NRSG 301 Foleys – Questions With Indepth Solutions
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what are appropriate indications for - pt. has acute urinary retention or bladder outlet obstruction
indwelling catheter use? - need accurate measurements of urinary output
perioperative use for surgical procedures
- assist in healing open or sacral or perineal wounds in
incontinent pts.
- improve comfort for end of life care if needed
what are INAPPROPRIATE uses of - as a substitute for nursing care of pt. or resident with
indwelling catheters? incontinence
- as a means of obtaining urine for culture or other diagnostic
tests when the pt. can voluntarily void
- for prolonged postoperative duration without appropriate
indications
urinary retention inability to void (; due to surgery, urethral trauma, obstruction)
which may be chronic or acute
signs and symptoms of urinary retention bladder distension, absence of urine output for several hours,
severe pain or pressure in pelvic area, restlessness,
diaphoresis, urgency
incontinence the inability to control the release of urine
What is the assessment for urinary - palpation
retention? - percussion
- bladder scanner
palpate just over the symphysis pubis for rounded bladder. Pt.
can often feel the distension and is exacerbated with pressure
unless under spinal/epidural
percuss down from umbilicus for a change in sound to dull
over bladder
, what are the three types of catheters? Foley catheter - indwelling with balloon ;
latex- last about 1 month
Silicone - 8-12 weeks
Silastic - 8-12 weeks
Always select the smallest diameter and ballon size possible
to facilitate draining, decrease friction, injury and bacteria
growth
female 12 F, and Male 14 F
Catheterization Complications - introduction of microorganisms; CAUTI (infection within 48
hours of insertion
- urethral trauma
removal of indwelling catheter - provide instructions to pt. and provide perineal hygiene
- check volume of water in balloon
- clean procedure
- blue pad and perineal privacy
- deflate balloon with syringe
- gentle removal
- pericare, encourage fluid intake, monitor for post catheter
voiding
what if the balloon will not deflate? ensure there are no kinks. check to see how much fluid was
put in the balloon. try to inflate the balloon again and the
deflate. NEVER PULL IT OUT WITH THE BALLOON INFLATED.
notify physician.
Options: if catheter is draining, leave in place 1-2 more days
and periodically re-attempt to deflate balloon
how to document catheter removal -indicate time of removal
- integrity of balloon and catheter tip
- volume of fluid removed from deflated balloon
- patient's tolerance of procedure
- type of urine sample collected and sent to lab if pertinent
urine specimen collection 1. clamp foley for up to 30 mins
2. cleans port and attach syringe
3. withdraw sample (min 30 mL)
4. disconnect and place sample in sterile container
5. unclamp foley
6. label sample, place in biohazard bag and send to lab
where should the nurse clamp the catheter below the port
in order to obtain a sample?
what if the patient complains for discomfort, assess output and see if the catheter is kinked
cramping, and urge to void? what is your
first step
how much urine should be produced per minimum 30 mL per, bladder holds 300-500 mL, trigger at 150
hour? mL, 1-2L/24 hrs
Save
Students also studied
WSC 2026: Are we there yet? Social Science Nationalism Vocab T... WSC 2026 Next Year
Teacher 156 terms 21 terms Teacher 50 terms
Amy_Woodall4 Preview Keiya_Raja Preview Sandywu1205
Terms in this set (29)
what are appropriate indications for - pt. has acute urinary retention or bladder outlet obstruction
indwelling catheter use? - need accurate measurements of urinary output
perioperative use for surgical procedures
- assist in healing open or sacral or perineal wounds in
incontinent pts.
- improve comfort for end of life care if needed
what are INAPPROPRIATE uses of - as a substitute for nursing care of pt. or resident with
indwelling catheters? incontinence
- as a means of obtaining urine for culture or other diagnostic
tests when the pt. can voluntarily void
- for prolonged postoperative duration without appropriate
indications
urinary retention inability to void (; due to surgery, urethral trauma, obstruction)
which may be chronic or acute
signs and symptoms of urinary retention bladder distension, absence of urine output for several hours,
severe pain or pressure in pelvic area, restlessness,
diaphoresis, urgency
incontinence the inability to control the release of urine
What is the assessment for urinary - palpation
retention? - percussion
- bladder scanner
palpate just over the symphysis pubis for rounded bladder. Pt.
can often feel the distension and is exacerbated with pressure
unless under spinal/epidural
percuss down from umbilicus for a change in sound to dull
over bladder
, what are the three types of catheters? Foley catheter - indwelling with balloon ;
latex- last about 1 month
Silicone - 8-12 weeks
Silastic - 8-12 weeks
Always select the smallest diameter and ballon size possible
to facilitate draining, decrease friction, injury and bacteria
growth
female 12 F, and Male 14 F
Catheterization Complications - introduction of microorganisms; CAUTI (infection within 48
hours of insertion
- urethral trauma
removal of indwelling catheter - provide instructions to pt. and provide perineal hygiene
- check volume of water in balloon
- clean procedure
- blue pad and perineal privacy
- deflate balloon with syringe
- gentle removal
- pericare, encourage fluid intake, monitor for post catheter
voiding
what if the balloon will not deflate? ensure there are no kinks. check to see how much fluid was
put in the balloon. try to inflate the balloon again and the
deflate. NEVER PULL IT OUT WITH THE BALLOON INFLATED.
notify physician.
Options: if catheter is draining, leave in place 1-2 more days
and periodically re-attempt to deflate balloon
how to document catheter removal -indicate time of removal
- integrity of balloon and catheter tip
- volume of fluid removed from deflated balloon
- patient's tolerance of procedure
- type of urine sample collected and sent to lab if pertinent
urine specimen collection 1. clamp foley for up to 30 mins
2. cleans port and attach syringe
3. withdraw sample (min 30 mL)
4. disconnect and place sample in sterile container
5. unclamp foley
6. label sample, place in biohazard bag and send to lab
where should the nurse clamp the catheter below the port
in order to obtain a sample?
what if the patient complains for discomfort, assess output and see if the catheter is kinked
cramping, and urge to void? what is your
first step
how much urine should be produced per minimum 30 mL per, bladder holds 300-500 mL, trigger at 150
hour? mL, 1-2L/24 hrs
