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Insertion, Maintenance and Removal of an Indwelling Urinary Catheter (IUC) (Adult & Pediatric) (3.31)

Insertion, Maintenance and Removal of an Indwelling Urinary Catheter (IUC) (Adult & Pediatric) (3.31) - Policies, Clinical, UWHC Clinical, Department Specific, Nursing Patient Care, Genitourinary

3.31

NURSING PATIENT CARE POLICY & PROCEDURE





Effective Date:
July 29, 2016
Amended:
July 17, 2017

Administrative Manual
Nursing Manual (Red)
Other _______________

Policy #: 3.31AP

Original
Revision

Page
1
of 11

Title: Insertion, Maintenance and Removal of
an Indwelling Urinary Catheter (IUC)
(Adult & Pediatric)

I. PURPOSE

Provide guidance for the insertion, maintenance care and removal of an indwelling
urinary catheter (IUC).

II. POLICY

A. Indwelling catheter insertion and removal will be performed by a qualified:
1. Registered Nurse (RN)
2. Nurse practitioner
3. Physician
4. Fellow/resident
5. Student (with supervision)
6. Physician Assistant (PA)
7. Medical assistant (ambulatory setting)
8. Surgical technician (only when necessary during surgical procedure)
B. Indwelling catheters should only be inserted when necessary for:
1. Acute urinary retention or obstruction.
a. For pediatrics, this can be confirmed by a bladder scan residual.
See estimated pediatric bladder volume by age document in the
CAUTI Prevention Webpage on U-Connect.
2. Monitoring of urine output in critically ill patients when other methods
of determining urine output are not sufficient.
3. Post-operative requirements for specific procedures.
4. To assist healing of open sacral or perineal wounds in incontinent
patients if conservative methods (condom catheter, positioning) have
failed.
5. Patients requiring prolonged immobilization (i.e. potentially unstable
thoracic/lumbar spine, significant pelvic fractures)
6. Gross hematuria.
7. End-of-life care.
C. The need for the catheter should be assessed daily at a minimum.
D. The smallest appropriate sized catheter should be used when inserting an IUC
(see pediatric catheter recommendations in the CAUTI Toolbox on U-Connect).
E. Alternatives to an IUC may include:
1. Intermittent catheterization
2. A toileting program
3. Condom catheters
4. Bedpan
5. Urinals (female and male)

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6. Incontinence pads.
F. IUCs should not be changed routinely. Please see appendix for specific criteria.
1. Prior to exchanging an indwelling urinary catheter please assess if
the urinary catheter can be discontinued entirely or if alternatives
could be utilized.
2. Patient’s excluded from catheter change/exchange: (check with the
provider first)
a. Urological Surgery/reconstruction
b. Gynecologic oncology procedures/reconstruction
c. Pelvic trauma/reconstructive surgery
d. Acute spinal cord injury
e. End of life care
f. Renal transplant during this admission
g. Indwelling catheters placed by urology
h. Lumbar epidural
3. Indications for changing urinary catheter:
a. Catheter has been in >14 days and a urine culture is ordered.
i. Adult patients only: Collect specimen from newly placed
catheter as culture from existing catheter might contribute
to a false positive result.
b. Before beginning antibiotic treatment for CAUTI or UTI
c. If a patient arrives to a UW Health hospital with a non-urine
meter bag
d. Different size or type of catheter required (i.e. 2-way to 3-way or
latex to silicone)
e. Occlusion even with irrigation or unable to be irrigated due to
clots
f. Chronic catheter where patient has an agreement with an outside
provider for routine catheter changes
g. If the sterility of the catheter system is compromised
4. A nursing communication order can be entered by the provider to alert
the RN for the need to change the IUC.
G. The IUC should be removed as soon as its use is no longer indicated.
H. Catheter care is routinely performed twice daily, after a bowel movement
(ensuring catheter is also cleaned), and as needed and documented.
1. Catheter care can be performed by RNs or delegated to nursing
assistants or patient care technicians after proper instruction and
observation.

III. PROCEDURE FOR INSERTION

A. Equipment
1. Indwelling urinary catheter kit
2. Organization-approved cleansing product (see Skin Care and
Cleansing Product Descriptions on the Wound, Skin, Ostomy, and
Continence Care website on U-Connect)
3. Washcloths
4. Non-sterile gloves

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5. Sheet to provide privacy
6. Blue pad/linen saver
7. Urinary catheter securing device
8. Specimen container (if collecting urine specimen)
9. Sterile water or sterile saline (ONLY if patient allergic to antiseptic
cleanser in urinary catheter kit)
10. Indwelling urinary catheter insertion checklist (available as a reference
electronically and/or in hard copy).

B. Procedure
1. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene and UWMF Employee Health/Infection Control
Policy and Procedure 104.027, Hand Hygiene.
2. Observer:
a. A second person (RN, physician, member of the surgical team
when insertion occurs in the operating room, or an Emergency
Technician in the Emergency Department) is needed as an
observer to ensure that all elements of the insertion checklist are
followed.
b. The insertion checklist can be viewed or printed from U-
Connect or Health Link to be used as a reference by the observer
during the procedure.
c. Use of an observer and an insertion checklist are not required in
emergent situations (i.e. Codes).
3. Explain procedure to patient or caregiver as appropriate, emphasizing
the need to maintain a sterile field.
a. For pediatric patients, provide parents with a copy of Health
Facts For You 7675, The Tube that Drains Your Child’s Bladder.
4. Verify patient is not allergic to cleansing agents, lubricant, or catheter
materials.
5. Provide privacy.
6. Don non-sterile gloves.
7. Raise bed to a comfortable working height. Lower side rails. Assist the
patient into a dorsal recumbent or side lying position.
a. For female patients, visualization of the urinary meatus is easiest
when the patient is in a dorsal recumbent position with legs
widely separated and the knees flexed.
8. Place disposable blue pad/linen saver under patient’s buttocks.
9. Provide light to allow better visualization.
10. Wash perineal area with approved cleansing product:
a. For female patients, open labia and cleanse entrance to urinary
meatus with approved cleanser and washcloth wiping from front
to back on each side with a downward stroke, using a new
washcloth with each stroke. If the patient is in a side lying
position, pull upward on upper labia minora.
b. For male patients, cleanse suprapubic and pubic area with
approved cleanser and washcloth. Grasp the shaft of the penis
firmly. Cleanse urinary meatus and glans with approved cleanser
and washcloth beginning at the urethral opening. Retract foreskin

Page 4 of 11

on uncircumcised male patients. Cleanse in a circular motion
moving from the meatus outward towards the shaft of the penis.
11. Dispose of used washcloth in dirty laundry hamper.
12. Remove and discard gloves.
13. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene and UWMF Employee Health/Infection Control
Policy and Procedure 104.027, Hand Hygiene.
14. Drape patient with sheet to provide privacy exposing only perineum.
15. Set up sterile field:
a. Remove catheter kit from outer plastic package.
b. Place catheter kit between patient’s knees (preferred). Carefully
open outer edges opening the first flap away from the RN. If
using side lying position, place kit about one (1) foot from
perineal area near thighs.
c. Don sterile gloves.
d. Remove full drape from kit. Maintain glove sterility by folding
corners of drape over hands to avoid touching patient’s skin.
Place plastic side down and just under buttocks by having the
patient lift his or her hips. Keep top side of drape sterile as this
will be the sterile work field.
16. Prepare items in kit for use during catheter insertion:
a. Pour antiseptic solution over applicators (i.e., cotton
balls/swabs).
b. Lubricate catheter tip with gel (for adult sized patients: 3-4
inches for females; 7-8 inches for males). Place it back into tray
so catheter tip is secure in tray.
c. If drainage tubing is already attached to the catheter, place tubing
and bag securely on sterile field, close to other equipment.
Attach catheter to drainage bag if not already done.
d. Check clamp on collection bag to be sure it is closed.
e. Attach prefilled syringe to balloon port, but DO NOT test the
balloon.
17. With sterile hand, move cleaning tray to end of the sterile field. Move
catheter and collection bag closer to the patient.
a. For female patients:
i. Remove fenestrated drape from kit and drape perineum so
labia are exposed.
ii. Separate labia minora with non-dominant hand (refer to
step III, B, 10, a).
iii. With the dominant hand, cleanse meatus with the
appropriate applicators.
• For patients with sensitivity or allergy to the
antiseptic solution provided in the urinary catheter
kit, sterile saline or sterile water can be applied to
applicator for meatal cleansing.
iv. Wipe downward once with each applicator and discard.
v. Begin at labium on side furthest from you and move toward
labium closest to you.
vi. Wipe once down the center of the meatus.
b. For male patients:

Page 5 of 11

i. Remove fenestrated drape from kit and place penis through
hole in drape with non-dominant hand. Keep dominant
hand sterile.
ii. Pull penis up to a 90-degree angle to the patient’s body.
iii. With the non-dominant hand, gently grasp the glans (tip) of
the penis and retract foreskin, if necessary.
iv. With the dominant hand, cleanse the meatus and glans with
antiseptic solution, beginning at urethral opening and
moving toward the shaft of the penis. Make one complete
circle around the penis with each applicator, discarding
after each wipe.
• For patients with sensitivity or allergy to the
antiseptic solution provided in the urinary catheter
kit, sterile saline or sterile water can be applied to
applicator for meatal cleansing.
18. Using the sterile dominant hand, pick up the catheter about 1½ - 2
inches from the tip with the thumb and first finger.
19. Carefully gather additional tubing into the dominant hand.
20. Ask patient to bear down and take slow, deep breaths. Encourage slow
deep breathing until catheter is placed.
21. Insert tip of catheter slowly through the urethral opening.
a. For adult females, approximately 3-4 inches or until there is
urine noted in tubing.
b. For adult males, approximately 7-9 inches or until there is urine
noted in tubing. Lower penis to about a 45-degree angle after
catheter is inserted about halfway.
c. For pediatric males and females, advance to hub of catheter and
watch for urine flow.
22. If resistance is met, verify position. DO NOT FORCE the catheter. If
unable to advance catheter, remove catheter and notify provider.
23. After the catheter has been advanced successfully, advance another 1 –
1½ inches.
24. Inflate balloon with the appropriate amount of sterile water (amount
will be printed on catheter) and gently pull back on catheter until it
stops/meet resistance.
a. Replace foreskin for uncircumcised male patients.
25. Secure the catheter loosely to the thigh with an approved securement
device on the side where the drainage bag will be hanging.
a. In male patients, the catheter can be secured to the thigh or
abdomen with an approved securement device.
26. To prevent skin breakdown, securement devices must be removed and
changed every seven (7) days according to manufacturer’s
instructions.
27. If there is an order for urinalysis and/or urine culture, remove gloves,

Page 6 of 11

28. perform hand hygiene and don new non-sterile gloves prior to
specimen collection.
29. Make certain that tubing is not kinked, twisted, obstructed or caught
on railing.
30. The drainage bag should always be below the level of the bladder to
prevent reflux of urine but not touching the floor.
31. Clear bed of all equipment.
32. Remove and discard gloves. Perform hand hygiene.
33. Position patient for comfort and replace linens for privacy.
34. Raise side rails and put bed in lowest position.
35. Measure amount of urine in drainage bag.
36. Document the following in the patient’s clinical record:
a. Bladder scan results (if bladder scan performed)
b. Date and time of catheterization
c. Type and size of catheter
d. Amount of sterile water inserted into balloon
e. Insertion attempts
f. Amount, color, consistency and/or odor of urine returned upon
catheter insertion
g. Difficulties encountered during insertion of urinary catheter
h. Urine specimen collection (UA, urine culture, etc.)
i. Observer name and if the insertion checklist was used as a
reference


IV. PROCEDURE FOR CATHETER SITE CARE

A. Equipment
1. Non-sterile gloves
2. Blue pad/linen saver
3. Organization-approved cleansing product (see Skin Care and
Cleansing Product Descriptions on the Wound, Skin, Ostomy, and
Continence Care website on U-Connect)
4. Wash cloths
5. Approved securement device
6. Sheet for privacy
B. Procedure
1. Catheter care and perineal cleansing can be delegated to a nursing
assistant or patient care technician after proper instruction and
observation.
2. Gather supplies.
3. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene and UWMF Employee Health/Infection Control
Policy and Procedure 104.027, Hand Hygiene.
4. Explain procedure to patient/caregiver as appropriate, emphasizing the
need to clean around the catheter and manipulate tubing.
5. Determine if patient is allergic to antiseptics or soaps.
6. Provide privacy with sheet.

Page 7 of 11

7. Don non-sterile gloves.
8. Raise bed to a comfortable working height and lower side rails.
9. Drain IUC tubing.
10. Place blue pad under patient’s buttocks.
11. Remove tubing from securement device.
12. Position patient in supine, dorsal recumbent or side-lying position.
a. For male patients, cleanse suprapubic and pubic area with
approved cleanser and washcloth. Grasp the shaft of the penis
firmly. Cleanse urinary meatus and glans with approved cleanser
and washcloth beginning at the urethral opening. Retract foreskin
on uncircumcised male patients. Cleanse in a circular motion
moving from the meatus downward and outward towards the
shaft of the penis. For uncircumcised male patients, push
foreskin back into place.
i. For pediatric male patients, apply antibiotic ointment to tip
of penis if ordered by the provider.
b. For female patients, open labia and cleanse entrance to urinary
meatus with approved cleanser and washcloth wiping from front
to back on each side with a downward stroke, using a new
washcloth with each stroke, cleaning the innermost surface
outward.
13. Remove gloves, perform hand hygiene and don a new pair of non-
sterile gloves.
14. Monitor catheter insertion site for redness or unusual drainage. Notify
provider if irritation is noted or patient has discomfort.
15. Clean the catheter from the insertion site to approximately six (6)
inches distally with hospital approved cleanser and washcloths.
16. Remove any dried secretions on the tube. Be sure not to pull on the
catheter.
17. Dispose of used washcloth in dirty laundry hamper.
18. Re-anchor catheter tubing with approved securement device.
a. For male patients, on the abdomen or thigh.
b. For female patients, on the thigh.
19. Remove all supplies/equipment from bed.
20. Position the patient for comfort.
21. Raise side rails and put bed in the lowest position.
22. Remove and discard gloves.
23. Perform hand hygiene.
24. Document in the patient’s clinical record.
C. Maintenance
1. Keep drainage bag below the level of bladder at all times.
2. Be sure tubing is not kinked, twisted, obstructed or caught on side
rails.
3. Keep drainage bag off of the floor.
4. Tubing should be secured with a securement device.
5. Empty bag prior to transport off of unit to another department.

Page 8 of 11


V. PROCEDURE FOR REMOVAL OF AN IUC

A. Equipment
1. Syringe (appropriate size to remove water from balloon catheter)
2. Graduate container
3. Non-sterile gloves
4. Blue pad/linen saver
5. Organization-approved perineum cleanser (see Skin Care and
Cleansing Product Descriptions on the Wound, Skin, Ostomy, and
Continence Care website on U-Connect)
6. Washcloths
7. Speciman Urine Collection Device (optional) (Central Service Item
Number 1219129)
B. Procedure
1. Verify provider order or authorization of protocol to remove
indwelling urinary catheter. Refer to Inpatient Delegation Protocol 25,
Indwelling Urinary Catheter Removal – Inpatient – Adult (found on U-
Connect).
2. Review the patient’s clinical record to check amount of sterile water
inserted into balloon.
3. Explain procedure to patient/caregiver as appropriate.
4. Provide privacy.
5. Perform hand hygiene according to UWHC Administrative Policy
13.08, Hand Hygiene and UWMF Employee Health/Infection Control
Policy and Procedure 104.027, Hand Hygiene.
6. Don non-sterile gloves.
7. Raise bed to a comfortable working height and lower side rails.
8. Position patient in supine or side-lying position.
9. Place disposable blue pad under patient’s buttocks.
10. Insert syringe into balloon port valve.
11. Aspirate total amount of sterile water that was used to inflate the
balloon. Once started the syringe should fill passively. If unsure the
balloon is totally deflated, cut the inflation port and allow the water to
drain.
12. Remove approved securement device.
13. Instruct patient to relax and take slow deep breaths.
14. Slowly pull catheter out onto disposable blue pad.
15. Hold catheter up until all urine in tubing has drained into the drainage
bag.
16. Empty urine from drainage bag into graduated container, noting color
and odor.
17. Measure the amount of urine in the graduated container.
18. Discard catheter and drainage bag by wrapping them in disposable
blue pad.
19. Cleanse perineal area with approved cleanser.
a. For male patients, cleanse suprapubic and pubic area with
approved cleanser and washcloth. Grasp the shaft of the penis

Page 9 of 11

firmly. Cleanse urinary meatus and glans with approved cleanser
and washcloth beginning at the urethral opening. Retract foreskin
on uncircumcised male patients. Cleanse in a circular motion
moving from the meatus outward towards the shaft of the penis.
For uncircumcised male patients, push foreskin back into place.
b. For female patients, open labia and cleanse entrance to urinary
meatus with approved cleanser and washcloth wiping from front
to back on each side with a downward stroke. Use a new
washcloth with each stroke. In side lying position, pull upward
on upper labia minora.
20. Discard used washcloth in dirty laundry hamper.
21. Position patient for comfort.
22. Raise side rails and put bed in lowest position.
23. Remove gloves and perform hand hygiene.
24. Instruct patient to notify nurse of need to void. If it is necessary for the
patient to save urine, place a Speciman Urine Collection Device in the
toilet of the patient’s room. For male patients, place urinal within
reach.
25. Document the following in the patient’s clinical record:
a. Reason for removal
b. Date and time of catheter removal
c. Amount of urine, color, and odor of urine
d. Difficulty with removal of catheter
e. Patient’s tolerance of procedure
26. For patients with radioactive prostatic seed implants, catheter removal
and disposal of urine is performed according to UW Health Clinical
Policy 2.3.8 Radioactive Prostatic Seed Implants.
27. For patients with hazardous drugs ordered, disposal of urine is
performed according to UWHC Administrative Policy 8.89,
Preventing Non-therapeutic Exposure to Hazardous Drugs.


VI. UWHC CROSS REFERENCES

A. CAUTI Toolbox (on U-Connect)
B. Health Facts For You (HFFY) 7355, Urinary Catheters and Urinary Tract
Infections
C. Health Facts For You (HFFY) 7675, The Tube that Drains Your Child’s Bladder
D. Inpatient Delegation Protocol 25, Indwelling Urinary Catheter Removal –
Inpatient – Adult (found on U-Connect)
E. Nursing Practice Guideline: Catheter-Associated Urinary Tract Infection
(CAUTI) (found on U-Connect)
F. UWHC Administrative Policy 8.89, Preventing Non-Therapeutic Exposure to
Hazardous Drugs
G. UWHC Administrative Policy 13.08, Hand Hygiene Nursing Patient Care Policy
H. UW Health Clinical Policy 2.3.8 Radioactive Prostatic Seed Implants
I. UW Health Clinical Policy 2.5.2, Collecting a Urine Specimen
J. Nursing Patient Care Policy 13.12A, Basic Care Standards (Inpatient Adult)

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K. Nursing Patient Care Policy 13.16P, Basic Care – Inpatient Pediatrics (Birth-18
years of age) (Pediatric)
L. Surgical Services Policy 6.10, Radioactive Prostatic Seed Implants
M. UWMF Employee Health/Infection Control Policy and Procedure 104.027, Hand
Hygiene
N. NICU Urinary Catheter Bundle: Catheter Associated Urinary Tract Infection
(CAUTI) Reduction (see Related section of this policy on U-Connect)
O. Peri/catheter Care for Females Checklist (see Related section of this policy on
U-Connect)
P. Peri/catheter Care for Males Checklist (see Related section of this policy on
U-Connect)
Q. Skin Care and Cleansing Product Descriptions (found on U-Connect)
R. Indwelling Urinary Catheter Insertion Checklist document (found on U-Connect,
CAUTI Prevention/Resources page)
VII.
REFERENCES

A. Center for Disease Control and Prevention (2009). Guideline for Prevention of
Catheter-Associated Urinary Tract Infections. Retrieved from
http://www.cdc.gov/hicpac/pdf/CAUTI/CAUTIguideline2009final.pdf
B. Hooton, T.M., Bradley, S.F., Cardenas, D.D., Colgan, R., Geerlings, S.E., Rice,
J.C., Nicolle, L.E. (2010). Diagnosis, prevention, and treatment of catheter-
associated urinary tract infection in adults: 2009 International Clinical Practice
Guidelines from the Infectious Diseases Society of America. Clinical Infectious
Diseases. 50, 625-663.
C. Lo, E., Nicolle, L., Classen, D., Coffin, S., Gould, C., Maragakis, L., Meddings,
J., et al (2014). Strategies to prevent catheter-associated urinary tract infections in
acute care hospitals: 2014 Update. Infection Control and Hospital Epidemiology,
35 (5), 464-479.
D. Smith-Temple, J., & Young Johnson, J. (2009). Nurses’ guide to clinical
procedures (6
th
Ed.). Philadelphia, PA: Lippincott Williams & Wilkins.
E. Wald, H. L., Fink, R. M., Flynn-Makic, M. B., & Oman, K. (2012). Catheter-
associated urinary tract infection prevention. In Boltz, M., Capezuti, E., Fulmer,
T., Zwicker, D. Evidence-based geriatric nursing protocols for best practice (4
th

Ed.) (pp. 388-408). New York, NY: Springer Publishing Company, LLC.
F. Willson, M., Wilde, M., Webb, M. L., Thompson, D., Parker, D., Harwood, J.,
Gray, M., & et al (2009). Nursing intervention to reduce the risk of catheter-
associated urinary tract infection. Part 2: Staff education, monitoring, and care
techniques. Journal of Wound, Ostomy, and Continence Nursing, 36(2), 137-154.

VIII. WRITTEN BY

Clinical Nurse Specialist, Nursing Quality & Safety

IX. REVIEWED BY

Clinical Nurse Specialist, Transplant-General Surgery
Clinical Nurse Specialist, Geriatrics

Page 11 of 11

Clinical Nurse Specialist, Gyn., Urol., Plastics & ENT
Clinical Nurse Specialist, Trauma Life Support Center
Clinical Nurse Specialist, Universal Care
Clinical Nurse Specialist, General Medicine and Geriatrics
Infection Control Practitioner, Infection Control
Pediatric CAUTI Workgroup
Director, Professional Services UW Health at The American Center
Nursing Patient Care Policy and Procedure Committee, July 2016

SIGNED BY

Beth Houlahan, DNP, RN, CENP
Senior Vice President, Chief Nurse Executive