21.15 Checklist for Foley Removal

Use the checklist below to review the steps for completion of “Foley Removal.”

Video Review of Removing a Foley Catheter :^[1]

Steps

Disclaimer: Always review and follow agency policy regarding this specific skill.

1. Verify order.
2. Gather supplies: urinary graduated cylinder, gloves, 10-mL syringe, peri-care supplies, chux/waterproof pad, and wastebasket.
3. Perform safety steps:
   • Perform hand hygiene.
   • Check the room for transmission-based precautions.
   • Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
   • Confirm patient ID using two patient identifiers (e.g., name and date of birth).
   • Explain the process to the patient.
   • Be organized and systematic.
   • Use appropriate listening and questioning skills.
   • Listen and attend to patient cues.
   • Ensure the patient’s privacy and dignity.
   • Assess ABCs.
4. Place peri-care supplies, chux, and syringe on the overbed table. Place the wastebasket near the bed and place the urinary graduate on the floor near the Foley bag:
   • Empty urine from the tubing into the catheter bag. Empty the catheter bag into the urinary graduate.
   • Note amount of urine for I & O.
   • Empty graduate in the bathroom.
5. Remove gloves. Perform hand hygiene and then apply clean nonsterile gloves.
6. Uncover the patient so that only the genital area and catheter are exposed.
7. Place a protective pad under the patient.
8. Remove any securement device holding the catheter to the upper thigh.
9. Attach the 10-mL syringe into the balloon port and remove all the fluid from the balloon; while holding the plunger, detach the syringe.
10. Ask the patient to take a deep breath and exhale, as you remove the catheter on expiration. Stop if resistance is met.
11. Inspect the catheter to determine if it was removed intact; place it in the wastebasket or facility-approved receptacle.
12. Cleanse the perineal area or allow the patient to cleanse the area.
13. Remove the catheter materials and waste and place them in the wastebasket.
14. Remove gloves and perform hand hygiene.
15. Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
16. Ensure safety measures when leaving the room:
    • CALL LIGHT: Within reach
    • BED: Low and locked (in lowest position and brakes on)
    • SIDE RAILS: Secured
    • TABLE: Within reach
    • ROOM: Risk-free for falls (scan room and clear any obstacles)
17. Perform hand hygiene.
18. Document the procedure and related assessment findings. Report any concerns according to agency policy.