Steps

Rationale/Points of Emphasis

1a Perform hand hygiene and gather the necessary supplies.

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

caREminder

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

1b Select a 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 in; for male infants, insert 3 in; for male toddlers, insert 3-4 in).

1c Have extra catheters available to use if needed.

If a catheter becomes contaminated, is inadvertently placed in the vagina, or is the incorrect size, a new 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 gloves and protective apparel.

Standard precautions to reduce the transmission of microorganisms.

5a Place a waterproof pad under the child’s buttocks while positioning the child/infant.

Prevents the bed linens from being soiled.

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

This position facilitates visualization of the inner labia.

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

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.

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

6 Place a drape over the child/infant. For a female, 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, 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, by 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 the 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 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, allowing the hymen and urethra to drop open.

13b For a male, follow the same procedure and use your nondominant hand to position the child’s penis perpendicular to the body. In an uncircumcised male, 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, by using 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, using a new povidone-iodine swab each time.

Prevents contamination of the catheter by microorganisms on the skin and prevents introduction of open 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, place the sterile specimen container on the sterile field between the child’s legs and place the open end of the sterile catheter into the sterile specimen container. (If using a prepackaged catheter kit, the catheter comes already inserted into a sterile specimen tube. Gently pull 4-6 inches of the length of the catheter out of the sterile collection tube.)

Placing the end of the catheter in the specimen container prevents the sterile field from becoming wet and contaminating the catheter and the sterile field.

16 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 a male child, using lubricant on the tip of the catheter promotes opening of the sphincter mechanism.

17a 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.

17b Do not touch the child’s perineal hair or skin as the catheter is advanced.

Hair or skin will contaminate the catheter.

17c For a male child, insert the lubricated catheter tip into the urethra without allowing the intraurethral lubricant 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.

17d 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 that he or she needs to urinate during catheter insertion. Tell the child to go ahead and try to do so; this opens the urethra for passage of the catheter.

18 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). Once the catheter is inserted in the urethra, remove the catheter from the vagina. In males, 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), if the child vigorously contracts the pelvic muscles, temporarily stop insertion of the catheter. Hold the catheter in place with steady gentle pressure. Assist the child to press the hips against the bed or examination table and relax the pelvic muscles before gently advancing the catheter into the bladder. 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. Gently pressing the suprapubic region (Credé maneuver) may also assist urine to drain. Avoids possible painful swelling of the glans (paraphimosis).

19 Let 10-20 mL of urine drain into a sterile specimen container and close container. Allow the remaining urine to drain into the urine receptacle.

Draining the urine directly into the specimen container decreases the possibility of contaminating the specimen.

20 Remove the catheter.

Once the specimen is obtained, the catheter is no longer needed.

21 Put the lid on the container, label the specimen, and place in the biohazard bag.

Standard precautions

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

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 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.

24 Label specimen with the child’s name, medical record number, and date and time the specimen was obtained and by whom; place in plastic biohazard transmittal bag following standard precautions. Send to laboratory as soon as possible.

Ensures that correct tests are performed on specimen. Prompt testing reduces changes in specimen (e.g., bacterial growth).

25 Dispose of used equipment and waste in appropriate receptacle.

Standard precautions.

26 Remove gloves and perform hand hygiene.

Reduces the transmission of microorganisms.