Nursing Care of Patients with Indwelling Urinary Catheters

Learning Objectives

Understand the anatomy and physiology of the urinary system related to catheterization

Identify appropriate indications and contraindications for indwelling catheters

Demonstrate proper insertion and maintenance techniques

Implement evidence-based CAUTI prevention strategies

Recognize and manage complications effectively

Apply critical thinking in clinical decision-making

Anatomy and Physiology Review

Figure 1: Cross-sectional view of the urinary system with properly placed indwelling catheter

Key Anatomical Structures

1

Bladder (Vesica Urinaria)

Hollow, muscular organ that stores urine. Capacity: 300-500 mL in adults

2

Urethra

Tube connecting bladder to external environment. Length: 3-4 cm (female), 15-20 cm (male)

3

Urethral Sphincters

Internal (involuntary) and external (voluntary) sphincters control urination

Physiological Considerations

                            Normal Urine Production
                            Average output: 1-2 L/day (30-50 mL/hour)
Minimum output: 0.5 mL/kg/hour
Color: Pale yellow to amber
Specific gravity: 1.003-1.030

                        

Micturition Reflex

The bladder’s stretch receptors trigger the micturition reflex at ~150-200 mL capacity. Catheterization bypasses this normal mechanism.

Catheter Types and Sizing

Foley Catheter

Design: Two-way with inflatable balloon
Balloon volume: 5-30 mL
Most common: 10 mL balloon
Material: Latex or silicone

Three-way Catheter

Design: Additional irrigation lumen
Use: Continuous bladder irrigation
Indication: Post-surgical bleeding
Size: Typically 20-24 Fr

Suprapubic Catheter

Insertion: Through abdominal wall
Advantage: Reduced UTI risk
Use: Long-term catheterization
Size: 12-16 Fr typically

French Sizing System

Patient Population	Recommended Size (Fr)	Color Code	Balloon Volume
Pediatric (2-12 years)	5-10 Fr	Green/Blue	3-5 mL
Adult Female	12-14 Fr	Orange/Red	10 mL
Adult Male	14-16 Fr	Red/Brown	10 mL
Hematuria/Clots	18-24 Fr	Yellow/Purple	30 mL

Memory Aid: French Size Selection

“Small Kids Get Frustrated Making Big Decisions”

Small (5-8 Fr) – Pediatric
Kids (10-12 Fr) – Adolescent/Small Adult
Get (12-14 Fr) – Adult Female
Frustrated (14-16 Fr) – Adult Male
Making (18-20 Fr) – Post-surgical
Big (22-24 Fr) – Hematuria/Clots
Decisions (26+ Fr) – Specialized procedures

Indications and Contraindications

Appropriate Indications

Urinary retention – Acute or chronic inability to void
Perioperative management – Major surgery with expected prolonged immobility
Accurate I&O monitoring – Critically ill patients requiring precise fluid balance
Neurogenic bladder – Spinal cord injury, multiple sclerosis
Genitourinary surgery – Prostate, bladder, or urethral procedures
Comfort care – End-of-life care to maintain dignity

Contraindications

Urethral trauma – Suspected urethral injury or stricture
Severe prostatitis – Acute inflammation of prostate
Patient refusal – Competent patient refuses procedure
Convenience purposes – Staff convenience, incontinence management
Pelvic fracture – Risk of urethral injury
Allergy to materials – Latex or catheter materials

Clinical Pearl: The “CAUTI-ous” Approach

Always ask yourself: “Is this catheter still necessary?”

Remember: Every day a catheter remains increases infection risk by 3-7%. The best catheter is no catheter when medically appropriate.

Sterile Insertion Procedure

Critical Safety Reminders

Never force the catheter – Risk of urethral trauma
Verify urine flow before balloon inflation – Prevents urethral damage
Use only sterile water for balloon inflation – Prevents balloon rupture

Pre-Insertion Checklist

Patient Assessment

☐ Verify physician order
☐ Check allergies (latex, betadine)
☐ Assess cognitive status
☐ Evaluate mobility/positioning
☐ Review medical history

Equipment Preparation

☐ Sterile catheter kit
☐ Appropriate catheter size
☐ Sterile gloves
☐ Adequate lighting
☐ Privacy measures

Step-by-Step Insertion Procedure

1

Patient Preparation

Explain procedure, obtain consent, ensure privacy and comfort

Implementation: Position patient supine with knees flexed and separated

2

Hand Hygiene and Gloving

Perform thorough hand hygiene, don sterile gloves

Implementation: Use alcohol-based hand rub or antiseptic soap for 20 seconds

3

Sterile Field Setup

Open catheter kit, arrange supplies on sterile field

Implementation: Place fenestrated drape over patient’s thighs

4

Perineal Cleansing

Clean urethral meatus with antiseptic solution

Implementation: Female – separate labia, clean front to back; Male – retract foreskin, clean in circular motion

5

Catheter Insertion

Insert catheter slowly until urine flows, then advance 1-2 inches more

Implementation: Female – 2-3 inches; Male – 7-9 inches until urine flows

6

Balloon Inflation

Inflate balloon with sterile water as indicated on catheter

Implementation: Typically 10 mL for standard adult catheter

7

Secure and Connect

Gently pull back until resistance felt, connect to drainage bag

Implementation: Secure catheter to thigh with tape or catheter holder

Memory Aid: “STERILE” Insertion

Set up sterile field
Test balloon before insertion
Explain procedure to patient
Retract foreskin (male) or separate labia (female)
Insert catheter slowly until urine flows
Lubricate catheter tip adequately
Ensure balloon inflation after urine flow

Maintenance and Daily Care

Daily Care Routine

Perineal hygiene – Clean with soap and water daily
Catheter cleaning – Clean 4-6 inches of catheter from meatus outward
Secure properly – Tape to thigh allowing catheter movement
Maintain position – Keep drainage bag below bladder level

Drainage System Management

Gravity drainage – Ensure unobstructed flow to bag
Empty regularly – When 1/2 to 2/3 full or every 8 hours
Avoid disconnection – Keep closed system intact
Monitor output – Document color, clarity, and amount

Assessment Parameters

Urine Characteristics

Color: Pale yellow to amber
Clarity: Clear to slightly cloudy
Odor: Mild, not foul
Amount: 30-50 mL/hour minimum

Catheter Function

Patency: Free-flowing drainage
Position: Secure, no tension
Balloon: Properly inflated
Tubing: No kinks or obstructions

Patient Comfort

Pain level: Minimal discomfort
Urge to void: May persist initially
Spasms: Bladder spasms may occur
Mobility: Maintain as possible

When to Empty Drainage Bag

Timing: Every 8 hours or when 1/2 to 2/3 full
Technique: Use separate collection container for each patient
Hygiene: Clean hands before and after, don’t touch drainage spout
Documentation: Record amount, color, clarity, and odor

CAUTI Prevention Strategies

CAUTI: A Serious Healthcare Challenge

Statistics

• 75% of UTIs are catheter-associated
• 3-7% daily infection risk increase
• $1,000+ additional cost per case
• Increased length of stay

Risk Factors

• Female gender
• Advanced age
• Prolonged catheterization
• Immunocompromised state

Evidence-Based Prevention Bundle

Insertion Best Practices

✓ Sterile technique always
✓ Trained personnel only
✓ Smallest appropriate catheter
✓ Sterile, single-use lubricant
✓ Proper hand hygiene

Maintenance Excellence

✓ Maintain closed system
✓ Keep bag below bladder
✓ Secure catheter properly
✓ Empty bag regularly
✓ Daily necessity assessment

Daily CAUTI Prevention Checklist

Morning Assessment

☐ Is catheter still needed?
☐ Any signs of infection?
☐ System integrity intact?
☐ Proper positioning?

Ongoing Care

☐ Perineal hygiene completed
☐ Catheter cleaned
☐ Bag emptied appropriately
☐ Output documented

End of Shift

☐ Removal criteria met?
☐ Patient education provided
☐ Family involved in care
☐ Documentation complete

Memory Aid: “PREVENT” CAUTI

Position bag below bladder
Remove catheter ASAP
Empty bag regularly
Verify necessity daily
Ensure closed system
No routine irrigation
Training for all staff

Complications and Management

Catheter-Associated Urinary Tract Infection (CAUTI)

Signs and Symptoms

• Fever >38°C (100.4°F)
• Suprapubic tenderness
• Cloudy, foul-smelling urine
• Increased urgency/frequency
• Flank pain
• Altered mental status (elderly)

Nursing Interventions

• Obtain urine specimen for C&S
• Assess for removal criteria
• Monitor vital signs
• Increase fluid intake if appropriate
• Administer antibiotics as ordered
• Document findings thoroughly

Catheter Obstruction

Causes

• Blood clots
• Sediment/debris
• Kinking of tubing
• Encrustation
• Balloon malposition

Management

• Check for kinks in tubing
• Ensure proper positioning
• Gentle milking of tubing
• Irrigation if ordered
• Consider catheter replacement

Urethral Trauma

Prevention

• Never force catheter insertion
• Use appropriate lubrication
• Proper catheter size selection
• Gentle insertion technique
• Secure catheter properly

Signs of Trauma

• Bleeding from urethra
• Severe pain during insertion
• Inability to advance catheter
• Hematuria
• Swelling around meatus

Bladder Spasms

Contributing Factors

• Large catheter balloon
• Catheter irritation
• Bladder infection
• Anxiety/stress
• Constipation

Management Strategies

• Antispasmodic medications
• Proper catheter securing
• Patient education/reassurance
• Bladder training if appropriate
• Address underlying causes

When to Notify Healthcare Provider

Immediate notification: No urine output for 2 hours, gross hematuria, severe pain
Within 1 hour: Signs of infection, catheter displacement, system compromise
Next routine contact: Decreased output, minor complications, patient concerns

Patient and Family Education

Home Care Instructions

Daily hygiene: Clean catheter and surrounding area with soap and water
Bag management: Keep below bladder level, empty regularly
Fluid intake: Maintain adequate hydration unless restricted
Activity: Resume normal activities as tolerated
Monitoring: Watch for signs of infection or complications

When to Seek Help

Emergency: No urine output, severe pain, fever >101°F
Call healthcare provider: Cloudy/foul-smelling urine, burning sensation
Urgent care: Catheter falls out, bag leaking, persistent bleeding
Routine follow-up: Scheduled appointments, catheter changes

Teaching Points by Development Stage

Pediatric Considerations

• Age-appropriate explanations
• Involve parents/caregivers
• Use play therapy techniques
• Address body image concerns
• Maintain dignity and privacy

Adult Education

• Detailed care instructions
• Return demonstration
• Written materials provided
• Support resources
• Encourage questions

Geriatric Considerations

• Cognitive assessment
• Simplified instructions
• Caregiver involvement
• Mobility adaptations
• Frequent reinforcement

Nursing Implementation in Clinical Practice

Comprehensive Nursing Assessment

Physical Assessment

• Bladder distension palpation
• Urethral meatus inspection
• Catheter positioning check
• Drainage system evaluation
• Skin integrity assessment

Functional Assessment

• Cognitive status evaluation
• Mobility and self-care ability
• Pain assessment (0-10 scale)
• Quality of life impact
• Psychosocial adjustment

Nursing Diagnosis and Care Planning

Risk for Infection

Related to: Invasive procedure, compromised urinary tract

Interventions: Maintain sterile technique, monitor for signs of infection, implement CAUTI prevention bundle

Impaired Urinary Elimination

Related to: Urinary retention, neurogenic bladder, obstruction

Interventions: Monitor I&O, assess catheter patency, plan for removal when appropriate

Disturbed Body Image

Related to: Presence of catheter, altered elimination pattern

Interventions: Provide emotional support, encourage verbalization, maintain dignity

Quality Indicators and Outcomes

Process Measures

• Appropriate catheter utilization
• Adherence to insertion protocol
• Daily necessity assessment
• Maintenance bundle compliance

Outcome Measures

• CAUTI rate reduction
• Catheter-days minimized
• Patient satisfaction scores
• Complication rates

                            
                            Interprofessional Collaboration
                        
                                Physician/NP
                                • Order verification
• Complication management
• Removal criteria

                                Infection Control
                                • Surveillance data
• Policy development
• Staff education

                                Patient/Family
                                • Education and support
• Shared decision-making
• Discharge planning

Documentation and Legal Considerations

Essential Documentation Elements

Insertion: Date, time, size, type, difficulty level, patient response
Daily care: Catheter assessment, perineal care, system integrity
Output: Amount, color, clarity, odor, specific gravity
Complications: Signs, symptoms, interventions, provider notification
Education: Patient/family teaching provided and understood

Legal and Ethical Considerations

Informed consent: Patient understanding of risks and benefits
Privacy: Maintain dignity during procedures and care
Competency: Ensure trained personnel perform procedures
Advocacy: Question unnecessary catheter use
Standards: Follow evidence-based guidelines

Sample Documentation Templates

Insertion Note

“14 Fr Foley catheter inserted per sterile technique for urinary retention. 10 mL sterile water used to inflate balloon. Clear yellow urine returned immediately. Catheter secured to right thigh with StatLock. Patient tolerated procedure well with minimal discomfort. Drainage bag positioned below bladder level.”

Daily Assessment

“Foley catheter patent and draining clear yellow urine. Catheter secured appropriately, no signs of infection at insertion site. Perineal care completed. Drainage bag emptied of 350 mL urine. Patient denies pain or discomfort. Necessity for continued catheterization discussed with provider.”

Key Takeaways and Summary

                        
                            Critical Success Factors
                        
                        1. Use catheters only when medically necessary
Maintain sterile technique during insertion
Implement comprehensive CAUTI prevention strategies
Assess daily for removal criteria
Educate patients and families thoroughly
Document all care comprehensively

Final Memory Aid: “CATHETER”

Clean technique always
Assess necessity daily
Teaching patients/families
Hygiene maintenance
Early removal when possible
Trouble signs recognition
Evidence-based practice
Remove ASAP safely

Excellence in Catheter Care

Excellence in indwelling urinary catheter care requires a commitment to evidence-based practice, continuous education, and patient-centered care. By implementing comprehensive prevention strategies, maintaining meticulous technique, and advocating for appropriate catheter use, nurses play a crucial role in preventing complications and optimizing patient outcomes. Remember that every catheter-day avoided is a victory in infection prevention and patient safety.

References and Further Reading

1. Centers for Disease Control and Prevention. (2024). Guidelines for Prevention of Catheter-Associated Urinary Tract Infections. CDC Guidelines
2. American Nurses Association. (2023). CAUTI Prevention Tool. ANA Resources
3. Association for Professionals in Infection Control and Epidemiology. (2023). CAUTI Prevention Guidelines. APIC Guidelines
4. Healthcare Infection Control Practices Advisory Committee. (2023). Guideline for Prevention of Catheter-Associated Urinary Tract Infections. HICPAC Guidelines
5. Society of Urologic Nurses and Associates. (2023). Clinical Practice Guidelines for Urinary Catheter Management. SUNA Guidelines
6. American Association of Family Physicians. (2023). Urinary Catheter Management. AAFP Guidelines