Republic of the Philippines
TARLAC STATE UNIVERSITY
COLLEGE OF SCIENCE
DEPARTMENT OF NURSING
Lucinda Campus, Brgy. Ungot, Tarlac City Philippines
[Link].: 4931865 Fax: (045) 982-0110 website: [Link]
Performance Evaluation Checklist
PERINEAL CARE AND URINARY CATHETERIZATION
Name of Student: ______________________________________________________________
Year/ Section/Clinical Group: __________________School Year: ________________________
Term: ___________
Inclusive Dates of Clinical Rotation: ________________________________________________
Instructor: ____________________________________________________________________
PERFORMANCE EVALUATION CHECKLIST
PERINEAL CARE AND CATHETERIZING THE MALE & FEMALE URINARY
BLADDER (INDWELLING)
Procedure 1 2 0
ASSESSMENT
1. Review and acknowledge physician's order and indications for
urinary catheter insertion.
2. Gather all the necessary items including appropriate size and
type of urinary catheter.
3. Identify your client and gather all necessary data (history of allergies to
latex and iodine)
4. a. Assess the need and frequency of perineal care.
b. Assess whether perineal care should be done under an
aseptic technique or a clean technique
c. Assess the patient ability for self-care and assess the patient
mental state to follow instructions.
d. Assess patient’s blood pressure and pulse.
e. Assess patient’s level of comfort.
f. Assess patient’s and family member’s understanding of urinary
catheterization
5. Provide privacy. Expose body part, drape patient as needed.
PLANNING
6. Formulate your nursing objective for the perineal care and
catheterization
7. In planning for perineal care and catheterization consider and give
priority to the essential and recognized needs of the individual and his
family.
8. In planning include patients’ and family member’s understanding of
urinary catheterization.
IMPLEMENTATION
9. Greet the client and Introduce yourself. Explain to the client what you
are going to do, why it is necessary, and how the client can cooperate.
[Link] hand hygiene and don clean gloves.
11. Assist patient to the dorsal recumbent position with knees flexed and
feet about 2 feet apart.
[Link] waterproof pad or mackintosh under patient appropriately.
[Link] bed pan. Remove bedpan after use. Keep the clean bed-pan on
the bed on your working side.
[Link] to wash the perineal area with soap and water. Use water of
safe temperature for washing and rinsing.
[Link] front perineum after washing and rinsing with dry gauze or cotton
swab.
[Link] gloves and performed hand hygiene.
[Link] lubricant onto the sterile gauze.
[Link] sterile gloves.
[Link] sterile drape under the buttocks and cover the perineum while
maintaininq its sterilitv.
[Link] the catheter and created closed urine drainage system as
needed. Do not test the balloon unless specified by the manufacturer's
instruction.
[Link] antiseptic solution over cotton balls. Open specimen container if
specimen is to be drained. Cleanse the urethral meatus using sterile
technique.
[Link]:
▪ Clean perineum from the midline downward using a single
stroke in the following order
a. The vulva
b. The labia
c. Inside of labia on both sides.
d. Outside of labia on both sides
MALE:
▪ Lift penis with your non-dominant hand, which is then
considered contaminated.
▪ Retract foreskin in the uncircumcised male patient. Clean area
at meatus with cotton ball held with forceps
▪ Use circular motion, moving from the meatus toward base of
the penis for three cleansing
[Link]:
▪ With thumb and one finger of your non dominant hand, spread
labia and identify meatus.
▪ *Insert the catheter aseptically. Insert the catheter into the
meatus 7 to 7.5 (2-3 inches).
▪ After visual confirmation of urine return into the tubing,
continue to advance the catheter.
MALE:
▪ Hold the penis with slight upward tension and perpendicular to
patient’s body.
▪ Instill 10ml of lubricant into the urethra then gently insert the tip
of the catheter with lubricant into the urethra.
▪ Insert the tip into the meatus. Advance intermittent catheter 15
to 20 cm (6-8 inch) or until urine flows.
[Link] not use force to introduce the catheter. If the catheter resists to
enter, ask patient to breathe deeply and rotate catheter slightly
[Link] the balloon with sterile water to the volume indicated by the
manufacturer (5-15)
[Link] the catheter tubing gently until resistance is felt. Secure the
indwelling catheter properly
[Link] the drainage bag below the level of the bladder without
touching the floor
[Link] equipment and make patient comfortable in bed. Clean and
dry perineal area. Care for equipment according to agency policy
[Link] gloves. Perform Hand Hygiene
CATHETER REMOVAL
[Link] and acknowledge physician's order for removal of catheter.
[Link] and verify patient. Explain the procedure.
[Link] hand hygiene and don clean gloves.
[Link] the hub of a syringe into the catheter's inflation valve to remove
the originally instilled amount of sterile water.
[Link] out the catheter slowly and gently. Empty the urine bag.
[Link] the contaminated catheter in a waterproof pad. Discard into
appropriate receptacle.
[Link] gloves and perform hand hygiene.
RECORDING AND REPORTING
[Link] time of catheterization, amount of urine removed, description
of urine, patient’s reaction to procedure and your name.
[Link] evaluation of patient or caregiver learning.
[Link] any sensations of burning, numbness, or unrelieved skin color
changes to healthcare provider
[Link] to scenario questions appropriately.
TOTAL POINTS: (80 PTS)
TOTAL SCORE:
TRANSMUTED GRADE
Shown to me:
_______________________________________
Signature over Printed Name
Student
Evaluated by:_______________________________________
Signature over Printed Name
Clinical Instructor