Introduction

Insertion of an indwelling urethral catheter is an invasive procedure that should only be carried
out by a qualified competent health care professional using aseptic technique. Catheterization of
the urinary tract should only be done when there is a specific and adequate clinical indication, as
it carries a high risk of infection.

Aim
To ensure the insertion and care of the urinary catheter is carried out in a manner that minimizes
trauma and infection risks.

Definition of Terms
IDC: Indwelling Urinary Catheter

Indications
To drain the bladder prior to, during, or after surgery

For investigations

To relieve retention of urine

To accurately measure the urine output

To relieve urinary incontinence when no other means is practical

Environment
Explained procedure to the child and the parents and obtain consent
 The bed is screened to ensure privacy

Keep the child warm at all times

Ensure adequate light source

Equipment
Dressing trolley

Catheterization pack and drapes

Sterile gloves

Appropriate size catheter (see catheter size guideline below)

Xylocaine jelly syringe (plain sterile lubricant for infants)

Sterile water for balloon

5ml Syringe

Specimen jar

Antiseptic solution. Aqueous Chlorhexidine 0.1% with Cetrimide (yellow solution) or

Aqueous Chlorhexidine 0.1% (blue solution).

Tape to secure catheter to leg

Drainage bag

Urine bag holder

Catheter size guideline

Use the smallest bore that will allow good drainage to minimise bladder and urethral
trauma
 Consider silicone catheter if for long term use

Age Weight Foley

Neonate < 1200g 3.5Fr umbilical catheter

Neonate 1200-1500g 5Fr umbilical catheter

Neonate 1500-2500g 5Fr umbilical catheter or size 6 Foley

0-6 months 3.5-7kg 6

1Y 10kg 6-8
2Y 12kg 8
3Y 14kg 8-10
5Y 18kg 10
6Y 21kg 10
8Y 27kg 10-12
12Y Varies 12-14

Procedure for insertion of urinary catheter

The procedure should be carried out by a nurse or doctor competent in urinary
catheterization only

Female child

1. Place child in supine position with knees bent and hips flexed

2. If soiling evident, clean genital area with soap and water first

3. Perform hand hygiene

4. Open catheter pack

5. Add equipment needed using aseptic technique

6. Pour antiseptic onto tray

7. Perform aseptic hand wash and don sterile gloves

 8. Apply drapes

9. Separate labia with one hand and expose urethral meatus.

10. Using swabs held in forceps in the other hand clean the labial folds and the urethral
meatus. Move swab from above the urethral meatus down towards the rectum. Discard
swab after each urethral stroke.

11. Lubricate catheter

12. Place sterile tray onto drape.

13. Insert catheter into meatus, upward at approximately 30 degree angle until urine begins to
flow.

14. Inflate the balloon slowly (do not use balloon catheter in neonates) using sterile water to
the volume recommended on the catheter. Check that child feels no pain. If there is pain,
it could indicate the catheter is not in the bladder. Deflate the balloon and insert further
into the bladder. ALWAYS ensure urine is flowing before inflating the balloon.

15. Withdraw the catheter slightly till resistance is felt and attach to drainage system.

16. Secure the catheter to the thigh with tape

17. Ensure the child is left dry and comfortable.

18. Remove gloves and dispose of used articles into yellow biohazard bag.

19. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine
handwash

Male child

1. Place child in supine position

2. If soiling evident, clean genital area with soap and water first

3. Perform hand hygiene

4. Open catheter pack

5. Add equipment needed using aseptic technique

6. Pour antiseptic onto tray

7. Perform aseptic hand wash and don sterile gloves

8. Apply the drapes

9. Lift the penis and retract the foreskin if non circumcised. Do not force the foreskin back,
especially in infants

10. Using other hand, clean the meatus with swabs held in forceps. Use a circular motion
from the meatus to the base of the penis.

11. For older boys insert the Xylocaine gel into the urethra. Hold the distal urethra closed and
wait 2 - 3 minutes to give the gel time to work. For infants apply sterile lubricant to
catheter before insertion. Post urology surgery consider using two syringes

12. Place the sterile tray on the drapes.

13. Hold the penis with slight upward tension and perpendicular to the child's body. Insert the
catheter.

14. When the first sphincter is reached (at level pelvic floor muscles) lower the penis 90
degrees (facing child's toes), apply constant gentle pressure. If resistance is felt the
following strategies should be considered:

a. 2nd tube lubricant

b. Increase traction on penis and apply gentle pressure on the catheter

c. Ask the child to take a deep breath

d. Ask the child to cough and bear down eg try to pass urine

e. Gently rotate the catheter.

f. If unable to pass the catheter seek assistance from treating medical team or
Urology registrar

g. DO NOT use force as you may damage the urethra

15. Advance the catheter and gently insert it into the urethra until urine flows.

16. Inflate the balloon slowly (do not use balloon catheter in neonates)using sterile water to
the volume recommended on the catheter. Check that child feels no pain. If there is pain,
it could indicate the catheter is not in the bladder. Deflate the balloon and insert further
into the bladder. ALWAYS ensure urine is flowing before inflating the balloon.

17. Withdraw the catheter slightly till resistance is felt and attach to drainage system.

18. Secure the catheter to the thigh with tape

 19. Reposition the foreskin if applicable.

20. Ensure the child is left dry and comfortable.

21. Remove gloves and dispose of used articles into yellow biohazard bag.

22. Perform hand hygiene with either Microshield Hand gel or Green Chlorhexidine
handwash

Specialprecautions
Rapid drainage of large volumes of urine from the bladder may result in hypotension
and/or haemorrhage

o Clamp catheter if the volume seems excessive. Release clamp after 20 minutes to
allow more urine to drain

For post obstructive diuresis IV replacement of electrolytes may be required

Documentation
The procedure is documented in the child's Care Plan Activity. The documentation should be
signed by the person inserting the catheter. Documentation should include:

Indication for catheterization

Time and date of procedure

Type of catheter.

Size of catheter

Expiry date of catheter

Amount of water in balloon

Any problems with insertion

Description of urine, colour and volume

 Specimen collected

Review date

Ongoing nursing management

Measure urine output hourly and document

o Normal urine output is 0.5-1ml/kg/hr. Report any variation from this

o If oliguric ensure catheter is not blocked (see trouble shooting below)

No routine change of urinary catheter or drainage bag is necessary.

Change for clinical indicators if infection, obstruction or if system
disconnects or leaks. Replace system and/or catheter using aseptic
technique and sterile equipment

o Maintain unobstructed urine flow. Gravity is important for drainage and

prevention of urine backflow. Ensure the drainage bag is below the level of the
bladder, is not kinked and is secured

Urine for urinalysis or culture should be collected fresh from sampling

port of catheter tubing (not drainage bag). Clean port with disinfectant first

Drainage system

o Adherence to a sterile continuously closed method of urinary drainage has been

shown to markedly reduce the risk of acquiring a catheter associated infection

Hygiene

o Daily warm soapy water is sufficient meatal care or PRN if build up of secretions
is evident

o Uncircumcised boys should have the foreskin gently eased down over the catheter
after cleaning

Infection surveillance

o Consider daily the need for the IDC to remain insitu. Remove as soon as no
longer required to reduce risk of UTI
 o Cloudy, offensive smelling or unexplained blood stained urine is not normal and
needs further investigation

o Full Ward Test (dipstick) should be done each day. This test can detect urinary
protein, blood, nitrates (produced by bacterial reduction of urinary nitrate) and
leucocyte esterase (an enzyme present in White Blood Cells)

o Specimen collection

o Large volumes e.g. 24hr collection, can be collected from drainage bag

Record fluid balance. A fluid balance which keeps the urine dilute will lessen the risk of
infection. This may not be possible due to the clinical condition of the child

Troubleshooting
Catheter not draining/ patient oliguric

o Check catheter/tubing not kinked

o Check catheter is still secured to patient leg and hasn't migrated out of bladder

o Checking patency by irrigating catheter with 2-3ml of sterile 0.9% normal saline.
Do not use force to instil fluid. This is an aseptic procedure

Catheter leaking

o Remove catheter. If indication for IDC remains follow insertion procedure with
new catheter

Removal of urinary catheter

1. Explain procedure to child and family

2. Perform hand hygiene & don gloves

3. Deflate balloon completely

4. Gently withdraw catheter

 o If resistance felt, and catheter cannot be removed easily do not force, leave
catheter insitu and consult medical team

5. Inspect catheter for intactness. Report if not intact

6. Dispose of catheter and drainage system in appropriate waste

7. Remove gloves & perform social hand wash

8. Document catheter removal in patient notes

9. Observe for urine output post catheter removal

Complications
Inability to catheterize

Urethral injury from trauma sustained during insertion or balloon inflation in incorrect
position

o Haemorrhage

o False passage

o Urethral strictures following damage to urethra. This may be a long term problem

Infection

Psychological trauma

Paraphimosis due to failure to return foreskin to normal position following catheter

insertion

Companion Documents
Kids Health Info Fact Sheet: Indwelling urinary catheter

References
 A guide for nurses- Management and care of catheters and collection systems (2001).
USA: Bard

Gould, C; Umscheid,C; Agarwal,R; Kuntz,G; Pegues, D; and the Healthcare Infection

Control Practices Advisory Committee (HICPAC).(2009). Guideline For Prevention Of
Catheter-Associated Urinary Tract Infections. Centre for Disease Control. Downloaded
from: http://www.cdc.gov/hicpac/cauti/001_cauti.html

Department of Health. (2001). Guidelines for preventing Infections associated with the
Insertion and Maintenance of Short Term Catheters in Acute Care. Journal of Hospital
Infection, 47(Suppl), S39 - S46

Laker, C (1995). Urological Nursing. Great Britain, Alden Press Ltd.

Royal Children's Hospital, Infection Control Dept. Antiseptic and Disinfectant Usage.

Association of Continence Advice, Notes on Good Practice (2006) Urethral

Catheterisation NO.6

Robson, J (2001) Urethral Catheter Selection. Nursing Standard. 15 (25)

Royal College of Nursing Catheter Care RCN Guidance for Nurses ( 2007)

The Australian and New Zealand Urological Nurses Society INC. (ANZUNS) Talbot,
Kay (2006)

Kids Health Info for Parents. The Royal Children's Hospital, Melbourne. Indwelling
Urinary Catheter Fact Sheet. ( 2008)

Simpson, L (2001) Indwelling Urethral Catheters. Nursing Standard. 15 (46) : 47 - 54

Evidence Table
Indwelling urinary catheter insertion and management evidence table

Please remember to read the disclaimer.

The development of this clinical guideline was coordinated by Maureen Scoble, Rosella - PICU.
Approved by the Clinical Effectiveness Committee. Authorised by Bernadette Twomey,
Executive Director Nursing Services. First published March 2012, revised February 2013.