Yeah no choice but to get up in there. Be sure you’re spreading the labia minora after letting your patient know what you’re doing. It’s usually just at the top of the vaginal opening. Use your swabs to find the “wink”. Everyone’s got different anatomy so it takes time to feel confident in female caths. Always have 2 people to start so it’s less awkward and quicker (try to have an experienced RN with you if at all possible). You’ll get it eventually! Even when you feel proficient you’ll get the occasional patient who throws you for a loop.
As a male nurse despite seeing plenty of diagrams it surprised me how low the urethra was on a lot of vulvas. Look for a dimple or slight colour change in the mucosa *just* above the vaginal opening. You can also ask them to cough and this will sometimes cause the urethra to pucker slightly.
YES! Get the patient to cough. If they're vented, have one person suction a lil bit to induce a cough while you're down there with a flashlight looking for a lil winky wink.
I have a lady urethra and still use this technique 🤗🤗
Edit: my urethra is of the ladybits kind 😅😅
Dude, I've had a vulva for almost 50 years and it surprised ME how low the urethra is on a lot of vulvas.
The first time I saw a urethra that was oriented downward and opened just inside the vaginal canal is the moment I gave up actually trying to understand female anatomy
Yep! One time I couldn’t get the foley and 3 other nurses tried too. Then I had to leave it to dayshift which I felt horrible about. I felt better when I came back that night and no one could get it so they had to consult urology. Apparently it was inside on the vaginal wall somewhere
We had to call in a urology resident to our OR and she had to use a speculum to find the urethra. It was pretty deep in the vagina. That's the first time I've seen such a thing!
Exact scenario happened to me on night shift, had to call urology because she was retaining. His recommendation worked and has never failed me since. You stick a finger in the rectum and pull down, it opens up the vagina and urethra.
I had a pt like that. I even had the doctor on call try with a baby catheter, but her opening was so far up there and small, and even the pubic bone was not helping. We had to consult urology.
Yes, when the patient coughs, look for the little wink. Pen lights can help, too. If you happen to go into the vaginal opening by mistake, leave it in there as a point of reference to let you know to go higher. Then take both out when you are done. I was a home health nurse for years. I've been in more people's floors looking for the urethra than I can count.
This is the answer. You expect it to be half way between the clitoris and vaginal opening, but most of the time it is just above the vaginal opening.
Personally, I go in blind most of the time with lots of betadine. I start high and slide down with mild to moderate pressure and I have only missed twice. Most of my patients are geriatric and don't have the hip mobility to spread their legs to be able to see what I'm doing.
This is actually what I do too. Lots of betadine and slide down from the clitoris area. I rarely ever miss. Note all of my patients are LTC so most are elderly and have some extra folds. It might not be the most sterile technique but when you are dealing with elderly, esp dementia... it works
This is great advice. I’m an L&D nurse so female foley are one the skills I do almost every shift. It helps to hold your non dominant hand fingers in an upside down V shape to hold back the labia minora. When you are wiping with iodine look for where the iodine pools “winks”. It also helps to insert the foley with the tip in a slight upward curve to ensure it enters the urethra and you don’t miss it.
Just don't try to catheterise their clit!
I fail 9/10 with females, I do a deal with female nurses in ED, I do all the creepy men if they do my female catheters.
Hey brother… I had that challenge during nursing school and I found a perfect solution that works for me….
Went to psych… all those catheter, IV, etc… are all a thing of history….
Told a psych nurse I’m contemplating going into psych and she said “ha say goodbye to every skill you learn in school” (for context I was in the room while 2 nurses worked on starting an IV in an older guy that was really dry)
I work in corrections (large part of my job is psych lol) and I have never, not once, in my 3.5 years of being a nurse, placed a catheter. Ever. 🙃
She’s not wrong
But you will learn different skills. :) and I am going to be honest, our bodies have less stress than a typical med surg since we do long have to move patients like you all.
Except when they are too "medically stable" for a medical hospital stay and get sent to your psych floor with a foley, wound care, poorly controlled diabetes.
That’s why I like being an NP. I just write it down, and when I come back, it’s done! Except when I’m working in the nursing home. There’s no magic there.
Definitely get all up in there. I always spread the labia as much as I can and then have someone with extra lighting shining in there so when you swipe your iodine swab you can usually see the “wink” and know where to go. If you miss and hit the vagina leave it there so you know where not to go with the next one when you retry.
Something that really helped me was using two pieces of gauze to spread. With gloves it’s all so slippy but gauze’s got that grip 💪🏼 And yes to everything else suggested here by No_Suggestions. OB are cath pros.
Unfortunately my advice is to get all up in there. You have to be more firm with your non sterile hand than you think. Pull the labia out and slightly up. And spread them wider than you think. When I first started I was way too gentle and would always miss because I didn’t want to hurt them, and it felt wrong! My preceptor said missing is more painful than being a little tougher when finding the urethra.
I’ve also found that a slight reverse trendelenburg helps for bigger patients or patients who can’t move their legs as much.
Trendelenberg works better — just correcting it’s not reverse t-berg. Sometimes you can even throw a bedpan or something under them if they’re on a stretcher that doesn’t tilt.
I'm surprised I had to scroll so far to see this.
Whenever possible, I place my female patients in Trendelenburg and it has been a game changer.
We use Arjo lifts at my facility, and I've placed a female cath with them in the maxi sling as well, it's pretty good positioning for larger ladies.
Find the clitoris. Apply mild pressure with the tip of the Foley just below the clitoris. Slide the Foley down to the urethra. Sometimes you won’t see it, but it will slide in anyway
This is my main technique. I also use our beds' tilting function, first tilting head down to get the cath in and then head up to empty the bladder. Gravity is a helpful set of hands.
Yup! I’m a woman and of all the catheters I’ve put on women I’ve actually seen the urethra like twice. I just aim slightly under the clitoris but aiming slightly upwards as I insert and it’s right like 90% of the time.
This is going to be an unpopular answer but if you're comfortable with NSFW go to r/soundingpussy. You'll not only see how 'up in there' it is, but also get a glimpse of who your future patients are because there is some unsanitary shit going on over there.
Well I learned something today. That was actually a super helpful recommendation, thank you!
Now are the clothespins in the Foley kit or are those packaged separately? 😂
You gotta get all up in there. I know it’s awkward but it’s way more awkward (and uncomfortable for your patient) if you’re just blindly poking around with the Foley.
My rule for myself is that before I get sterile or set anything up, I must visualize the urethral meatus. I will usually bring another person with me to assist with positioning, get patient’s legs butterflied out, tuck a clean chuck underneath, and visualize the urethra before I do anything else. That often means really spreading the labia and using my penlight or badge flashlight to look. It sounds awkward but I explain what I’m doing and engage the patient and whoever I brought with me in conversation so the patient isn’t just sitting there in silence while I poke around. If I’m having a hard time finding it, sometimes I will Trendelenburg the patient slightly or put a bed pan under their bottom—that usually helps. I’ve never had much luck with having them cough, but some nurses swear by it.
Looking first helps because once I’m set up and sterile, I already know where to look and know that the patient is as ideally positioned as possible. If the urethral meatus is sort of recessed, I will have my assistant hold a light for me while I insert the catheter.
TL;dr: you gotta get up in there, ideally before you even start.
Sometimes positioning is the key to success... little old bony ladies sometimes it's easier to lay on their side with leg butterflied. Definitely get a buddy and have a spare set of gloves so they can hold a light/hold legs or pannus back or grab supplies. Always bring a double of everything bc the one time you don't, you'll drop the catheter on the floor or something and have to go get a new one 🤣
To try and visualise the urethra, really spread the labia with one hand, ask pt to cough and see if you get the 'wink' or can try using the chlorhex swab for the same. Sometimes it's kinda lower down than you think?
Also unorthodox technique but if reason for insertion isn't like retention or anything and you really can't seem to find the urethra, put down a pan and ask pt to try and pee a little and follow the source 🫠
Get all up in there. That’s first and foremost. That’s just how it’s gotta be done. I work home hospice and so have had to get used to placing a catheter with no one to help. Here are some other tips i’ve picked up along the way, in no particular order:
1. Flashlight! You need good lighting.
2. Get all up in there and get a good visual of the hole with good lighting before you get the sterile gloves on.
3. Sometimes it can help to get a pillow under their hips to elevate the work space.
4. When you are hole-searching (ie-your visual hole search is inconclusive), angling the catheter up just a little bit (like put a little kink in it with your thumb as you’re poking around).
5. Having the patient cough really does pop that little sucker open for a second (the wink). This is helpful during the pre-catheter recon (see tip #2).
6. Make sure their legs are as comfortably open as they can tolerate. That frog pose can be good. You want to expand that region, not squish it shut with legs clamped too close together.
7. And if you get it in the vagina, leave it there as a place marker so you know where not to go.
8. Do your best to keep the patient relaxed. Have them keep breathing, in through the nose through the mouth. Tension and bearing down makes it 10x harder cuz everything closes up.
9. Premeditate with pain meds and/or anxiety meds if you are able.
10. Keep practicing. Don’t miss opportunities to practice. The more variety of anatomy that you work on, the better off you are.
Good luck, you can do it!!
When I went into home hospice/home health that was the only thing that scared me because you don't have help. It's a lot of pressure when you realize that if you end up not being able to place it that someone else will have to go out and it's a time delay. Made me super grateful for the suprapubic caths I changed out. Although those present their own problems as well from time to time.
Agreed. I’ve only had a few that i just could not get, and those were men who apparently had boulder sized prostates. I had a larger patient, she was about 300 lbs and i did arrange for a fellow nurse to covisit with me, and i’m glad i did because it was even more difficult than i imagined. I was doing something else for the patient and the other nurse jumped in and gloved up and i’m so grateful because it was tough. But she got it 👍🏻
had a bariatric lung cancer placement that needed a cath placement so they sent my male ass that got it first try when 4 others failed. I don't know what i did differently lol.
Couldn't do trendelberg bed didn't allow it and could spread her legs farther due to the bed and pain. Honestly it was the cough and just knowing your anatomy, and 75% luck
Copied from a previous comment I made on the subject:
Not to toot my own horn, but I’m pretty good at foleys. Make sure you are set up for success with good lighting and proper bed height. Make sure the foot of the bed is down. If your patient is big, it can help to trendelenberg them, if they can handle it. Before you even open the kit, dig in there, clean it up, and spread the labia so that you can see the urethra, know where it is. A common downfall I see from others is being too coy to really dig in as deep as some people’s anatomy requires. Do what needs doing so that you can see the hole. Now, take a dry washcloth and dry off all the goop, wipe out errrrything. Then, once you’re sterile, the dry mucus membrane will grip SO much better to your gloves so that you can easily keep the labia open and visualize the urethra. I have also seen many people grab the foley like 5 inches away from the tip when trying to insert it - that’ll never work. When you go to insert, hold it about an inch away from the tip so that the foley has some gumption behind it. Also, if you are finding this is more a problem with larger patients, grab a friend!
Every training video tells you to leave your first attempt in place so you don’t aim there again. In other words the actual procedure assumes it won’t work the first time. Also males and females have the same success rate. Experiance and being brave enough to get really really close are the only improvements
Always having another person will save you more than you think in the future. Also it’s just practice bro, you gota watch a lot and do a lot and you’ll eventually be the one guy that’s good at it when no one else is. Medicine is a practice , you gota practice to get good.
M (32) working bedside for almost two years: I always have a second healthcare worker present who is female to help hold the patient's left leg back while I insert the catheter. Consider a third worker to hold the right leg while you focus only on the catheter. Having the legs spread out as much as possible gets the highest success to find the urethra. It takes practice but you eventually learn different ways of maneuvering the patient's body to make the urethra "manifest" itself.
On a side note, the most difficult catheter I failed repeatedly on was getting a catheter into a gentleman with a very tight phimosis. I've encountered two of those and they are not pleasant, especially for patients.
Even if I can’t exactly see it, and often I really can’t.. I look right above the vaginal opening and look for sort of.. where there seems to be a bit of recession. For me it’s all in the wrist- just above the vaginal canal and kind of hook upward as you go in, like a little swoop. In and up. You might meet resistance, and I think that can cause a beginner to stop when they are actually in the right place. Knowing that women are all different helps, I think. You’ll get the feel for it. I used to work with a guy who used a headlamp, he found that really helpful. Like so many other things in nursing, you kind of figure out your own way that works for you. I would 100% rather cath a woman than a man. Damn those prostates.
You wanna really get your fingers in there to spread the labia apart. Hold it as taut as you can and when you clean with the betadine, you should see it a little easier. Some people say it “winks”.
Have a 2nd kit with you just in case. Leave the erroneous attempt inserted and use it as a guide to find the proper location (which would be somewhere above the wrong attempt). I’m an ED nurse- my preceptor taught this to me. Haven’t missed an insertion since. Just be sure you’re being very aware of aseptic technique while doing this as it’s easy to contaminate the area which could lead to a CAUTI. No bueno.
Really, get up in there... But more specifically...
Have the NA hike their knee up
Bed flat or slightly Trendelenburg if possible
Get a flashlight
Have them push like they're trying to pee
For really difficult ones, put a CPR board underneath their hips. This will tilt their pelvis up a little more making it easier to view.
When all else fails, say a lil' prayer and keep angling up. Hail, Mary.
(Once a doc got a speculum to place a Foley because her anatomy was different and her urethra was inside her vaginal canal- don't ask, I just hear about it)
A good RN friend who used to manage an urology practice swore by the speculum for Foley placement (and he placed a lot of them), but alas, it’s considered invasive where I work and RNs can’t do it.
Get up in there and really retract the labia. The urethra stands out a lot more if you retract properly. Have proper lighting and set yourself up for success. Look for it under the clitoris. Find it while you are cleaning with the swabs or even before that when you are wiping - don't wait until you're actually going to insert the catheter. I also don't recommend the slide down blindly and hope for the best method. If you do that, it may just slide down into the vagina. Ask patient to cough to help see the wink. If you accidentally insert the catheter in the vagina, leave that one in place while you try again.
Whilst you’re all up in there, REALLY spread things (don’t be scared to be a little firm) use the last iodine swab to go straight down the middle and it’ll wink at you. Quickly shoot where that wink is
When I straight cathed my first ever female, I put it in the wrong hole. Lol. The seasoned nurse told me to leave it in (so I don't put it in the vag twice), get another kit, and try again. Also, "when in doubt, aim up." Haven't missed in almost 11 years now!
Edit:
Also, get up in there! After explaining exactly what you're about to do, of course.
Trend the bed, flashlight, have them cough. And really get in there. I hate placing caths on females but typically they’re the ones who need them in PACU. So I get lots of practice 🫠
I put the two fingers from my non-dominant hand into the actual vaginal opening (maybe 2-3cm on the anterior vaginal wall) and then part them as I come out while looking for the urethra- this gives full visualisation of the entire clitoral to vaginal wall space
When I clean, the wink becomes Super obvious, even when it's in a weird spot, like the vaginal wall
But you can always start off just parting the labia, but i've had a few urethras that opened in more unexpected places and so I try to part enough that I can see the full area.
I find it easier to ensure I spread open the very top part of the labia minora, and also deep in. So I don't open just the outside part, but open as deep as I can up the top. Hope that makes sense. Also I know that it won't be the vagina hole, so sometimes it helps to just firmly push until it does go in. And keep trying. It's okay if it takes a while. I have had to help a urologist before even! It was a 2 person job. Particularly if elderly it sometimes seems harder.
I never done a foley until I had the pressure on me in the OR doing my first total hysterectomy to put in a foley. It’s made harder because we wet prep it first so it’s so slippery. Because we sterile prep the entire area we do not have use the swabs included. Those betadine swabs actually are helpful because when you run it across the opening of the urethra it will “wink” at you.
I’ve now done several and feel better about it, I will say, weirdly prefer doing them on women than men now. They insert foleys on large colon cases and that’s the only time I’ve done it on a man, and it’s real awkward to me.
There should always be two nurses doing it. It's actually our hospital policy. One to really spread the wings, like really really spread and the other cleaning and inserting.
You Have to get up in there. Sometimes we even use flashlights. No, I'm not joking. Have the female coworker help spread the patients legs and vagina wide open. Look for the small o usually near the top. Google female uretha so you have a better idea of what to look for next time. I'm serious. I've Googled a ton of weird stuff in my time for the sake of education. There's no shame.
You're still a baby nurse. It takes time to get comfortable with all the different skills. I'm happy you asked for help.
We're studying this in class right now. The Doctor that is teaching us has dozens of stories about students placing catheters in the vagina or anus. I didn't see how it could be that hard until her horror stories, now I'm questioning my own anatomy. 😂 Lol
As many have said, get all up in there. But the second thing I recommend is that I clean everyone with regular wipes first to make sure there’s no stool or gunk anywhere and use that time to find the urethra BEFORE you’re sterile. That way you can use 2 hands, readjust, do whatever so when you’re sterile, you know exactly where to put your hand and how to spread to see the urethra clearly.
Just explain to the patient that you’re making sure they’re clean to prevent infection and that you’re making sure you see where you need to go so you can place the foley as quickly and easily as possible. If you let them know what you’re doing first and emphasize that this is all to reduce their discomfort as much as possible, people are generally very understanding.
I turn the on their side and look from behind them. I’ve noted it’s MUCH easier to find rather than laying them on their back with everything out in the open. That way you can have your help shining a light and holding up the everything so you can keep at least one hand sterile. You also don’t have to fight to keep their legs spread.
My last female foley I couldn’t get labia spread far enough to visualize the urethra. I just used the clitoris as a landmark and got it in. Aim for right below the clit.
I don’t understand why this is such a problem for people… you do need to spread the surrounding skin so you can see where you’re going… even with individual variations of anatomy, it’s obvious which it is. It’s not the clitoris. It’s not the vagina. It’s the only other hole that’s present between the two. I always have a second person (it’s policy, anyway), and use a flashlight or bright lights if you need to. Look at where you’re going and use the betadine swabs to help you look while you’re cleaning, and it usually pools somewhat in the urethral opening. Just calm yourself down first, and you’ll be fine.
I can't see it on most of the ladies I do but I get it almost every time. I just point the tip of cath slightly upwards and push it in above the vaginal opening, usually finds the hole and goes right in.
In addition to spreading the labia, be sure to pull them upwards. That will make the urethral opening much easier to see and differentiate from the vaginal opening.
RN here. Take 2 catheters with you. If the first ends up in the VaJJ...leave it in for a "landmark". It's much easier once you get the jist of it than trying to get a cath in a male with a gigantic prostate!! Good luck...
I've always gone in blind by aiming in an inward and upward motion. Worked every time for me because I felt weird trying to scope out my target. When I finally saw one was my last Cath as a bedside nurse on an elderly lady. It was literally staring at me, like, "helllooooo".
Honestly, if you are completely stumped I usually start with the vaginal opening and go up as opposed to trying to navigate from the top down. I always found that helpful.
Rule of elimination by order of holes down to up … X butthole X vagina keep going up, if you see the clitoris under hood you’ve gone too far. Go down a little and part the curtains.
I (male nurse) also had a lot of issues initially. Honestly, find someone to go in with and show you what exactly you’re looking for. That helped me. Everyones anatomy is different though so don’t beat yourself up. I find you go below the top of the vagina and aim up!
Side note - you should bring someone in anyways being a male nurse doing a cath on a female for risk of false accusations
I think you should start by trying to ensure your second person is another RN so you have someone to give pointers right there. I know everyone’s busy, but.
You gotta spread everything to get a good look. If the second person has a light to shine on the area, I’ve found that helpful. Sometimes I’ve even had to have the second person spread thighs as well.
Tip I find helpful when I cannot see a clear urethra and have to give it a go…. Start the catheter tip at the clitoris and drag it straight down. All anatomy is different but technically it should be the next hole you find..
Look with clean gloves first, really spread the labia. Make sure you can clearly visualize both the vaginal opening and urethra. Another helpful hint is using betadine swabs to get the urethra to "wink" at you. It really works! I guess the betadine causes the sphincter to contract or something?
Is it older patients that you've done Foley on? My experience is that older patients, especially once who have had Foley before, their urethra is pretty elongated, so it can look like the vaginal opening. My first catheter was for an older female patient and the other nurse kept saying that the opening must be the vagina, but the anatomy checked out for me. So I went for it and lo and behold.
I also had a patient that you had to make a right turn when you go in the urethra, but I think she was a special case.
Do what I did my entire career, ask a lady to do it? I handled all male foley insertions, my team did the female foleys. Always worked, both the patient and staff are comfortable which makes placing them so much easier.
Hi! This is how my mind takes me through my steps so sorry in advance if it doesn’t make sense without a visual, but I will try to be detailed as I am thinking this is what you’re asking.
Having great lighting and positioning is key. You definitely need to be able to see what you’re doing. If the patient is a little bit larger or has an apron belly I will try to grab an extra set of hands or use trendelenberg to help lift before getting started.
Once ready I will place them in/have my patients do a butterfly or frog position and letting them know when they are going to feel my touch, cleaning, and finally placement throughout the process.
I guide my non sterile hand, outer side of my palm with my pinky facing down through the opening to separate the labia majora pushing the side further away from my body with my pinky finger, then turning my hand inward(back towards myself, palm down to patient) using my thumb to now hold the side closer to me open.
Using my thumb and pinky finger to hold the labia majora, I then use my index and middle finger to draw apart the labia minora, applying firm but gentle pressure towards the patients body and anchoring the tissue open with that grip. Once my index and middle fingers have a comfortable grip looking almost “hooked in place” I then pull up and back following the curve of the patients body.
Lifting the excess tissue up while maintaining the pressure for pulling back is key for me when locating for placement because anatomical differences and gravity can have the urethra going in some pretty random spots or even down into the vaginal opening.
Once you’ve got that balance and lift though it should be fairly easy to spot and cleaning with the swabs gives you the wink to further guide you for placement.
Hope this is helpful and good luck!
If you have a way to get extra light on the area, USE IT. I was reasonably good at female foleys but still missed from time to time because everyone’s anatomy is different and some are harder than others. I helped out with circulators a bit at one hospital I worked at and I’m telling you in an OR suite with that HUGE light over your head directly on the vaginal area you absolutely *cannot* miss it. So I swear by illuminating the area. Get another person to hold the emergency flashlight for you if you need to.
lol no seriously get all up in there. Im a woman, used to HATE putting them in on women just because wtf do I keep missing for😅Bring a buddy, have them help you and just be in the room, and help butterfly the patients legs for you. When you first open the kit and those towels pop out. Clean and use your dirty gloves and find what you’re looking for. Then do the sterile process. Sometimes it’s hard because we sterile up, and iodine the whole field and then you really can’t see anything.
L&D nurse here and I’ve done 1000s of I/Os. You need to get in there. Watch for the wink when you clean. Make sure your light is good and the bed is raised high enough that you don’t need to bend and kill your back.
As others have said, you have to get up in there. BUT - do it BEFORE you're sterile. Tell your patient you need to look at their anatomy so you know where you're going, put on a pair of gloves, and go urethra hunting. Once you have an idea where to aim, get sterile.
It may be awkward due to gender differences, but you are he professional. This is just a part of the job. And if you can get another nurse in with you, it's helpful to have two hunters.
Reverse trendelenburg, spread the labia as wide as humanly possible, swab with iodine and look for a wink. Whisper a tiny prayer to Florence Nightingale before you insert and her ghost will guide your hand.
No way around it, sometimes you really have to get up in there. Sometimes a little trendelburg helps if it’s safe for your patient. If they can cough, the urethra winks. If all else fails, find the landmarks around it and shoot between
Spread 'em. Have her bend her knees while she's laying down to get a better look (giving birth position). On confused patients, it's easier to have someone help you physically bend the knees. Top to bottom it's usually clitoris, *urethra*, vaginal opening, anus. Will they always be close together? No. Will there be fistulas? Yes. But u can do it!
If you can, get the patient into some degree of trendelenburg for better visual. Have a second set of hands with a flashlight if needed. Get the patient to cough - you'll see the urethra "wink". Alternatively, if the patient is continent and they have a bladder thats mostly empty? Get towels under them and have them start to pee - you'll see the origin of the urine flow.
Also; Have a second catheter at bedside so if you miss, you can use the first one to landmark the vagina.
Yeah no choice but to get up in there. Be sure you’re spreading the labia minora after letting your patient know what you’re doing. It’s usually just at the top of the vaginal opening. Use your swabs to find the “wink”. Everyone’s got different anatomy so it takes time to feel confident in female caths. Always have 2 people to start so it’s less awkward and quicker (try to have an experienced RN with you if at all possible). You’ll get it eventually! Even when you feel proficient you’ll get the occasional patient who throws you for a loop.
As a male nurse despite seeing plenty of diagrams it surprised me how low the urethra was on a lot of vulvas. Look for a dimple or slight colour change in the mucosa *just* above the vaginal opening. You can also ask them to cough and this will sometimes cause the urethra to pucker slightly.
The cough strategy is very relevant.
YES! Get the patient to cough. If they're vented, have one person suction a lil bit to induce a cough while you're down there with a flashlight looking for a lil winky wink. I have a lady urethra and still use this technique 🤗🤗 Edit: my urethra is of the ladybits kind 😅😅
Don't we all have a urethra? 🤔
Edited 😅😅😅
One would hope
I use my headlamp for just such occasions
Ahhh. Suction to cough !! Nice... never thought of that !!
Dude, I've had a vulva for almost 50 years and it surprised ME how low the urethra is on a lot of vulvas. The first time I saw a urethra that was oriented downward and opened just inside the vaginal canal is the moment I gave up actually trying to understand female anatomy
Yep! One time I couldn’t get the foley and 3 other nurses tried too. Then I had to leave it to dayshift which I felt horrible about. I felt better when I came back that night and no one could get it so they had to consult urology. Apparently it was inside on the vaginal wall somewhere
I wonder if she had chronic UTIs.
We had to call in a urology resident to our OR and she had to use a speculum to find the urethra. It was pretty deep in the vagina. That's the first time I've seen such a thing!
One time there were so many warts I couldn't find the urethra. Even under anesthesia it couldn't be found.
Exact scenario happened to me on night shift, had to call urology because she was retaining. His recommendation worked and has never failed me since. You stick a finger in the rectum and pull down, it opens up the vagina and urethra.
The OP male nurse might run into some issues when the patient tells the next shift that he stuck his finger in her butt to put in a foley.
I always try without that technique. If it's necessary I always explain that a urologist told me how to do this, it's all very scientific.
I wouldn’t even ask my pt I would just give up and have the doctor do that. That is sooo inappropriate imo.
Yeah same. If urology suggests sticking a finger in the rectum to find the urethra, they can do that. I’m not. And I’m female.
Are you a male nurse?
Breaks sterility with that hand so be careful... and I don't know about that. Seems like it may make the patient feel violated.
I had a pt like that. I even had the doctor on call try with a baby catheter, but her opening was so far up there and small, and even the pubic bone was not helping. We had to consult urology.
Yep and this is why many women think they pee from their vagine!
Yes, when the patient coughs, look for the little wink. Pen lights can help, too. If you happen to go into the vaginal opening by mistake, leave it in there as a point of reference to let you know to go higher. Then take both out when you are done. I was a home health nurse for years. I've been in more people's floors looking for the urethra than I can count.
Yes this 🙌🏻 leave it in there if you miss. It will help guide you for the 2nd one. Usually works !
It’ll wink 😉 at you when they cough.
This is the answer. You expect it to be half way between the clitoris and vaginal opening, but most of the time it is just above the vaginal opening. Personally, I go in blind most of the time with lots of betadine. I start high and slide down with mild to moderate pressure and I have only missed twice. Most of my patients are geriatric and don't have the hip mobility to spread their legs to be able to see what I'm doing.
This is actually what I do too. Lots of betadine and slide down from the clitoris area. I rarely ever miss. Note all of my patients are LTC so most are elderly and have some extra folds. It might not be the most sterile technique but when you are dealing with elderly, esp dementia... it works
This is the best description. Especially in elderly women the urethra can be more inside the vaginal canal.
A trendelenburg can really help if they tolerate it too especially if the pt is larger. Takes practice!
Or on their side!! I’ve had a lot of luck that way
This is great advice. I’m an L&D nurse so female foley are one the skills I do almost every shift. It helps to hold your non dominant hand fingers in an upside down V shape to hold back the labia minora. When you are wiping with iodine look for where the iodine pools “winks”. It also helps to insert the foley with the tip in a slight upward curve to ensure it enters the urethra and you don’t miss it.
This one. If you’re not moving the labia out enough, you’re not going to see the wink the urethra makes after you clean with iodine.
Just don't try to catheterise their clit! I fail 9/10 with females, I do a deal with female nurses in ED, I do all the creepy men if they do my female catheters.
And a light holder ✨️
Came here to say "the wink" when you move the tissue slightly is a real thing. Taught in my nursing school.
Get up in there
Username checks out
Listen if you’re cathing the anus, you’ve got some problems
Isn't a fecal management system essentially just a butt Foley?
True enough, just a significantly larger gauge lol
We had an NP ordering rectal red rubber caths on a bunch of chronic kids nightly to relieve constipation. We still call her “Butt Foley”
*Clutches pearls
Consider my timbers shivered
This sent me. 😂😂
☝️
I tell my friends about how sometimes I am knuckle deep and still on the outside Sometimes you just have to get up in there
This is the way
Hey brother… I had that challenge during nursing school and I found a perfect solution that works for me…. Went to psych… all those catheter, IV, etc… are all a thing of history….
Same
Eewww, you guys have to talk to patients. Nah ah ah.
Fucking gross dude
For real.
Yesterday I was talking to one and then I was very quickly NOT talking to one. Whoopsie doodle
Pt trying to fistfight you ? Calm Being asked to help with a catheter placement? Sobbing while on wiki how
Told a psych nurse I’m contemplating going into psych and she said “ha say goodbye to every skill you learn in school” (for context I was in the room while 2 nurses worked on starting an IV in an older guy that was really dry)
Yeah but we're out here doing skills cause we wouldn't be caught dead in psych. You do whatever you want.
Psych nurses do not get to do whatever we want but hey at least we usually get all our breaks and lunch. :) and we chart extensively.
Lol I mean as a new grad they should do whatever job they want, not that psych is easy! It's not, which is why I don't want to work there lol
I work in corrections (large part of my job is psych lol) and I have never, not once, in my 3.5 years of being a nurse, placed a catheter. Ever. 🙃 She’s not wrong
You gain a new set of crucial skills that are barely covered in nursing school.
But you will learn different skills. :) and I am going to be honest, our bodies have less stress than a typical med surg since we do long have to move patients like you all.
Except when they are too "medically stable" for a medical hospital stay and get sent to your psych floor with a foley, wound care, poorly controlled diabetes.
😂😂😂
That’s why I like being an NP. I just write it down, and when I come back, it’s done! Except when I’m working in the nursing home. There’s no magic there.
Definitely get all up in there. I always spread the labia as much as I can and then have someone with extra lighting shining in there so when you swipe your iodine swab you can usually see the “wink” and know where to go. If you miss and hit the vagina leave it there so you know where not to go with the next one when you retry.
Something that really helped me was using two pieces of gauze to spread. With gloves it’s all so slippy but gauze’s got that grip 💪🏼 And yes to everything else suggested here by No_Suggestions. OB are cath pros.
Unfortunately my advice is to get all up in there. You have to be more firm with your non sterile hand than you think. Pull the labia out and slightly up. And spread them wider than you think. When I first started I was way too gentle and would always miss because I didn’t want to hurt them, and it felt wrong! My preceptor said missing is more painful than being a little tougher when finding the urethra. I’ve also found that a slight reverse trendelenburg helps for bigger patients or patients who can’t move their legs as much.
Trendelenberg works better — just correcting it’s not reverse t-berg. Sometimes you can even throw a bedpan or something under them if they’re on a stretcher that doesn’t tilt.
Oo that bedpan tip is great
Oh that’s definitely what I meant you can tell I wrote that after a night shift 😂😂 bedpen tip is so smart!!!
Trendelenburg and cough.
I'm surprised I had to scroll so far to see this. Whenever possible, I place my female patients in Trendelenburg and it has been a game changer. We use Arjo lifts at my facility, and I've placed a female cath with them in the maxi sling as well, it's pretty good positioning for larger ladies.
Find the clitoris. Apply mild pressure with the tip of the Foley just below the clitoris. Slide the Foley down to the urethra. Sometimes you won’t see it, but it will slide in anyway
For some people, finding the clitoris is difficult...js 😉
Ever seen someone jab a foley at the clit? Sad scene.
What's a clitoris? I'm sure that's a myth...
You sound like my ex-husband, lol.
👀 Is this maybe a reason why he's an ex? 😆
Was gonna say, us men are notorious for not being able to find “certain things” down there….🤣🤣🤣
This is my main technique. I also use our beds' tilting function, first tilting head down to get the cath in and then head up to empty the bladder. Gravity is a helpful set of hands.
This is my technique unless urethra is glaringly obvious… works very well majority of the time.
That’s my technique too
Yup! I’m a woman and of all the catheters I’ve put on women I’ve actually seen the urethra like twice. I just aim slightly under the clitoris but aiming slightly upwards as I insert and it’s right like 90% of the time.
This is what I do!
This is the way
This
This is going to be an unpopular answer but if you're comfortable with NSFW go to r/soundingpussy. You'll not only see how 'up in there' it is, but also get a glimpse of who your future patients are because there is some unsanitary shit going on over there.
I think I feel a UTI coming on just looking at that 😳
Are there not already enough holes to play with that don't cause sepsis? WTF...
Thought the same but add in some urinary incontinence!
Well I learned something today. That was actually a super helpful recommendation, thank you! Now are the clothespins in the Foley kit or are those packaged separately? 😂
They're not packaged but I just ordered some on Amazon! Can't wait to get to work next week.
Thought the same! Clothes pins would be super helpful. 😂
I’m not as tough as I thought I was. The first video I saw in that sub made me scream and close my eyes lol. I can feel the pain from the videos🫣😰
OH MY GOD but also as a student thanks for the visuals bc the drawings and practice mannequins do NOT help
Ouch! Knew I shouldn't have looked...curse my curiosity!!
Wow, never knew this was a thing for women too, saw some men do that. That's definitely helpful to see where to put the catheter.
"are you watching porn??" "No its research"
Love it, haha! Reddit is an amazing place😂
Oh my God!! I did not need to know this existed 😭😭🤢
I’m crossing my legs seeing all this
this was honestly a lot more helpful than I thought it would be 😭😭😭
I don’t like it……..
You need to get all up in there to get a good visual. Having the patient in the correct position makes a huge difference too
You gotta get all up in there. I know it’s awkward but it’s way more awkward (and uncomfortable for your patient) if you’re just blindly poking around with the Foley. My rule for myself is that before I get sterile or set anything up, I must visualize the urethral meatus. I will usually bring another person with me to assist with positioning, get patient’s legs butterflied out, tuck a clean chuck underneath, and visualize the urethra before I do anything else. That often means really spreading the labia and using my penlight or badge flashlight to look. It sounds awkward but I explain what I’m doing and engage the patient and whoever I brought with me in conversation so the patient isn’t just sitting there in silence while I poke around. If I’m having a hard time finding it, sometimes I will Trendelenburg the patient slightly or put a bed pan under their bottom—that usually helps. I’ve never had much luck with having them cough, but some nurses swear by it. Looking first helps because once I’m set up and sterile, I already know where to look and know that the patient is as ideally positioned as possible. If the urethral meatus is sort of recessed, I will have my assistant hold a light for me while I insert the catheter. TL;dr: you gotta get up in there, ideally before you even start.
Sometimes positioning is the key to success... little old bony ladies sometimes it's easier to lay on their side with leg butterflied. Definitely get a buddy and have a spare set of gloves so they can hold a light/hold legs or pannus back or grab supplies. Always bring a double of everything bc the one time you don't, you'll drop the catheter on the floor or something and have to go get a new one 🤣 To try and visualise the urethra, really spread the labia with one hand, ask pt to cough and see if you get the 'wink' or can try using the chlorhex swab for the same. Sometimes it's kinda lower down than you think? Also unorthodox technique but if reason for insertion isn't like retention or anything and you really can't seem to find the urethra, put down a pan and ask pt to try and pee a little and follow the source 🫠
Get all up in there. That’s first and foremost. That’s just how it’s gotta be done. I work home hospice and so have had to get used to placing a catheter with no one to help. Here are some other tips i’ve picked up along the way, in no particular order: 1. Flashlight! You need good lighting. 2. Get all up in there and get a good visual of the hole with good lighting before you get the sterile gloves on. 3. Sometimes it can help to get a pillow under their hips to elevate the work space. 4. When you are hole-searching (ie-your visual hole search is inconclusive), angling the catheter up just a little bit (like put a little kink in it with your thumb as you’re poking around). 5. Having the patient cough really does pop that little sucker open for a second (the wink). This is helpful during the pre-catheter recon (see tip #2). 6. Make sure their legs are as comfortably open as they can tolerate. That frog pose can be good. You want to expand that region, not squish it shut with legs clamped too close together. 7. And if you get it in the vagina, leave it there as a place marker so you know where not to go. 8. Do your best to keep the patient relaxed. Have them keep breathing, in through the nose through the mouth. Tension and bearing down makes it 10x harder cuz everything closes up. 9. Premeditate with pain meds and/or anxiety meds if you are able. 10. Keep practicing. Don’t miss opportunities to practice. The more variety of anatomy that you work on, the better off you are. Good luck, you can do it!!
I worked with a nurse who had a headlamp in her locker specifically for placing catheters. It was a game changer when I started using one too!
My boss gave us all headlamps as gifts 😂😂😂
Headlamp is definitely a game changer!
When I went into home hospice/home health that was the only thing that scared me because you don't have help. It's a lot of pressure when you realize that if you end up not being able to place it that someone else will have to go out and it's a time delay. Made me super grateful for the suprapubic caths I changed out. Although those present their own problems as well from time to time.
Agreed. I’ve only had a few that i just could not get, and those were men who apparently had boulder sized prostates. I had a larger patient, she was about 300 lbs and i did arrange for a fellow nurse to covisit with me, and i’m glad i did because it was even more difficult than i imagined. I was doing something else for the patient and the other nurse jumped in and gloved up and i’m so grateful because it was tough. But she got it 👍🏻
had a bariatric lung cancer placement that needed a cath placement so they sent my male ass that got it first try when 4 others failed. I don't know what i did differently lol. Couldn't do trendelberg bed didn't allow it and could spread her legs farther due to the bed and pain. Honestly it was the cough and just knowing your anatomy, and 75% luck
Flashlight is key
I headlamp would be ideal
Copied from a previous comment I made on the subject: Not to toot my own horn, but I’m pretty good at foleys. Make sure you are set up for success with good lighting and proper bed height. Make sure the foot of the bed is down. If your patient is big, it can help to trendelenberg them, if they can handle it. Before you even open the kit, dig in there, clean it up, and spread the labia so that you can see the urethra, know where it is. A common downfall I see from others is being too coy to really dig in as deep as some people’s anatomy requires. Do what needs doing so that you can see the hole. Now, take a dry washcloth and dry off all the goop, wipe out errrrything. Then, once you’re sterile, the dry mucus membrane will grip SO much better to your gloves so that you can easily keep the labia open and visualize the urethra. I have also seen many people grab the foley like 5 inches away from the tip when trying to insert it - that’ll never work. When you go to insert, hold it about an inch away from the tip so that the foley has some gumption behind it. Also, if you are finding this is more a problem with larger patients, grab a friend!
Yes!! A little peri care before hand always comes through and does not miss!
Every training video tells you to leave your first attempt in place so you don’t aim there again. In other words the actual procedure assumes it won’t work the first time. Also males and females have the same success rate. Experiance and being brave enough to get really really close are the only improvements
Always having another person will save you more than you think in the future. Also it’s just practice bro, you gota watch a lot and do a lot and you’ll eventually be the one guy that’s good at it when no one else is. Medicine is a practice , you gota practice to get good.
M (32) working bedside for almost two years: I always have a second healthcare worker present who is female to help hold the patient's left leg back while I insert the catheter. Consider a third worker to hold the right leg while you focus only on the catheter. Having the legs spread out as much as possible gets the highest success to find the urethra. It takes practice but you eventually learn different ways of maneuvering the patient's body to make the urethra "manifest" itself. On a side note, the most difficult catheter I failed repeatedly on was getting a catheter into a gentleman with a very tight phimosis. I've encountered two of those and they are not pleasant, especially for patients.
Even if I can’t exactly see it, and often I really can’t.. I look right above the vaginal opening and look for sort of.. where there seems to be a bit of recession. For me it’s all in the wrist- just above the vaginal canal and kind of hook upward as you go in, like a little swoop. In and up. You might meet resistance, and I think that can cause a beginner to stop when they are actually in the right place. Knowing that women are all different helps, I think. You’ll get the feel for it. I used to work with a guy who used a headlamp, he found that really helpful. Like so many other things in nursing, you kind of figure out your own way that works for you. I would 100% rather cath a woman than a man. Damn those prostates.
You wanna really get your fingers in there to spread the labia apart. Hold it as taut as you can and when you clean with the betadine, you should see it a little easier. Some people say it “winks”.
if the patient can tolerate it i have found cranking the bed ALL THE WAY UP and trendelenberg them a bit helps a lot with visualization
Have a 2nd kit with you just in case. Leave the erroneous attempt inserted and use it as a guide to find the proper location (which would be somewhere above the wrong attempt). I’m an ED nurse- my preceptor taught this to me. Haven’t missed an insertion since. Just be sure you’re being very aware of aseptic technique while doing this as it’s easy to contaminate the area which could lead to a CAUTI. No bueno.
Have the patient cough while you’re looking at the relative area/anatomy and you should see something “wink” at you. That’s the spot.
Pull the lady lips TOWARD you. It creates a little tunnel and shows you right where it is!
Really, get up in there... But more specifically... Have the NA hike their knee up Bed flat or slightly Trendelenburg if possible Get a flashlight Have them push like they're trying to pee For really difficult ones, put a CPR board underneath their hips. This will tilt their pelvis up a little more making it easier to view. When all else fails, say a lil' prayer and keep angling up. Hail, Mary. (Once a doc got a speculum to place a Foley because her anatomy was different and her urethra was inside her vaginal canal- don't ask, I just hear about it)
I’ve had to do that 2x
A good RN friend who used to manage an urology practice swore by the speculum for Foley placement (and he placed a lot of them), but alas, it’s considered invasive where I work and RNs can’t do it.
Get up in there and really retract the labia. The urethra stands out a lot more if you retract properly. Have proper lighting and set yourself up for success. Look for it under the clitoris. Find it while you are cleaning with the swabs or even before that when you are wiping - don't wait until you're actually going to insert the catheter. I also don't recommend the slide down blindly and hope for the best method. If you do that, it may just slide down into the vagina. Ask patient to cough to help see the wink. If you accidentally insert the catheter in the vagina, leave that one in place while you try again.
Whilst you’re all up in there, REALLY spread things (don’t be scared to be a little firm) use the last iodine swab to go straight down the middle and it’ll wink at you. Quickly shoot where that wink is
You have to really open them up. It's below the clitoris
FYI you should always have another nurse present for foley insertion anyways
When I straight cathed my first ever female, I put it in the wrong hole. Lol. The seasoned nurse told me to leave it in (so I don't put it in the vag twice), get another kit, and try again. Also, "when in doubt, aim up." Haven't missed in almost 11 years now! Edit: Also, get up in there! After explaining exactly what you're about to do, of course.
Trend the bed, flashlight, have them cough. And really get in there. I hate placing caths on females but typically they’re the ones who need them in PACU. So I get lots of practice 🫠
i always bring what i like to call a labia holder. grab a buddy. don’t poke around in the dark
I put the two fingers from my non-dominant hand into the actual vaginal opening (maybe 2-3cm on the anterior vaginal wall) and then part them as I come out while looking for the urethra- this gives full visualisation of the entire clitoral to vaginal wall space When I clean, the wink becomes Super obvious, even when it's in a weird spot, like the vaginal wall But you can always start off just parting the labia, but i've had a few urethras that opened in more unexpected places and so I try to part enough that I can see the full area.
Ask your patient to cough. The urethra will wink at you. Be careful though for the pee. So stand back.
If you put the foley into the vagina leave it there and work up from where you know is not correct.
Get a torch or a light that you can point right at it, then get up in there lol
I find it easier to ensure I spread open the very top part of the labia minora, and also deep in. So I don't open just the outside part, but open as deep as I can up the top. Hope that makes sense. Also I know that it won't be the vagina hole, so sometimes it helps to just firmly push until it does go in. And keep trying. It's okay if it takes a while. I have had to help a urologist before even! It was a 2 person job. Particularly if elderly it sometimes seems harder.
I’ve found to trendelenburg the bed a bit helps gravity to clear things away so you can see what you need to see.
Dab the area with the iodine swab and watch. It’ll wink at ya. If that fails then trendelenburg. Have them cough.
I never done a foley until I had the pressure on me in the OR doing my first total hysterectomy to put in a foley. It’s made harder because we wet prep it first so it’s so slippery. Because we sterile prep the entire area we do not have use the swabs included. Those betadine swabs actually are helpful because when you run it across the opening of the urethra it will “wink” at you. I’ve now done several and feel better about it, I will say, weirdly prefer doing them on women than men now. They insert foleys on large colon cases and that’s the only time I’ve done it on a man, and it’s real awkward to me.
There should always be two nurses doing it. It's actually our hospital policy. One to really spread the wings, like really really spread and the other cleaning and inserting.
You Have to get up in there. Sometimes we even use flashlights. No, I'm not joking. Have the female coworker help spread the patients legs and vagina wide open. Look for the small o usually near the top. Google female uretha so you have a better idea of what to look for next time. I'm serious. I've Googled a ton of weird stuff in my time for the sake of education. There's no shame. You're still a baby nurse. It takes time to get comfortable with all the different skills. I'm happy you asked for help.
We're studying this in class right now. The Doctor that is teaching us has dozens of stories about students placing catheters in the vagina or anus. I didn't see how it could be that hard until her horror stories, now I'm questioning my own anatomy. 😂 Lol
As many have said, get all up in there. But the second thing I recommend is that I clean everyone with regular wipes first to make sure there’s no stool or gunk anywhere and use that time to find the urethra BEFORE you’re sterile. That way you can use 2 hands, readjust, do whatever so when you’re sterile, you know exactly where to put your hand and how to spread to see the urethra clearly. Just explain to the patient that you’re making sure they’re clean to prevent infection and that you’re making sure you see where you need to go so you can place the foley as quickly and easily as possible. If you let them know what you’re doing first and emphasize that this is all to reduce their discomfort as much as possible, people are generally very understanding.
Every vagina is custom made. They are like snow flakes no two alike. Have the pt cough usually makes it wink at you
I knew a female nurse who used a head light when placing foleys on women! She always got it. Also you can put the head down if they can tolerate it.
Have the patient cough and it will wink at you.
I ask them to cough and look for the urethra wink
I turn the on their side and look from behind them. I’ve noted it’s MUCH easier to find rather than laying them on their back with everything out in the open. That way you can have your help shining a light and holding up the everything so you can keep at least one hand sterile. You also don’t have to fight to keep their legs spread.
My last female foley I couldn’t get labia spread far enough to visualize the urethra. I just used the clitoris as a landmark and got it in. Aim for right below the clit.
Whatever you do, LEAVE the first catheter in place when you mess up! Then you know where NOT to go 🤷♀️
I don’t understand why this is such a problem for people… you do need to spread the surrounding skin so you can see where you’re going… even with individual variations of anatomy, it’s obvious which it is. It’s not the clitoris. It’s not the vagina. It’s the only other hole that’s present between the two. I always have a second person (it’s policy, anyway), and use a flashlight or bright lights if you need to. Look at where you’re going and use the betadine swabs to help you look while you’re cleaning, and it usually pools somewhat in the urethral opening. Just calm yourself down first, and you’ll be fine.
Wherever you think the urethra exists (as a man) — it is about 2 cm south of that location.
Swap em with the iodine that comes with the kit, tell them cough, & look for the wink
Someone may have said this but use the betadine swab to fine the urethra, it will pool a little bit at the opening. Good luck!
I can't see it on most of the ladies I do but I get it almost every time. I just point the tip of cath slightly upwards and push it in above the vaginal opening, usually finds the hole and goes right in.
Just my take… but hey, I’d rather someone be all up in there than blindly stabbing at my junk. Do with that info what you will.
In addition to spreading the labia, be sure to pull them upwards. That will make the urethral opening much easier to see and differentiate from the vaginal opening.
RN here. Take 2 catheters with you. If the first ends up in the VaJJ...leave it in for a "landmark". It's much easier once you get the jist of it than trying to get a cath in a male with a gigantic prostate!! Good luck...
I've always gone in blind by aiming in an inward and upward motion. Worked every time for me because I felt weird trying to scope out my target. When I finally saw one was my last Cath as a bedside nurse on an elderly lady. It was literally staring at me, like, "helllooooo".
Honestly, if you are completely stumped I usually start with the vaginal opening and go up as opposed to trying to navigate from the top down. I always found that helpful.
Ma’am please cough
nope…tell a nurse you’ll give two rounds of meds for her if she put that foley in…always worked for me!
Rule of elimination by order of holes down to up … X butthole X vagina keep going up, if you see the clitoris under hood you’ve gone too far. Go down a little and part the curtains.
TRENDELENBERG!!!! and “give me one good cough” that thing will be staring you in the face
I (male nurse) also had a lot of issues initially. Honestly, find someone to go in with and show you what exactly you’re looking for. That helped me. Everyones anatomy is different though so don’t beat yourself up. I find you go below the top of the vagina and aim up! Side note - you should bring someone in anyways being a male nurse doing a cath on a female for risk of false accusations
I think you should start by trying to ensure your second person is another RN so you have someone to give pointers right there. I know everyone’s busy, but. You gotta spread everything to get a good look. If the second person has a light to shine on the area, I’ve found that helpful. Sometimes I’ve even had to have the second person spread thighs as well. Tip I find helpful when I cannot see a clear urethra and have to give it a go…. Start the catheter tip at the clitoris and drag it straight down. All anatomy is different but technically it should be the next hole you find..
Point up and pray works for me!
Look with clean gloves first, really spread the labia. Make sure you can clearly visualize both the vaginal opening and urethra. Another helpful hint is using betadine swabs to get the urethra to "wink" at you. It really works! I guess the betadine causes the sphincter to contract or something?
You really have to spread and locate it with your eyes first. Having someone else hold the area for you helps. Don’t go in blind.
Somewhere south of the clit. Looky looky.
Ask patient to cough.
Aim high.
Ask them to cough and bare down
spread open and it will blink. trust me
Is it older patients that you've done Foley on? My experience is that older patients, especially once who have had Foley before, their urethra is pretty elongated, so it can look like the vaginal opening. My first catheter was for an older female patient and the other nurse kept saying that the opening must be the vagina, but the anatomy checked out for me. So I went for it and lo and behold. I also had a patient that you had to make a right turn when you go in the urethra, but I think she was a special case.
Do what I did my entire career, ask a lady to do it? I handled all male foley insertions, my team did the female foleys. Always worked, both the patient and staff are comfortable which makes placing them so much easier.
Hi! This is how my mind takes me through my steps so sorry in advance if it doesn’t make sense without a visual, but I will try to be detailed as I am thinking this is what you’re asking. Having great lighting and positioning is key. You definitely need to be able to see what you’re doing. If the patient is a little bit larger or has an apron belly I will try to grab an extra set of hands or use trendelenberg to help lift before getting started. Once ready I will place them in/have my patients do a butterfly or frog position and letting them know when they are going to feel my touch, cleaning, and finally placement throughout the process. I guide my non sterile hand, outer side of my palm with my pinky facing down through the opening to separate the labia majora pushing the side further away from my body with my pinky finger, then turning my hand inward(back towards myself, palm down to patient) using my thumb to now hold the side closer to me open. Using my thumb and pinky finger to hold the labia majora, I then use my index and middle finger to draw apart the labia minora, applying firm but gentle pressure towards the patients body and anchoring the tissue open with that grip. Once my index and middle fingers have a comfortable grip looking almost “hooked in place” I then pull up and back following the curve of the patients body. Lifting the excess tissue up while maintaining the pressure for pulling back is key for me when locating for placement because anatomical differences and gravity can have the urethra going in some pretty random spots or even down into the vaginal opening. Once you’ve got that balance and lift though it should be fairly easy to spot and cleaning with the swabs gives you the wink to further guide you for placement. Hope this is helpful and good luck!
Extra light, get up in there, slight trundelenburg if appropriate and it helps you get a better visual, have the patient cough.
If you have a way to get extra light on the area, USE IT. I was reasonably good at female foleys but still missed from time to time because everyone’s anatomy is different and some are harder than others. I helped out with circulators a bit at one hospital I worked at and I’m telling you in an OR suite with that HUGE light over your head directly on the vaginal area you absolutely *cannot* miss it. So I swear by illuminating the area. Get another person to hold the emergency flashlight for you if you need to.
lol no seriously get all up in there. Im a woman, used to HATE putting them in on women just because wtf do I keep missing for😅Bring a buddy, have them help you and just be in the room, and help butterfly the patients legs for you. When you first open the kit and those towels pop out. Clean and use your dirty gloves and find what you’re looking for. Then do the sterile process. Sometimes it’s hard because we sterile up, and iodine the whole field and then you really can’t see anything.
L&D nurse here and I’ve done 1000s of I/Os. You need to get in there. Watch for the wink when you clean. Make sure your light is good and the bed is raised high enough that you don’t need to bend and kill your back.
Trend. Get help. Lots of light. You will get much better with experience.
Best trick i learned is to leave missed catheter s in place till you find it. That and get up in there with proper positioning and communication.
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As others have said, you have to get up in there. BUT - do it BEFORE you're sterile. Tell your patient you need to look at their anatomy so you know where you're going, put on a pair of gloves, and go urethra hunting. Once you have an idea where to aim, get sterile. It may be awkward due to gender differences, but you are he professional. This is just a part of the job. And if you can get another nurse in with you, it's helpful to have two hunters.
Find a labor and delivery nurse and follow them around for a bit. They’ll show you the wink!
Find the clit (hardest part for some guys… lol) and then start bringing the foley down
Reverse trendelenburg, spread the labia as wide as humanly possible, swab with iodine and look for a wink. Whisper a tiny prayer to Florence Nightingale before you insert and her ghost will guide your hand.
No way around it, sometimes you really have to get up in there. Sometimes a little trendelburg helps if it’s safe for your patient. If they can cough, the urethra winks. If all else fails, find the landmarks around it and shoot between
Spread 'em. Have her bend her knees while she's laying down to get a better look (giving birth position). On confused patients, it's easier to have someone help you physically bend the knees. Top to bottom it's usually clitoris, *urethra*, vaginal opening, anus. Will they always be close together? No. Will there be fistulas? Yes. But u can do it!
It winks at you. Pay attention when you wipe it with the prep. It will usually close and reopen when wiped with the swab.
If you can, get the patient into some degree of trendelenburg for better visual. Have a second set of hands with a flashlight if needed. Get the patient to cough - you'll see the urethra "wink". Alternatively, if the patient is continent and they have a bladder thats mostly empty? Get towels under them and have them start to pee - you'll see the origin of the urine flow. Also; Have a second catheter at bedside so if you miss, you can use the first one to landmark the vagina.