PC- Nurse-Driven Urinary Catheter Removal

Purpose: Reduce catheter associated
urinary tract infections (CAUTI).
 Definitions: CAUTI – A nosocomial
infection that can develop in patients with
an indwelling urinary catheter.
Policy: Patients meeting specific
assessment criteria will have the urinary
catheter removed by a nurse.
1. Assess the need to continue urinary catheter as
part of their ongoing assessment using the
Nurse-Driven Urinary Catheter Assessment. (See
Addendum A).
2. If none of the specified indications for continued
catheter use are met, the catheter will be
discontinued by the nurse.
3. Continue to reevaluate and assess the need to
reinsert the urinary catheter following removal
of the urinary catheter.
4. Contact the patient’s physician for further
orders if patient is unable to void following
catheter removal.
Patient/Family Education
Patient and/or family will be educated on:
1. Risk of complications associated with urinary
2. Importance of adequate fluid intake after removal
of urinary catheter .
3. Measurement of intake and output to be done to
assess the patient’s ability to empty bladder after
removal of urinary catheter.
Documentation: Nurse to document
assessment and removal of urinary catheter
and continued reassessment post removal, in
the patient’s medical record.
Assess Patient for Indications
for Continued Catheter Use:
Aggressive treatment
with diuretics
Gross hematuria within
Spinal cord
last 24 hours
immobilization issues
Accurate monitoring of
Urologist involved in
urinary output
case/catheter placed by
Chronic long term
indwelling catheter
Management of urinary catheterization
incontinence in patient
History of urinary
with Stage III or greater
Post op/post procedure retention
pressure ulcers
(less than 48 hours prior)
MD order to continue
End of life/comfort care
Presence of epidural
urinary catheter
Indications present? Yes or No
Are any indications present?
If Yes…
Continue catheter care per policy.
 Ensure compliance with catheter “bundle”:
 Securing device used. (example: stat-lock)
 No dependent loops in tubing.
 Secure tubing to bed.
 Bag not overfilled or touching floor.
 If spinal cord injury, assess readiness for bladder
And re-evaluate need at each
subsequent SBAR Handoff
If No…
RN may remove catheter without
MD order
Patient care to include:
 Frequently offer
 Encourage mobilization/activity and PO fluids
as indicated.
 For men, consider external (condom) cath.
 Bladder scan if unable to void in 6 hours.
• If < 300 ml, recheck in 4 hours.
If > 300 ml, straight cath X1.
 Re-scan if unable to void in 6 hours.
• If >300 ml, call MD for catheter reinsertion order.
74 yo female
ED admission to Med/surg nursing unit
Dx: ALOC, Laceration to forehead due to fall at
Hx: Diabetes type II, osteoarthritis, mild HTN,
lives alone & independent.
Labs: normal CBC, Na+ 125, K+ 3.8
UA: normal, obtained from urinary cath while in
CAT Scan: Negative for stroke
Admission to nursing unit from ED
Received on unit @ 1900
Vitals stable
Lethargic, c/o of headache, oriented to self
Unsteady gait, hands tremulous
Urinary catheter in place
The next day on Med/surg
Awake, alert x4
Gait slow but balanced
Classified as a high fall risk due to
medication and age.
Able to rise from chair w/o help
Asking, “why do I still have this tube?”
Assessment Questions:
 Does the patient’s condition warrant a urinary
Is the patient able to make needs known?
 Does patient have history of retention?
 Does the patient have a Stage III or greater
pressure ulcer and is incontinent?
 Is the patient receiving large doses of diuretics?
 Do you have an order for urinary catheter?
According to the policy,
Nurse Driven Urinary Catheter Removal,
you can discontinue the catheter without the
need of calling the Physician, for a d/c
urinary catheter order.
Patient education post catheter removal
Instruct patient and family of the:
 Importance of calling for
assistance for toileting
 Importance of fluid intake as
 Importance of activity: up in
chair, ambulating in room and
around unit
 Reinforce safety precautions:
“Call don’t Fall”
Reference / Regulations
Brosnahan, J.E. & Kent, B. (2004). Short-term indwelling
catheters (a systematic review): Evidence for a primarily nursing
decision. Worldviews on Evidence-Based Nursing, 1, (4), 228.
Gotelli, J.M., Merryman, P., Carr, C., McElveen, L., Epperson, C.,
Bynum, D. (2008). A quality improvement project to reduce the
complications associated with indwelling urinary catheters.
Urologic Nursing, 28(6), 465-467, 473.
Griffiths, R., & Fernandez, R. Strategies for removal of short-term
indwelling urethral catheters in adults. Cochrane Database of
Systematic Reviews 2007, Issue 2, Art. No.: CD004011.
Topal, J., Conklin, S., Camp, K., Morris, V., Balcezak, T., &
Herbert, P. (2005). Prevention of nosocomial catheter-associated
urinary tract infections through computerized feedback to
physicians and a nurse-directed protocol. American Journal of
Medical Quality, 20, (3), 121-126.
Greenspan, Robert E MD, MEDICINE: Perspectives in History and
Art | ISBN-10 0972448608 | ISBN-13 978-0972448604

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