Fundamentals of Nursing Q 507
Which of the following is a primary nursing intervention necessary for all patients with a Foley Catheter in place?
A. Maintain the drainage tubing and collection bag level with the patient’s bladder.
B. Irrigate the patient with 1% Neosporin solution three times a day.
C. Clamp the catheter for 1 hour every 4 hours to maintain the bladder’s elasticity.
D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity.
Correct Answer: D. Maintain the drainage tubing and collection bag below bladder level to facilitate drainage by gravity
To prevent obstruction, the catheter and collecting tube should be kept free from kinking, the collecting bag should be positioned below the level of the bladder at all times and never placed on the floor. The collecting bag should be emptied regularly using a clean collecting container (HICPAC, 2009). In ambulatory patients, collecting bags may be disguised in bags and pouches.
Option A: Maintaining the drainage tubing and collection bag level with the patient’s bladder could result in reflux of urine into the kidney. The indwelling catheter should be secured to the thigh or abdomen after insertion to prevent movement and the exertion of excessive force on the bladder neck or urethra (Gray, 2008). Unsecured and displaced catheters can also cause pressure ulcers on the perineum and buttock (Siegel, 2008).
Option B: Irrigating the bladder with Neosporin must be indicated and ordered by the physician. Nash (2003) conducted a recent review of the literature on self-cleaning of catheter training bags. The study showed that patients whose bags were irrigated with vinegar showed a significant reduction of bacteriuria compared with patients whose bags were irrigated with the hydrogen peroxide solutions (Washington, 2001). Authors concluded that more research is needed on the self-cleaning of Foley bags.
Option C: Clamping the catheter for 1 hour every 4 hours must be prescribed by a physician. Patients practicing intermittent catheterization should pay close attention to the catheterization schedule and avoid bladder overdistension and unnecessary catheterizations. As CAUTIs are more prevalent for intermittent catheterization in patients with high residual urine volumes at the time of catheterization, urine volume should determine the catheterization schedule.