Foley Catheter Removal and Voiding Assessment Interventions Standing Orders

PLACE LABEL HERE

FOLEY CATHETER REMOVAL and

VOIDING ASSESSMENT / INTERVENTIONS

STANDING ORDERS

Nurse initiated standing order based on

medical staff approved policy #6143.

FOLEY CATHETER REMOVAL:

1.  If patient has Foley catheter for 24 hrs, remove Foley catheter unless the patient meets one or more of the following criteria:

a.  Patient has acute urinary retention, drug/anesthesia induced urinary retention, or bladder outlet obstruction

b.  Critically ill patients with need for accurate measurements of urinary output.

c.  Patients undergoing urologic surgery or other surgery on contiguous structures of the genitourinary tract

d.  To assist in healing of open sacral or perineal wounds in incontinent patients

e.  Patient requires prolonged immobilization (e.g., potentially unstable thoracic or lumbar spine, multiple traumatic injuries, such as pelvic fractures)

f.  To improve comfort for end-of-life care, if needed

2. Implement Voiding Assessment / Interventions post Foley catheter removal.

VOIDING ASSESSMENT / INTERVENTIONS:

1.  Assess patient for symptoms of bladder distention, discomfort, pain, and/or feeling of fullness.

Indications:

a.  Difficulty voiding

b.  Unable to void for 6 hours post-operatively or post procedure

c.  Unable to void 6 hours after removal of an indwelling Foley catheter

d.  1st void after Foley catheter removal is < 250 mls

2.  If patient has any of the above symptoms/ indications and is not pregnant or postpartum (up to 6 wks):

a.  Assist patient to void.

b.  Conduct bladder scan.

·  If 400 mls and no symptoms, assess hydration and /or renal status (see back reference page).

·  If 400 mls or 400 mls with symptoms, perform straight cath

c.  If patient unable to void 6 hrs after straight cath, repeat bladder scan;

·  If 400 mls or 400 mls with symptoms, repeat straight cath

d.  If patient unable to void 6 hrs after 2nd straight cath, repeat bladder scan;

·  If 400 mls or 400 mls with symptoms, insert Foley cath

3.  If patient is pregnant or postpartum (up to 6 wks) and has any of the above symptoms/indications, perform straight cath. If patient needs to be catheterized more than once, insert Foley to bedside bag and notify physician.

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Date Time Nurse Signature Physician Signature PID Number

*2-31620* FORM 2-31620 REV. 01/2014 Page 1 of 2

PLACE LABEL HERE

FOLEY CATHETER REMOVAL and

VOIDING ASSESSMENT / INTERVENTIONS

STANDING ORDERS

Reference Page

Voiding Assessment Algorithm

FORM 2-31620 REV. 01/2014 Reference Page Page 2 of 2