Sample Documentation Of Foley Catheter Removal

Foley Catheter Removal: A Comprehensive Guide for Healthcare Professionals

Foley catheter removal is a common procedure in healthcare settings, yet it requires meticulous attention to detail to ensure patient safety and comfort. This comprehensive guide provides a step-by-step documentation sample, emphasizing key aspects for accurate record-keeping and best practices. Understanding the procedure and its associated documentation is crucial for minimizing complications and promoting positive patient outcomes.

Understanding Foley Catheterization and Removal

Before delving into the documentation, let's briefly revisit the purpose of a Foley catheter and the rationale behind its removal. A Foley catheter, also known as an indwelling urinary catheter, is a thin, flexible tube inserted into the bladder via the urethra to drain urine. This procedure is often necessary for various reasons, including:

• Urinary retention: Inability to empty the bladder completely.
• Urinary incontinence: Uncontrolled leakage of urine.
• Monitoring urine output: Accurate measurement of fluid balance.
• Surgical procedures: To keep the bladder empty during and after surgery.
• Wound healing: To keep the surgical site clean and dry.

Removal of the Foley catheter is indicated when the underlying condition is resolved, and the patient can effectively manage their bladder function. Premature removal can lead to complications, while delayed removal increases the risk of infection and other adverse events.

Pre-Removal Assessment: Key Considerations

Accurate and thorough assessment before catheter removal is crucial. This assessment should be documented meticulously. Key aspects to consider and record include:

1. Patient History & Current Condition

• Reason for catheterization: Document the original indication for catheter placement.
• Duration of catheterization: Note the length of time the catheter has been in place. Prolonged catheterization increases the risk of infection.
• Current medication: List all medications the patient is taking, including anticoagulants which might increase the risk of bleeding.
• Allergies: Document any known allergies, particularly to latex or antiseptic solutions.
• Fluid balance: Assess the patient's hydration status. Dehydration can increase the risk of complications during and after removal.
• Vital signs: Record the patient's temperature, pulse, blood pressure, and respiratory rate before the procedure. Any abnormal readings should be reported to the physician.

2. Physical Assessment

• Bladder palpation: Gently palpate the bladder to assess for distension. A distended bladder indicates incomplete emptying and may necessitate further intervention before removal.
• Perineal assessment: Examine the perineal area for any signs of infection, such as redness, swelling, or discharge.
• Catheter patency: Verify that the catheter is draining urine freely. Kinks or blockages should be addressed before removal.
• Urine characteristics: Note the color, clarity, and odor of the urine. Any abnormalities should be documented and reported.

Foley Catheter Removal Procedure: Step-by-Step Documentation

The following documentation sample details the steps involved in Foley catheter removal. Remember to adapt it to your specific institution’s policies and procedures.

Date: October 26, 2023 Time: 10:00 AM Patient Name: Jane Doe Patient ID: 1234567 Physician's Order: Removal of Foley catheter

Procedure:

1. Pre-Procedure:

• Verification: Confirmed physician's order for Foley catheter removal. Patient identification verified using two identifiers (name and date of birth).
• Assessment: Performed thorough pre-removal assessment (detailed above). Bladder non-distended. Perineal area clean and without signs of infection. Urine output clear yellow. Vital signs: BP 120/80 mmHg, HR 72 bpm, RR 16 breaths/min, Temp 36.8°C.
• Hand Hygiene: Performed thorough hand hygiene using alcohol-based hand rub.
• Explanation: Explained the procedure to the patient, answering any questions and obtaining informed consent.

2. Procedure Steps:

• Equipment: Assembled necessary equipment: sterile gloves, antiseptic solution (e.g., chlorhexidine), sterile gauze pads, drainage bag, measuring cylinder.
• Positioning: Assisted the patient into a comfortable supine position.
• Hand Hygiene: Performed hand hygiene.
• Glove Application: Donned sterile gloves.
• Perineal Cleaning: Cleansed the perineal area with antiseptic solution using aseptic technique. Cleansed from meatus outwards in a circular motion.
• Catheter Deflation: Carefully deflated the Foley balloon by aspirating the fluid using a syringe. Note the amount of fluid aspirated: 10 mL.
• Gentle Catheter Withdrawal: Slowly and gently withdrew the catheter while maintaining firm traction.
• Measurement: Measured the amount of residual urine in the catheter using a graduated cylinder. Amount: 15 mL.
• Post-Withdrawal Care: Cleansed the perineal area again with antiseptic solution. Applied a clean, dry dressing if needed.
• Disposal: Disposed of used equipment according to infection control protocols.

3. Post-Procedure:

• Monitoring: Monitored vital signs every 15 minutes for the first hour after catheter removal.
• Fluid Balance: Encouraged the patient to increase fluid intake.
• Output Monitoring: Monitored the patient's urinary output carefully.
• Patient Education: Educated the patient on signs and symptoms of infection (fever, chills, cloudy urine, pain, discomfort) and instructed them to report any immediately.

4. Post-Procedure Assessment:

• Time: 10:45 AM
• Vital Signs: BP 122/80 mmHg, HR 70 bpm, RR 16 breaths/min, Temp 36.9°C.
• Urine Output: Voided 250 mL of clear, yellow urine spontaneously.
• Comfort Level: Patient reported minimal discomfort; pain rated 2/10 on a numerical rating scale.

5. Physician Notification: Notified the physician of the procedure and post-procedure assessment findings.

6. Documentation Completion: Completed the procedure documentation and added any significant observations.

Overall Assessment: Foley catheter removed successfully without complications. Patient tolerated the procedure well and is comfortable. Regular monitoring of urine output and patient's condition will continue.

Potential Complications and Documentation

It is crucial to document any potential complications that may arise during or after Foley catheter removal. These may include:

• Urinary tract infection (UTI): Document signs and symptoms (fever, chills, dysuria, cloudy urine).
• Bleeding: Note the amount and type of bleeding. Apply pressure if needed.
• Urinary retention: Document the inability to void and interventions taken (bladder scan, catheterization).
• Trauma: Document any injuries to the urethra or surrounding tissues.
• Pain: Assess and document the patient's pain level using a standardized pain scale.

Thorough and accurate documentation of Foley catheter removal, including pre-procedure assessment, procedure steps, post-procedure monitoring, and any complications, is essential for maintaining high standards of patient care and minimizing legal risks. This sample documentation provides a framework; always tailor it to your specific context and institutional guidelines. Remember that clarity, accuracy, and completeness are paramount in medical record keeping.