Foley sterile field

[AJPV]

I'm practicing for a school checkoff doing a foley. Sterile technique is the biggest thing we're focusing on. There is a tray that sits in the top part of the box that the cath comes in. The tray contains the cotton balls & iodine. The catheter sits below the tray in the box itself. I realize that I have to don the sterile gloves, then test the cath balloon & apply lube to the cath (which is below the tray), then when everything is ready, I can finally prep & use the cotton balls (which is when I will contaminate my non-dominant hand).

My question relates to the fact the the catheter is initially inaccessible due to the tray being over the top of it. After donning the sterile gloves, is it okay to remove the tray from the top of the box and set it on the bed between the pt's knees (on the sheet and not on top of the sterile drape due to the size of the drape not accomodating the box and tray side by side)? I have to somehow get the tray out of the way to access the cath so I can test the ballon and lube the tip - BEFORE I use the cotton balls and thus contaminate my non-dominant hand. But if I move the tray and set it down on the sheets (not on the sterile drape) does that make the cotton balls contained in the tray officially "contaminated" because the tray is not sitting on top of the sterile drape?

Any tips would be great - thanks!

[justalpnwmg]

Open the sterile kit using the covering as a sterile field, done your gloves, pick up the top portion of the kit and place underneath the other,putting your cleansing agents in the top one where they are accessable; this arrangement gives you more space on your sterile field with less chance for contamination, just be careful in shifting the two. Check your balloon leave the sryinge on the catheter this gives the cath some weight and has less chance for contamination replacing it during inflation and during insertion. Open the lubricant and squeeze into the well. Carefully remove the covering on the catheter with your nondominant hand coil it(the cath) into your dominate hand place tip of cath in lubricant. Connect the cath and tubing to the collection bag allowing all to rest in bos. Cleanse the area with nondominant hand, place cath watch for urine, inflate balloon to rec. inflation tug slightly to seat and place collection bag appropriately. Clean up area wash hands and document.

[AJPV]

Great tips - thanks everyone! I like the tip to lift the tray, pull the tubing out a little, then put the tray back.

[canesdukegirl, BSN, RN]

I always prepare my foley kit in advance on a prep table. The reason I do this is because I don't want my female pt being in a frog leg position for too long while I prepare my foley. Some elderly women have quite a bit of pain in their hips while in this position. I also don't like to expose my patients (male or female) for a long period of time while I am preparing the foley. I have found that it just more kind to do it this way.

I also pull my own gloves when doing my "advance foley prep". A gyn nurse taught me this trick years ago, and I always teach this method to new med students.

Open your foley kit on the prep table. Drag the trash can close to you. Have another foley in the room in case you contaminate the one in the kit. Don the sterile gloves that you pulled on another table. Get rid of the things in the tray that you don't need: if there is no order for a sterile specimen, toss the specimen cup (but if you want to save it, these make great containers for salad dressing, creamer for your coffee, or even to put your jewelry in when you travel). You should only need 3 cotton balls (the kits we use come with 5), but leave 4 in case two of them stick together. Pour the Betadine over the cotton balls and stick the forceps in the cotton balls. I never use the diamond shaped drape, so I throw it out too. Take the top tray off and put it beside the bottom tray-yes it is a tight fit, but the sterile wrapper should be large enough to do this. Take the plastic covering off the foley itself. Squirt some lube in one corner of the bottom of the box, being mindful not to squirt it into the holes. Dip your foley into the lube. Go ahead and place your syringe onto the foley and test your balloon if that is what you are being taught in school (there is a great deal of controversy about inflating the balloon or not, so just go with what your instructor says). Leave the syringe in place. The bottom of the tray is ready. Place the top back on with the sterile gloves on top.

Position your patient. Don the sterile gloves. Place the drape as you normally would. Then take the top of the tray and lay it on the drape. (The reason I don't lay the entire tray on a regular sheet is because the bottom of the kit has holes in each corner.) Prep your patient. When you are done prepping, use your sterile hand, grab the top tray by the corner that is opposite of the prep corner and throw out the top of the tray when you are done prepping. Now you have plenty of room! Grab the bottom of the tray and put it on the drape. You are still sterile, because the top of the tray is impervious. All you have to do now is place your foley in the "peace sign" for a woman, and feed the cath up to the hilt for a man.

If you aren't seeing liquid gold, have an assistant lightly palpate the bladder just above the symphysis pubis. If you don't have an assistant, you can take your unsterile hand to do this yourself, being mindful that you must then clean your patient up when you are done.

I don't know if your instructors will love the idea of prepping a foley catheter in advance, but this works well in practice. I strongly encourage you to prepare the foley on a prep table however.

Good luck to you! I hope you do well.

[Adri_RN]

AJPV said:

Yeah, you didn't know you could cut a slit in a foley bag and use it as a really big central line dressing??? But really, anyone with tips on how to handle the tray in the foley kit?

I have never heard of this ...can you please explain further? Thanks ?

[Horseshoe, BSN, RN]

Gently.me said:

Yes ask! It is hard enough having to worry about getting it in the correct hole (sometimes on elderly ladies, anatomy is not what it should be), but something so stupid as to where to put the sterile tray....

Dont worry, in the real-world of nursing, practicality trumps "the way they teach you in nursing school". But since you are in training, do it their way, period. Even if it is stupid....

Sometimes the anatomy is difficult in younger women as well. It's great when you get the "textbook" anatomy. It's almost like having a bulls eye right there for your convenience :). Other times, it's a struggle. Practice makes perfect, though.

[roser13, ASN, RN]

I love all these tips and will non doubt use some of them myself.

But again, I caution OP: the only tips that count are the ones that your instructor condones/accepts.

[Double-Helix, BSN, RN]

Adri_RN said:

I have never heard of this ...can you please explain further? Thanks ?

This is what is known as "sarcasm." ?

[thehipcrip]

Something no one mentioned here is the use of Lidocaine 2% gel to make insertion less uncomfortable. Apply a liberal amount of lidocaine gel to the patient's meatus and leave it to start working while prepping your insertion tray. You can also mix the Lidocaine gel in with the Surgilube. It doesn't necessarily make the insertion more comfortable but does eliminate irritation/discomfort shortly after.

Question -- why do hospitals/clinics all seem to use the insertion trays with the cotton balls and tongs instead of the prepackaged antiseptic swabs? For women, it's so much easier to ensure the swabs get into the labial folds than using those clumsy tongs and drippy cotton balls.

[Jackfackmasta, ASN, RN]

I am a level 3 student and work in an ER. They call me the Foley queen and I do literally every female catheter. Through error and trial I have found this to be best.

1. I do allergy checks and all the safety steps. Pt gets undies off, I raise the bed, lower the side rail on my dominant side, so If I am R handed I am on the pt's right side.

2. I don clean gloves and check perineal area to see if it needs to be wiped down with a wipe and to visualize uretha. Discard. Open my sterile gloves package and set on the paper wrapping with gloves in it on the table

3. I always have a tray and open the package and take out the foley kit.

4. Ask pt to open legs and have them fall to side and tell them them to stay still

5. Open package sterily, away, sides and then to you. I open and place on my sterile gloves. Pick up the sterile drape and ask pt to lift bottom up. I slide it under the bottom sterily with the edges folded towards me and then let it go back to place when I place it down

6. I will squeeze out the lubricant into the designated box in the tray on top of the foley. Separate 3 cotton balls into 1 container and open the iodine onto the balls. I then pinch the center of the tray and place it on the sterile drape keeping sterility.

7. I then test integrity of the balloon in the box with the syringe while keeping the syringe on the port and then take off the blue wrapper. One of the lessons I have learned is to seperate the tubing enough so that when you lift the foley tip up the tubing follows instead of getting snagged on something and you have to untangle it. I place the box with the foley behind the tray with the cotton balls.

8. With non dominant hand spread labia and find urethra again, grab forceps with R hand and cotton balls and wipe the labia down each with separate cotton balls and then down the middle while taking the used balls around the field and I drop them on top of my tray where the paper packaging i opened for my sterile gloves I had put on and place it there. Then when I am ready to insert the foley I pinch the middle of the tray and pick it up and place it next to the foley box.

9. Then I pick up the foley end while having the my pinky wrapped around my the tubing tip the dip it into the lubricant and then insert it while maintain sterilty. I usually let the bag rest on the sterile field while my R hand inserts the tube. When I am ready I hold the cathater with my non dominant hand and inflate the ballon with my right hand and then get urine sample off port. Apply stat lock , position bag and clean up and document.

This is how I've done it. I've seen it done a million ways. Find what works for you best

[Horseshoe, BSN, RN]

Jackfackmasta said:

I am a level 3 student and work in an ER. They call me the Foley queen and I do literally every female catheter. Through error and trial I have found this to be best.

That's so funny. I used to be called the "Foley Queen" where I worked. I sucked at IVs because we rarely had to start them. But I could get a Foley into just about anyone, even nursing home admits who had contractures which made the normal position for insertion impossible. Now I work at a facility where we NEVER put in Foleys and we start 55-60 IVs per day between 3 nurses.

It's kind of amusing how things change...I do occasionally work prn in an OR and I always volunteer to put in the Foley because I don't want to lose my skills entirely.

Good for you that you have found something you are good at that will make you stand out from the crowd...:)

[klone, MSN, RN]

I insert foleys into female patients daily, sometimes more than once a shift. In OB, pretty much everyone who gets an epidural, gets a foley.

First, it's no longer EBP to test inflate the catheter.

Second, the kits we use have the cotton balls and plastic tongs. I don't use the tongs. The first cotton ball gets swiped down her urethra/vulva, then I use it with my non-sterile hand between my finger and her labia to keep her labia separated. It's hard to describe without a visual.

If you have an obese patient, don't be shy to ask for another nurse to help you hold labial folds out of the way.

[nerdtonurse?, BSN, RN]

When nothing else works...trendelenburg, lube and place 2 fingers in the lady parts to form a floor for the urethra, push up, and guide the foley in on the "track" you've made with the fingers of the other hand. This is obviously a multiperson approach, but sometimes if you've got someone who's anatomy has grossly shifted, that's the only way to get it done.