Elimination Checklist - Blank

INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE
Name: _ ___________________ __ Grade: ________________ __
Year and Section: __ _______ __ Date: _ _______________

EQUIPMENT: Legend:
Indwelling or straight catheter 10 cc syringe, prefilled with water 1- Excellent
Urinary bag with drainage tubing Sterile KY Jelly 2- Very Satisfactory
Adequate lighting source Plaster and bandage scissor 3- Satisfactory
Disposable sterile gloves Warm water, soap 4- Needs Improvement
Towel, blanket Sterile forceps 5- Poor
PROCEDURE RATIONALE 1 2 3 4 5
1. Check the doctor’s order
2. Gather the equipment needed.
3. Bring the materials to the bedside.
4. Introduce yourself, check patient’s identity and

explain procedure to the patient.
5. Provide for privacy
6.. Provide client with opportunity to perform

personal hygiene. Assist as necessary.
6. Wash hands.
7. Obtain, prepare and arrange equipment according

to use. Carry at bedside.
 Open cleansing solution and pour over half

of the sterile cotton ball. (do not touch the
top of the bottle to the container)
 Attach the catheter to the urine drainage
bag if it is not connected.
8. Assist the client to a supine position.
9. Drape legs to midthigh. Position rubber sheet on

buttocks.
10. Ensure adequate lighting of the perineal area.
11. Pull on sterile gloves.
12. Place fenestrated drape over client’s genitalia.
13. With non-dominant hand. Hold penis at 90

degree angle to his body. If uncircumcised, pull
down foreskin with this hand to visualize urinary
meatus. (This hand is now unsterile).
14. Using the sterile forceps, pick up antiseptic
solution saturated cotton ball. Cleanse meatus with
one downward stroke or use circular motion from
meatus to base of penis.
15. With sterile hand, pick up catheter and lubricate
generously 4-6 inches from tip.
16. gently insert catheter into urethra approximately

6-8 inches until urine begins from tip.
 If catheter resist entry, ask patient to

breathe deeply and rotate catheter slightly
another inch and allow bladder to empty
and remove straight catheter.
17. If using straight catheter. Insert catheter another
inch and allow bladder to empty and remove
straight catheter.
18. If using indwelling catheter. Continue inserting 1-
3 inches.
19. attach the water-filled 10 cc syringe to the
inflation port. Inflate the retention balloon.
20. Check placement by gently pulling catheter until

balloon is resting snugly against the bladder neck.
(Resistance will be felt when balloon is in place).
21. Tape catheter securely to the abdomen.
22. Attach drainage bag to bed frame, below the

level of the bladder. Make sure the tubing lies over,
not under the leg. Do not let it rest on the floor.
23. Remove the discard gloves. Do after care and
wash hands.
24. Do proper documentation: time the procedure
was completed, size & type of catheter used, client’s
response and amount, color quality of urine.
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Total divided by no. of items = __________
Comments:
_______________________________________________________________________________________________________________________-______________
__ ________________ _____ _______________________________________
Student’s Signature over Printed Name Clinical Instructor’s Signature and Date over
Printed name
ROUTINE CATHETER CARE

Name: _ ______________ __ __ Grade: ________________ __
Year and Section: __ _______ __ Date: _ ______ ___

EQUIPMENT: Legend:
Antiseptic Solution 1- Excellent
Sterile swabs 2- Very Satisfactory
Clean Gloves 3- Satisfactory
Washcloth, soap and water 4- Needs Improvement
5- Poor
1. Wash hands.
2. Check institutional protocol or care plan
3. Identify the client and explain the procedure
4. Provide privacy
5. Place client in a supine position and expose the

perineal area and catheter.
6. Put on gloves.
7. Cleanse the perineal area with soap and water.
8. Cleanse meatus in circular motion from the most

inner surface to the outside. Use soap and water
unless these is purulent drainage. The non-
irritating antiseptic solutions on cotton maybe
used.
9. Cleanse catheter from meatus out to end of the
catheter, taking care not to pull the catheter.
10. Be sure to repeat catheter care anytime it

becomes soiled with stool or drainage.
11. place linen or cotton balls in proper receptacle.
12. Wash hands.
DOCUMENTATION
Nurse’s Notes:
 Document the time the procedure was performed and the condition of the are surrounding the
catheter.
Nurse’s Tips:
 When doing catheter care, do not allow urine to drain back into the bladder.
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________
__ ___________________ _____ _______________________________________
Printed name
REMOVING AN INDWELLING CATHETER
Name: _ ______________ __ __ Grade: ________________ __

Year and Section: __ ________ __ Date: _ __________ ___
EQUIPMENT: Legend:
100 cc syringe 1- Excellent
Clean Gloves 2- Very Satisfactory
Paper towel or gauze 3- Satisfactory
Waste receptacle 4- Needs Improvement
5- Poor
1. Verify doctor’s order
2. Identify patient and explain the procedure.
3. Wash hands.
4. Obtain necessary equipment and carry to the

bedside and arrange according to use.
5. Screen patient properly.
6. Assist patient to supine position.
7. Don on clean disposable gloves.
8. Loosen tape holding catheter in place.
9. Insert hub of syringe into balloon inflation of

catheter and draw out all liquid.
10. Ask client to breathe in and out deeply. Gently

remove catheter as client exhales.
11. Wrap end catheter in paper towel and dispose
properly.
12. Assist client to cleanse and dry genitals. Make
patient comfortable.
13. Do after care. Wash hands.
14. Measure and document urine in drainage bag and
time of catheter removal.
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Comments:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_______________________________________
__ ___________________ _____ _______________________________________
Printed name
FLEET ENEMA
Name: _ ___________________ __ Grade: ________________ __
Year and Section: __ ______ __ Date: _ ___________ ___

Legend:
1- Excellent
2- Very Satisfactory
3- Satisfactory
4- Needs Improvement
5- Poor
PLANNING
1. Before administering enema, determine that
there is a primary care provider’s order
2. Equipment:
2.1 Fleet Enema
2.2 Disposable linen-saver pad/incontinent pad
2.3 bath blanket
2.4 clean gloves
2.5 bedpan or commode
2.6 water-soluble lubricant
2.7 paper towel

IMPLEMENTATION
3. Prior to performing the procedure, introduce
yourself and verify the client’s identity.
4. Perform hand hygiene. Wear clean gloves and
observe appropriate infection control procedure.
5. Provide privacy
6. Place the bedpan or commode in position for
patient who can’t ambulate to the toilet or have
difficulty with sphincter control.
7. Assist the client to the left lateral position with the
right leg as acutely flexed as possible.
8. Lubricate about 5cm (2inches) of the rectal tube.

Some commercially prepared enema set already
have lubricated nozzle.
9. Separate the buttocks and locate the rectum.
10. Instruct the patient that you will insert the nozzle
and to take a slow deep breath.
11. Insert the tube smoothly and slowly administer

the solution into the rectum directing towards the
umbilicus.
12. Roll up the plastic container as the fluid is
instilled.
13. Do after care.

14. Wash hands.
15. Document the procedure.
ATTITUDE
16. Accepts constructive suggestions and criticisms
17. Assume responsibility of his or her actions.
Scoring:
1x ____________ = __________
2x ____________ = __________
3x ____________ = __________
4x ____________ = __________
5x ____________ = __________
Comments:
_____________________________________________________________________________________
__ ___________________ _____ _______________________________________
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INSERTING A STRAIGHT OR INDWELLING CATHETER: MALE

Name: _ ___________________ __ Grade: ________________ __

Year and Section: __ _______ __ Date: _ _______________

2. Gather the equipment needed.

3. Bring the materials to the bedside.

4. Introduce yourself, check patient’s identity and

5. Provide for privacy

6.. Provide client with opportunity to perform

7. Obtain, prepare and arrange equipment according

 Open cleansing solution and pour over half

9. Drape legs to midthigh. Position rubber sheet on

13. With non-dominant hand. Hold penis at 90

16. gently insert catheter into urethra approximately

 If catheter resist entry, ask patient to

20. Check placement by gently pulling catheter until

22. Attach drainage bag to bed frame, below the

Total divided by no. of items = __________

__ ________________ _____ _______________________________________

ROUTINE CATHETER CARE

Year and Section: __ _______ __ Date: _ ______ ___

2. Check institutional protocol or care plan

3. Identify the client and explain the procedure

5. Place client in a supine position and expose the

8. Cleanse meatus in circular motion from the most

10. Be sure to repeat catheter care anytime it

12. Wash hands.

Total divided by no. of items = __________

__ ___________________ _____ _______________________________________

REMOVING AN INDWELLING CATHETER

Name: _ ______________ __ __ Grade: ________________ __

2. Identify patient and explain the procedure.

4. Obtain necessary equipment and carry to the

5. Screen patient properly.

6. Assist patient to supine position.

7. Don on clean disposable gloves.

8. Loosen tape holding catheter in place.

9. Insert hub of syringe into balloon inflation of

10. Ask client to breathe in and out deeply. Gently

Total divided by no. of items = __________

__ ___________________ _____ _______________________________________

Name: _ ___________________ __ Grade: ________________ __

Year and Section: __ ______ __ Date: _ ___________ ___

2.1 Fleet Enema

2.2 Disposable linen-saver pad/incontinent pad

2.3 bath blanket

2.4 clean gloves

2.5 bedpan or commode

2.6 water-soluble lubricant

2.7 paper towel

8. Lubricate about 5cm (2inches) of the rectal tube.

11. Insert the tube smoothly and slowly administer

13. Do after care.

17. Assume responsibility of his or her actions.

Total divided by no. of items = __________

__ ___________________ _____ _______________________________________

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