(1) Remove all equipment from the patient's bedside. Discard disposable
items and return other equipment to the appropriate storage areas.
(2) Measure the urine. Send the sterile specimen to the laboratory with the
appropriate request slips.
(3) Record the procedure in the Nursing Notes: include the date, time,
amount and appearance of urine obtained, whether specimen was sent to the lab, and
2-21. FOLLOW-UP NURSING CARE FOR RETENTION CATHETER AND CLOSED
The retention catheter and drainage system may be continued for days, weeks,
or indefinitely. As a general rule, the retention catheter is changed in accordance with
the infection control standard operating procedure (SOP). Daily, continuing care of the
patient and the equipment includes the following essentials:
a. Maintain an accurate intake and output record. Unless otherwise ordered,
encourage the patient to drink at least 3000 ml of fluids daily to provide an effective
"internal irrigation" system for the bladder, catheter, and drainage tubing.
b. Observe the tubing and catheter connections frequently for kinks. Make sure
the patient is not lying on the tubing since this both obstructs drainage and causes
undue pressure on the skin.
c. Maintain cleanliness and protect the urethral meatus. This requires direct
observation and specific hygiene measures. Wash the perineal area carefully, from
front to back. Remove secretions of mucus and other discharge gently but thoroughly
to help reduce irritation and possible infection. Follow infection control SOP for
guidance on frequency of catheter care and choice of antiseptic/antimicrobial cleansers
to be used.
d. Measure and record the collected output in accordance with (IAW) local
SOP. Never permit the drainage bag to become more than three-fourths full in order to
prevent any possibility of the tubing outlet becoming immersed in the draining urine.
e. Do not disconnect tubing from drainage bag.
f. Keep the collecting bag below the level of the bladder, but never allow it to
touch the floor.
g. Provide continued gravity drainage for the ambulating patient. Check to see
that the tubing is not excessively long or looped below the level of the bag when he is