PROCEDURE: REMOVING AN INDWELLING CATHETER
Purpose:
• Terminates urinary catheterization
• Permits return of client controlled voiding
Equipment: Documentation
• Assessment of lower
abdomen before
• Syringe (appropriate size to remove water from balloon on catheter)
removal
• Graduatd container • Assess genitals, note
• Pair ofclean gloves abnormalities
• Linen saver • Size of catheter
• Amount, color,
Assessment consistency of urine
Assessment should focus on the following: • Any difficulties
• Reports of discomfort
• Length of time catheter has been in place and agency policy regarding maximum • Status of catheter
length of time before catheter removal or change • Time and amount of first
• Order for catheter removal and parameters for removal (e.g., after specimen voiding
obtained, when client is • Specimen obtIaine (cath
ambulatory) tip sent to lab if
• Client's knowledge of catheter removal procedure applicable
• Size of catheter and balloon
• Characteristics of urine (e.g., color, clarity, odor, amount)
• Amount of urine output
• Distention, pain, or tenderness of lower abdomen
ACTION RATIONALE
Explain procedure to client. Promotes cooperation and decreases
1.
anxiety
2. Provide privacy. Protects client's dignity and decreases
embarrassment
3. Apply non sterile gloves Reduces nurse's exposure to client‘s
body secretions
4. Place client in supine or lateral position, and place linen saver Provides access to catheter and prevents soiling
under client's buttocks. linens
5. Obtain urine specimen if ordered. Permits removal of sterile specimens before loss of
access
6. Insert syringe into balloon port inflation valve. Provides access to remove water from the balloon to
deflate it
7. Aspirate total amount of fluid that was used to inflate the Fully deflates balloon to prevent damage to urethra
balloon. If unsure if balloon is fully deflated, cut the inflation during removal process
port and allow water to drain.
8. Remove tape or catheter holder. Allows removal of catheter
9. Instruct clients to relax and take slow deep breaths. Slowly and Promotes relaxation of sphincter; prevents trauma to
smoothly pull cathter out onto towel urethral mucosa
10 Hold catheter up until urine has drained into bag. Permits collection of urine and prevents spilling of urine
onto client
11. Measure amount of urine in collection container or drainage Provides assessment data; decreases exposure to body
bag, noting color and consistency of urine, and discard catheter waste’ properly disposes of contaminated substances
and drainage bag by wrapping them in a linen saver.
12. Position client for comfort and discard all disposable equipment Promotes clean environment
wit gloves
13. Perform hand hygiene, Reduces microorganism transfer
14. Instruct client to notify nurse of next voiding to save urine Allows nurse to assess ability to void after catheter
removal
