POLICY/PROCEDURE

FACILITY: LHN
DEPT NO:
POLICY NO:
DEPARTMENT: NURSING
TITLE: Nurse Initiated Foley Catheter Removal
Page 1 of 2

STANDARD: To prevent catheter acquired urinary tract infections (CAUTI) with prompt and
appropriate removal of Foley catheters

POLICY: Patients will be assessed for criteria for continuing Foley catheter use by licensed
nursing staff. If a criterion for catheterization is not met, a RN or LPN may remove the Foley
catheter without a physician order.

1. Patents with indwelling urinary catheters will be assessed by a licensed nurse upon
admission, and daily thereafter for the continued need of the Foley catheters.

2. Criteria for continuing a Foley catheter include the following:

Criteria for Continuing Foley Catheter
Strict I & O or aggressive treatment with diuretics or fluids
Chronic urinary retention or bladder outlet obstruction
Critically ill patient hemodynamic instability
Renal failure
Recent renal/urology procedure
Acute neurogenic bladder
History of chronic, prolonged catheterization or suprapubic catheter
Hematuria
Chemical sedation or paralysis
Terminally ill or palliative care patient
Epidural catheter
Pelvic or hip fracture
Stage 3 or greater pressure ulceration on coccyx or buttocks

3. Nursing will discontinue Foley catheter when the above criteria are no longer met.
An M.D. order is not needed for removal.

4. Date and time of Foley removal is documented by nurse on the Foley Catheter
intervention.
5. Due to void time (DTV) is documented on the Foley Catheter intervention and
communicated in shift to shift report.
6. Continue to monitor patients output upon catheter removal. Notify the physician if
the patient is unable to void within 5 8 hours.

POLICY/PROCEDURE

FACILITY: LHN
DEPT NO:
POLICY NO:
DEPARTMENT: NURSING
TITLE: Nurse Initiated Foley Catheter Removal
Page 2 of 2


References:
Center for Disease Control and Prevention, Healthcare Infection Control Practices Advisory
Committee (HICPAC) Guideline to Preventing Catheter Associated Urinary Tract Infections
(http://www.cdc.gov/hicpac/cauti/001.html)

Washington State Hospital Association Washington state Stop UTI project tools and
resources (http://www.wsha.org/0391.cfm)