FOLEY CATHETER INSERTION

Review of Anatomy
 In urology, a Foley catheter (named for Frederic Foley, who produced the original design in 1929)
is a flexible tube that a clinician passes through the urethra and into the bladder to drain urine.
Patients are prescribed to be inserted with a urinary catheter when they experience one or
more of the following:

 Urinary retention
 A need to thoroughly monitor fluid intake and urine output
 As part of preoperative management
 For patients who are incontinent or on prolonged bed rest
 Patients with sacral or perineal wounds
 Bedridden patients
 Those who are at the end-of-life care

Other purposes of inserting urinary catheters include:

 Obtaining sterile urine specimens from patients

 Measuring the amount of residual urine in the bladder
 Complete bladder emptying, especially prior to diagnostic or surgical procedures
 To serve as irrigation route for patients needing bladder irrigation

The Intermittent and Indwelling Catheter

Inserting a urinary catheter into the bladder is considered part of routine nursing
interventions and is not necessarily a complex skill. However, it can also be a difficult skill
for the nurse to master as both male and female patients face challenges in inserting the
catheter.

It is important to ensure adequate lighting to help visualization of the urethra,

especially among female patients. Positioning the patient correctly is also important, taking
into consideration of the patient’s condition and any contraindications for certain positions
(i.e., female in the last trimester of pregnancy in the supine lithotomy position).

There are two major types of catheterization generally used for patients needing
them: intermittent and indwelling.

Intermittent catheterization is done using a single-lumen catheter and is usually used for
patients needing:

1. Immediate relief from urinary retention,

2. Long-term management of an incompetent bladder;
3. Obtaining a sterile urine specimen for diagnostic tests; and
4. Assessment of the urinary bladder for residual urine after voiding.
An indwelling catheter, on the other hand, may use a double or triple lumen catheter and is
used for:

 Promotion of normal urinary elimination patterns

 Measuring the accurate amounts of urine output
 Prevention of skin breakdown
 Helps facilitate wound management
 In helping surgical sites such as the urethra, bladder, and surrounding structures
heal after surgery
 Instillation of irrigation fluids and/or medications
 Assessment of persistent abdominal or pelvic pain
 Assisting in the diagnosis of conditions involving the genitourinary system

The lumens of the indwelling catheters have their distinct uses. In the double-lumen
catheter, one of the lumens is used mainly for draining urine into a collection bag, while the
other lumen is used as a port for the liquid used in inflating the balloon to keep it in place. In
the triple-lumen setup, the third lumen is usually used to instill medication and/or irrigating
solution into the bladder. The catheter is also attached to a collection bag hung lower than
the catheter so that the flow of urine remains unrestricted.

Catheters inserted into the bladder are also used based on the French (Fr) scale sizes. This
scale is used to denote the diameter of the tubes.

Recommended Fr sizes for female patients range from 12 to 16, while male
patients normally use Fr 14 to Fr 16.
Insertion of Catheter

Prior to the actual insertion of the catheter, the nurse must remember to check and verify
the order and refer to the protocols implemented in the facility regarding the procedure. An
informed consent for catheterization is also required to be signed prior to the actual
procedure. It may be signed by the patient or an authorized guardian if he is unable to give
consent.

Prior to insertion

Prior to inserting the catheter, the nurse must prepare the following materials to be used in
the procedure: sterile gloves, catheterization kit, cleaning solution, water-based lubricant (if
not included in the kit), prefilled syringe for balloon inflation based on catheter size, foley
catheter and urine bag. The following tips should also be remembered:

1. Perform hand washing to reduce the risk of transferring infections.

2. Assess the patients’ room/environment thoroughly to determine appropriate
lighting, need for privacy and other additional precautions.
3. Confirm the patient’s identity and explain the procedure and how he can
cooperate with the process.
4. Prepare the necessary materials for easier access during the insertion of the
catheter.
 5. Inflate the balloon using a syringe before use to determine the patency of the
balloon. Aspirate the fluid back into the syringe and set it aside.
6. Prepare the necessary materials to be used in a sterile field.

During insertion

The table below presents the steps to be followed in catheter insertion with the rationale for
each action.

Procedure Rationale

Determine the size of the catheter to be Large catheter sizes increase the risk of
used. If possible, choose the smallest size for urethral trauma and may cause pain during
the patient. insertion.
Place a waterproof pad under the patient’s This helps protect the linens from soiling
perineal area. during the procedure.

Position the patient appropriately.

Female patient: On back with knees flexed

and thighs relaxed so that hips rotate to Positioning the patient appropriately helps to
expose the perineal area. Alternatively, if the visualize the insertion site, making it easier
patient cannot abduct the leg at the hip, the for the nurse to perform the procedure
patient can be side-lying with the upper leg safely.
flexed at the knee and hip, supported by
pillows.
Male patient: Supine with legs extended
and slightly apart.
Draw curtains around the bed and place a
This helps provide privacy to the patient,
blanket or sheet to cover the patient and
maintaining his dignity and modesty.
expose only required anatomical areas.
According to agency policy, apply clean Cleaning removes any secretions, urine, and
gloves and wash the perineal area with feces and reduces the risk of CAUTI
warm water and soap or a perineal cleanser. (catheter-acquired urinary tract infection).
This helps the nurse to visualize the site
Ensure that there is adequate lighting near
better, thereby ensuring accuracy and speed
the insertion site.
of the insertion.
A urinary bag should be closed to prevent
urine drainage from leaving the bag.
Remove gloves and discard. Wash hands.

Open catheter kit or individual sterile

This step is necessary to observe the aseptic
supplies. Don sterile gloves and
technique and reduce the risk of infections.
organize supplies on sterile field
Drape patient with drape found in The outer edges (2.5 cm) of the drape is
catheterization kit, either using sterile gloves considered to be unsterile. Touching this
or using ungloved hands and only touching part would render the entire field unsterile,
the outer edges of the drape. Ensure that which may increase the risk of infections.
any sterile supplies touch only the middle of
the sterile drape (not the edges), and that
sterile gloves do not touch non-sterile
surfaces. Drape patient to expose perineum
or penis.
Applying lubricants to the tip of the catheter
Lubricate the tip of the catheter using sterile
ensures more accessible and more effortless
lubricant included in-tray, or add lubricant
insertion, decreasing urethral trauma and
using sterile technique.
discomfort.
Check balloon inflation using a sterile This maintains the sterility of the catheter
syringe. and helps determine its patency.
Place sterile tray with catheter between A sterile tray will collect urine once the
patient’s legs. catheter tip is inserted into the bladder.

Clean perineal area as follows.

Female patient: Separate labia with fingers

of non-dominant hand (now contaminated
and no longer sterile). Using a sterile
technique and dominant hand, clean labia
and urethral meatus from clitoris to anus and
from outer labia to inner labial folds and
urethral meatus. Use sterile forceps and a
new cotton swab with each cleansing stroke.
Male patient: Gently grasp penis at shaft
and hold it at a right angle to the body
throughout the procedure with non-dominant
hand (now contaminated and no longer
sterile). Using a sterile technique and
dominant hand, clean urethral meatus in a
circular motion working outward from
meatus. Use sterile forceps and a new cotton Perineal care helps in reducing the introduction
swab with each cleansing stroke. of microorganisms into the urethra, thereby
reducing infections.
Holding the catheter closer to the tip will
Pick up catheter with sterile dominant hand
help to control and manipulate the catheter
7.5 to 10 cm below the tip of the catheter.
during insertion.

Insert catheter as follows.

Female patient: This process helps visualize the urethral

meatus and relax the external urinary
 Ask the patient to bear down
sphincter.
gently (as if to void) to help
expose urethral meatus.
Note: If the catheter does not advance in a
 Advance catheter 5 to 7.5 cm until male patient, do not use force. Ask the
urine flows from the catheter, then patient to take deep breaths and try again. If
the catheter still does not advance, stop the
advance an additional 5 cm. procedure and inform the physician. The
Male patient: patient may have an enlarged prostate or
urethral obstruction.
 Hold penis perpendicular to the
body and pull up slightly on the
shaft.
 Ask the patient to bear down Note: If urine does not appear in a female
patient, the catheter may be in the patient’s
gently (as if to void) and slowly vagina. You may leave the catheter in the
insert the catheter through the vagina as a landmark and insert another
sterile catheter.
urethral meatus.
 Advance catheter 17 to 22.5 cm or
until urine flows from the catheter.
Slowly inflate the balloon for indwelling The inflated balloon will help keep the
catheters according to catheter size, using a catheter in place and reduce the risk of it
prefilled syringe. accidentally being pulled out.
After inflating the balloon, pull gently on the Moving the catheter back into the bladder
catheter until resistance is felt and then will avoid placing pressure on the bladder
advance the catheter again. neck.
Connect the urinary bag to the catheter The urinary bag will ensure that urine will be
using the sterile technique. collected and output monitored
Closed Drainage System: appropriately.
a. Drainage Bag: Connect catheter to tubing
end of drainage bag. Place
 the bag below the bladder level. Check to be
sure there are no kinks or
obstructions in the tubing.

b. Leg Bag: Connect catheter to tubing end

of leg bag. A leg bag is
usually worn during the day and allows for
increased mobility.

Secure catheter to patient’s leg using

securement device at tubing just above
catheter bifurcation.

Female patient: Secure catheter to the

inner thigh, allowing enough slack to prevent Securing catheter reduces the risk of CAUTI,
tension. urethral erosion, and accidental catheter
removal.
Male patient: Secure catheter to the upper
thigh (with penis directed downward) or
abdomen (with penis directed toward chest),
allowing enough slack to prevent tension.
Ensure foreskin is not retracted.

If using an indwelling catheter and closed

drainage system, attach a urinary bag to the
bed and ensure that the clamp is closed.

Dispose of used materials according to

This reduces the transfer of microorganisms
infection control procedure. Remove gloves
and reduces the risk o infections.
and perform hand hygiene.

Document procedure according to agency

policy.
Document in the clinical record:
1. Type and size of catheter inserted.
2. Date and time of catheter insertion.
3. Urine return and characteristics, color, Timely and accurate documentation
and odor, if any. promotes patient safety.
4. Amount of urine prior to residual
catheterization.
5. Any difficulties or discomfort.
6. Teaching provided and client/caregiver
response.

After Insertion

Ensure that the patient’s response to the procedure is appropriately monitored and that
urine output is documented. Ensure also that the urine bag and insertion sites are free from
obstructions, and if there is a need to replace any part of the system.
Once the goal of the catheterization is met, its removal is expected to be ordered since
prolonged use of the catheter may place the patient at an increased risk of developing
infections. Preferably, catheters should be removed within 24 hours.

Patients require an order to have an indwelling catheter removed. Although the order is
necessary, the health care provider’s responsibility is to evaluate if the indwelling catheter is
required for the patient’s recovery. Removal of the catheter should be done after assessing
whether the patient’s bladder function has returned and any untoward responses to the
therapy should be reported to the physician. These symptoms include:
 Hematuria
 Inability or difficulty in voiding
 Incontinence after catheter removal
 Signs of infection such as pain upon urination, fever, and chills
Moreover, the nurse should also include in the patient education the expected symptoms
after catheter removal, such as mild burning sensation immediately after removal. Also,
patients should receive the following instructions while on catheter:

 Increase fluid intake to at least 3000ml per day unless contraindicated

 Bladder training, if needed: instruct the patient to void when he can do so and to
make sure that he empties his bladder within 6 hours of catheter removal.
 Take note of the first voided urine characteristics and report these to the health
care provider: color, volume, sensation upon urination, and any abnormality in
smell and transparency.
 Report any pain, burning sensation, or blood tinged-urine
 Inform the nurse or other members of the health team of any signs indicating
catheter-acquired urinary tract infection

Removing the Catheter

Procedure Rationale
Verify the order for the removal of the
This ensures that the order for the removal
catheter. Once verified, prepare necessary
of the catheter is made correctly.
materials for removal.
Ensure that the patient is properly identified Providing privacy helps protect the dignity of
and necessary measures to protect privacy the patient and increases his trust in the
are instituted. health care provider.
Provide patient teaching on the symptoms This helps ensure that the patient knows
he may feel after removing the catheter and what symptoms to report, what to expect,
what he can do to alleviate them. and how to manage them.
Performing hand hygiene prior to preparing
Perform hand hygiene and don non-sterile
the materials also helps break the chain of
gloves.
infection.
Measure, empty, and record contents of Documentation is a vital aspect of caring for
catheter bag. Remove gloves, perform hand
hygiene, and apply new non-sterile gloves. patients with impaired urinary function,
while using sterile gloves reduces the risk of
transferring pathogens to the patient.

To make it easier for the nurse to pull out

Remove catheter securement/anchor device.
and remove the catheter later on.
Perform catheter care with warm water and This reduces the transfer of microorganisms
soap or according to agency protocol. into the urethra.
Insert syringe in balloon port and drain fluid
from the balloon. Verify balloon size on the A partially deflated balloon will cause trauma
catheter to ensure all fluid is removed from to the urethra wall and pain.
the balloon.
Pull catheter out slowly and smoothly. The
catheter should slide out slowly and
smoothly.
Note: If resistance is felt, stop removal and This reduces trauma to the urinary tract and
reattempt to remove the fluid from the minimizes the discomfort the patient may
balloon. Attempt removal again. If unable to feel during the removal.
remove the catheter, stop and notify the
physician.

Wrap used catheter in waterproof pad or

gloves. Unhook catheter tube from a urinary This prevents accidental spilling of urine
bag. Discard equipment and supplies from the catheter.
according to agency policy.
Provide perineal care as required and
reposition the patient to a comfortable This promotes patient comfort.
position.
Review post-catheter care, fluid intake, and
expected and unexpected outcomes with the
patient.
Ensure patient has access to toilet,
commode, bedpan, or urinal—place call bell
These measures ensure that the patient
within reach. Ensure the first void (urine
would have lower risks of having CAUTI and
output) is measured as per agency policy.
would be able to achieve normal voiding
patterns after catheterization.
Encourage the patient to maintain or
increase fluid intake to maintain average
urine output (unless contraindicated).

Lowering the bed helps prevent falls. Hand

Lower bed to a safe position, remove gloves hygiene prevents the transmission of
and perform hand hygiene. microorganisms from patient to health care
provider.
 Document time of catheter removal,
condition of the urethra, and any teaching
related to post-catheter care and fluid
Document procedure according to agency intake.
policy. Document time, amount, and characteristics
of the first void after catheter removal.

1. Basavanthappa, B., (2015). Medical Surgical Nursing. New Delhi: Jaypee Brothers
Medical Publishers.
2. Billings, D. and Hensel, D., 2019. Lippincott Q & A Review For NCLEX-RN. 13th ed.
St. Louis, MO., USA.: Wolters Kluwer Medical.
3. Hinkle, J.L. & Cheever, K.H. (2018). Brunner & Suddarth’s Textbook of Medical-
Surgical Nursing (14th ed.). Philadelphia: Wolters Kluwer.
4. Morton, P., & Fontaine, D. (2018). Critical Care Nursing. Wolters Kluwer.
5. Potter, P.A., Perry, A.G., Stockert, P.A., & Hall, A.M. (2019). Essentials for Nursing
Practice (9th ed.). St. Louis: Elsevier.

Prepared by: GFP