MENDOCINO COAST DISTRICT HOSPITAL
GENERAL PATIENT CARE POLICY AND PROCEDURE STATEMENT
NUMBER: 205.1330
PAGE: 1 OF 3
TITLE: FOLEY CATHETER – Routine Foley Catheter Care
PURPOSE: Patients with indwelling catheters have specific perineal hygiene needs to reduce the risk of urinary tract infection. Any secretions or encrustations at the catheter insertion site must be completely removed.
POLICY: Routine foley catheter care should be performed daily with bath and after every bowel movement or incontinence. Catheter care may be performed by an RN, LVN or C.N.A.
EQUIPMENT: Disposable gloves
Bed protector
Bath blanket
Soap and washcloth
PROCEDURE:
1. Wash hands, don gloves.
2. Close curtains around the bed or close the door to room and explain procedure to patient.
3. Raise bed to appropriate working height. Raise side rails on opposite side of bed.
4. Organize equipment for perineal care.
5. Position patient correctly and cover with bath blanket, exposing only perineal area.
a. Female in dorsal recumbent position.
b. Male in supine position.
6. Place waterproof pad under patient.
7. Drape bath blanket on bedclothes so that only perineal area is exposed.
8. Don gloves.
9. With non dominant hand:
a. Female patient –
i. Gently retract labia of female patient to fully expose urethral meatus and catheter insertion site; maintain position of hand throughout procedure.
b. Male patient –
i. Retract foreskin (if patient is not circumcised), and hold penis at shaft just below glans. Maintain position of hand throughout procedure. After cleansing, pull foreskin back over glans.
10. Assess urethral meatus and surrounding tissues for inflammation, swelling, discharge. Note amount, color, odor and consistency of discharge. Ask patient if he/she feels burning or discomfort.
11. Cleanse perineal tissues:
a. Female patient:
i. Use a clean washcloth and fresh soap and water to cleanse each labium majora, moving down toward the anus. Use a new area of washcloth for each stroke. Repeat process to cleanse labia minora, then cleanse around the urethral meatus. Rinse with clean water and cloth.
b. Male patient:
i. While spreading urethral meatus, cleanse around the catheter first, then use clean washcloth to wipe in circular motion around meatus and glans.
12. Reassess urethral meatus for discharge.
13. Take clean washcloth and wipe in circular motion along length of catheter for about 10 cm (4 inches).
14. Replace urinary tubing and collection bag if necessary, adhering to principles of surgical asepsis. Urinary tubing and collection bag should be changed if there are signs of leakage, odor, sediment buildup; and usually changed at least once a week. Date bag when put into use.
15. Check drainage tubing and bag to ensure that:
a. No tubing loops hang below level of bladder.
b. Tube is coiled and secured onto bed linen.
c. Tube is not kinked or clamped.
d. Drainage bag is positioned appropriately on the bed frame.
16. Collection bag should be emptied as necessary but at least every 8 hours.
17. Assist patient to safe, comfortable position.
18. Dispose of contaminated gloves, supplies and wash hands.
19. Lower the bed to its lowest position.
EVALUATION:
1. Inspect condition of urethra.
2. Note character and amount of urine.
3. Assess patient’s temperature.
4. Ask if patient senses urethral discomfort.
5. Unexpected outcomes that may occur and need to be reported to the RN and/or the physician include:
a. Odor is present.
b. Urethral meatus is reddened and swollen.
c. Client has fever.
d. Urine is leaking.
RECORDING:
Record in nurses’ notes when catheter care was given, the assessment of urethral meatus and character of urine.
New: Revised: 05/09
Approval Signatures:
______
Nurse Manager Date
______
Chief Clinical Officer Date
______
Medical Chief of Staff Date
______
Chief Executive Officer Date
______
President, Board of Directors Date