Documenting a foley cath removal

How do I document a removal of a catheter removal.

I know I need to include that the tip was visually intact. Do I just start with saying that per the physicians order the cath was removed on this date at this time. Patient tolerated procedure well, no pain meds given. Tip was visually intact upon inspection.

Thanks for any advice.

5 Answers

Specializes in ER, progressive care.

this is what I document:

"Foley cath d/c'd per order. Withdrew 10cc of water from balloon. Catheter removed without difficulty; catheter tip intact. Patient instructed to notify nurse of first void."

and of course you can put "pt tolerated well" (most of them think foley cath removal will be agonizing but many tell me "oh, that wasn't bad at all!" after I remove it) and things like "no needs at this time; call light w/in reach," etc.

patient needs to void within 6 hours of foley cath removal (I've heard 4-6, but I was always taught within 6 hours).

Specializes in LPN.

Indwelling cath removed per doctor order. Pt tolerated procedure well. Pt has been instructed on need to inform on first void. Will monitor.

I don't think it is important to montior about the cath itself unless there is something wrong with it.

I would also mention any clots or bleeding or pain experienced. Though like the previous person said, most people don't even know it's out, until you tell them. It is a very easy procedure, just do it gently, like everything in nursing.

Write this:

"Imagined catheter tubing was the starter cord on a Stihl, gas-powered weedeater and pulled. Catheter removed."

lol... I don't think that would be acceptable to my instructor.

Thank you very much!!

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