Foley and Catheter Management Policy

HIGHLANDS – CASHIERS HOSPITAL, INC.
and
ECKERD
H I G H L A N D S, N O R T H C A R O L I N A
LIVING

CENTER
POLICIES & PROCEDURES
Subject: Foley Catheter Management
Reference Location: Nursing Services Policy and Procedure
Policy Index: NUR090
Original date: 11/12
Revised: 12/13
Med Staff Approved : January 2013
Purpose: To outline nursing and physician’s responsibility in managing indwelling
foley catheters.
Policy: An indwelling catheter (IUC) is used only when clinically indicated and, when
used, is assessed daily for appropriateness of removal. Evidence-based practices are used
to prevent indwelling catheter-associated urinary tract infections (CAUTI’s).
Catheter associated urinary tract infections (UTI’s) are the most common hospital
acquired infection and can lead to increased length of stay, increased mortality and
increased hospital cost. It is estimated that up to 25% of hospitalized patients are
catheterized during their stay. UTI’s account for 40% of all hospital acquired infections
and more than 80% of those infections are secondary to foley catheter. Refer to “Clinical
Nursing Skills” for insertion and management of indwelling foley catheter. The most
important intervention in the reduction of UTI and sepsis is avoiding the use of
catheters or limiting the duration of use (preferably 4 days or less).
CRITERIA FOR CATHETER INSERTION:
A.
B.
C.
D.
E.
F.
G.
H.
I.
J.
Pelvic and hip fractures
Hemodynamically unstable
Accurate monitoring of intake and output in critically ill patient
Urinary retention not manageable by other means
Bladder irrigation or medication installation
Management of urinary incontinence with stage 3 or greater sacral pressure ulcer
Comfort measures for terminally ill
Hematuria/irrigation
Urological/gynecological or perineal surgical procedure
Chronic indwelling catheters
Alternatives to indwelling catheters should be considered and utilized as appropriate,
such as:
1. Condom catheters for male patients.
2. Frequent and schedule toileting routine.
3. Intermittent catheterization.
4. Bladder scanning can be used to evaluate decreased urine output.
If indwelling foley catheters must be used the following standard of practice for care and
maintenance will be followed:
1. Only qualified staff will insert and care for urinary catheters.
2. Perform hand hygiene and don clean gloves when manipulating the catheter site
or apparatus.
3. Use sterile technique for catheter insertion, irrigation, and collection of urine for
culture.
4. Secure indwelling catheter by using appropriate device. Female patients secure to
inner thigh. Male patients secure to top of thigh or lower abdomen.
5. Maintain catheter bag and tubing distal to and below the level of the bladder at all
times including during transportation and/or ambulation and maintain tubing
above the level of the bag with no dependent loops.
6. Maintain a closed drainage system at all times. If disconnection or leakage occurs
to the collecting system, replace using aseptic technique after disinfecting the
catheter-tubing junction with alcohol or chloraprep. When changing from a
bedside bag to a leg bag, perform hand hygiene, don gloves, disinfect the catheter
tubing junction using alcohol or chloraprep for 10 to 15 seconds. Use urometer for
frequent output measurements.
7. Clean perineum q shift and as needed after each bowel movement using soap and
water.
8. If occlusion is suspected, assess for abdominal distention/discomfort and use
bladder scanning as needed.
9. Change catheter only with physician order and when clinically indicated (such as
suspected occlusion or patient discomfort) unless otherwise contraindicated.
COLLECTION AND DOCUMENTATION OF URINE SPECIMENS
A. Initiate a nursing care plan (Elimination) and chart on the flow sheet (Assistive
Devices) the Insertion of the catheter, date and size.
B. Document if patient has any of the following symptoms with or without a foley
catheter:
 fever (>38 C / 100.4 F) in a patient that is <=65 years of age
 urgency
 Frequency
 Dysuria
 suprapubic tenderness, or costovertebral angle pain or tenderness
C. Ask the physician if he/she wants a UAC (UA with culture if indicated) if there
are any of the above signs and symptoms.
CATHETER REMOVAL
A. Notify Physician before foley catheter removal
B. The catheter may be removed only when one of the above criteria for catheter
insertion no longer applies.
C. Following removal, assess the patient’s ability to void:
1. Perform bladder scan after the first and second voids
2. If results > 300ml, perform in and out catheterization and repeat the
bladder scan and I&O every 6 hours until post void residual is <300ml
D. Notify the physician;
1. If the patient does not void within 8 hours after catheter removal.
2. If the patient requires I&O catheterization 24 hours after catheter removal.
3. If the patient does not tolerate I&O catheterization, request CPOE order
for placement of indwelling catheter
ONGOING MANAGEMENT
A. The nurse should verify with the physician the necessity of the indwelling catheter
on a daily basis. This is documented in the care plan.
B. The following items need assessed and documented every shift in the care plan.
Foley cath tubing secured
Foley cath below patient bladder
Foley cath care/perineal care q shift and after bowel movements
Aseptic technique used when emptying bag

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