine flows out the catheters end. When urine appears,advance the catheter another 2.55 cm. Do not use forceagainst resistance.

____ ____ ____ ____________________

(3) Release the labia and hold the catheter securely with yournondominant hand. Slowly inflate the balloon if the in-dwelling catheter is being used.

____ ____ ____ ____________________

B. Male client:

(1) Lift the clients penis to position perpendicular to theclients body, and apply light traction. ____ ____ ____ ____________________

(2) Ask the client to bear down gently as if to void urine, andslowly insert the catheter through the urethral meatus.

____ ____ ____ ____________________

(3) Advance the catheter 1722.5 cm (79 inches) in an adultor until urine flows out the catheters end. If resistance isfelt, withdraw the catheter; do not force it through theurethra. When urine appears, advance the catheter another2.55 cm. Do not use force against resistance.

____ ____ ____ ____________________

(4) Lower the clients penis and hold the catheter securely inyour nondominant hand. Place the end of the catheter inthe urine tray. Inflate the balloon if an in-dwelling catheteris being used.

____ ____ ____ ____________________

(5) Reduce (or reposition) the foreskin. ____ ____ ____ ____________________28. Collect the urine specimen as needed. Fill the specimen cup or jar to

the desired level (2030 mL) by holding the end of the catheter overthe cup with your dominant hand.

____ ____ ____ ____________________

29. Allow the clients bladder to empty fully (about 8001000 mL)unless institution policy restricts the maximal volume of urine todrain with each catheterization. Check institution policy beforebeginning catheterization.

____ ____ ____ ____________________

30. Inflate the balloon fully per manufacturers recommendation, andthen release the catheter with your nondominant hand and pullgently.

____ ____ ____ ____________________

31. Attach the end of the in-dwelling catheter to the collecting tube ofthe drainage system. The drainage bag must be below the level ofthe bladder. Attach the bag to the bed frame; do not place the bagon the beds side rails.

____ ____ ____ ____________________

32. Anchor the catheter.A. Female client:

(1) Secure the catheter tubing to the clients inner thighor abdomen with a strip of nonallergenic tape (ormultipurpose tube holders with a Velcro strap). Allowfor slack so that movement of the thigh does not createtension on the catheter.

____ ____ ____ ____________________

B. Male client:(1) Secure the catheter tubing to the top of the thigh or lower

abdomen (with the penis directed toward the chest). Allowfor slack so that movement does not create tension on thecatheter.

____ ____ ____ ____________________

33. Assist the client to a comfortable position. Wash and dry theperineal area as needed.

____ ____ ____ ____________________

34. Remove gloves and dispose of equipment, drapes, and urine inproper receptacles.

____ ____ ____ ____________________

35. Perform hand hygiene. ____ ____ ____ ____________________36. Palpate the clients bladder. ____ ____ ____ ____________________37. Ask whether the client is comfortable. ____ ____ ____ ____________________38. Observe the character and amount of urine in the drainage system. ____ ____ ____ ____________________39. Ensure that no urine is leaking from the catheter or tubing

connections.____ ____ ____ ____________________

40. Record and report catheterization, characteristics and amount ofurine, specimen collection (if performed), and clients response toprocedure and teaching concepts.

____ ____ ____ ____________________

41. Initiate intake and output records. ____ ____ ____ ____________________

44-2_InsertingCatheter

Documents

Transcript of 44-2_InsertingCatheter