Foley Catheter Management Protocol

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Version 1
Foley Catheter Management Protocol
For Adult Hospital Inpatients and Rehab ONLY
** Excludes OB/Maternal Child Health, OB/GYN/Urology procedures or foley placed by Urologist**
5/18/15
IF this protocol has not been initiated by a provider, an order for initiation must be obtained prior to
implementation
Foley Catheter Use Criteria: Assess and Document every shift
Criteria for insertion and continued Foley use:
1) Placed by Urology/OB-GYN for procedure or surgery
2) For OR and/or Post-op: If needed > 48 hrs postop provider to document reason
3) Measure urinary output more often than every 2 hours
4) To manage urinary retention or bladder outlet obstruction
5) Protect healing Stage III/IV pressure ulcer from urine leakage
6) For patients with neurological disorder and bladder dysfunction
7) For patients with neurological disorder and urinary retention
8) For patients with neurological disorder and incontinence
9) To improve comfort during end of life care at request
10) Hematuria present within the past 24 hours or continuous bladder irrigation
11) History of chronic catheter placement
12) Required for specific laboratory testing
13) Required for pelvic x-ray or ultrasound
Foley Discontinuation
Discontinue Foley when criteria for Foley use are not met and begin void trials
**DO NOT DISCONTINUE ANY FOLEY PLACED BY UROLOGIST OR FOR OB/GYN/UROLOGY
PROCEDURES. PROVIDER MUST ORDER DISCONTINUATION OF THESE**
BVI/Straight Cath Protocol
Frequency of BVI and Straight Cath is determined by comfort and to maintain total bladder volume </= 400 mL
After catheter removal toilet or offer urinal every 2 hours in daytime hours and every 4-6 hrs at night until
pattern is established. Document void trials and results in BVI screen
After catheter removal if incontinent and this is new for the patient continue to toilet or offer urinal every 2 hrs
in daytime and every 4-6 hrs at night.
Monitor for distention and check Bladder Volume Index (BVI) at 4 hours after catheter removal and then at 2
hrs intervals depending on fluid intake and urinary output.
Spontaneous Void or Incontinent within 4 hours after catheter d/c
Perform Bladder Volume Index (BVI) Post-Void Residual
Post Void BVI < /= 250 mL
 Monitor patient to insure adequate emptying
Post Void BVI > 250 mL
Urinary straight catheterization if post void BVI volume is > 250 mL
For Discomfort at any time and unable to void or No Spontaneous Void within 4 hours after catheter
d/c
BVI < /= 400 mL
Perform Bladder Volume Index (BVI) every 2 hour and monitor for spontaneous void
BVI > 400 mL
Urinary straight catheterization if BVI volume is > 400 mL without spontaneous void
Notify provider
If straight cath needed more than 2 times
If straight cath urine volume is > 400 mL and patient is uncomfortable
Page 1 of 1
FOLEY CATHETER MANAGEMENT PROTOCOL
For Adult Hospital Inpatients and Rehab ONLY
** Excludes OB/Maternal Child Health, OB/GYN/Urology procedures or foley placed by Urologist**
Foley Catheter Insert/Maintain
Nurse documents the reason for insertion and assesses the
need for a Foley catheter Q shift with the goal of removing
catheter as soon as criteria for use are not met..
Criteria for insertion and
continued Foley use:
1) Placed by Urology/OB‐GYN for
procedure or surgery
2 ) For OR procedure and/or post‐
op: If needed > 48 hrs postop
provider to document reason
3) Measure urinary output more
often than every 2 hours
4) To manage urinary retention or
bladder outlet obstruction
5) Protect healing Stage III/IV
pressure ulcer from urine
leakage
6) For patients with neurological
disorder and bladder dysfunction
7) For patients with neurological
disorder and urinary retention
8) For patients with neurological
disorder and incontinence
9) To improve comfort during end
of life care at request
10) Hematuria present within the
past 24 hours or continuous
bladder irrigation
11) History of chronic catheter
placement
12 )Required for specific laboratory
testing
13) Required for pelvic x‐ray or
ultrasound
If incontinent
and this is new
for the
patient,
continue to
toilet/offer
urinal q2hr
Does the patient
meet criteria for
Foley use?
Reassess Q shift
Document reason for indwelling catheter Q
shift with goal of removing catheter as soon
as criteria for use are not met
YES
** NOTE: If Foley left in place >48hrs post
surgery Provider must document reason why
NO
DO NOT DISCONTINUE ANY
FOLEY PLACED BY UROLOGIST
OR FOR OB/GYN/UROLOGY
PROCEDURES. PROVIDER MUST
ORDER DISCONTINUATION OF
THESE
Discontinue Foley per protocol and
document in Urinary device assessment
Void Trial/offer urinal q2hr in daytime and
q4‐6hr at night until pattern is established
Uncomfortable
(at any time)
AND
unable to void?
YES
NO
YES
Spontaneous
Void within 4 hrs
post Foley D/C or
Straight Cath?
NO
Perform BVI
NO
Perform Post void
BVI
YES
Perform BVI
Q2H and
monitor for
spontaneous
void
Spontaneous
Void?
NO
(≤400mL)
BVI is > 400mL
or pt uncomfortable
and unable to void?
YES
Monitor
patient to
insure
adequate
emptying
(>400ml)
NO
(≤ 250m L)
Post void BVI >
250ml?
YES
**NOTIFY PROVIDER**
LEGEND
BVI: Bladder Volume Index
Perform
Straight Cath
(>250m L)
YES
Straight
Cath needed more
than 2 times OR
Straight cath volume
> 400mL?
NO
(<400mL)