Lesson 1, Topic 1
In Progress

Closing comments

April 11, 2024

Patient Coaching
Most men younger than 50 years of age have not seen a provider in years. Medical studies reveal that attitude, not biology, has a lot to do with the difference between men’s and women’s life spans. Men just do not go to the doctor as often as women do and tend to ignore symptoms of disease. The solution to maintaining good health is preventive care, and the first step is establishing a good rapport with a provider of choice. As a general rule, a man in good health should have three checkups in his 20s, three to four in his 30s, and a checkup every other year in his 40s. After the age of 50, a yearly checkup is recommended. In addition to testing for conditions such as cancer, heart disease, and diabetes, patient education can help male patients make responsible healthcare decisions.
      The urinary system is a very private, personal part of the patient’s body. Patients often feel embarrassed to ask questions about how to obtain the requested urine or semen sample. The medical assistant can provide this information in a sincere, confidential manner to relieve the patient’s anxiety and worry. Diagrams, models, and handouts help the patient understand disease processes and treatments and encourage patient compliance.


Legal and Ethical Issues
When working in a urology office, the medical assistant must be very careful to ensure that patients have provided informed consent for ordered procedures. If the patient refuses a procedure, the assistant must have the patient sign the appropriate informed refusal forms, which are then included in the health record. All patient education should be done after the provider has completed the explanation and given the assistant instructions to do so. Never diagnose, prescribe, or offer comments about a patient’s condition. Medical assistants who overstep their professional boundaries may place the provider and themselves in legal jeopardy. Remember that the patient who is legally informed and satisfied with the care received is less likely to take legal action.


Patient-Centered Care
Respecting a patient’s preference is a key element of patient-centered care. When a medical assistant gathers a medical history on a patient regarding a male reproductive or a urology concern, the patient may hesitate to give information. These topics are sensitive, and the patient may only want to discuss concerns with the provider. Telling the patient, “If you would rather share the information with the provider, I will let them know,” can show sensitivity. It is important for the medical assistant to respect the patient’s wishes and help put the patient at ease.


Professional Behaviors
A urology practice manages many sensitive patient issues that require strict adherence to confidentiality guidelines. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) protects the patient’s confidential information, not just the paper or electronic records of that information. This means that verbal disclosure of a patient’s information is limited to only the personnel who have the right to that information according to individual state laws.


Summary of Scenario

When Hannah started working with the urology team, she realized she knew very little about the urinary system. She had studied it during her medical assistant program but never appreciated what it might be like if her kidneys did not work. She was familiar with kidney cancer and UTIs but was amazed at all the other urinary diseases. As she learned more, she realized that hypertension (high blood pressure) could lead to kidney disease. She also figured out that kidney disease could lead to hypertension.
      Looking back over the past weeks, Hannah realized that one of her favorite experiences was working with Mr. Rodgers. He had been on dialysis for the past 5 years and never had a vacation. He wanted to see his new grandson, who lived on the East Coast. Hannah found a dialysis unit in the city where he would be staying. She was able to get him scheduled for 2 weeks’ worth of dialysis during his stay. She still can recall Mr. Rodgers’ excitement when he realized he could do dialysis while on vacation. He started talking about other trips he was dreaming of taking.
      Hannah is excited to continue her work with the urology team. She has learned so much in the short time she has worked with the patients.


Summary of Learning Objectives

1. Examine the anatomy of the urinary system.

The urinary system is composed of two kidneys, two ureters, a urinary bladder, and a urethra. The kidneys are located posterior to the peritoneum, the muscles of the back, and between the T12 and L3 vertebrae. They filter the blood and eliminate waste through the passage of urine. The ureters move urine from the kidneys to the bladder. The urinary bladder, in the pelvic cavity, stores the urine until it is excreted. The urethra is the tube that conducts the urine out of the bladder.

2. Examine the physiology of the urinary system.

The urinary system has several important roles that help regulate homeostasis in the body:

• Maintains fluid volume

• Maintains the normal composition of body fluids

• Maintains an adequate blood pressure

• Controls red blood cell production

• Activates vitamin D

Many of these roles are performed during the formation of urine. The body rids itself of unneeded substances produced during the metabolic process. The process of urine formation includes three steps:

Filtration: During this phase in the glomerulus, substances from the blood such as electrolytes, waste products, and other substances move through the capillary wall into the filtrate.

Reabsorption: This process starts as the filtrate moves out of the Bowman capsule and into the proximal tubule. Substances move from the filtrate back into the blood in the peritubular capillaries.

Secretion: This process allows substances from the blood to move into the filtrate. This allows the body to maintain homeostasis and move unneeded substances back into the filtrate.

3. Analyze the life span changes to the urinary system.

When babies are born, they have the same number of nephrons as adults, though the nephrons are not mature until age 2. During childhood, the bladder continues to grow. Bladder control is usually learned between ages 2 and 3.

During pregnancy, the filtration rate increases in women. The number of nephrons remains the same, but the filtration surface increases. This increase allows the kidneys to filter more blood, which is useful with the increased blood flow during pregnancy. In late pregnancy, the bladder may be twice as big.

In older adults, the kidney tissue and number of nephrons are reduced by up to 20%. The renal arteries can harden, causing the kidneys to filter blood slower. The kidneys become less able to regulate water balance. Older adults are at more risk of dehydration when the weather is hot or if they have diarrhea. The bladder wall becomes less stretchy with age. The bladder cannot hold as much urine as before. Bladder muscles weaken. The urethra may be obstructed by an enlarged prostate gland or a prolapse of the bladder or vagina.

4. Differentiate among the types of urinary system diseases and disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.

Common urinary signs and symptoms include the following: dysuria, nocturia, polyuria, frequency, urgency, urinary incontinence, and urinary retention. Typically, common signs of urinary system disorders found on medical imaging and laboratory tests include calculi, hydronephrosis, and azotemia. Abnormal substances in the urine include albuminuria or proteinuria (albumin), azoturia (excessive nitrogen compounds), bacteriuria (bacteria), glycosuria (glycose), hematuria (blood), and pyuria (pus).

Common urinary system disorders include bladder cancer, kidney cancer, polycystic kidney disease, acute cystitis, glomerulonephritis, pyelonephritis, chronic kidney failure, end-stage renal disease, nephrotic syndrome, neurogenic bladder, renal calculi, and urinary incontinence. Refer to the disease sections for more information regarding the signs, symptoms, etiology, diagnostic procedures, and treatments.

5. Examine the anatomy of the male reproductive system.

In the male reproductive system, the testes are surrounded by a white, fibrous capsule and are suspended together in a sac outside the body called the scrotum. The epididymis is a coiled tube that rests on top of and behind each testis. Each vas deferens connects to the base of the epididymis and passes along the side of the testis. The vas deferens travels into the pelvic cavity to just behind the bladder. The prostate gland is the size of a walnut and is found below the bladder in males. It surrounds part of the urethra.

The primary reproductive organs in the male are a pair of testes. Testes produce the gametes called spermatozoa. The prostate gland, seminal vesicles, and Cowper glands provide fluid either to nourish or aid in motility and lubrication. The sperm and the fluid together make up a substance called semen.

6. Examine the physiology of the male reproductive system.

At puberty, the interstitial cells in the testicles begin to produce testosterone. Testosterone is responsible for maintaining reproductive structures and for the development of sperm cells and secondary sex characteristics (e.g., deep voice, broad shoulders, narrow hips, and additional body hair).

In addition to testosterone, the follicle-stimulating hormone (FSH), secreted by the pituitary gland, promotes the formation of spermatozoa. The pituitary gland also produces luteinizing hormone (LH), which stimulates the interstitial cells to produce testosterone.

7. Analyze the life span changes in the male reproductive system

The testicle develops in the abdomen, start descending into the scrotum around the seventh month, and produce testosterone during puberty. As a male gets older, gradual aging changes begin. Changes occur in the testicular tissue, sperm production, and erectile function. The testicular tissue mass decreases. Testosterone levels gradually decrease and may cause issues with erections. The testes continue to create sperm but at a slower rate.

8. Differentiate among the types of male reproductive diseases and disorders, including the etiology, signs, symptoms, diagnostic procedures, and treatments.

Common male reproductive disorder signs and symptoms include redness, swelling, or lumps in the organs. Changes in the urinary stream or issues during sexual intercourse (copulation) can also be seen.

Common male reproductive system disorders include prostate cancer, testicular cancer, benign prostatic hyperplasia, erectile dysfunction, and male infertility. Refer to the disease sections for more information regarding signs, symptoms, etiology, diagnostic procedures, and treatments.

9. Examine the medical assistant’s role in examinations and diagnostic procedures for urinary and male reproductive diseases and disorders.

As with physical examinations, a careful history provides the physician with valuable information, and the medical assistant should ask specific questions to gather important information on the patient’s chief complaint for the visit.

The medical assistant can coach patients on doing the testicular self-exam. PROCEDURE 27.1 outlines the steps followed to coach patients on the testicular self-exam. A TSE model and a brochure can be used to help with coaching. The patient should be given a TSE brochure to take home as a reference for the procedure.

Diagnostic procedures for urology and male reproductive disorders include the following:

Cystoscopy: Used to examine the urethra and bladder and for procedures like removing small tumors.

Ureteroscopy: Can be done at the same time as cystoscopy. A smaller endoscope is used to examine the ureters.

Digital rectal examination (DRE): The provider inserts a gloved, lubricated finger into the rectum to feel for abnormalities in the prostate, bladder, ovaries, or uterus.

DMSA scan: A renal scan that uses the radioisotope, technetium-99m dimercaptosuccinic acid (DMSA), to evaluate the kidneys.

Intravenous pyelogram (IVP): An intravenous iodine contrast is given, and then x-ray images are taken to see how the kidneys filter the contrast from the blood.

Postvoid residual (PVR) urine test: Measures the amount of urine in the bladder after urination.

Urodynamic testing: Using x-rays or US scans, pictures or videos are taken as the bladder fills and empties.

Voiding cystourethrogram (VCUG): A minimally invasive test that involves fluoroscopy to visualize the urinary tract and bladder.

10. Examine the medical assistant’s role in treatments used for urinary and male reproductive diseases and disorders.

Treatments vary for the different diseases. Medications commonly prescribed in urology include antibiotics, antimuscarinics, diuretics, electrolytes, and erectile dysfunction agents. Vasectomies, a permanent form of male birth control, are also done in urology and family practice departments.

PROCEDURE 27.1  Coach a Patient on Testicular Self-Exam
Tasks
Coach a patient to do a testicular self-exam (TSE) while considering the patient’s developmental life stage. Document your teaching in the patient’s health record.
Scenario:
You are working with Dr. David Kahn. For Truong Tran (DOB 05/30/19XX), he ordered testicular self-exam (TSE) coaching.
Directions:
Role-play this scenario with a peer, who will be the patient.
Equipment and Supplies
                • Testicular self-examination brochure (optional)
                • Testicular model
                • Provider’s order
                • Patient’s health record
Procedural Steps
1. Wash your hands or use hand sanitizer.

PURPOSE: Hand sanitization is an important step for infection control.

2. Read the provider’s order. Assemble the equipment.

PURPOSE: It is important to know the provider’s order before starting the procedure.

3. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to identify the patient in two different ways to ensure that you have the correct patient. Explaining the procedure can make the patient feel more comfortable and reduces anxiety.

4. Ask the patient what he knows about the self-exam. Clarify any inaccuracies. Build on the patient’s prior knowledge of the topic during the session. Identify the patient’s motivating factor for learning about the self-exam. Listen to the patient’s concerns.

PURPOSE: It is important to adapt the coaching to the patient’s developmental stage. Because of the patient’s age, identifying motivating factors is important.

5. Explain to the patient that the best time to do the self-exam is after a warm shower or bath.

PURPOSE: The scrotal skin is more relaxed.

6. Demonstrate with the model while discussing the technique. Instruct the patient to examine each testicle gently with both hands. Roll the testicle between the thumb and fingers (Figure 1). Show the patient the epididymis, the soft curved structure behind and on top of the testicle (Figure 2). Then show the patient how to examine the vas deferens, which is the tube that runs up the epididymis (Figure 3).

PURPOSE: This allows the person to do a better self-exam.

7. Instruct the patient to feel for any abnormalities and lumps. These could be painless or painful. Instruct the patient to look for changes in the size, texture, or shape.

PURPOSE: Any changes should be reported to the provider for possible follow-up.

8. Have the patient demonstrate the technique on the model. Coach the patient on ways to improve the exam if needed.

PURPOSE: It is important to have the patient demonstrate the teaching to check for the accuracy of the technique and correct understanding.

9. Answer any questions the patient may have. Provide the patient with a brochure to take home (optional).

PURPOSE: It is important to answer any questions the patient has and, if possible, provide him with a brochure to take home.

10. Document the patient education in the patient’s health record. Include the provider’s name, the order, what was taught, how the patient responded, how the patient did the demonstration, and any handouts provided.

PURPOSE: It is important to document the patient education in the health record to show it was done.

Documentation Example
07/19/20XX 1505 Per Dr. Kahn’s order, instructed pt on TSE. Instructed the patient on how to check for changes in the testes. Explained the technique and encouraged the patient to do monthly checks after a warm shower/bath. Pt provided an accurate return demonstration. His questions were answered. Gave pt the “TSE” brochure. ——————————————————– Hannah Yang, CMA (AAMA)


PROCEDURE 27.2  Urinary Catheterization: Insert an Indwelling Foley Catheter
Tasks
Insert an indwelling catheter with a drainage bag using a sterile technique. Remove an indwelling catheter. Document the procedures.
Equipment and Supplies
                  • Patient’s health record
                  • Gloves
                  • Waterproof pad (optional)
                  • Provider’s order
                  • Straight catheterization tray kit containing the following items:
                                  • Waterproof pad
                                  • Fenestrated drape
                                  • Sterile gloves
                                  • Presaturated antiseptic applicators or antiseptic solution (povidone-iodine or chlorhexidine), sterile cotton balls, and sterile forceps
                                  • Water-soluble lubrication jelly packet or syringe
                                  • Indwelling urethral catheter connected to a urine drainage bag
                                  • Prefilled syringe with fluid
                  • Mayo stand
                  • Catheterization training model
                  • Waste container and biohazard waste container
                  • Disinfectant wipes for cleaning
Provider’s Order
Insert Foley catheter.

Procedural Steps
1. Wash your hands or use hand sanitizer. Read the provider’s order. Assemble the necessary supplies.

PURPOSE: A provider’s order is required to insert a Foley catheter.

2. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to answer the patient’s questions before starting a procedure.

3. Place a waterproof pad on the lower part of the examination table. Provide a drape for the patient. Instruct the person to remove clothing from the waist down and sit on the examination table with the drape covering the patient’s lap. Give the patient privacy.

PURPOSE: To ensure cooperation during the procedure. Having the patient disrobe will allow access to the perineal area.

4. Before entering the room, give a courtesy knock. Ensure adequate lighting.

PURPOSE: Adequate lighting is necessary to safely complete the procedure.

5. Position the patient. Place a drape to cover the patient and expose only the required anatomic areas.

Female patient: On the back with the knees flexed and the thighs relaxed, so the hips rotate to expose the perineal area.

Male patient: Supine with the legs extended and slightly apart.

PURPOSE: This provides access to the urethra.

6. Put on gloves. Open the outer kit wrap.

PURPOSE: Standard Precautions should be observed while cleaning the area and preparing the patient for the procedure.

7. Cleanse the perineal area with wipes from the kit or a washcloth, warm water, and soap or a perineal cleanser, according to facility policy.

PURPOSE: Cleaning removes any secretions and reduces the risk of urinary tract infection (UTI).

8. Remove and dispose of gloves. Use hand sanitizer to perform hand hygiene.

9. Carefully open the catheterization kit, to avoid contaminating the sterile interior.

PURPOSE: This will serve as your sterile field and keep supplies needed free of microbes.

10. Put on sterile gloves using sterile technique.

11. Using the waterproof pad from the kit, wrap the edges of the pad around your sterile gloved hands. Place it between the patient’s legs, creating a sterile field.

PURPOSE: Wrapping hands around the edges protects the sterile gloves from contamination.

12. Place the fenestrated drape on the patient, only exposing the perineum or penis.

PURPOSE: This will provide a sterile surface around the patient, which works to minimize the risk of contamination of the supplies and the risk of UTI.

13. Working in the sterile field, prepare supplies. Open antiseptic applicators or open the antiseptic solution and pour it over the cotton balls. Open the lubricant packet or use the lubricant jelly syringe and place the water-soluble jelly on the tray. Remove the plastic upper tray from the bottom tray and place it nearby.

PURPOSE: The upper plastic tray will remain as a sterile field.

14. In the lower tray, place the water-filled syringe at the inflation port on the catheter. If required by the facility’s procedures, check the Foley catheter’s balloon. Push the plunger of the syringe, filling the balloon. Make sure the balloon fills correctly, and there are no leaks or tears. Withdraw the fluid from the balloon. Keep the syringe attached to the catheter. Make sure the tubing to empty the Foley bag is closed.

PURPOSE: Checking the integrity of the balloon reduces the risk of the catheter malfunctioning and falling out.

15. Lubricate the tip of the catheter about 1.5 to 2 inches. Make sure to keep the catheter sterile.

PURPOSE: Lubricant will minimize discomfort and reduce the risk of urethral trauma during the procedure.

16. Clean the perineal area:

Female Patient
                  • Separate the labia with the fingers of the nondominant hand; this will contaminate the hand, and it can no longer be used in the sterile field. This hand will continue to hold the labia until the catheter is inserted.
                  • With the dominant hand, pick up an applicator or use the forceps and pick up a cotton ball. Wipe down the left side of the vagina from top to bottom. Discard the applicator or cotton ball.
                  • Repeat the above procedure but wipe down the right side of the vagina. Lastly, repeat the same action, wiping down the center over the urinary meatus toward the rectum (Figure 1).

FIGURE 1 From Laplant, N, Perry, AG, Potter, PA, and Ostendorf, WR: Clinical nursing skills & techniques, ed 10, St. Louis, 2022, Elsevier.

Male Patient
                • Gently grasp the penis shaft and hold it at a right angle to the body with the nondominant hand. If the patient is uncircumcised, use this hand to gently retract the foreskin. (After the catheter is inserted, make sure to push the foreskin back to the original position.) This will contaminate the hand. This hand will continue to hold the penis until the catheter is inserted.
                • With the dominant hand, pick up an applicator or use the forceps and pick up a cotton ball. Using the applicator or cotton ball, wipe the center of the urinary meatus and work outward in a circular manner (Figure 2). Discard the applicator or cotton ball. Repeat this cleaning technique two additional times, using a new applicator or cotton ball each time.
PURPOSE: This will reduce the number of microbes in the area of catheter insertion and minimize the transmission of microorganisms.

FIGURE 2 From Laplant, N, Perry, AG, Potter, PA, and Ostendorf, WR: Clinical nursing skills techniques, ed 10, St. Louis, 2022, Elsevier.

17. Pick up the catheter and the lower tray with the sterile dominant hand. Place the bottom tray between the patient’s legs. Make sure hold the catheter approximately 2 to 3 inches from the tip.

PURPOSE: Holding the catheter closer to the tip will help control it during insertion. Holding it too close to the tip risks contaminating the sterile hand by touching the patient during insertion.

18. Insert the catheter. If you meet resistance while inserting the catheter, do not force it. Discontinue the procedure if continued resistance is met or the patient is having unusual discomfort or pain. Talk with the provider.

Female
• Ask the patient to bear down gently to help expose the urethral meatus.
                • Insert the catheter 2 to 3 inches into the meatus until urine starts to flow (Figure 3). Then advance the catheter an additional 1 to 2 inches to ensure it is in the bladder.
                • Release the labia with the nondominant hand and hold the catheter in place as the dominant hand inflates the balloon. Disconnect the syringe and gently pull on the catheter until you feel resistance.
Note: If urine does not appear, the catheter may be in the patient’s vagina. You may leave the catheter in place as a landmark and insert another sterile catheter into the urinary meatus. The catheter in the vagina is no longer sterile. Do not reuse that catheter. Do not allow the new catheter to come into contact with the previous catheter.

FIGURE 3 From Stockert PA, Hall AM, Potter, PA, and Perry AG: Essentials for nursing practice, ed 9, St. Louis, 2019, Elsevier.

Male
• With the nondominant hand (which is holding the penis at a right angle to the body), pull up slightly on the shaft (Figure 4).
                • Ask the patient to bear down gently and slowly insert the catheter through the urethral meatus. Advance the catheter 6 to 8 inches until urine flows. Then advance the catheter an additional 1 to 2 inches to ensure it is in the bladder.
                • Hold the catheter in place with the nondominant hand while the dominant hand inflates the balloon. Disconnect the syringe and gently pull on the catheter until you feel resistance.
Note: If the catheter does not advance in the male patient, do not force it. The patient may have an enlarged prostate or urethral obstruction.

 

FIGURE 4 From Stockert PA, Hall AM, Potter, PA, and Perry AG: Essentials for nursing practice, ed 9, St. Louis, 2019, Elsevier.

19. Secure the catheter on the thigh with tape or a catheter holder. Allow enough slack to prevent tension. Ensure the catheter is not secured too tightly, affecting movement or blocking urine drainage.

PURPOSE: The catheter holder has an elastic band that is placed around the thigh and a Velcro strip that is used to secure the catheter.

20. Discard all biohazardous waste in the biohazardous waste container. Discard all other waste in the waste container. Remove your gloves and discard them in the biohazardous waste container. Wash your hands. After the patient has dressed and left the room, put on gloves, and disinfect the examination table and Mayo stand.

21. Remove the gloves and dispose of them appropriately. Wash your hands or use hand sanitizer.

22. Using the patient’s health record, document the procedure. Include the ordering provider’s name, the size of the catheter inserted, how the patient tolerated the procedure, and the urine output.

Documentation Example
12/11/20XX 10:10 a.m. Per Dr. Walden’s order, 16 Fr Foley catheter inserted. The patient tolerated the procedure well with minimal discomfort. Within 5 minutes, 100 mL of clear, pale-yellow urine drained. Patient was instructed on how to drain urine from the bag and how to maintain Foley catheter system at home. ————————————————————————————————- Susie Rana, CMA (AAMA)
Scenario update: The patient returns for removal of the indwelling Foley catheter.

23. Wash your hands or use hand sanitizer. Read the provider’s order. Assemble the necessary supplies. Place a waterproof pad on the lower part of the examination table.

PURPOSE: A provider’s order is required to remove a Foley catheter.

24. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure. Instruct the person to remove clothing from the waist down and sit on the examination table; provide a drape for the patient to place over the lap. Put on nonsterile gloves.

25. Measure the contents of the catheter bag. Empty urine from the bag. Remove any securement or anchor device from the patient’s thigh.

26. If indicated by the facility’s procedures, clean around the meatus and catheter using soap and water or an antiseptic solution. Always wipe away from the urethral meatus and use a new cloth or swab with each wipe.

PURPOSE: This will reduce the transfer of microorganisms into the urethra.

27. Attach a syringe to the inflation port on the catheter. Verify the balloon size on the catheter. Withdraw that amount of fluid from the balloon.

PURPOSE: A partially deflated balloon will cause trauma to the urethral wall.

28. Remove the catheter by pulling it out slowly and smoothly. If resistance is met, it might mean that fluid is still in the balloon. Reattach the syringe and pull back any remaining fluid. Continue to remove the catheter and wrap the used catheter in the waterproof pad.

PURPOSE: This will prevent accidental spilling of urine from the catheter.

29. Discard waste in the appropriate waste containers. Wash or sanitize your hands. Using the patient’s health record, document the procedure.

Documentation Example
12/28/20XX 10:10 a.m. Per Dr. Walden’s order, indwelling Foley catheter removed. The patient tolerated the procedure well with minimal discomfort. Drained 250 mL of clear, pale yellow urine. ————————————— Hannah Yang, CMA (AAMA)


PROCEDURE 27.3  Urinary Catheterization: Insert a Straight Catheter to Obtain a Urine Specimen
Tasks
Place a urinary catheter to collect a urine specimen using a sterile technique and document the procedure.
Equipment and Supplies
                • Patient’s health record
                • Gloves
                • Waterproof pad (optional)
                • Provider’s order
                • Straight catheterization tray kit containing the following:
                • Waterproof pad
                • Fenestrated drape
                • Sterile gloves
                • Presaturated antiseptic applicators or antiseptic solution (povidone-iodine or chlorhexidine), sterile cotton balls, and sterile forceps
                • Water-soluble lubrication jelly packet
                • Specimen container with lid
                • Urethral catheter (properly sized)
                • Outer basin tray
                • Specimen label
                • Mayo stand
                • Catheterization training model
                • Waste container and biohazard waste container
                • Disinfectant wipes for cleaning
Provider’s Order
UA using a straight catheter for specimen collection.

Procedural Steps
1. Wash your hands or use hand sanitizer. Read the provider’s order. Assemble the necessary supplies.

PURPOSE: A provider’s order is required to gather a urine specimen by a straight catheterization.

2. Greet the patient. Identify yourself. Verify the patient’s identity with full name and date of birth. Explain the procedure to be performed in a manner that the patient understands. Answer any questions the patient may have about the procedure.

PURPOSE: It is important to answer the patient’s questions before starting a procedure.

3. Place a waterproof pad on the lower part of the examination table (optional). Provide a drape for the patient. Instruct the person to remove clothing from the waist down and sit on the examination table with the drape over the patient’s lap. Give the patient privacy.

PURPOSE: To ensure cooperation during the procedure. Having the patient disrobe will allow access to the perineal area.

4. Before entering the room, give a courtesy knock. Ensure adequate lighting.

PURPOSE: Adequate lighting is necessary to safely complete the procedure.

5. Position the patient. Place a drape to cover the patient and expose only the required anatomic areas.

Female patient: On the back with the knees flexed and the thighs relaxed, so the hips rotate to expose the perineal area.

Male patient: Supine with the legs extended and slightly apart.

PURPOSE: This provides access to the urethra.

6. Open the kit. Put on sterile gloves using sterile technique.

7. Using the waterproof pad from the kit, wrap the edges of the pad around your sterile gloved hands. Place the pad between the patient’s legs, creating a sterile field.

PURPOSE: Wrapping the hands around the edges of the pad protects the sterile gloves from contamination.

8. Working in the sterile field, prepare supplies. Open the antiseptic applicators or open the antiseptic solution and pour it over the cotton balls. Open the lubricant packet. Lubricate the tip of the catheter about 1.5 to 2 inches.

PURPOSE: Lubricant will minimize discomfort and reduce the risk of urethral trauma during the procedure.

9. Clean the perineal area.

Female Patient
                • Separate the labia with the fingers of your nondominant hand. This will contaminate the hand, and it can no longer be used in the sterile field. This hand will continue to hold the labia until the catheter is inserted.
                • With the dominant hand, pick up an applicator or use the forceps and pick up a cotton ball. Wipe down the center over the urinary meatus toward the rectum. Discard the applicator or cotton ball.
                • Repeat the above but wipe down the right side of the vagina. Lastly, repeat the same action, but wipe down the center over the urinary meatus towards the rectum.
Male Patient
                • Gently grasp the penis shaft and hold it at a right angle to the body with the non-dominant hand. If the patient is uncircumcised, use this hand to gently retract the foreskin. (After the catheter is inserted, make sure to push the foreskin back to the original position.) This will contaminate the hand. This hand will continue to hold the penis until the catheter is inserted.
                • With the dominant hand, pick up an applicator or use the forceps and pick up a cotton ball. Using the applicator or cotton ball, wipe the center of the urinary meatus and work outward in a circular manner. Discard the applicator or cotton ball. Repeat this cleaning technique two additional times, using a new applicator or cotton ball each time.
PURPOSE: This will reduce the number of microbes in the area of catheter insertion and minimize the transmission of microorganisms.

10. Place the sterile collection cup in the sterile tray. Place the tray between the patient’s legs. Place the end of the catheter in the sterile collection cup. Pick up the catheter with the sterile dominant hand approximately 2 to 3 inches from the tip.

PURPOSE: The sterile cup will catch urine as it starts to flow. Holding the catheter closer to the tip will help control it during insertion. Holding the catheter too close to the tip risks contaminating the sterile hand by touching the patient during insertion.

11. Insert the catheter. If you meet resistance while inserting the catheter, do not force the catheter. Discontinue the procedure if continued resistance is met or the patient is having unusual discomfort or pain. Talk with the provider

Female
                • Ask the patient to bear down gently to help expose the urethral meatus.
                • Insert the catheter 2 to 3 inches into the meatus until urine starts to flow.
Note: If urine does not appear, the catheter may be in the patient’s vagina. You may leave the catheter in place as a landmark and insert another sterile catheter into the urinary meatus. The catheter in the vagina is no longer sterile. Do not reuse that catheter. Do not allow the new catheter to come into contact with the previous catheter.

Male
                • With the nondominant hand (which is holding the penis at a right angle to the body), pull up slightly on the shaft.
                • Ask the patient to bear down gently and slowly insert the catheter through the urethral meatus. Advance the catheter 6 to 8 inches until urine flows.
Note: If the catheter does not advance in the male patient, do not force it. The patient may have an enlarged prostate or urethral obstruction.

12. Once the specimen is obtained, secure the cover on the container. Make sure not to touch the inside of the container or cover. Set the specimen container on the Mayo stand.

PURPOSE: The inner surface of the specimen container and cover are sterile and need to remain sterile.

13. Remove the catheter by pulling it out slowly and smoothly. Wrap the used catheter in the waterproof pad.

PURPOSE: This will prevent accidental spilling of urine from the catheter.

14. Discard all biohazard waste in the biohazard waste container. Discard all other waste in the waste container. Remove your gloves and discard them in the biohazard waste container. Wash or sanitize your hands.

15. After the patient has dressed and left the room, put on gloves and disinfect the examination table and Mayo stand. Label the urine specimen.

16. Remove the gloves and dispose of them appropriately. Wash your hands or use hand sanitizer.

17. Using the patient’s health record, document the procedure. Include the ordering provider’s name, the size of the catheter inserted, how the patient tolerated the procedure, and the urine output.

Documentation Example
12/11/20XX 10:10 a.m. Per Dr. Walden’s order, urine specimen obtained through use of a 16 Fr straight catheter. The patient tolerated the procedure well with minimal discomfort. 50 mL of clear, pale-yellow urine obtained. Specimen sent to the lab. ——————————————————————————— Hannah Yang, CMA (AAMA)