How to Be a Urethra Whisperer
When I was a student nurse, I viewed Foley catheter insertion as, somehow, the trademark of a real nurse. During clinicals I chased after opportunities to insert one, but they were infuriatingly elusive. I don’t know why I latched on to that particular skill as something I needed to conquer so that I would feel that I was truly becoming a real nurse, but for whatever reason, I did. Finally at the end of my last semester an unconscious intubated male patient needed a Foley, so I inserted it and mentally checked the task off my list. Little did I know that I would insert too many Foleys to count over the next few years and, more to the point, that inserting one into an unconscious male is not representative of the task at hand. There is an art to it, especially if the patient is elderly. Even elderly men can be troublesome Foley recipients because they have enlarged prostates.
Between the cardiac ICU, where everyone needed Foleys because they had to lie flat for a long time, and the ER, where we get a lot of elderly patients with hip fractures who need Foleys, I’ve developed a decent arsenal of tricks not to be found in any textbook.
- Put the bed in reverse Trendelenburg for women. This lets gravity help you and the patient. Elderly folks have stiff hips and weak muscles, and leaning back helps them let their legs fall open. If the patient has respiratory issues, you can also leave the head of the bed raised somewhat while you insert the Foley so your patient isn’t blue when you’re done.
- Also for women, use the “wink” to find the urethra. It’s not so easy to find on a real person sometimes, is it? Pro tip: use your Betadine swab and run it straight down toward the vagina: usually the urethra will wink at you.
- Another female trick: don’t get too lube-happy, and get a short grip. Hold the tube only about a half inch from the end when you approach the urethra. Otherwise the thing has a tendency to snake into the vagina at the last second.
- For men and women, remember the oft-neglected Coudé catheter. It’s got a stiff curved tip and is known to be helpful for navigating the prostate in men, but many older women have a urethra that is nearly in the vagina. You can use an upward-pointing Coudé tip to defeat this anatomical trick. For truly difficult anatomy, have another nurse insert a finger in the vagina and slide the cathether over it straight into the urethra.
- Men only: approach the penis with confidence! Get a good firm grip and hold it perpendicular to the abdomen. If you don’t start out this way the skin will fold up on you and you will, pardon the pun, be hosed. And speaking of skin, if the patient is not circumcised, please remember to be a good citizen and put things back the way you found them (replace the foreskin).
- Once the catheter is in, secure it with a stat-lock or leg band so it doesn’t get yanked out. If the patient has truly awful bladder spasms or ones that last beyond 30 minutes, investigate whether your facility has B&O (belladonna and opium—no, I’m not making this up) suppositories. Many physicians have never heard of them, but pharmacists can dig them up, and they work really well for post-Foley discomfort.
And there you have it…a bag of tricks to make at least one task easier on both nurse and patient.
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