How to MASTER the Foley

Foley Catheter Insertion + Advanced Tips & Tricks

A foley collection bag half filled with urine

William Kelly, MSN, FNP-C

Author | Nurse Practitioner

What is a Foley Catheter Insertion?

Foley catheter insertion is one of the main procedures you will learn as a nurse in school, and you will have to put in a LOT of foley catheters if you work as a bedside nurse in the hospital. 

The term ‘catheter’ is just a term that refers to a flexible tube that is inserted into a part of the body. Some examples include an intravenous catheter (IV), cardiac catheterization, and urinary catheters.

Foley catheters are also referred to as indwelling urinary catheters. These are essentially just a tube that is inserted into the bladder to allow urine to drain into a bag instead of staying in the bladder.

A foley is intended for both short and long-term use, both within and outside of the hospital. 

Foley catheter insertion Indications

Foley catheter insertions are ordered for various reasons, but long story short. -they are ordered when the patient cannot effectively drain their bladder. It’s also ordered when this is anticipated (like with surgery… see below).

Urinary Retention

An enlarged prostate and urinary retention

Urinary retention With obstruction

Also called a bladder outlet obstruction, this is when something is blocking or obstructing the ability of the bladder to empty.

Common causes include Benign Prostatic Hyperplasia (BPH), tumors, blood clots, or severe constipation. Other causes include infections, scarring, strictures, or trauma. 

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Neurogenic Bladder

This is when the bladder doesn’t work normally due to a central cause – aka there’s something with the brain. This could be from a stroke, degenerative diseases like MS, spinal cord injuries, or nerve damage. 

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Pharmacologic Urinary Retention

Certain medications can lead to the bladder being unable to fully empty itself, requiring a foley catheter insertion.

Medications that weaken the bladder muscles include anticholinergics like Tricyclic antidepressants and diphenhydramine (Benadryl).

Medications that increase the tone of the prostate and bladder neck include decongestants, stimulants, or other sympathomimetics.

There are many other medications that can cause urinary retention, including muscle relaxers, certain antipsychotics, hormones, or even NSAIDs and opioids

Other Reasons to place a foley catheter

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Acute Hematuria

If a patient has significant bleeding in their urine, a foley catheter insertion can be ordered to monitor their output.

When there is significant amount of bleeding, this often clots, causing an obstruction and a distended bladder, along with severe discomfort.

A three-way catheter is usually placed and CBI (continuous bladder irrigation) is started to prevent the patient’s urinary tract from obstructing again. 

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Urine Output Monitoring

Patients who need strict I&Os done may have a foley catheter insertion ordered. This is often critically ill patients in the ICU, like with severe CHF or renal failure.

For hourly output, make sure your foley bag has a urometer. This way the urine first drains into the urometer, then each hour can be emptied into the main collection bag.

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Intubated Patients or critically ill

Patients who are intubated and many of those who are critically ill are unable to empty their bladder on their own. To prevent skin breakdown as well as monitor their urinary output, foleys can beneficial.

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All the Tubes

After intubation, once the endotracheal tube is placed, that isn’t the last tube you have to worry about.

Immediately after intubation, you will need to place a foley catheter, as well as an Nasogastric or Orogastric tube to decompress the stomach and prevent aspiration.

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Surgery

Foleys are placed before/during surgery to monitor fluid status and prevent bladder overdistention.

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Immobilized patients

Patient’s who are immobilized from spinal cord injuries, strokes, or pelvic fractures often have foley catheters placed.

Hip fractures will almost always be going for surgery anyway, so a foley can help offer quite a bit of comfort.

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Open Wounds

If the patient is incontinent and has open sacral or coccygeal wounds, sitting in their urine can make the breakdown worse and make it more difficult to heal. A foley can help promote wound healing in these cases.

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Patient Comfort (End of Life)

Patients who are reaching their end of life often are very weak and uncomfortable, and a foley catheter insertion gives them one less thing to worry about and can make them feel more comfortable overall.

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Incontinence?

Foley catheters really shouldn’t be used to manage urinary incontinence. This is an inappropriate use of foleys and the potential complications and longer hospital stay outweigh any benefit. 

When to NOT put in a foley?

There really is only one absolute contraindication to a foley catheter insertion, which is trauma with hematuria. This should be managed by a urologist.

There are some relative contraindications, which include urethral strictures, recent UTIs, or artificial sphincters.

Of course, benefits and risks should always be weighed. Introducing anything invasive into the body increases the risk of causing infection, which is very common but can be lethal. See monitoring parameters below.

What are the different types of Urinary catheters?

While this article specifically focuses on foley catheter insertion, there are other types of urinary catheters that work similarly but may be used for alternate scenarios.

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Foley Catheter

This indwelling catheter is placed in the bladder and left in place. This foley catheter insertion is ordered when ongoing use is anticipated. It is secured to the patient’s leg and drains into a leg bag or a larger collection bag that hangs on the patient’s bed.

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Straight Cath

Sometimes referred to as intermittent bladder catheterization, this is for once or as needed emptying of the bladder. This often ordered for short-term urinary retention, where the benefits of putting in an indwelling foley don’t outweigh the risks (i.e. infection).

This drains into a plastic collection chamber for drainage. Once the urine is completely drained, the catheter is immediately removed

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Suprapubic Catheter

This is when a catheter is surgically placed through the peritoneum by a urologist or general surgeon. You’ll see this stitched in place below their belly button. This is placed in some patients with chronic incontinence/urologic issues. Nurses should never replace these.

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Three-way Cath

No – this isn’t THAT kind of Three-way…

Also called a triple-lumen catheter, this is essentially a larger catheter that has 3 tips.

  1. The urine drainage port, which is in the middle and is connected to the tubing to drain into the collection bag as usual.
  2. The balloon port, which is used to inflate the 10mL balloon once successfully placed.
  3. An irrigation port, which is not found on regular foley catheters. This allows irrigation to be manually done, or allows CBI (continuous bladder irrigation) to be connected to prevent clotting. 

A three-way is typically only ordered for significant hematuria when clotting and obstruction are occurring or trying to be prevented. 

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Coude Catheter

This is a catheter with a special-shaped tip that helps you maneuver past an enlarged prostate. 

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Using a Coude

Make sure nurses are able to use coude catheters at your facility. This may be reserved for Providers or Urology to use. 

 There are some alternatives to foley catheter insertion that can sometimes be used. These are non-invasive so they do not carry the same risks as causing infection. These are excellent solutions when the main issue is incontinence.

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Texas Catheter

Also called a condom catheter, this fits over a man’s penis that drains incontinent urine into a suction canister. 

An enlarged prostate and urinary retention

Purewick Catheter

This is the same concept but placed in incontinence women attached to suction. 

Choosing a catheter size

Just like IV sizes and gauges, foley catheters have specific sizes as well. For foleys, these sizes are called “French units”. Each french unit increases the size of the diameter of the catheter by 0.33mm

For most adult patients, a 14-16 Fr catheter is standard. If you are worried about obstruction from sediment, a larger size is better. If you are worried about blood clotting, a three-way may be a better option.

Neonatal
3.5 - 5 Fr
Pediatric
6 - 10 Fr
Adult
14 - 16 Fr
Three-way
20 - 24 Fr
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kangaroo nasogastric Tubing

Your facility may or may not have specific foley catheters for infants, depending on which facility and unit you work on.

Some units may use the purple kangaroo PVC nasogastric tubing to catheterize infants and toddlers.  These are also sized in French units, so using a 5 french is common. Make sure you are always following facility and unit protocols.

Foley Catheter insertion procedure

 

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Collect your Equipment

Make sure you have all of the required equipment for the procedure. This usually includes:

  • Foley catheter insertion tray
    • Foley Catheter connected to tubing & foley bag
    • Lubricant
    • Betadine swabs or solution/cotton swabs/forceps
    • Sterile gloves
  • Cath-secure device or tape
  • Sterile gloves
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Prepare the Patient

Make sure to explain the procedure and obtain verbal consent from the patient. Also verify there is an order (verbal or otherwise) to insert the foley.

Ask or help the patient remove everything from the waist down, and place them in a hospital gown. Position them supine.

If they are female, have them extend their legs in a “frog” position. Males can remain with relaxed legs.

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Pre-clean and pre-locate
It can be super helpful to clean the peri-area before setting up your equipment. You can do this with soap and water, or bath wipes depending on your facility’s protocol. This area is. notclean enough for most hospitalized patients, but this also gives you an opportunity to visually inspect and pre-locate the urethra.

“If you can find it clean, you won’t miss it sterile!”

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Lighting is Everything

Setting up for the actual procedure may be just as important as actually performing it. Make sure you have proper lighting in order to see where you need to go. If the room has one of those adjustable overhead lights, this would work perfectly.

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Set up your equipment

Wash your hands and open your foley kit, which is best placed in-between the patient’s legs. Open up the sterile drapes of the kit so you can have access to the sterile contents inside once you get sterile.

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Apply Sterile Gloves

Apply sterile gloves as this is a sterile procedure. This minimizes the risk of introducing pathogens into the patient’s bladder, which can cause infection.

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Extra Sterile Gloves

The foley tray kit usually comes with gloves, but these are small and not very stretchy, and often rip (especially for someone with larger hands).

This is where an additional pair of sterile gloves come in handy. You can choose your specific size, and these gloves are much stretchier and easier to maneuver (anyone else a 7.5?)

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PrEP Sterile Field

Once your sterile gloves are on, utilize the sterile drapes inside the kit to carefully place underneath the patient’s buttock, and place the fenestrated drape over their vagina/penis. Be careful not to touch the patient or bed with your sterile gloves. 

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Lubricate the Catheter

Remove the catheter from its plastic covering, and place it inside a sterile lube package. The lubricant will help glide the catheter into the urethra, and placing it in the package will help keep your catheter from flopping around.

Your kit may instead have a pre-filled syringe with lube. If so, this is squirted onto your sterile tray, and stick the catheter in the lube where it isn’t going to fly off.

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Attach Syringe to balloon port

Attach the 10mL pre-filled syringe to the balloon port on the foley.

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Testing the balloon?

It used to be standard practice to test the balloon by inflating. the full 10mL into the balloon and then allow it to flow back into the syringe. This is no longer recommended and has the potential to stretch and distort the catheter and lead to more trauma during insertion.

An enlarged prostate and urinary retention

Clean with Betadine

Using pre-packaged betadine swabs, or betadine and cotton swabs/forceps, gently cleanse the region surrounding the urethra.

In females, swab in one direction front to back on the left, then the right, and finally down the middle.

In males, swab in one direction around the left side of the glans, then the right, then down the middle. 

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Prepare for Insertion

Now that everything is ready, it’s time to get ready to insert the catheter.

In females, spread apart the labia with your non-dominant hand to better visualize the urethra and make sure nothing gets in the way.

In males, retract any foreskin and stabilize the penis between your rounded hand.

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Insert the Catheter

Insert the catheter into the urethra with steady force. Advance until you see urine in the tube. Once you do, advance a little more before blowing up the balloon.

A sterile gloved hand holding the vagina open, and inserting a yellow catheter inside the urethra. There is betadine surrounding the urethra and vulva.
A sterile gloved hand holding the penis, and inserting a yellow catheter inside the urethra. There is betadine surrounding the urethra.
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If at first you don't succeed...

If you meet resistance, do NOT try to apply more pressure and force it through. Remove it and consult the Provider/urology, as the patient’s prostate is likely enlarged or there are tracts or strictures.

In women, if you don’t see any urine backflow within about 5-6 centimeters, you are likely in the vagina. Do not reuse this same catheter as this will likely cause an infection. Leave the foley in place and get a new sterile kit to retry the procedure. Aim superior to this foley.

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Blow up Balloon

Steadily push the 10mL syringe to blow up the balloon. Inflating the ballon should keep it in place within the bladder.

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Retract the catheter

Gently pull back on the foley until light resistance is met. This is. to ensure the balloon is resting right at the bladder neck.

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Secure the Catheter

Secure the foley to the patient’s thigh using a cath secure, stat-lock, or tape. This is to ensure that the foley doesn’t get caught on anything or cause urethral trauma.

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Place Collection Bag

Place the collection bag below the level of the bladder but off of the floor. This prevents backflow which could lead to infection.

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Collect / Drain the Urine

Collect any urine that you may need and send it off to lab, otherwise measure and empty the urine, and document accordingly

How to Remove a Foley

Removing a foley should be quick and easy. Verify the order before doing so, or if the patient insists it be removed then remove it regardless (as long as they aren’t confused).

  1. Collect your equipment: You really only need an empty 10mL syringe.
  2. Unsecure the catheter: Remove the catheter from any cath-secure, stat lock, or tape that is securing it to the patient’s leg.
  3. Deflate the balloon: Hook an empty 10mL syringe to the balloon port and drain a full 10mL from the balloon. Remove the syringe.
  4. Remove: Gently pull on the catheter to remove it. There should not be any resistance.
  5. Dispose: Dispose of the foley catheter, tubing, and collection bag into a biohazard bag if possible.

Foley Catheter Assessment & Monitoring

Assessments of the catheter should be performed each shift along with your head-to-toe assessment. If there are any new or related symptoms or discomfort, this should be assessed more frequently.

The biggest thing to watch out for is signs and symptoms of a UTI, as foley catheters increase this risk.

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Urine

Assess the urine. Is it draining? What color is it? Is there any blood, pus, or sediment? 

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Skin

Is there any skin breakdown, erythema, or discharge near the insertion site?

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Tubing/Collection

Assess the tubing and collection bag, checking for any leakage. Make sure it is secure and in place, and that the collection bag always remains below the level of the bladder

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s/s of infection?

The main thing you are going to monitor for is the development of infection (UTI) and sepsis from the foley catheter. This is usually evidenced by fevers, tachycardia, and frequently altered mental status in the elderly hospitalized patients. 

Foley Catheter Insertion Complications

During and after foley catheter insertion, be on the lookout for complications that may occur. 

An enlarged prostate and urinary retention

Infection (UTI)

Infections are a common complication of UTIs. While common, UTIs can be severe and even kill patients, so preventing this is very important.

Using sterile technique is super important during the procedure to decrease the risk of infection. Also, make sure the collection bag remains below the level of the bladder at all times to prevent backflow.

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Epididymitis

Foley catheters can rarely lead to epididymitis in males and sometimes extend to orchitis (infection and pain of the testicle).

An enlarged prostate and urinary retention

Bladder perforation

While rare, catheters can cause a bladder perforation. If so, the patient will develop extreme pain, bloody urine, and signs of peritonitis (abdomen rigidity and rebound tenderness, etc). 

An enlarged prostate and urinary retention

Bladder stones

Bladder stones can form due to the presence of a foreign body within the bladder. This can lead to obstruction and pain.

Urea-splitting bacteria (like proteus mirabilis and Pseudomonas aeruginosa) are more likely to cause these stones. 

An enlarged prostate and urinary retention

Bladder fistula

A fistula is when a false passage forms between two different organs due to chronic inflammation, such as with a chronic Foley catheter. These are rare but can lead to significant complications, and infections, and will need surgery to fix it.

Foley Catheter Care

Managing a foley catheter after the foley catheter insertion is just one more aspect of the patient that you will need to care for. 

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Assessment

The foley should be assessed with each head-to-toe shift assessment. You should be monitoring for things as below. 

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Clean Meatus

Clean the insertion area with soap and water daily

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Ensure Tubing secure

To secure the tube in place and prevent any urethral trauma, secure the foley to the patient’s leg. Many facilities will have Cath secures, but basic medical tape can also be used instead. 

An enlarged prostate and urinary retention

Collection Bag

Keep the bag below the level of the bladder to prevent backflow. This should be drained often as well.

See if the patient is ordered I&Os, and chart how many mLs are emptied each time. 

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Collecting Urine

If a UA is ordered, you can now obtain and send this after the foley catheter insertion. 

Everything online will tell you NOT to use the collection bag to obtain urine samples, as they may be contaminated. But nothing seems to distinguish a foley that was just placed or one that has been already drained and in place for some time.

However, if you just put in the foley, the bag should still be sterile, so some nurses do consider this first urine as a sterile sample. Whether or not this is appropriate is unsure, but always follow your facility protocols.

The recommended method to collect urine from a foley is to clamp the foley and withdraw urine from the collection port with a needle and large syringe, then transfer the urine to a sterile specimen cup.

To learn how to actually interpret the UA results, you can check that out here!

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Routine Changing of Foley

There is no reason to change a foley catheter simply based on time. There is no evidence to support routine change, and it is not recommended by the ISDA or the CDC. Foley’s are often ordered to be changed if there is obstruction, it is not working correctly, there is infection, or if it is being discontinued altogether.

And now you know exactly how to place a foley like a pro! Let us know in the comments if you have any other helpful tips or questions!

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