Removing an indwelling urinary catheter (commonly called a Foley catheter) is a standard nursing procedure that must be done with care to prevent trauma, infection, or urinary retention.
Purposes for Removing an indwelling urinary catheter
- To promote normal bladder function.
- To prevent trauma to the urethra. 3. To prevent infection.
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- Syringe without needle (10 mL).
- Clean gloves.
- Protective pad.
- Soap, towel, and washcloth.
- Container for waste disposal.
- Urinal or bedpan.
- Kidney tray.
Procedure for Removing an indwelling urinary catheter
| Nursing Actions | Rationale | |
| 1. | Before procedure If bladder conditioning is to be performed: 10 hours before removal, clamp indwelling catheter for 3 hours. Unclamp and drain urine for 5 minutes. Repeat clamping for 3 hours and draining for 5 minutes two more times. | Volume of urine stretches bladder wall to stimulate muscle tone. Unclamping the catheter simulates voiding. Patients who receive bladder conditioning are able feel urge to void sooner than those who have no conditioning. |
| 2. | During procedure Wash hands. | Decreases the transmission of microorganisms. |
| 3. | Check the doctor’s order. | Ensures correct patient and treatment. |
| 4. | Identify the patient and explain procedure. | Elicits patient’s cooperation. |
| 5. | Provide privacy and position the patient on back. | Providing privacy demonstrates respect for patient’s dignity. |
| 6. | Remove covers and drape so as to expose catheter but do not overly expose perineal area. | Protects patient’s privacy and reduces embarrassment. |
| 7. | Place protective pad under patient’s thighs. | Prevents bed from becoming soiled. |
| 8. | Empty urine in tubing into urobag. | Prevents leakage from catheter onto patient, when the catheter is removed. |
| 9. | Remove any tape that may be holding the catheter to the leg. | Allows for easy removal of catheter. |
| 10. | Insert syringe end into balloon port and remove all the air or fluid from the balloon, generally 5-10 CC. Do not cut the port. | Removal of fluid from balloon prevents damage to urethra, while removing the catheter. |
| 11. | Ask the patient to take a deep breath if able and gently and smoothly remove the catheter on expiration. Stop if you meet resistance and recheck the balloon port. | Damage to the urethra may occur if the balloon is not fully deflated. |
| 12. | Note any sediment, mucus or blood that may be on the catheter. If needed culture the tip of catheter by cutting it off with sterile scissors and placing in appropriate container. | Assesses for any Indications of infection or trauma related to the catheter. |
| 13. | Cleanse the patient’s perineal area or provide a warm, moist cloth with instructions for self-cleaning. | Provides comfort and reduces transmission of microorganisms. |
| 14. | After procedure Remove gloves and wash hands. | Reduces transmission of microorganisms. |
| 15. | Cover the patient and position comfortably. | Provides for privacy and comfort. |
| 16. | Instruct the patient to drink oral fluids as tolerated and to call when he/she needs to void. | Determines that patient has returned to usual voiding patten. |
| 17. | Record time and amount of first voiding. Offer bedpan/urinal every 2 – 4 hours. | Allows assessment of the patient’s voiding pattern. |
| 18. | If the patient is unable to void within 8 hours, report to the physician. | Allows assessment and intervention to determine the cause of the patient’s inability to void after catheter is removed. |
Special Considerations
- Instruct the patient to inform the nurse, if experiencing any pain, or symptoms of bladder infection, after the catheter is removed.
- Check if the physician has ordered bladder conditioning before removal of catheter.
- Keep track of intake and output for at least 24 hours after removal of catheter.
- If patient has not voided within 8 hours after catheter removal, the catheter (intermittent or indwelling, depending on order of physician) may have to be reinserted.
REFERENCES
- Annamma Jacob, Rekha, Jhadav Sonali Tarachand: Clinical Nursing Procedures: The Art of Nursing Practice, 5th Edition, March 2023, Jaypee Publishers, ISBN-13: 978-9356961845 ISBN-10: 9356961840
- Omayalachi CON, Manual of Nursing Procedures and Practice, Vol 1, 3 Edition 2023, Published by Wolters Kluwer’s, ISBN: 978-9393553294
- Sandra Nettina, Lippincott Manual of Nursing Practice, 11th Edition, January 2019, Published by Wolters Kluwers, ISBN-13:978-9388313285
- Adrianne Dill Linton, Medical-Surgical Nursing, 8th Edition, 2023, Elsevier Publications, ISBN: 978-0323826716
- Donna Ignatavicius, Medical-Surgical Nursing: Concepts for Clinical Judgment and Collaborative Care, 11th Edition ,2024, Elsevier Publications, ISBN: 978-0323878265
- Lewis’s Medical-Surgical Nursing, 12th Edition,2024, Elsevier Publications, ISBN: 978-0323789615
- AACN Essentials of Critical Care Nursing, 5th Ed. Sarah. Delgado, 2023, Published by American Association of Critical-Care Nurses ISBN: 978-1264269884
- Ernstmeyer K, Christman E, editors. Nursing Fundamentals [Internet]. 2nd edition. Eau Claire (WI): Chippewa Valley Technical College; 2024. PART IV, NURSING PROCESS. Available from: https://www.ncbi.nlm.nih.gov/books/NBK610818/
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