Foley Fall 24

Rhodes State College Division of Health Sciences/Nursing
Foley Catheter Insertion- Female
Student: ______________________ Evaluator: _________________ Date: ________ Course: _____
S/U Skill Critical Elements
In Pt.’s Room: WIEO: Hand hygiene (if this step is not

W- Wash hands & identify yourself completed immediately upon
entering the patient room it is
I-Identify patient and allergies considered an automatic failure).
E-Explain procedure & provide for privacy Scan patient.
O- Organize supplies Patient Identification.
Log in to correct patient and verify physician’s order. Check for Allergies.
Assess for medication, latex, and tape allergies on patient’s chart. Check physician’s order in EHR.
Skill time limit= 25 minutes
Verbalize: Offer perineal care if not already provided. Perform hand

hygiene.
Move bed to comfortable working height.
Assist the patient to a dorsal recumbent position with knees flexed
and legs abducted. Drape patient with a bath blanket to maintain
modesty.
Verbalize: Set up a light source if necessary
Remove the catheter kit from the outer wrapper. Place the outer
wrapper at the foot of the bed or within easy reach.
Place the catheterization kit at an angle on the table top. Open sterile Use sterile technique to open kit
catheterization tray (open flap away from the student) on a clean over
bed table using sterile technique.
Lift the sterile drape so the bottom is at chest level. Place the drape Maintain sterility
between the patient’s legs close to the buttocks, shiny side down.
Apply sterile gloves. Maintain sterility
Prepare sterile supplies for easy access during procedure, keeping Maintain sterility
elbows tucked. (T-Rex arms)
Attach prefilled syringe of sterile water to catheter port- DO NOT
INFLATE THE BALLOON.
Lubricate 1″ to 2″ of catheter tip and lay catheter back down on the Maintain sterility
sterile surface.
Place sterile kit on sterile drape in close proximity to the meatus, Maintain sterility. Speak to patient to
allowing room in area closest to you to prevent crossing over sterile warn of catheter insertion
field. Warn patient of catheter insertion at this time.
With thumb and one finger of non-dominant hand, spread labia and
identify meatus. Be prepared to maintain separation of labia with one
hand until catheter is inserted and urine is flowing well and
continuously.
S/U Skill Critical Elements
Using the dominant hand pick up an antiseptic swab. Clean the labial Must clean from top to bottom.
folds using appropriate sterile technique; top to bottom (from above Cleaning must be completed before
the meatus down toward the rectum), labial folds then down the inserting catheter. (If catheter is
center. Discard the antiseptic swabs without crossing the sterile field. inserted prior to cleaning, this will
result in an unsuccessful attempt).
Maintain sterility.
Using the dominant hand, hold the catheter 2″ to 3″ from the tip and Verbalize: Advance catheter until urine
insert slowly into the urethra. Verbalize: Advance the catheter until return observed
there is a return of urine (approximately 2″ to 3″). Once urine drains,
advance catheter another 2″ to 3″
Hold the catheter securely at the meatus with the non-dominant hand. Inflate balloon without letting go of
Use the dominant hand to inflate the catheter balloon. Inject entire syringe
volume of sterile water supplied in prefilled syringe. Do not release
thumb from syringe. Release labia. Do not release thumb from syringe
Pull gently on catheter after balloon is inflated to feel resistance. Ensure catheter in place
Remove the syringe and verbalize discard into sharps
Verbalize: Secure catheter to patient and discard used equipment
appropriately.
Secure catheter to bed safely and return patient to a comfortable Secure catheter to immovable part of
position. bed
Ensure bed is in lowest position for patient safety Bed is in lowest position
Verbalize: Empty drainage bag once the bladder is initially empty. Hand hygiene performed before
Perform hand hygiene with hand sanitizer. documenting
Complete 7th Right- Document, then log off
Document completely and correctly
then log off
Follows Professional Attire/Grooming/Conduct in RSC Student Handbook
**The student should bring a Foley kit to the competency check-off**
The student will demonstrate each of the steps identified in the criteria. There are many instances in which the steps
do not have to be completed in the exact order listed, but must be performed prior to completing the skill.
Every element of the rubric must be completed successfully. The student may identify and correct most
errors- up to two (2) times with not more than one being a critical element. More than two identified errors,
even if identified and corrected, will be considered an unsatisfactory competency test.
Where to document: Flowsheets-Interventions-New Entry-Urinary Catheter
Initiated: 8/12
Revised: 10/12; 11/12; 5/13; 5/14; 10/14; 12/14; 8/16, 5/17, 12/17, 12/18, 4/20, 6/21, 8/22, 1/23, 5/24 Reviewed:
5/15; 10/15; 4/16; 8/16 Reviewed in Acad. Curr.: 11/12; 12/14, 5/22, 12/22, 5/24

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Rhodes State College Division of Health Sciences/Nursing

Foley Catheter Insertion- Female

Student: __________ Evaluator: _ Date: Course: _

S/U Skill Critical Elements

In Pt.’s Room: WIEO: Hand hygiene (if this step is not

Skill time limit= 25 minutes

Verbalize: Offer perineal care if not already provided. Perform hand

Follows Professional Attire/Grooming/Conduct in RSC Student Handbook

The student should bring a Foley kit to the competency check-off

Where to document: Flowsheets-Interventions-New Entry-Urinary Catheter

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