Steps

Rationale/Points of Emphasis 1

1a Perform hand hygiene and gather the necessary supplies.

Reduces transmission of microorganisms. Promotes efficient time management and provides an organized approach to the procedure.

caREminder

Another caregiver such as a registered nurse (RN), licensed practical nurse (LPN), or unlicensed nursing personnel (UAP), should be present to assist if the child is unable to cooperate for any reason.

1b Select catheter size appropriate for the child (see Table 107-1 ).

Selection of the catheter is based on the child’s age and gender, construction material of the catheter, and the internal and external diameters of the catheter. Small catheter sizes promote comfort and are adequate for specimen collection. Use of shorter-length urinary catheters and basing the length on gender and age can reduce incidence of knotting (e.g., for toddlers and younger girls, insert 2 inches; for male infants, insert 3 inches; for male toddlers, insert 3-4 inches). Using the smallest possible catheter size minimizes urethral dilation and the risk of trauma, but large catheters may be required if there is a lot of debris in the urine.

1c Have extra catheters readily accessible during the procedure.

If a catheter becomes contaminated, is inadvertently placed in the vagina, or turns out to be the incorrect size, an extra catheter will be immediately needed to maintain sterility and complete the procedure in a timely manner.

2 Close the door to the child’s room or draw the curtains around the child’s bed.

Provides privacy during the procedure.

3 Raise the bed to a comfortable working height, or stand on a step stool at crib side.

Reduces the strain placed on your back.

4 Don nonsterile gloves and protective apparel.

Standard precaution to reduce the transmission of microorganisms.

5a Place a waterproof pad under the child’s/infant’s buttocks while positioning the child/infant. If needed, position an examination light to better visualize the genitalia area.

This prevents the bed linens from being soiled.

5b Position a female child in the supine position with the heels of the feet together and the knees tilted outward (called the frog position). Use rolled blankets, pillows, or towels to support legs in this position.

This position facilitates visualization of the inner labia.

5c Position a male child in the supine position with the legs together. Use rolled towels under the knees. Raise the penis and scrotal sac to rest on top of the thighs.

This position facilitates visualization of the urethral opening. Bending the knees slightly may be a more comfortable position for the child.

KidKare Remind the child to keep his or her buttocks on the bed or table and to keep the perineal muscles relaxed. The child will most likely need to be reminded of this several times during the procedure.

6 Place a drape over the child/infant. For a female child, place the drape in a diamond configuration with one corner at the child’s sternum, one corner over each knee, and one corner over the perineum. For a male child, cover the child’s chest and lower extremities with a sheet, leaving only the genital area exposed.

Allows exposure of the child’s perineum while covering the rest of the body, allowing for privacy.

7 Wash the child’s genital area with warm water and soap. Rinse and dry the area.

Removes secretions and feces.

8 Remove gloves and perform hand hygiene.

Reduces transmission of microorganisms.

9 Establish a sterile working area, using a sterile towel spread open.

Establishes a space from which to gather sterile equipment and proceed with catheterization without contamination.

10 Using sterile technique, open the sterile catheter, sterile povidone-iodine, sterile lubricant, swabs, and sterile prefilled syringe of water and drop them on the sterile towel. Open the sterile gravity drainage and collection bag and leave it sitting in the packaging container.

Facilitates ease of access to the equipment. If lidocaine gel is to be used, assemble lidocaine applicator according to the manufacturer’s instructions and follow procedure for use of lidocaine lubricant gel.

11 Aseptically place a sterile towel between the female child’s legs under the perineal area or on the thighs of a male child.

The pad becomes an extension of the sterile work area.

12 Don sterile gloves.

Reduces introduction of microorganisms into the urinary tract, which is normally sterile.

13a While laying your nondominant arm across the midsection of the lower abdomen, use the thumb and the middle finger of your nondominant sterile hand to spread open the female child’s labia.

Allows for exposure and visualization of the urethral opening. Swelling of the labia in neonates, due to maternal hormones, may make it difficult to visualize the urethral opening. A flashlight or examination light may be helpful in locating the urethral opening. If locating the urethra in female child is difficult, have an assistant, wearing sterile gloves, grasp the labia majora and gently pull forward, forming a cave-like opening and causing the hymen and urethra to drop open.

13b For a male child, follow the same procedure and use your nondominant hand to position the child’s penis perpendicular to the body. In an uncircumcised child, withdraw the foreskin just far enough to visualize the urethral opening. Do not pull back behind the glans.

Withdrawing the foreskin further will be painful to the child and could cause tears that could lead to potential sites of infection.

14 With your dominant sterile hand, cleanse the area around the urethral opening with the sterile povidone-iodine swabs and discard them in a nearby waste receptacle. For a female child, use a separate povidone-iodine swab for each stroke, cleanse both the right and left sides of the inner labia with one downward stroke. Then clean midline, from the clitoris down to the rectum with one stroke. For a male child, cleanse the penis in an outgoing circular motion, from the urethral opening to the base of the penis, by using a new povidone-iodine swab each time.

Prevents contamination of the catheter by microorganisms on the skin and prevents introduction of organisms into the patient’s urethra and bladder.

caREminder

The labia should not be allowed to close during the entire procedure because this contaminates the sterile field. If the labia do close, stop the procedure, don new sterile gloves, and start over at this step.

15 With your sterile dominant hand, lubricate the tip of the sterile catheter with the water-soluble lubricant that has been squirted on the sterile field. The catheter should be lubricated approximately 2 inches for a female child and approximately 6 inches for a male child.

Lubricant decreases the friction between the catheter and the urinary tract during catheterization. In male child, using lubricant on the tip of the catheter promotes opening of the sphincter mechanism.

16a Lift the lubricated tip of the catheter with your dominant sterile hand and gently insert it into the child’s urethral opening.

Allows for catheterization to obtain sterile urine specimen.

16b Do not touch the child’s perineal hair or skin as the catheter is advanced.

Hair or skin contaminates the catheter.

16c For a male child, insert the lubricated catheter tip into the urethra without allowing the intraurethral lubricant (if lidocaine gel was used) to exit the urethral meatus. Because gentle pressure may cause an erection in an adolescent male, hold the penis firmly but not tightly. If held tightly, pressure will collapse the urethra and will prevent advancement of the catheter.

If the adolescent has an erection, stop the procedure until there is a nonerectile state, and then continue with the procedure.

16d Ask the child to take a deep breath while you insert the catheter.

Taking a deep breath helps to relax the urinary tract.

caREminder

The child may state he or she needs to urinate during catheter insertion. Tell the child to go ahead and try to do so; slightly straining down opens the urethra for passage of the catheter.

17 Insert the catheter to the hub. If an obstruction is encountered, do not force the catheter. If the catheter is inadvertently placed in the vagina, leave it in place and put a second catheter in the other opening (urethra). After the second catheter is in place, remove the catheter from the vagina. In a male child, the prepuce is retractable; put it back in the natural position after inserting the catheter.

When the catheter reaches the striated sphincter (proximal urethra in males and midurethra in females), the child may vigorously contract the pelvic muscles, temporarily stopping insertion of the catheter. Hold the catheter in place with steady gentle pressure. Assist the child to press the hips against the bed or the examination table and relax the pelvic muscles before gently advancing the catheter into the bladder For the male child, instruct the child to cough, as this can also help to relax the sphincter. Wait for the sphincter to relax before advancing the catheter. If still unable to advance the catheter, discontinue the procedure and notify the healthcare prescriber.

Forcing the catheter can cause trauma, bleeding, and possible scar formation, which can lead to strictures and obstruction of the urethra. If lidocaine gel is used, it will increase the volume of intraurethral lubricant. Therefore, urine return may not be as rapid as when minimal amounts of water-soluble lubricant are used. Avoids possible painful swelling of the glans (paraphimosis).

18 After the catheter has been inserted to the hub and urinary flow is established, inflate the secondary lumen balloon port of the catheter with sterile water to the amount specified (usually specified on the balloon port itself) and disconnect the syringe.

Prevents the catheter from slipping and from accidental dislodgment. Overinflation of the balloon can cause balloon rupture. Use only the amount specified by the manufacturer.

19 Gently tug or pull back slightly on the catheter.

Ensures that the catheter is securely seated in the bladder and not floating.

20 Tightly connect the sterile gravity drainage and collection bag to the urinary catheter.

Provides for a closed-system collection of urine output

21 Attach the bag to the frame of the bed or crib below the level of the bladder, ensuring there are no kinks or obstructions in the tubing.

Positioning the bag below the level of the bladder prevents reflux of urine through the tubing and back into the bladder.

22 Wash and cleanse the child’s perineal area and return the foreskin to its natural position after cleansing on the uncircumcised male.

Cleansing promotes the child’s comfort and sense of well-being, while removing the povidone-iodine solution from the area. Failure to return the foreskin can lead to swelling of the penis and impairment of circulation.

23 Tape the catheter tubing to the thigh of the older child. For small male infants and neonates not using a balloon catheter, tape the catheter to the lower abdomen or upper perineum, allowing the penis to point upward toward the umbilicus. For small female infants or neonates not using a balloon catheter, tape the catheter at its closest point outside on the left or right labia.

Taping prevents any tension from being placed on the catheter from inside the bladder and avoids dislodgment from accidental pulling or tugging. Movement of the catheter in and out can lead to contamination from microorganisms or cause trauma and inflammation to the urethra or bladder.

caREminder

Ensure that there are no pressure points or areas of skin breakdown before taping to the thigh, leg, abdomen, or perineum.

24 Return the child’s bed to the lowest position or to a level that is age appropriate, and raise the bed rails.

Reduces potential injury from falls.

25 Dispose of used equipment and waste in appropriate receptacle.

Standard precautions.

26 Remove PPE and perform hand hygiene.

Reduces the transmission of microorganisms.