Catheter Insertion Helpful Hints
Types of Catheters
- Condom (or Texas): for males and is placed the same as a condom with either adhesive inside to adhere to the penis or an inflatable cuff.
These require actual catheter insertion into the bladder. The sizes range for adults 10 Fr to 24 Fr (French). The bigger the number, the bigger the circumference of the catheter.
- Straight (Intermittent): usually seen as either red rubber or clear silicone, it is used to drain urine from the bladder and is removed immediately after. There is no balloon on this catheter
- Foley (Indwelling): made of a variety of materials. Balloon sizes (5 cc, 10 cc, 30 cc). A 5 cc balloon can be inflated up to 10 cc maximum.
- Silastic: which is a type of silicone. Usually a mint green color. Used when patients react to the latex in the silicone coated catheter. I found urologists generally like to use this type.
- All silicone: usually clear and rather stiff. It is my last choice of catheters as it can be more uncomfortable inserting due to its stiffness.
- Silicone coated latex: a light tan in color, and is the most commonly seen. I would not use this in patients who have a known latex allergy.
- Silver tipped: usually clear has silver imbedded in the tip to prevent UTIs (Urinary Tract Infections)
- Three way irrigation (or retention): has three lumens. One to drain urine, one to inflate the balloon and the last to instill medication continuously into the bladder.
- Coude or Tieman: has a curved tip to facilitate getting past and enlarged prostate. It also has a small bump on the other end where it is connected to the down drain bag. This bump allows the person inserting the cath to know what direction the tip is pointing once it is inside the patient and the tip cannot be seen.
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Tips on Catheter Insertion
In most facilities, it is left to the nurse’s discretion what size catheter and balloon to use. For long term catheter patients, the orders for changing the catheter and bag is usually every 4-6 weeks.
In Home Care you are required to get an order for the specifics of catheter insertion.
Usual adult sizes are either 16 or 18 Fr with a 5 cc balloon inflated to 10 cc or a 10 cc balloon. Most physicians other than urologists are happy to let you recommend a size.
Large amounts of lubricant can clog the catheter for a few minutes until it “melts” off the holes once catheter insertion is complete..
Make sure you have urine return in the tubing before leaving the patient. All you need to see is a drop or two to know you have successfully inserted the urinary catheter in the right place.
Sometimes bladder spasms occur and the urine squeezes around the catheter and the patient becomes wet with urine. It is hard to determine the reason for this. You have to play detective.
Did the spasms start when the balloon size was changed from a 10 cc to a 30 cc balloon? Any other symptoms that could be construed as a possible UTI? Does the tubing get kinked so the urine can’t flow freely into the bag and the bladder gets too full.
Some patients think the spasms are them having to urinate. They need to be educated that drainage of urine is constant not intermittent as when they void without a catheter.
Even if you can’t figure it out, sometimes the physician is willing to order an antispasmodic such as baclofen which solves the problem.
A bladder is considered full at 1000 mls. If you are doing a catheter insertion for urinary retention (the patient is unable to empty their bladder, the maximum you should drain at one time is 1000 ml. If urine is still draining after that, clamp the tubing for 15 20 minutes then open it up and allow the remainder to drain. The reason is that over 1000 mls could cause the patient to become shocky if it occurs too quickly.
So, someone asked me if there was any specific research or studies to verify the 1000ml of urine maximum removal rule. And my response was that it was just one of many things taught me without any specifics on where the limits came from. And that of course brought me to the thought we should test this theory and either verify it or trash it.
It also got me wondering if things had changed since I was taught.
So I asked a few nurses I work with. Most agreed with the limit and the rationale and so never removed more than 1000 mls at one time. Nor could anyone give a solid reason WHY a patient would go into shock from removal of fluid that is already isolated from the main circulatory system.
However, one nurse actually had it happen to her. Well, to the urologist she was with at the time. He pulled 2,000 mls from the bladder at once and she was like, "Whoa, whoa, don't you want to stop?" and the urologist's response was, "Nahhh, nothing's going to happen." After which the patient promptly went into shock. I'm thinking we should stick to the 1000 mls...
Replacing a Foley Catheter That Has Been Inserted for any Length of Time
You may notice a few things:
- The bladder will be empty because the catheter has been continually letting it drain, so getting urine return may take a few minutes or longer because the body will have to manufacture more. Asking the patient to drink fluids just before the procedure can help to create urine a little more quickly. I also remove the old catheter right away and have the patient on an incontinence pad in case of leaking. Then I open up my new kit, taking my time so the bladder can begin to fill up with urine before I do the catheter insertion.
- Bladders are like balloons, they expand when full and contract when empty. Having the bladder empty for a few weeks or months because urine is constantly draining through the catheter will shrink the bladder. They will be very little room between the top of the bladder and the urethra. To make sure the balloon is past the urethra and in the bladder, during the catheter insertion you may have to push the catheter against the top of the bladder, (which is uncomfortable for the patient). Then inflate the balloon and finally let go of the catheter so the pressure to the bladder top is relieved.
Leg Bags and Extension Tubes
I've seen many people coming out of the hospital with a catheter and a leg bag attached to the thigh without an extension tube. I personally don't see this as a good thing for a few reasons.
- If you happen to be one of those people that don't change to a large drainage bag at night and sleep on you back with your legs bent, the bag will be higher than the bladder and the urine can't flow up stream. You may end up with leakage.
- If you want to empty the bag during the day, without an extension tube to bring the bag down to the ankle, you will have to get undressed to reach the bag. With an extension tube, you just have to lift up the pants to get to the bag.
Securing the Catheter
While tape securing a catheter to the thigh of the patient has been used for millennium (just being a tad sarcastic...) there are better options out there if your facility has them.
Purple Urine Bag Syndrome (PUBS)
Every once in a while you will come across a patient whose catheter bag and tubing but NOT the urine is purple. This is due to a bacterial urinary tract infection that metabolizes tryptophan into indigo causing the discoloration. Patients are usually asymptomatic.
For some reason it is noted particularly in long term female catheter patients with alkaline urine, usually dehydrated and associated with constipation.
Usually considered benign, it can be treated as other UTIs in addition to resolving dehydration and constipation.
Urinary Nursing Skills
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