Do We Place a Foley?
Your patient begins to complain of a feeling of discomfort and fullness in their suprapubic region.
When you perform a bladder scan, there is 325mL in their bladder.
Should we avoid placing the foley and what can we try instead?
YES
I&O Catheterization
Rationale: While these signs and symptoms certainly warrant catheterization, it should not be indwelling. Indwelling can lead to worsening retention, mobility issues, and outpatient issues. The preferable option is to straight catheterize and attempt to identify and fix the cause of retention – for example, constipation or missed medications such as Flomax. On the table in front of you is a copy of the new Voiding Trial order set, which guides I&O catheterization in terms of volumes and frequency.
Your patient had a hip fracture repaired yesterday and just ambulated to the restroom for a bowel movement.
You check the foley order, and it says to remove post-op day #2.
Should try to remove the foley and what can we try instead?
YES
Voiding
Rationale: If a patient is up and ambulating they are likely ready for a voiding trial. Leaving the catheter in place creates a higher risk for infection due to potential backflow during ambulation, not to mention a fall hazard while ambulating. So it is worth asking the surgeon if we can discontinue it early.
After how many days with a Foley in place we should consider replacing it prior to drawing a urine culture?
TWO
Rationale: Biofilm starts to grow within a few hours of foley insertion. Replace the foley with a new/clean on before collecting a specimen
Your patient arrives to the ED in severe respiratory distress and is then intubated.
After an uneventful transport to CT, you are preparing to transfer to ICU. When calling report, the ICU nurse asks you to place a Foley.
Should we avoid placing the foley, and what can we try instead?
YES
External Catheter
Rationale: Just because a patient is intubated doesn’t mean they need Foley catheter. We can monitor output in immobile patients with external catheters without adding the risk of infection with Foley. The exception would be if a patient was experiencing respiratory or hemodynamic decompensation with turning, but since they tolerated CT (including the transferring and turning for that procedure), likely they can tolerate an external catheter.
Your patient arrives to the ED with a Foley catheter in place.
The family reports the patient has had it for years after a spinal cord injury and struggles with chronic UTIs.
Should we try to remove the foley and what can we try instead?
No
Rationale: Chronic retention normally managed by a Foley will likely continue to be managed the same way in the hospital. This patient likely has a neurogenic bladder and while some patients with that condition I&O cath at home, if a patient uses a Foley we will likely do the same here. However if we are asked to culture it, we will likely exchange it first to ensure a clean sample.
True or False: A urine culture alone is sufficient to identify a UTI
FALSE
We also need a symptom element and a UA
Answer & Rationale: False – many patients who are chronically catheterized will have a positive urine culture that does not indicate infection, merely colonization. It is important that we order a UA as well to identify signs of infection in their urine such as an elevated white blood cell count or the presence of leukocyte esterase.
Your patient has a large sacral wound due to pressure and lack of turning at their outside care facility.
The patient can sometimes vocalize when they need to use the restroom, but only minutes before they are incontinent.
Should we avoid placing the foley and what can we try instead?
YES
External Catheter
Rationale: We should do our best to keep urine out of their wound, and if there is truly not enough time for us to respond to get the patient to a commode, then an external device would be appropriate. We should really do our best to prove an alternative won’t work prior to assuming the patient needs a Foley (as truly needing a Foley for this indication is much more rare than you would think).
Your patient was just transferred out of ICU to the floor.
The last Foley indication documented by the nurse says it is in for I&O monitoring, and the patient is still receiving diuretics.
Should we try to remove the foley and what can we try instead?
YES
Voiding
Rationale: I&O monitoring indication specifies every 1 to 2 hours. While we may still want to closely monitor their urine output, it is unlikely their plan of care will be updated every 1-2 hours on the floor based on urine output, so we can measure less frequently, preferably by allowing the patient to void, and we won’t know whether they an until we give them a chance.
How far do you insert a Foley catheter on a male patient?
To the Bifurcation
Answer & Rationale: To the bifurcation! The male urethra is waaaay longer than a females, and it may take the entire catheter length to get into their bladder. By inserting the full length of the catheter, we can hopefully avoid inflating the balloon inside the patient’s prostate.
Your patient has been in ICU for the last couple weeks and their prognosis is grim.
The family has elected for comfort care, and many of the patient’s medications such as vasopressors and antibiotics are being discontinued. The patient and family requests the Foley be replaced.
Should we avoid placing a foley and what can we try instead?
NO
Rationale: Foleys may be used in comfort care, especially when patients are not anticipated to survive long. Not having to manage incontinence or be repeatedly turned to be cleaned can help to promote comfort. This should not be automatic however and is on a case-by-case basis in discussion with the patient and family, because some patients may feel the catheter makes them more uncomfortable.
Keep in mind though that since the patient is comfort care we would not be escalating care, and that would include treating new infections. Therefore, we should not be drawing any urine cultures on comfort care patients, as that would only create additional testing costs with no treatment benefit to those patients.
Your patient arrives to the unit with a Foley in place.
Family states he normally pees just fine, but the catheter was placed outpatient by a urologist a week ago.
They can’t really articulate why.
Should we try to remove the foley and what can we try instead?
No
Rationale: Catheters that require specialist placement, i.e., by a urologist, are often related to the patient having some sort of complex anatomy. This can make it more challenging to reinsert a catheter if needed. While we wouldn’t want to pull it right away, it would be worth finding out (if we can) why it was placed. It is also critical to document “requires urologist placement or consultation” as the catheter indication so that those that follow are aware of this too.
How do you dispose of a suction cannister that was attached to an external catheter?
DEPENDS
Answer & Rationale: It depends! The rules follow the body fluid in this case, not necessary the container. If just urine, seal tightly and place in regular trash. If there is blood present, seal tightly and place in the biohazard bin. If the patient is receiving chemo or did recently, seal tightly and place in the chemo bin.