21.13 Checklist for Foley Removal
Open Resources for Nursing (Open RN)
Use the checklist below to review the steps for completion of “Foley Removal.”
Steps
Disclaimer: Always review and follow agency policy regarding this specific skill.
- Verify order.
- Gather supplies: urinary graduated cylinder, gloves, 10-mL syringe, peri-care supplies, chux/waterproof pad, and wastebasket.
- 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.
- 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.
- Remove gloves. Perform hand hygiene and then apply clean nonsterile gloves.
- Uncover the patient so that only the genital area and catheter are exposed.
- Place a protective pad under the patient.
- Remove any securement device holding the catheter to the upper thigh.
- Attach the 10-mL syringe into the balloon port and remove all the fluid from the balloon; while holding the plunger, detach the syringe.
- Ask the patient to take a deep breath and exhale, as you remove the catheter on expiration. Stop if resistance is met.
- Inspect the catheter to determine if it was removed intact; place it in the wastebasket or facility-approved receptacle.
- Cleanse the perineal area or allow the patient to cleanse the area.
- Remove the catheter materials and waste and place them in the wastebasket.
- Remove gloves and perform hand hygiene.
- Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.
- 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)
- Perform hand hygiene.
- Document the procedure and related assessment findings. Report any concerns according to agency policy.