Foley Care Nursing Diagnosis: A Comprehensive Guide for Healthcare Professionals

Impaired urinary elimination is a prevalent health concern that can significantly affect a patient’s comfort, health, and overall quality of life. While the original article broadly addresses impaired urinary elimination, this revised version will specifically focus on Foley Care Nursing Diagnosis. Foley catheters, indwelling urinary catheters, are frequently used in healthcare settings to manage urinary elimination, but they also introduce specific risks and nursing considerations. This article aims to provide a comprehensive guide for nurses and healthcare professionals on nursing diagnoses related to Foley catheter care, enhancing the original content with a targeted approach and SEO optimization for an English-speaking audience.

Understanding Foley Catheters and Urinary Elimination Issues

Foley catheters are thin, sterile tubes inserted into the bladder to drain urine. They are essential medical devices used in various clinical scenarios but are not without potential complications. Understanding why and how Foley catheters are used is crucial before delving into related nursing diagnoses.

What is a Foley Catheter?

A Foley catheter is a type of indwelling urinary catheter that remains in place in the bladder for continuous urine drainage. It features a balloon at its tip, which is inflated with sterile water after insertion to prevent the catheter from slipping out of the bladder. Urine drains through the catheter into a drainage bag. Foley catheters are made of various materials, including latex, silicone, and Teflon-coated latex, chosen based on patient needs and potential allergies.

Why are Foley Catheters Used?

Foley catheters are utilized for a range of medical reasons, including:

• Urinary Retention: When a patient cannot empty their bladder naturally due to obstruction, neurological conditions, or medication side effects.
• Monitoring Urine Output: In critically ill patients or post-surgery to accurately track fluid balance.
• Perioperative Management: During and after certain surgeries, especially those involving the urinary tract or prolonged procedures.
• Management of Incontinence: In specific cases where other methods have failed and skin integrity is at risk due to continuous incontinence.
• Bladder Irrigation: To deliver medications or flush out blood clots or debris from the bladder.
• Comfort for End-of-Life Care: To manage urinary incontinence and improve patient comfort in palliative care.

While Foley catheters are invaluable in these situations, their use is associated with significant risks, most notably catheter-associated urinary tract infections (CAUTIs). Therefore, appropriate nursing care and accurate nursing diagnoses are paramount to minimize complications and ensure patient safety.

Common Nursing Diagnoses Related to Foley Catheter Care

Several nursing diagnoses are directly relevant to patients with Foley catheters. These diagnoses guide nursing care and interventions to prevent complications and promote optimal patient outcomes. Focusing on “foley care nursing diagnosis,” the most pertinent diagnoses include:

Risk for Infection (specifically CAUTI)

This is arguably the most critical nursing diagnosis related to Foley catheter care. CAUTIs are among the most common healthcare-associated infections (HAIs). The presence of a Foley catheter disrupts the body’s natural defenses against infection, providing a pathway for bacteria to enter the bladder.

Risk Factors for CAUTI:

• Prolonged catheterization
• Female gender
• Older age
• Diabetes mellitus
• Compromised immune system
• Improper catheter insertion technique
• Inadequate catheter maintenance
• Disconnection of the drainage system
• Colonization of the drainage bag

Nursing Interventions:

• Strict aseptic technique during insertion: Using sterile gloves, drapes, and antiseptic solutions.
• Secure catheter appropriately: To prevent movement and urethral irritation.
• Maintain a closed drainage system: Ensuring all connections are secure and intact.
• Proper drainage bag positioning: Keeping the bag below the level of the bladder and off the floor.
• Regular perineal care: Cleaning the perineal area and catheter insertion site with soap and water daily and after each bowel movement.
• Assess for signs and symptoms of UTI: Monitoring for fever, chills, dysuria, urgency, frequency, hematuria, and changes in urine odor or clarity.
• Judicious catheter use: Removing the catheter as soon as clinically indicated to minimize duration of catheterization.
• Catheter securement devices: Utilizing these to minimize catheter movement and urethral trauma.

Impaired Urinary Elimination

While Foley catheters are placed to manage impaired urinary elimination, issues can still arise related to catheter function or after catheter removal.

Related to Foley Catheter:

• Catheter blockage: Obstruction of the catheter due to clots, debris, or kinking, leading to urinary retention.
• Bypass leakage: Urine leaking around the catheter, often due to bladder spasms, blockage, or inappropriate catheter size.

Post-Catheter Removal:

• Urinary retention: Difficulty voiding after catheter removal, potentially due to bladder atony or edema.
• Urinary incontinence: Temporary or persistent incontinence following catheter removal, especially after prolonged catheterization.

Nursing Interventions:

• Regularly assess catheter patency: Checking for kinks, sediment, and ensuring free urine flow.
• Bladder irrigation (if ordered): To clear blockages, using sterile technique.
• Monitor urine output: Ensuring adequate drainage and documenting any changes.
• Assess for bladder spasms: Managing spasms with prescribed antispasmodics if necessary.
• Post-void residual measurement: After catheter removal to assess for urinary retention.
• Bladder training: To restore normal bladder function after catheter removal.
• Pelvic floor exercises: To strengthen pelvic muscles and improve bladder control.

Urinary Retention

Urinary retention can be a reason for Foley catheter insertion, but it can also be a problem related to catheter malfunction or post-catheter removal.

Related to Foley Catheter:

• Catheter occlusion: As mentioned above, blockage can lead to acute urinary retention even with a catheter in place.

Post-Catheter Removal:

• Detrusor muscle weakness: Prolonged catheterization can lead to temporary bladder muscle weakness.
• Urethral edema: Trauma during catheter removal can cause swelling and temporary retention.
• Fear or anxiety: Psychological factors can sometimes contribute to post-voiding difficulty.

Nursing Interventions:

• Identify and address catheter blockages promptly.
• Monitor for bladder distention: Palpating the bladder and using bladder scanners as needed.
• Encourage fluid intake (if not contraindicated): To promote bladder function post-removal.
• Provide privacy and comfortable positioning for voiding.
• Warm compresses to the perineum: To promote relaxation and voiding.
• Crede’s maneuver (if appropriate and ordered): Gentle manual pressure over the bladder to assist with emptying.
• Intermittent catheterization (if ordered): For persistent retention after catheter removal.

Impaired Skin Integrity

Prolonged pressure from the catheter, tape or securement devices, and potential urine leakage can compromise skin integrity.

Risk Factors:

• Prolonged catheterization
• Friction and pressure from the catheter
• Moisture associated with urine leakage
• Allergic reaction to catheter materials or tape
• Poor hygiene

Nursing Interventions:

• Assess skin around the catheter insertion site and perineum regularly.
• Ensure proper catheter securement: To minimize movement and friction.
• Use skin protectants: To create a barrier between the skin and moisture.
• Maintain perineal hygiene: Keeping the area clean and dry.
• Select appropriate catheter material and securement devices: Considering patient allergies and skin sensitivity.
• Prevent urine leakage: Addressing bladder spasms or catheter blockages promptly.

Pain

Pain and discomfort can be associated with Foley catheter insertion, presence, and removal.

Types of Pain:

• Insertion pain: Acute pain during catheter insertion, often due to urethral trauma.
• Bladder spasms: Painful bladder contractions while the catheter is in place.
• Urethral irritation: Discomfort from catheter friction or irritation of the urethra.
• Removal pain: Discomfort during catheter removal, although typically less intense than insertion pain.

Nursing Interventions:

• Use appropriate catheter size: To minimize urethral trauma.
• Ensure adequate lubrication during insertion.
• Gentle insertion technique.
• Administer analgesics as ordered: For pain management.
• Antispasmodics (if ordered): To manage bladder spasms.
• Educate patient on reporting pain or discomfort.
• Monitor for signs of complications: Such as infection or trauma, which can exacerbate pain.

Nursing Assessment for Patients with Foley Catheters

Comprehensive nursing assessment is crucial for identifying and addressing potential problems related to Foley catheter care. Building upon the original article’s assessment section, here’s a Foley-catheter focused approach:

1. Assess Indication for Catheterization and Necessity:

• Review the medical record to understand the reason for catheter insertion.
• Evaluate if the catheter is still necessary based on the patient’s current condition and care plan. Prolonged use increases risk.

2. Catheter Insertion Site Assessment:

• Inspect the urethral meatus for redness, swelling, discharge, or signs of infection.
• Assess for pain or tenderness at the insertion site.

3. Catheter and Drainage System Assessment:

• Verify catheter size, type, and date of insertion.
• Ensure the catheter is securely connected to the drainage tubing and bag.
• Check for kinks, loops, or obstructions in the tubing.
• Confirm the drainage bag is positioned below bladder level and off the floor.
• Assess the drainage bag for urine color, clarity, odor, and sediment.
• Monitor urine output volume and compare to intake.

4. Patient Symptoms Assessment:

• Inquire about pain, discomfort, bladder spasms, urgency, or feelings of incomplete emptying.
• Assess for signs and symptoms of UTI (fever, chills, flank pain, altered mental status in older adults).
• For patients post-catheter removal, assess for ability to void, frequency, urgency, incontinence, and pain on urination.

5. Review Relevant Medical History and Medications:

• Identify predisposing factors for UTI (diabetes, immunocompromised state, history of UTIs).
• Note medications that may affect urinary function or increase UTI risk (anticholinergics, immunosuppressants).

6. Assess Patient’s and Caregiver’s Knowledge:

• Determine the patient’s (and caregiver’s if applicable) understanding of Foley catheter care.
• Identify any knowledge deficits regarding catheter management, hygiene, and infection prevention.

7. Review Lab Work and Urinalysis (if indicated):

• Check urinalysis results for signs of infection (leukocytes, nitrites, bacteria).
• Review urine culture and sensitivity if infection is suspected or confirmed.

Nursing Interventions for Optimal Foley Catheter Care

Effective nursing interventions are essential to prevent complications and promote patient comfort and safety related to Foley catheter use. Expanding on the original article’s intervention section with a Foley focus:

1. Prevent Infection (CAUTI Prevention Bundle):

• Strict Aseptic Insertion: Adhere to guidelines for sterile insertion technique.
• Minimize Catheter Duration: Remove the catheter as soon as clinically indicated. Regularly assess necessity.
• Maintain Closed Drainage System: Ensure secure connections, avoid breaks in the system.
• Proper Catheter Care and Hygiene: Daily perineal care with soap and water.
• Catheter Securement: Use appropriate devices to prevent catheter movement.

2. Ensure Catheter Patency and Drainage:

• Regularly check for kinks and obstructions: Ensure free flow of urine.
• Encourage fluid intake (if not contraindicated): To promote urine flow and prevent sediment buildup.
• Consider bladder irrigation (if ordered and necessary): For suspected blockages, using sterile technique.

3. Manage Bladder Spasms and Discomfort:

• Assess for bladder spasms: Distinguish from catheter blockage.
• Administer antispasmodics as ordered.
• Ensure proper catheter size and placement: To minimize urethral irritation.

4. Promote Skin Integrity:

• Regular perineal care: Keep skin clean and dry.
• Use skin protectants as needed.
• Ensure proper catheter securement: Prevent friction and pressure.

5. Patient Education:

• Educate patient and caregivers on catheter care: Hygiene, drainage bag management, signs of infection, when to seek help.
• Instruct on importance of adequate fluid intake (if appropriate).
• Teach about bladder training and pelvic floor exercises post-catheter removal.

6. Prepare for Catheter Removal:

• Assess patient’s readiness for catheter removal.
• Obtain order for catheter removal.
• Educate patient about potential post-removal urinary issues (retention, incontinence).
• Monitor voiding after removal and assess post-void residual.

Foley Catheter Care Plan Examples

Adapting the original care plan examples to be more specific to Foley catheter scenarios:

Care Plan #1: Risk for CAUTI related to indwelling Foley catheter as evidenced by presence of urinary catheter and potential break in aseptic technique during insertion.

Expected Outcomes:

• Patient will remain free from CAUTI as evidenced by absence of fever, chills, dysuria, urgency, and bacteriuria.
• Patient will demonstrate understanding of CAUTI prevention measures.
• Catheter will be removed as soon as clinically indicated.

Assessment:

1. Assess risk factors for CAUTI: Prolonged catheterization, female gender, older age, diabetes, immunocompromise.
2. Monitor for signs and symptoms of UTI: Fever, chills, dysuria, urgency, frequency, hematuria, cloudy or foul-smelling urine.
3. Review catheter insertion technique and maintenance practices: Assess for adherence to aseptic technique and closed drainage system maintenance.

Interventions:

1. Ensure strict aseptic technique during any catheter manipulation or drainage system changes.
2. Minimize catheter duration; advocate for timely removal based on patient’s condition.
3. Maintain a closed urinary drainage system; avoid disconnecting tubing unnecessarily.
4. Perform daily perineal care with soap and water.
5. Educate patient and caregivers on CAUTI prevention measures, including hygiene and reporting signs of infection.
6. Monitor urinalysis and urine culture results as indicated.

Care Plan #2: Impaired Urinary Elimination related to Foley catheter blockage as evidenced by decreased urine output and bladder distention.

Expected Outcomes:

• Patient will maintain adequate urinary drainage through Foley catheter as evidenced by urine output consistent with intake and absence of bladder distention.
• Catheter patency will be restored promptly if blockage occurs.

Assessment:

1. Monitor urine output volume and frequency. Compare to baseline and expected output.
2. Assess for signs of catheter blockage: Decreased urine output, bladder distention, patient reports of fullness or discomfort.
3. Check catheter and tubing for kinks, sediment, or obstructions.
4. Assess for bladder spasms which may mimic blockage but are a different issue.

Interventions:

1. Regularly assess catheter patency and drainage.
2. Ensure adequate fluid intake (if not contraindicated) to promote urine flow.
3. Gently flush catheter with sterile saline as ordered if blockage is suspected (following institutional policy).
4. Troubleshoot catheter system for kinks or positioning issues.
5. Monitor for resolution of bladder distention and improved urine output.
6. If blockage persists, notify physician for further evaluation and orders.

Care Plan #3: Urinary Retention related to post-Foley catheter removal as evidenced by reports of inability to void and post-void residual volume >100ml.

Expected Outcomes:

• Patient will successfully void after Foley catheter removal as evidenced by adequate urine output and post-void residual volume <100ml.
• Patient will verbalize understanding of strategies to promote voiding post-catheter removal.

Assessment:

1. Assess patient’s ability to void within a reasonable timeframe after catheter removal (usually within 6-8 hours).
2. Monitor for signs of urinary retention: Bladder distention, complaints of inability to void, discomfort.
3. Measure post-void residual volume (PVR) as ordered or per protocol. Using bladder scanner or intermittent catheterization.
4. Assess for contributing factors to retention: Medications, pain, anxiety, underlying medical conditions.

Interventions:

1. Encourage fluid intake (if not contraindicated) to promote bladder filling.
2. Provide privacy and comfortable positioning for voiding.
3. Run water, pour warm water over perineum, or use other relaxation techniques to facilitate voiding.
4. Apply warm compresses to lower abdomen to promote relaxation.
5. If unable to void, consider intermittent catheterization as ordered to relieve retention.
6. Educate patient on bladder training techniques and the importance of reporting any difficulty voiding after discharge.

Conclusion

Foley catheter care nursing diagnosis is a critical aspect of patient care. By focusing on the specific risks and nursing considerations associated with Foley catheters, nurses can significantly improve patient outcomes and reduce complications like CAUTIs, urinary retention, and impaired skin integrity. This guide provides a framework for understanding common nursing diagnoses, conducting thorough assessments, and implementing evidence-based interventions to ensure safe and effective Foley catheter management. Prioritizing patient education and minimizing unnecessary catheter use remain paramount in promoting optimal urinary health and overall well-being.

References

1. Ackley, B.J., Ladwig, G.B.,& Makic, M.B.F. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care (11th ed.). Elsevier.
2. Byram Healthcare. (2019, May 6). Commonly Performed Urology Tests. Byram Healthcare. https://www.byramhealthcare.com/blogs/commonly-performed-urology-tests
3. Carpenito, L.J. (2013). Nursing diagnosis: Application to clinical practice (14th ed.). Lippincott Williams & Wilkins.
4. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
5. Gulanick, M. & Myers, J.L. (2014). Nursing care plans Diagnoses, interventions, and outcomes (8th ed.). Elsevier.
6. Harvard Health Publishing. (2010, April 20). Training your bladder. Harvard Health Publishing. https://www.health.harvard.edu/healthbeat/training-your-bladder
7. Herdman, T. H., Kamitsuru, S., & Lopes, C. (Eds.). (2024). NANDA-I International Nursing Diagnoses: Definitions and Classification, 2024-2026. Thieme. 10.1055/b000000928
8. Kubala, J. (2021, October 4). Does Cranberry Juice Help Treat UTIs? Myth vs. Science. Healthline. https://www.healthline.com/nutrition/cranberry-juice-uti
9. Medline Plus. (2021, January 10). Kegel exercises – self-care. Medline Plus. https://medlineplus.gov/ency/patientinstructions/000141.htm
10. Ng, M.& Baradhi, K.M. (2022). Benign prostatic hyperplasia. StatPearls. https://www.ncbi.nlm.nih.gov/books/NBK558920
11. Nabili, S. N. (2020, March 24). Bladder Control Medications. Emedicine Health. https://www.emedicinehealth.com/understanding_bladder_control_medications/article_em.htm#facts_on_bladder_control_medications
12. Wallace, R. (2017, September 28). 11 Foods to Avoid if You Have OAB. Healthline. https://www.healthline.com/health/11-foods-to-avoid-if-you-have-oab