Cool tips for Foley catheter insertion: because you never know what you going to find
These are “quick and dirty tips” but dirty might not be a good word, after all catheter insertions are suppose to be sterile at some point. But there are two ways to put a catheter – the first is the one taught at nursing school, and the second is how it’s done for real, with real people. In the end of the day, all you need is to do it fast, safely and effectively.
Unlike nursing school your patient is not made of plastic. He or she might be big, and may have an anatomy which is not favors you; and might not be cooperating. First understand this is a scary procedure for the patient. So every time you insert a catheter imagine someone is doing to do it on you. (that might bring yourself to understand what you’re about to do with your patient).
Check the doctor’s order thoroughly. Get the Foley tray and make sure the Foley is the right French per order. If the French size is not specified in the order call and clarify. If the patient already has a Foley inserted but just need to be changed that’s great because that old Foley is your friend; more on that in a minute.
After you talk to the patient and he/she is OK with the procedure. Start by doing your preparations:(watch the videos below, they cover almost everything about Foley insertion).
Lay out all the Foley insertion package on the bedside table so that every item you’ll need is visible. That allows you to make a plan of action. Everything has a timing. Slow way down and plan out in your mind what things you are going to do first. You plan of action may be something like this:
- Open sterile paper and lay all objects from Foley tray on it, shiny side up
- Take the betadine swab packet, open and lay in inside the plastic Foley tray by the bed
- Open one end of the Foley cathether plastic bag, opposite end from tip (don’t remove it)
- Attach Foley to the tubbing bag and attacth bag by the bed side
- Down the sterille gloves
- Pick the betadine swabs with dominant hand, clean genitals 3 times (your non dominant hand gets contaminated) be careful not to contaminate dominant hand
- Ask your helper to: remove the cathether from the bag and grab the sterile part with your dominant hand before the cathether touches anything
- Ask helper to place gel on the back of your non doninant hand. Add gel to the tip of the cathether
- Insert cathether
- Get urine return, fill ballon, attach cathether tubbing to patient let with estabilizer or tape if not available.
The Tip list
These tips are mainly for female catheter insertion. Male patients are usually much easier unless there is some strange abnormality with the penis. Hernias can be a problem for males because it create second spaces where to tube can go in rather then the bladder. Vaginas can have different anatomies and with age, obesity and disease processes can present marked anatomic differences.
- Measure the old tube – This might be helpful if you are a beginner. Before you remove the old Foley, paint a little dash with a marker on the old catheter, about 1 inch away from the vagina or the tip of the penis. This will give you an idea of how deep you have to go with the new one. If the old was working, the new one should work because you are about to insert the same length but if you still have no urine flow there must be for other reasons obstructing the flow.
- Test the balloon – Open the new catheter bag but make sure your opening it on the side where the end of the tube is, opposite side of the tip, leave the catheter in the bag so you don’t contaminate the tip. (If you get confused about what not to contaminate; remember is the tip of the catheter you want to protect or all parts that will be inserted). With the NS syringe inflate the balloon so you know the balloon is working. The last thing you want is to find out the balloon might be malfunctioning after you did a perfect insertion and now you have to tell the patient you’ll have to do it again.
- Prevent spills – Attach the catheter to the bag so when the urine comes out after insertion it wont end up with a puddle of urine all over the bed. (your CNA will not love you forever). This might seem like a silly tip but you can’t imagine how easy it is to forget this one.
- Mapping the anatomy – If you are catheterizing a female and specially if this patient has a difficult anatomy, is overweight or whatever, please before you pull out the old catheter look exactly where the catheter is coming out of. NOT ALL VAGINAS ARE THE SAME and some urethral opening might be difficult to locate. Try to visualize the spot where it came out. This will pay off handsomely when you deciding weather you are in the vagina or the urethral orifice.
- Mapping the anatomy 2 (the golden trick) – This is perhaps the most important trick of all. If you really want to get the job done and not get stuck with a sad face when you have to tell the patient you’ll have to try again – do this: Start by inserting the tip of your left hand indicator on the upper wall of the vaginal opening just so you define exactly where the top end of the vaginal opening is. Once you find that put the tip of the catheter right above where that location is. Slide the tip of the catheter on a 30 degree angle with a movement upwards as if you are trying to fall in the next orifice as you go up. The only possible place for the catheter has to slip in has to be the ureter. This will work every time!
Urine return – Don’t ever leave a Foley catheter in place if you didn’t get any urine return. You may leave it there for 15 min. then come back to check, maybe she/he had a empty bladder and now there is some urine (this rarely happens).
If no urine, empty the balloon and move the catheter up and down until you see urine flow. The good news is that you might not have to insert a new catheter because you already have one in there. If you still are not getting urine return and you are sure you inserted the catheter to the right length – don’t panic. Move the patient from one side to the other, or place the patient in different positions. No urine, do a bladder massage and you’ll be surprise how quickly you’ll see urine flow.
Lighting – You used all the super secret tips and still can’t find the hole. You’re there for a long time trying to fish that tiny little hole and could not find. You last best friend is your naked eye. In extreme difficult cases specially if the patient cannot open her legs due to contractures or rigidity; you actually have to visually find it. Ask someone to help you by holding a medical flash light pen and illuminate the area.
Stretch the area up and down and side ways until you see the orifice. Because the hole might be super small and the catheter might not slip in as desired. Seeing the small hole might be the only way for some patients. I takes a little work to find it with your eyes but for some patients that is the only way to get it there.
Now you found the urethra using all the smart techniques you learned. You are confident that you are in the right place and advance the catheter waiting for that glorious urine return but as you advance the catheter you run into a wall. You might think you are in the vagina but you are 100% sure you’re not in the vagina. The urethra is obstructed. This is a medical emergency and the patient must undergo other procedure in order to address the problem. Do not force entrance.
Male catheter insertion
If your patient is male you might get this easy feeling. Of course you cannot miss the meatus of a male. It is right there and all you have to do is to insert the Foley and voila urine return and victory. Not so fast. There is some really weird penises out there. If your male patient have severe hernias your catheter might go to spaces other then the bladder. Don’t panic. You might have to do a little searching until you find the right hole and sometimes it takes some work. So you are never sure. So if your patient has abdominal hernias be prepared to do some extra work.
Other tips and problems
It is common for catheters to stop working for some reason. You check the placement and the balloon still inflated and in place; you flush to check if the tube is patent and its all flowing fine. Next thing you do is to check if the bladder is distended. If the patient is having urinary retention you should feel like there is a grape fruit right were the bladder is. This is a medical emergency. If the bladder is distended you have to remove the catheter and insert a straight catheter to remove the urine.
If the patient is not distended but the urine still not flowing – massage the bladder gently and re position the patient a few times. This could get the urine flowing again and might be all you need to do.
These tips may seem over simplistic but they will save you a lot of head ache. It just take a little planning and thinking before you start. Remember, ounce you start you have to go forward so think and plan before you start.
Now that the catheter is in and flowing we want to keep it that way. So here is another tip: if your catheter is going to stay for a long time which happens often in nursing homes and skilled facilities you might find it that it will become stuck or stop being patent. depending on your patient. Before that happens you can order a flush with 50 cc of sterile saline q day or q shift. This is one way to keep the catheter from clogging.
For more great tips visit this website
Image credit: flickr.com
I selected these videos because they are real catheterizations. Plastic dummies are just dumb.
Female catheter, straight and Foley
Image credit: flickr.com