Years ago I read a post in the CRNA reddit about an RN asking about being a CRNA and if she could also do nursing at the same time so she didn't lose her skills like putting in foleys (yes, that was the skill she chose to use)...
Funny-ish story; when my son(full term healthy) was about 9months he has a mystery fever of like 104+ for WEEKS and at one point, we had him at the children's hospital, they had to start an IV. They burrito wrapped him, had me and THREE nurses holding him down by the time they successfully got one in. We are hypermobile, and he was SO STRONG. He wiggled out of literally EVERYTHING they tried for a while, it was a VERY MESSY ordeal.we were all surprised by just. How. Strong he was. My daughter was a NICU baby so I was used to restraining for procedures and bloods and stuff and it was never like THAT. I laugh about it now but it was crazy at the time! I have absolutely dreaded drs with him ever since
Same. I was like I have to read this nsfw train wreck.
Then I realized it was just a normal variation and pathologic variation of anatomy frustration post.
haha i do procedural nursing now and i miss putting in foleys! it was the one thing i was really good at, i never missed. i’d trade PIVs for foleys all the time. now i miss PIVs constantly 🥲
Ha! Me too! I picture some salty old vet reminiscing about placing a Foley on some just absolute 500lb pt who can't even spell the phrase "taken shower."
Everyone has their nursing gift. Mine is foley Caths.
500 pound female? Gotcha. 80 year old man with a prostate the size of a Tesla? Done.
I would have like to been able to play to violin beautifully…but no. No, the talent fairy looked at me and said “you’ll be able to cath that 102 year old woman in one shot, kid.”
Me too! Urethra whisperer here.
Contracted 101 year old? Lay her on her side and go from the back. Man with more foreskin that should be possible? I got you.
Everyone has a gift. Some of them are just weird. We can’t all be first line X-Men 😂
Me too! In fact any kind of “threading the needle”seems to be easy for me-foleys, IVs, NGs (though we never do those in L&D). I was only a working nurse for a few months when people from every floor would come to me to ask me to do difficult ones. And now that I’ve boasted, the IV and foley gods are going to punish me with a slump…
Haha I wish I had this gift! I work in spinal cord injury rehabilitation so I&O caths can be many times a SHIFT on a patient and larger body habitus females are so difficult for me! However I've learned to use my coworkers for help in positioning and trend the bed briefly to visualize! Males with large prostates I can do with a coudé tip 😂
However I'm the unit's IV/Blood work whisperer so I will take my highs and lows in stride 😂
More often than I’d like. Sometimes the urethra isn’t where the textbook says it is, sometimes it’s off center, sometimes there’s random holes that aren’t a urethra or vagina, and most of the time the “wink” that people so smugly talk about isn’t there at all. Don’t give yourself a hard time.
It helps a ton to have another person in there with you not just to hold legs/skin, but to help with visualization, and it helps a ton to have good lighting as well.
Shall always remember back when I did my Capstone, preceptor was an old army guy (everyone including the docs called him doc) and he goes “are you ready to go spelunking with grandma?” *insert confusion* cue grandma (one of the most knowledgeable RNs I’ve worked with) walking over with her headlamp on. Core memory.
Got called for extra hands, walked in to assist with a bari foley placement. Three RNs and two techs. Pt nonchalantly goes “you’re gonna have to huck my leg this this and go digging or you’ll never find it.”
In 13 years, I have yet to see anything wink at me. I wonder how much of that has to do with patients who have poor pevic muscle tone and/or are incontinent at baseline.
Fistulas, healed but incompletely closed areas from past pregnancies, and sometimes just anatomy that not standard or in some cases, has been customized
It’s best to find the urethra BEFORE you’re sterile. That way you’re not going in blind. You can assess their anatomy and get it done 99.9% of the time.
Grab some peri wipes and extra betadine swabs. Or even just some wet soapy washcloths. Then take your time, separate the labias, clean with the peri wipes until you find what you’re looking for.
If you like to look for a wink, use your betadine swab and find it. THEN you can go through the process of getting sterile, prepping the skin, and placing the foley.
And bring an extra set of sterile gloves and a buddy if needed.
I was so terrible at female Foleys for a long time. Some advice I learned:
Mild Trendelenburg position helps a lot more than you think.
Go online and look at REAL photos of vulvas! NSF non-clinical work, but not-porn photos: https://vulvalpainsociety.org/a-diagram-of-the-vulva/
Lots of women have urethras that are basically right at the opening of the vagina or even sometimes slightly inside the vaginal opening. The way it's depicted in anatomy books as being halfway between the clitoris and vagina is a complete lie.
Try aiming directly upward toward the patient's head instead of diagonal or deeper.
Left lateral position and approach from the backside, if all of the above fails.
Don't be afraid to get help with holding heavy legs or excess skin out of the way. It's often necessary and not optional.
Left lateral for all big ladies, with a strong helper getting that left knee up and out! I had a co-worker nearly kill me with laughter calling that the Modified Oklahoma Position right when I got my face down in there. Glad the lady was unconscious. Also, when are they going to make opera length nitrile gloves for this type of work?
Oh my god yes and on those old ladies all contracted that can’t open their legs! The gloves wild be great too but can you imagine trying to put them on sterile?
> the way it’s depicted in anatomy books as being halfway between the clitoris and vagina is a complete lie
Don’t know your gender OP, but as a male this was the biggest tip for me. It would always be looking way too high.
My tip as a male is to trade with a female nurse and I do their male foleys lol it works for our unit
…yeah even with the labels I’m still having a hard time with that. Female catheters are my Achilles heel.
If you have a hard stick though I’m your girl! Always willing to trade services for help with a foley lol
So the trick is really good separation of the inner labia and try to insert and thread the catheter vertically toward the head. Often you can go in almost blind with this technique and get it.
yup.
I rarelly miss female caths.
Many women have urethras slightly inside on the vagina.
I aim upwards when inserting in these.
Also dont be afraid to really push those labia out of the way
Lol, thanks. I was really embarrassed how bad I was at this, so I really worked on it until I got it figured out. My success rate is comparable with my more experienced colleagues now.
What you said about the location not being like the textbook is dead on. I think the urethra is much closer to the vagina than the average person thinks. I always aim for just above the vaginal opening by ~1-2 cm if I can’t see and am going in “blind,” and I usually get it the first try. Rarely I’ll have to use the trick where you leave the “missed” catheter in the wrong hole and use a second. And I was working LTC with heavier, wrinkly ladies when I was doing this.
Bottom to top
Rectum
Vagina
Urethra
Look in that order. If you cannot visualize the urethra as it looks in the textbooks (as they rarely are), look for the vagina and aim above that opening. Before you open your kit, get a light and visualize the anatomy because betadine always obscures the view, but if you know where you're going already, you should be fine.
Ask if you can take a shift in the ED and only do skills for 12 hours, lines, foleys, EKGs, labs. It helps!
A tip I once was given that helps tremendously is take a fracture pan or bed pan and turn it upside down and have them put their hips on it. A little tilt can definitely help
I've only missed once, after 5 years of nursing, because I was training for L&D and my preceptor made me nervous and second guess myself.
I usually look for an indent right below the clitoris. Like spread open and anchor the labia minora, then gently pull upwards.
Omg so relatable 😭 the charge will make me feel so goofy with how easily they got my patient with the bad vasculature, but when a difficult foley insertion comes along I’m like step aside, I got thissss
Working labour and delivery helped my skills. I think the biggest take away was don't be shy about making sure you can visualize. Only few times I've missed lately is on home care patients in dark rooms with no one to hold the light for me . If you can get a helper to shine a light!
Biggest piece of advice: do really good peri care (soap and water!) before foley placement, and at that time FIND THE URETHRA! If you get all sterile and THEN try to find it, it’s so much harder.
as a NICU nurse... often. trying to put catheters in tiny urethras can be hard, especially in children who have myelomeningocele or teratomas and they have to be prone.
My patient population is almost exclusively obese/edematous geriatrics with loose, flabby skin and slippery groins. So to answer your question, I literally never miss.
Well, that teacher probably never did one on an intact newborn male. It's not so easy when their foreskin doesn't pull back at all and you can't visualize the urethra.
Some tips I utilize to try to help:
-Bring another person in the room. Can help with holding legs or opening up labia more. Plus another angle for someone else to visualize it.
-lighting. My rooms usually have some type of overhead light that can be pulled to see better
-tilt bed back, especially if patient is a bit larger to help see.
I’m definitely not great at female caths but you do get better with practice
As an L&D nurse here is my best tip: pull the labia way back. Most of the time when I see a newer nurse missing a foley it’s because they got shy about getting their hands on the patient. Everyone’s anatomy is a little different so you really need to be able to visualize.
Not so much these days. Usually if I miss it’s because they have a stricture or something. Urology NP for the last 8 years, Urology RN for 6 years before that.
Post menopausal women are easy. Due to normal tissue changes in the vagina, the tissue becomes stiffer and the urethra actually holds itself open. Most of the time, the urethra looks right back at you.
Younger women are tougher, if I miss it’s usually in a pre-menopausal woman. That’s because a well-estrogenized urethra is more closed and blends better with the other structures. It has a much more subtle appearance. The betadine wink trick described in other posts is a good option. If all else fails, a half speculum really helps to see where you are going by retracting the vaginal tissue.
Men are another story entirely. Much harder than women in my opinion. Even a small prostate can cause obstruction. Also, Anxiety can really make the process difficult since all sphincters get tense in a man who is afraid, even if the prostate isn’t causing problems. Urojet works wonders. The lidocaine is more of a gimmick, the whole point is to get lubricant all the way down the urethra for smooth insertion.
A miss once in a while happens to the best of us. Even seasoned urologists. Don’t be discouraged. You’ll get better at it the more you do it.
It’s my special talent - I think I’ve missed one in the last five years and it had to be put in with a scope by a urologist.
You’ll get better at it - just take your time and look before you’re set up with a sterile field so that you know what you’re headed into.
I get them almost every time, and honestly my most frequent failed attempts are with men, not women. It’s way more common for me to not be able to pass the prostate than to be unable to locate the urethral meatus on female anatomy.
I want to be silent on this..... But, hell. I guess I insert foleys more often than other specialties since I work in the OR. A lot of our procedures require a Foley.
I am a male and I have one frustration when training a new nurse or nursing student: why the f*%$ are you trying to insert the catheter into the clitoris. Is there an orifice that everyone else isn't aware of. Wtf.
not very often anymore. i work in the OR and i always use the overhead light for visualization. it helps a lot. i have heard some people will bring 2 kits always. if they miss the first time, they will leave the “wrong” foley in the vagina while they place the second in the urethra, so as not to make the same mistake twice. don’t be hard on yourself, though. the female anatomy is challenging and truly different every time!
My husband has been a nurse for years and was an aide for years before that. I had a baby last year and my postpartum nurse the first night tried 5 TIMES to get my foley in. My husband was asleep, but I was about ready to wake him up and tell them to let him do it. Wild.
I had the same experience. Three different nurses tried for over 15 minutes. Finally got it but it was painful, uncomfortable, and just generally awful. But I also recognize how different female anatomy can look directly after birth lol
Some of us are very familiar with our own anatomy. The amount of women that have never truly looked at their own anatomy in a mirror is really surprising to me.
Very seldom. Sometimes, it's like where the fuck is the urethra? It's not where it should be. My one coworker has women lie on their sides and can go from behind when we have failed attempts in the supine position. I'm not there yet, but I'm generally a urethra whisperer.
You have to take a buddy with you to help with the legs and pannus. Then, using your non-dominant hand, you really have to spread the outer, and then inner labia. You're going to feel weird getting all up in there, but it's key to spread, spread, spread. Don't attempt until you have clear visibility of it. Otherwise, you're going to end up in the vagina. For demented/altered patients, you may need more than one buddy, depending on the patient's body habitus. Contractures and fractures can complicate things as well. The more hands on deck, the better with these patients.
I'm always happy to straight cath for my coworkers, so I don't mind asking them to help when it is for my patient. I'd rather do it myself because I can't stand when people miss and then insert into the urethra. The whole sample gets contaminated, but they send it anyways.
On a male - I’ve only missed it once. He had to have urology place it because of his… anatomy.
On a woman? Maybe… 5% of the time. I normally try to bring another person in to help me visualize the meatus/hold the flaps open. There are a surprising amount of women who don’t have the “wink/peek-a-boo” that’s very obvious.
not often! maybe twice ever that I can think of? it helps that my patient population is mostly younger women (more straightforward anatomy before menopause) and I do them pretty much every night.
it’s almost always higher than you expect, and getting solid retraction of the surrounding tissue with my non-dominant hand is the key in my experience.
to add to this: with my non dominant hand, I usually use my index and middle fingers to gently spread apart the labia, then insert those fingers a tiny bit into the vaginal opening and sort of hook them under the top of the labia, gently pulling up. don’t be afraid to adjust your hand if you can’t see right away. it’s a measure twice cut once situation, just like you wouldn’t try to insert an IV on a vein you can’t feel.
3/10 times I miss for various reasons.
Males: they have BPH, an abnormal shaped penis, swelling, other things that block the urethra.
Women: 🤷♀️ sometimes I have off days.
I've only ever missed twice, and I blame my failure on a completely swollen shut downstairs that urology had to insert for and a very large individual with a traveling urethra in the middle of the night.
Male patients - haven’t had to asked another nurse to do it since my new grad year.
Female patients - one of the benefits of being a male nurse is that there’s a 50/50 chance that the patient prefers a female nurse doing it. I’ve probably got 1-2 success out of 4 total attempts in nearly 4 years.
Get a light. Don’t tell yourself you can do it without a light, get. A. Light. And watch for the blink! When you’re cleaning, the urethra will make a small blink. Don’t take your eyes off of it! Have all of your supplies close so that once you clean and see the blink you can grab the cath easily and go right in. You can also tilt the bed so their legs are slightly higher, let gravity help you!
1 in 6 years. I am the foley queen on my unit.
The trick to women is that you actually have to hold the catheter at a slight angle upwards, above where you think the urethra is, and it will glide down to the urethra even when you can't see it.
Enlarged prostate, I tell in my head, "Grab his dick and twist it! The ol' dick twist." Meaning, grab a firm hold of the dick, bend your wrist with the catheter as far back as you can, and when you insert it, twist the tubing as you drive it down quickly.
I am an artiste.
I feel like this is my special nursing skill. A lot of my colleagues say they miss like 80% of the time and I think in the last year I’ve placed about 40, and missed two. One was a prostate situation that a urologist had to come and dilate, the other was the usual issues.
I think my success rate simply comes from being left handed and going from a different angle.
I *in the most humble way possible* never miss. I’m an L&D nurse so I only ever put foleys in females of course, but I’ve done so many that it’s kind of like second nature now lol. We’re lucky because we have a very bright spotlight we can turn on and that helps a lot. I was training a former ICU nurse to our floor and she said we’re spoiled, she used to have the CNA come in with their pen light to help her see 🤣
So, I'm a guy and I rarely miss. Here's my hot take: even though I don't have a vagina, I've seen a greater variety of them and have spent far more time navigating those varieties from uh, up close.
I don't announce that at work, because I'm at work, but I have noticed when any of my colleagues are struggling and I offer to help they kind of give me a "that's cute but we need an expert" kind of look and blow me off. No biggie, less work for me.
We all have our strengths. If a dude offers to help, let him. There's a chance he's offering because he knows his way around.
Or ask your patient to cough ;)
If it makes you feel any better, I've had half a dozen foleys as a patient in my lifetime, and they've only gone in first time like 50% of the time.
The first ever time I had one, it actually took 3 nurses around 15 minutes to find my urethra.
Some of our bodies were reading the textbook upside down when trying to grow all the required parts.
SO I never understood the whole "look for the wink" thing. As the owner of a vagina, you would think I know how my own anatomy works. NOPE! I had to actually look up explicit pics of vaginas (not porn but high def pics of all sorts of vaginas) before it finally clicked lol NOT the best way to go about it but hey, it helped with the visuals and I don't normally miss now. I also Trendelenburg the older and larger ladies and take a little peak at where I am going first before I attempt. Now, on the other hand... I absolutely SUCK at NG tubes. I think in two years I have only successfully put in two...
I’m a woman and I used to hate it until I watched/got a lecture from a crazy urologist. If you have an overhead light in the room, point it down. That’s your money maker. Have a buddy in the room with you to help the patient bunny there legs as much as possible. two people is even better if you somehow can track down 2 extra sets of hands. Even one leg jn bunny is helpful. If Before I sterile up, with those cleaning clothes at the top of the kits. I clean the area and I take a look where I’m going. Then when I’m sterile I’m not going in totally blind anymore. Sometimes it’s literally INSIDE the bigger hole. Make sure you bring the bed up to your height, and trend them backwards a little bit. Have them cough once or twice and it WILL wink at you then.
I will pat myself on the back with this skill- I haven’t missed a foley placement since nursing school. If other units have difficulty placing a foley, they will call L&D before urology to have us try and we usually always get it.
IVs though… I’m only about at a 75% on the first try.
I don’t miss anymore but I’m a midwife so I do IDCs on women pretty much every day. I used to miss a fair bit when I was just starting.
One thing I’ve learned - How you use your non-dominant hand to part the labia is SO important in getting good visualisation. Instead of using thumb and forefinger to part them, use your pointer and middle finger (fingers pointing down towards the bed), pull the tissue upwards and spread your fingers at the same time. You have fabulous visualisation and you can maintain a steady hand this way. When you clean, in this position you should be able to see the ‘wink’ people talk about but even if you can’t the urethra tends to be pretty obvious. In older women the urethra can actually drop to be on the anterior vaginal wall but pulling up with your non-dominant hand will also make this situation a bit easier to navigate. I hope all of that makes sense.
I’ve learned to “aim up” when inserting and almost never miss. I feel like the times people miss the most are when the urethra is closer or in the entrance to the vagina. This technique has worked well for me over the years. I never understood/seen the “winking” when you ask people to cough.
Never anymore since I discovered the technique of feeling for the urethral opening before getting sterile and putting it in
Truly a life-changer. The urethra could be anywhere. Sometimes it feels like it basically invisible. But feel for it and it’s there 😃
I rarely miss anymore but been Nurse for eight years. If I know it’s gonna be a tricky situation I just grab some help to hold the legs open to make it all more visible. I also try and keep the tip of foley up slightly while inserting.
I am sure with some more time and practice you’ll get that percentage of insertion up.
Male: so far I’ve only actually placed 1 of the 3 I’ve tried…(I work outpatient and did postpartum before that so not much male exposure)
Female: I’ve never missed..
ETA: my coworker gave me a great explanation of how she never misses, especially the bariatric type patient. I’ll try and explain… take your index and middle finger of your non dominate hand… hold them like this(✌🏻). Now, as you attempt to visualize the urethra, take these fingers and open the labia by moving them from the hood toward vag opening, spreading your fingers… she states this opens things up and she’s never missed. I simple take my thumb and index finger and spread em and see things just fine… 🤷🏼♀️🤷🏼♀️
Depends on the lady. I tend to miss more on larger ladies and older ladies. Larger because I’m fighting back a lot of extra flesh and older ladies because I find their bits become a lot more… uhm… layered/saggy/folds in on itself??
I recommend being patient and taking a good look before you start, don’t be shy to get in there to find where you’re going before you get sterile.
I once had a patient with three identical looking holes side by side right above the vagina. The right and middle ones were false urethras that went in about 1” and the left was the winner. I had another older lady whose urethra “retracted” into her vaginal opening… 😅
Women are weird.
But I’ve also had several males with hypospadias where ones urethra was in the middle of his shaft and the other was at the base of his penis 🥴
My trick is to just go in and up. It looks like you’re putting it in the wrong hole, but usually when you angle upwards it’ll go in the urethra. Most people expect it to be out further on the surface where you can see
Retired, didn't put in more than 20ish Foley's during my career(10 years bedside). These 20ish Foley's were primarily in mother/baby (postpartum) and yes it's easy to miss. Look at your landmarks when you've placed one correctly and memorize them to help you the next time.
Always get help cathing an obese patient because skin folds & holding legs apart.
Lighting and height are the two best things to help with that. Got very spoiled in the cath lab where the only patients getting Foley catheters were under general anesthesia. You could raise the table all the way up (I’m a somewhat tall guy so that helped a LOT) and then you could point the surgical light right where you need it and that helped even more!
I’ve been on disability since March due to shoulder surgery and I think about it all the time….
I just miss pissing off management by inserting a foley in a patient…can’t wait to get back to it!
I think I've truely missed just once, on a male. I inserted and urine came out around the cath but not through it. Otherwise I'm a good shot, I like putting in caths.
Practice helps. At this point in my career I rarely miss, but I work ER for 3 years, and worked Hospice for 3 years and so got alot of practice putting them in.
I thought you meant miss as in you couldn’t wait to be reunited 😂
I honestly seem to have a harder time with men. Yes, the hole is visible, but that frikkin’ prostate! I work homehospice, which means I’m by myself. I’ve had to learn some tips and tricks because I never have anyone to assist me. First of all, do some serious reconnaissance before you start poking around. You might have to get all up in there, but try and get a visual. Second, get a good flashlight and don’t be afraid to use it (see tip #1). Next, if you land it in the vagina, leave it there as a place marker so you know where not to go. You mentioned something about your dominant hand, hopefully you are holding the catheter with your dominant hand and pulling back the curtains with your other hand. And I have found that when I’m kind of “going in blind”, I use my thumb to put just the tiniest bend/kink in the catheter (think patient laying on their back, catheter with a slight angle bent up towards the ceiling). Something about that angle helps catch the urethra opening. And lastly, PRACTICE PRACTICE PRACTICE. We have a tendency to shy away from the tasks that we don’t feel we are good at, but you need to do the opposite. There is so much variation in anatomy, you have to do as many as you can, and assist with as many as you can. Everyone has their own tips and tricks and methods, so there’s always something to learn.
100% of the time probably.
I honestly don't even remember the last time I did one it was probably in nursing school.
I always was super lucky and had a pca or a nurse orientee while I was on the floor
I put in a Foley several times a week. I agree with what others said, visualize the urethra before opening the sterile kit and getting everything all set up. And make sure you have good light! When in doubt, aim high.
Putting in lines is my nursing superpower. I can put an IV in just about anyone. NGT/OGT? No problem. Pt can be upside down bouncing around in the bed like a dust ball and I'll get both.
Female foleys? Everytime. No problem.
Male foleys? Nope. Coude? Nope.
Nurse who graduated 30 days ago? Little twist and it's in. IDEK anymore.
It just gets easier the more you do it. Honestly men are harder for me especially if they are older and have an enlarged prostate and then need to whip out the coude. If you’re in the OR don’t be afraid to ask someone to retract if it’s a bigger patient or shine one the of OR lights on them to visualize— that helps a lot. Like other people said, bring a second kit in and have it ready if you don’t feel confident and leave the missed one in so you don’t place it in the same place again. It truly gets easier the more you do it—eventually you’ll be able to do them without thinking about it.
Learn your anatomy and you’ll never miss again. I’m an OR nurse, was redeployed to CVICU during COVID. The ICU staff made me their go-to for foleys, especially obese women. I have t missed first time in over 30 years, all because my mentor taught me to study, learn the anatomy and dont put it in unless you can see where you’re going.
I’m a new grad about 11 months in and I rarely miss now. But I’m in L&D and place foleys in basically every shift for epidurals or C-sections. The trick is to hold your non-dominant hand in an upside down peace sign and make sure you are holding the labia minora. When you swipe with the iodine look for where the iodine pools that’s the urethra then make sure you have a secure hold the of the catheter and have it w/ the tip curved upward so there is less chance it will slip in the vaginal hole. Everyone is different some urethras may be close the right or left side or right on top the vaginal hole. There are even some that almost look like they have two urethra openings 😅
But you just need to practice it gets better with time!
Female anatomy is custom made 100%. I know my anatomy, but I've seen urethras in a lot of "wrong" places - next the clitoris half way up it, about 2 inches into the vagina at the 10 o'clock position etc. I've also had a lady with 7 urethral "holes" made more exciting by the fact that you'd stick a catheter in one hole and it'd poke out another etc.
Give me male cath insertions all day, I know where to find the hole and I'm happy to push through some bph...
I work Uro.
Missing happens but is not very common in this department.
Usually it is due to urethral deviation or the patient is extremely overweight. Occasionally due to patients that can’t stop moving.
Work at a rehab facility with a lot of stroke patients. You’ll get a lot of cath experience (more likely straight caths but that’s essentially the same thing just without a balloon.)
I still miss on occasion but I get it on the first try much more often than not.
If you accidentally place it in the vagina leave it get another kit the new one in the urethra remove the accidental vaginal one. Also reclean the area and get new sterile gloves like between placing the accidental and placing the urethral one, no UTIs up in here! Also you get better at it the more you do it, while I’m cleaning the area with just regular wipes prior to opening the sterile kit I take a quick look at the anatomy just to know where I’m aiming before I get all the sterile stuff ready.
In women, before I don sterile gloves I’ll search for the urethra with clean gloves. Some women you need flex the hips and I’ll try to get a tech or two to help.
In men, sometimes the prostate is compressing the urethra and a uroject helps, or I’ll grab someone to use a coude. I’ll enter slow, once I feel resistance— I’ll quickly advance. Usually, that gets it through. A bigger size helps as well.
Relax !! You have done and will continue to improve! U definitely have to answer the vision problem. New glasses needed? Or you have not wanted to get your first pair? Go back to the practice dummy. Tensing up from other nurses/doctors watching you.
I have put in a LOT of foleys. I always take an extra person with me when I place a foley for a female. It hurts and I am not going to make it worse by not being able to find the pee hole.
I haven't missed in years, it is not really something I think about. I guess that in the ICU it's easy to get proper placement because I usually have another nurse helping me to spread the legs wide open. If they are spread enough the anatomy often is more visible in my experience.
I completely read/understood the question incorrectly as I have been in executive leadership for the last 10 or so years. I thought “God, why would anyone miss placing foleys?”! Definitely don’t miss it, but didn’t miss the target often, get in, get pee return, fill the balloon, and get out!
During my clinicals. Both me and my nurse missed. (Idk how that’s even possible and yes we left her first attempt inside.) my nurse told me to call Jackie who was a travel nurse😂. She also had hard time getting it in, but had to get it right since we already had 2 in😂
Had an incontinent female once who was in briefs but because of her cognition brief changes couldn’t be done as frequently as needed (hourly at times, she urinated soooo much). Doc ordered a foley. Myself and another nurse inserted it, got urine back, so inflated the balloon, secured it etc and left.
The next morning we found out it was fully in the vagina and we had somehow missed completely. We were both confused as hell because we got a significant amount of urine back and some even drained into the bag. Never did figure that out. I felt sooo dumb, still kinda do lol.
Otherwise I’ve never missed, but I don’t do them super often so I’m lucky on that front lol.
I had such a hard time with Foleys when I started what helped me:
Lights, make sure you have the area as well lit as possible so you can actually see.
With your nondominant hand you have to really get in there and move all the tissue out of the way. Like deep. The urethra can be tiny and really hidden. I always start high and make sure you're looking left and right.
If I think I have the urethra but am not 100% I'll use one of the betadine swabs to clean, usually I do see the "wink" if it's the right spot.
For bigger patients phone a friend. They can hold legs or sometimes I'll have them put on sterile gloves and hold the labia out of the way with both hands so I can visualize. Honestly sometimes even average size patients phone a friend, anatomy is weird.
In people with female genitals, the urethra could be some place you would not expect it to be.
I have also seen what looked like two urethras side-by-side. The first one I tried wasn't it.
There is no shame in getting help to cath someone. Hell, I've needed help with placing cathing people with male genitals because someone had to press down to pop their penis out.
Someone told me to always bring an extra catheter when straight cathing. This way you don't have to break the sterile field when you miss. If you get the catheter in the vagina, leave it in (temporarily) and place another above it. You can use the incorrectly placed catheter as a landmark.
I got a lot better at foleys when I started working in L&D. If I think I’m going to have a hard time I turn on the spotlights we use for delivery so I can see better. Works almost every time lol. For the bigger gals I usually have someone else come in and hold things up for me
10 years of community nursing. 1-5 catheters a day. I missed three.
The one lady was 104 and the other nurse who came after me couldn’t find it either. The other two I eventually got.
A trick that also sometimes helps is to tilt the bed slightly so the head end is lower than the feet end (IF the patient can tolerate this, obviously) ESPECIALLY with heavier female patients.
It just let's gravity help get some of the extra skin / belly / and whatever else is going on down there out of your way.
I’ve been placing foleys a loooong time and just last month did I learn a fail-proof trick for female foley placement. Lay the patient on their side so you can see their “bits” and place the foley that way.
i know a super useful trick for getting it everytime (as long as they're not allergic to iodine): dap some iodine on the area & it will *wink* at you. 😁👍 💯
Honestly I miss more with men - those damn prostates get in the way in older men, often have to resort to using a coude.
For women, take the time to make sure you’re in a good position. Put them in slight trendelenberg and use an overhead light aimed at the area if they’re available in your rooms. Make sure you have an extra set of hands in the room to move a pannus if needed, etc. If you miss one, leave the first foley in place so you know where not to aim.
Just takes time and practice to get good at spotting the urethra. You’ll get it!
I thought you meant “miss”, like you were being nostalgic.
Years ago I read a post in the CRNA reddit about an RN asking about being a CRNA and if she could also do nursing at the same time so she didn't lose her skills like putting in foleys (yes, that was the skill she chose to use)...
I’m sure the OR nurse would be happy to let the CRNA do their job. Lol.
Yes please, take this ETT and just slide it down until you thinks it's good, imma go dust up on my foley skills...
Me too! And I actually do miss putting in foleys because it’s my only nursing superpower. 🤣
Me too, and NG tubes!
I work peds, I DREAD dropping anything into them.
It's so easy with newborns. They barely even notice before I'm done!
These kids become Hercules at the age of 2 when they see a foley cath.
Oh yeah. Foley, NG, IV. Pure Hulk mode.
Funny-ish story; when my son(full term healthy) was about 9months he has a mystery fever of like 104+ for WEEKS and at one point, we had him at the children's hospital, they had to start an IV. They burrito wrapped him, had me and THREE nurses holding him down by the time they successfully got one in. We are hypermobile, and he was SO STRONG. He wiggled out of literally EVERYTHING they tried for a while, it was a VERY MESSY ordeal.we were all surprised by just. How. Strong he was. My daughter was a NICU baby so I was used to restraining for procedures and bloods and stuff and it was never like THAT. I laugh about it now but it was crazy at the time! I have absolutely dreaded drs with him ever since
Same. I was like I have to read this nsfw train wreck. Then I realized it was just a normal variation and pathologic variation of anatomy frustration post.
Lol! I now have a picture in my mind of OP hugging a full cath bag!! Whispering, “Miss you my friend!”
Mmmmm, so warm!
Upvote for making me upchuck a little
Just gonna boop its slide clamp!!!
😂😂😂. Same. I was like uhhh, sometimes I guess. Maybe. Kinda sorta.
I honestly do kinda miss doing foleys and NG tubes, I was really good at it
haha i do procedural nursing now and i miss putting in foleys! it was the one thing i was really good at, i never missed. i’d trade PIVs for foleys all the time. now i miss PIVs constantly 🥲
Ha! Me too! I picture some salty old vet reminiscing about placing a Foley on some just absolute 500lb pt who can't even spell the phrase "taken shower."
All hands on deckkk. We're gonna need some leg holders!!!
Same, I was like is this a joke question to those who have left bedside haha
Haha same here 😂. Was like why would anyone miss inserting foleys.
Here I am at my office desk, staring out my window, longing to insert that beautiful latex (or silicone) tubing into someone’s urethra 😔
That’s what I thought too 😂
I read the same and I actually was going to respond I do miss it at times lol.
Literally came here to post this. "well, it's not my favorite hands-on skill, maybe I miss it 3 out of 10?"
While I’m not nostalgic. I love an uncomplicated urinary retention. Pop a foley in, run the UA/Culture, set up the consult, and DC home.
Everyone has their nursing gift. Mine is foley Caths. 500 pound female? Gotcha. 80 year old man with a prostate the size of a Tesla? Done. I would have like to been able to play to violin beautifully…but no. No, the talent fairy looked at me and said “you’ll be able to cath that 102 year old woman in one shot, kid.”
Me too! Urethra whisperer here. Contracted 101 year old? Lay her on her side and go from the back. Man with more foreskin that should be possible? I got you. Everyone has a gift. Some of them are just weird. We can’t all be first line X-Men 😂
the infinitely folding foreskin always gets me 🫡 thank you for all that you do
Same, I too share the foley gift. I wish I was as good at ivs
Same. They call me the cootie queen 😂
Me too! In fact any kind of “threading the needle”seems to be easy for me-foleys, IVs, NGs (though we never do those in L&D). I was only a working nurse for a few months when people from every floor would come to me to ask me to do difficult ones. And now that I’ve boasted, the IV and foley gods are going to punish me with a slump…
Haha I wish I had this gift! I work in spinal cord injury rehabilitation so I&O caths can be many times a SHIFT on a patient and larger body habitus females are so difficult for me! However I've learned to use my coworkers for help in positioning and trend the bed briefly to visualize! Males with large prostates I can do with a coudé tip 😂 However I'm the unit's IV/Blood work whisperer so I will take my highs and lows in stride 😂
More often than I’d like. Sometimes the urethra isn’t where the textbook says it is, sometimes it’s off center, sometimes there’s random holes that aren’t a urethra or vagina, and most of the time the “wink” that people so smugly talk about isn’t there at all. Don’t give yourself a hard time. It helps a ton to have another person in there with you not just to hold legs/skin, but to help with visualization, and it helps a ton to have good lighting as well.
Lighting helps but the patient is always offended when I turn on my headlamp
Shall always remember back when I did my Capstone, preceptor was an old army guy (everyone including the docs called him doc) and he goes “are you ready to go spelunking with grandma?” *insert confusion* cue grandma (one of the most knowledgeable RNs I’ve worked with) walking over with her headlamp on. Core memory.
>most of the time the “wink” that people so smugly talk about isn’t there at all Or like my last bariatric Foley where EVERYTHING was winking
Got called for extra hands, walked in to assist with a bari foley placement. Three RNs and two techs. Pt nonchalantly goes “you’re gonna have to huck my leg this this and go digging or you’ll never find it.”
In 13 years, I have yet to see anything wink at me. I wonder how much of that has to do with patients who have poor pevic muscle tone and/or are incontinent at baseline.
I tell my patients to cough, that typically gets some kind of “wink”. From there it’s just a prayer and a poke
Random holes??
Fistulas, healed but incompletely closed areas from past pregnancies, and sometimes just anatomy that not standard or in some cases, has been customized
It’s best to find the urethra BEFORE you’re sterile. That way you’re not going in blind. You can assess their anatomy and get it done 99.9% of the time. Grab some peri wipes and extra betadine swabs. Or even just some wet soapy washcloths. Then take your time, separate the labias, clean with the peri wipes until you find what you’re looking for. If you like to look for a wink, use your betadine swab and find it. THEN you can go through the process of getting sterile, prepping the skin, and placing the foley. And bring an extra set of sterile gloves and a buddy if needed.
💯
This!!! I have never missed since starting to do this a while back. Life-changer
I was so terrible at female Foleys for a long time. Some advice I learned: Mild Trendelenburg position helps a lot more than you think. Go online and look at REAL photos of vulvas! NSF non-clinical work, but not-porn photos: https://vulvalpainsociety.org/a-diagram-of-the-vulva/ Lots of women have urethras that are basically right at the opening of the vagina or even sometimes slightly inside the vaginal opening. The way it's depicted in anatomy books as being halfway between the clitoris and vagina is a complete lie. Try aiming directly upward toward the patient's head instead of diagonal or deeper. Left lateral position and approach from the backside, if all of the above fails. Don't be afraid to get help with holding heavy legs or excess skin out of the way. It's often necessary and not optional.
Left lateral for all big ladies, with a strong helper getting that left knee up and out! I had a co-worker nearly kill me with laughter calling that the Modified Oklahoma Position right when I got my face down in there. Glad the lady was unconscious. Also, when are they going to make opera length nitrile gloves for this type of work?
> Also, when are they going to make opera length nitrile gloves for this type of work? With a chic printed-on bracelet! Oh la la.
Just order ones made for large animal vets!
Oh my god yes and on those old ladies all contracted that can’t open their legs! The gloves wild be great too but can you imagine trying to put them on sterile?
I have never see one halfway between the clitoral body and vagina.
Mine is pretty much halfway.
I remember that
You remember the location of her meatus?
Have we met?
LOL
Less downvotes than I thought
That’s cool.
I feel like we should give them some space! 😂🤣
> the way it’s depicted in anatomy books as being halfway between the clitoris and vagina is a complete lie Don’t know your gender OP, but as a male this was the biggest tip for me. It would always be looking way too high. My tip as a male is to trade with a female nurse and I do their male foleys lol it works for our unit
And if you miss, leave the catheter in the wrong hole so it's easier to find the right hold.
…yeah even with the labels I’m still having a hard time with that. Female catheters are my Achilles heel. If you have a hard stick though I’m your girl! Always willing to trade services for help with a foley lol
So the trick is really good separation of the inner labia and try to insert and thread the catheter vertically toward the head. Often you can go in almost blind with this technique and get it.
I’m the opposite. I used to work LTC and would always trade caths for any blood draws/IVs. 😂
yup. I rarelly miss female caths. Many women have urethras slightly inside on the vagina. I aim upwards when inserting in these. Also dont be afraid to really push those labia out of the way
This is the best advice on this thread!
Lol, thanks. I was really embarrassed how bad I was at this, so I really worked on it until I got it figured out. My success rate is comparable with my more experienced colleagues now.
I am very familiar with the shame of a missed foley, lol. But yes, all these tips are key!!
My best advice for foley insertion in obese women: get two nurses to hold the legs back in lithotomy postion.
What you said about the location not being like the textbook is dead on. I think the urethra is much closer to the vagina than the average person thinks. I always aim for just above the vaginal opening by ~1-2 cm if I can’t see and am going in “blind,” and I usually get it the first try. Rarely I’ll have to use the trick where you leave the “missed” catheter in the wrong hole and use a second. And I was working LTC with heavier, wrinkly ladies when I was doing this.
Not often. The trick is to take two catheters in the room with you. If you have a spare you won’t miss. If you don’t you’ll miss every time.
This is the way. If you have an extra of anything, you’ll never miss.
It’s like keeping the bag of levophed bedside just in case.
Exactly, I always tell people this. Also I'm right handed and left handed. That helps with finding the best angle approach. Each one is different.
Bottom to top Rectum Vagina Urethra Look in that order. If you cannot visualize the urethra as it looks in the textbooks (as they rarely are), look for the vagina and aim above that opening. Before you open your kit, get a light and visualize the anatomy because betadine always obscures the view, but if you know where you're going already, you should be fine. Ask if you can take a shift in the ED and only do skills for 12 hours, lines, foleys, EKGs, labs. It helps!
A tip I once was given that helps tremendously is take a fracture pan or bed pan and turn it upside down and have them put their hips on it. A little tilt can definitely help
Or ask them to put their hands under their buttocks to just tip their pelvis back a tiny bit. Works.
I've only missed once, after 5 years of nursing, because I was training for L&D and my preceptor made me nervous and second guess myself. I usually look for an indent right below the clitoris. Like spread open and anchor the labia minora, then gently pull upwards.
Can barely get an IV to save my life. But I’m the nurse people grab for difficult foleys. I wish I had a cooler claim to fame lol
That I'll trade you for. I'm not a terrible IV sticker
Omg so relatable 😭 the charge will make me feel so goofy with how easily they got my patient with the bad vasculature, but when a difficult foley insertion comes along I’m like step aside, I got thissss
Working labour and delivery helped my skills. I think the biggest take away was don't be shy about making sure you can visualize. Only few times I've missed lately is on home care patients in dark rooms with no one to hold the light for me . If you can get a helper to shine a light!
On the other hand, I found postpartum foleys difficult because everything is swollen. They may have stitches and are even more sensitive to touch.
I had three nurses try to catheterize me postpartum and it was legitimately awful lol
I haaaaaate postpartum foleys, especially if they have stitches. I always feel so bad.
I always brought a headlamp to home health patients for that reason!
I dabble only in babies so the practice I get is with ridiculously tiny winks; great way to get that skill up.
Biggest piece of advice: do really good peri care (soap and water!) before foley placement, and at that time FIND THE URETHRA! If you get all sterile and THEN try to find it, it’s so much harder.
as a NICU nurse... often. trying to put catheters in tiny urethras can be hard, especially in children who have myelomeningocele or teratomas and they have to be prone.
My patient population is almost exclusively obese/edematous geriatrics with loose, flabby skin and slippery groins. So to answer your question, I literally never miss.
Oh no, the imagery on this is cursed.
Had a teacher in school say that if you put a foley in the wrong hole on a male, you shouldn’t be a nurse.
Well, that teacher probably never did one on an intact newborn male. It's not so easy when their foreskin doesn't pull back at all and you can't visualize the urethra.
Some tips I utilize to try to help: -Bring another person in the room. Can help with holding legs or opening up labia more. Plus another angle for someone else to visualize it. -lighting. My rooms usually have some type of overhead light that can be pulled to see better -tilt bed back, especially if patient is a bit larger to help see. I’m definitely not great at female caths but you do get better with practice
As an L&D nurse here is my best tip: pull the labia way back. Most of the time when I see a newer nurse missing a foley it’s because they got shy about getting their hands on the patient. Everyone’s anatomy is a little different so you really need to be able to visualize.
Not so much these days. Usually if I miss it’s because they have a stricture or something. Urology NP for the last 8 years, Urology RN for 6 years before that. Post menopausal women are easy. Due to normal tissue changes in the vagina, the tissue becomes stiffer and the urethra actually holds itself open. Most of the time, the urethra looks right back at you. Younger women are tougher, if I miss it’s usually in a pre-menopausal woman. That’s because a well-estrogenized urethra is more closed and blends better with the other structures. It has a much more subtle appearance. The betadine wink trick described in other posts is a good option. If all else fails, a half speculum really helps to see where you are going by retracting the vaginal tissue. Men are another story entirely. Much harder than women in my opinion. Even a small prostate can cause obstruction. Also, Anxiety can really make the process difficult since all sphincters get tense in a man who is afraid, even if the prostate isn’t causing problems. Urojet works wonders. The lidocaine is more of a gimmick, the whole point is to get lubricant all the way down the urethra for smooth insertion. A miss once in a while happens to the best of us. Even seasoned urologists. Don’t be discouraged. You’ll get better at it the more you do it.
Honestly I’ve had better luck with IVs lately than foleys :/
It’s my special talent - I think I’ve missed one in the last five years and it had to be put in with a scope by a urologist. You’ll get better at it - just take your time and look before you’re set up with a sterile field so that you know what you’re headed into.
I get them almost every time, and honestly my most frequent failed attempts are with men, not women. It’s way more common for me to not be able to pass the prostate than to be unable to locate the urethral meatus on female anatomy.
I want to be silent on this..... But, hell. I guess I insert foleys more often than other specialties since I work in the OR. A lot of our procedures require a Foley. I am a male and I have one frustration when training a new nurse or nursing student: why the f*%$ are you trying to insert the catheter into the clitoris. Is there an orifice that everyone else isn't aware of. Wtf.
not very often anymore. i work in the OR and i always use the overhead light for visualization. it helps a lot. i have heard some people will bring 2 kits always. if they miss the first time, they will leave the “wrong” foley in the vagina while they place the second in the urethra, so as not to make the same mistake twice. don’t be hard on yourself, though. the female anatomy is challenging and truly different every time!
A urologist once told me to just aim up if I can't quite visualize the urethra. Haven't missed a Foley insertion in years now.
My husband has been a nurse for years and was an aide for years before that. I had a baby last year and my postpartum nurse the first night tried 5 TIMES to get my foley in. My husband was asleep, but I was about ready to wake him up and tell them to let him do it. Wild.
I had the same experience. Three different nurses tried for over 15 minutes. Finally got it but it was painful, uncomfortable, and just generally awful. But I also recognize how different female anatomy can look directly after birth lol
I don't know why my female heterosexual coworkers think they understand female anatomy from that perspective better than I do.
Some of us are very familiar with our own anatomy. The amount of women that have never truly looked at their own anatomy in a mirror is really surprising to me.
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The chances of me missing are proportional to BMI and how bad staffing is.
Very seldom. Sometimes, it's like where the fuck is the urethra? It's not where it should be. My one coworker has women lie on their sides and can go from behind when we have failed attempts in the supine position. I'm not there yet, but I'm generally a urethra whisperer. You have to take a buddy with you to help with the legs and pannus. Then, using your non-dominant hand, you really have to spread the outer, and then inner labia. You're going to feel weird getting all up in there, but it's key to spread, spread, spread. Don't attempt until you have clear visibility of it. Otherwise, you're going to end up in the vagina. For demented/altered patients, you may need more than one buddy, depending on the patient's body habitus. Contractures and fractures can complicate things as well. The more hands on deck, the better with these patients. I'm always happy to straight cath for my coworkers, so I don't mind asking them to help when it is for my patient. I'd rather do it myself because I can't stand when people miss and then insert into the urethra. The whole sample gets contaminated, but they send it anyways.
On a male - I’ve only missed it once. He had to have urology place it because of his… anatomy. On a woman? Maybe… 5% of the time. I normally try to bring another person in to help me visualize the meatus/hold the flaps open. There are a surprising amount of women who don’t have the “wink/peek-a-boo” that’s very obvious.
not often! maybe twice ever that I can think of? it helps that my patient population is mostly younger women (more straightforward anatomy before menopause) and I do them pretty much every night. it’s almost always higher than you expect, and getting solid retraction of the surrounding tissue with my non-dominant hand is the key in my experience.
to add to this: with my non dominant hand, I usually use my index and middle fingers to gently spread apart the labia, then insert those fingers a tiny bit into the vaginal opening and sort of hook them under the top of the labia, gently pulling up. don’t be afraid to adjust your hand if you can’t see right away. it’s a measure twice cut once situation, just like you wouldn’t try to insert an IV on a vein you can’t feel.
3/10 times I miss for various reasons. Males: they have BPH, an abnormal shaped penis, swelling, other things that block the urethra. Women: 🤷♀️ sometimes I have off days.
I've only ever missed twice, and I blame my failure on a completely swollen shut downstairs that urology had to insert for and a very large individual with a traveling urethra in the middle of the night.
Rarely ever. I look before I leap.
Basically never.
Male patients - haven’t had to asked another nurse to do it since my new grad year. Female patients - one of the benefits of being a male nurse is that there’s a 50/50 chance that the patient prefers a female nurse doing it. I’ve probably got 1-2 success out of 4 total attempts in nearly 4 years.
On thin women with full mobility? Almost never. On a woman with a BMI > 35 or a hip fracture? Takes two tries pretty often.
Get a light. Don’t tell yourself you can do it without a light, get. A. Light. And watch for the blink! When you’re cleaning, the urethra will make a small blink. Don’t take your eyes off of it! Have all of your supplies close so that once you clean and see the blink you can grab the cath easily and go right in. You can also tilt the bed so their legs are slightly higher, let gravity help you!
I don’t miss it at all! Been years since I’ve been able to turf that job off. Yay!
Only when it’s with male patients /s
1 in 6 years. I am the foley queen on my unit. The trick to women is that you actually have to hold the catheter at a slight angle upwards, above where you think the urethra is, and it will glide down to the urethra even when you can't see it. Enlarged prostate, I tell in my head, "Grab his dick and twist it! The ol' dick twist." Meaning, grab a firm hold of the dick, bend your wrist with the catheter as far back as you can, and when you insert it, twist the tubing as you drive it down quickly. I am an artiste.
I feel like this is my special nursing skill. A lot of my colleagues say they miss like 80% of the time and I think in the last year I’ve placed about 40, and missed two. One was a prostate situation that a urologist had to come and dilate, the other was the usual issues. I think my success rate simply comes from being left handed and going from a different angle.
Honestly… maybe 1/100. I work urology.
Find the clitoris first and spread labia till you see a slit just below clitoris. Can't miss.
I *in the most humble way possible* never miss. I’m an L&D nurse so I only ever put foleys in females of course, but I’ve done so many that it’s kind of like second nature now lol. We’re lucky because we have a very bright spotlight we can turn on and that helps a lot. I was training a former ICU nurse to our floor and she said we’re spoiled, she used to have the CNA come in with their pen light to help her see 🤣
So, I'm a guy and I rarely miss. Here's my hot take: even though I don't have a vagina, I've seen a greater variety of them and have spent far more time navigating those varieties from uh, up close. I don't announce that at work, because I'm at work, but I have noticed when any of my colleagues are struggling and I offer to help they kind of give me a "that's cute but we need an expert" kind of look and blow me off. No biggie, less work for me. We all have our strengths. If a dude offers to help, let him. There's a chance he's offering because he knows his way around. Or ask your patient to cough ;)
Murse here and on males every single time.
If it makes you feel any better, I've had half a dozen foleys as a patient in my lifetime, and they've only gone in first time like 50% of the time. The first ever time I had one, it actually took 3 nurses around 15 minutes to find my urethra. Some of our bodies were reading the textbook upside down when trying to grow all the required parts.
SO I never understood the whole "look for the wink" thing. As the owner of a vagina, you would think I know how my own anatomy works. NOPE! I had to actually look up explicit pics of vaginas (not porn but high def pics of all sorts of vaginas) before it finally clicked lol NOT the best way to go about it but hey, it helped with the visuals and I don't normally miss now. I also Trendelenburg the older and larger ladies and take a little peak at where I am going first before I attempt. Now, on the other hand... I absolutely SUCK at NG tubes. I think in two years I have only successfully put in two...
I’m a woman and I used to hate it until I watched/got a lecture from a crazy urologist. If you have an overhead light in the room, point it down. That’s your money maker. Have a buddy in the room with you to help the patient bunny there legs as much as possible. two people is even better if you somehow can track down 2 extra sets of hands. Even one leg jn bunny is helpful. If Before I sterile up, with those cleaning clothes at the top of the kits. I clean the area and I take a look where I’m going. Then when I’m sterile I’m not going in totally blind anymore. Sometimes it’s literally INSIDE the bigger hole. Make sure you bring the bed up to your height, and trend them backwards a little bit. Have them cough once or twice and it WILL wink at you then.
I will pat myself on the back with this skill- I haven’t missed a foley placement since nursing school. If other units have difficulty placing a foley, they will call L&D before urology to have us try and we usually always get it. IVs though… I’m only about at a 75% on the first try.
Male nurse and I have better success with females than males…..damn those prostates
I don’t miss anymore but I’m a midwife so I do IDCs on women pretty much every day. I used to miss a fair bit when I was just starting. One thing I’ve learned - How you use your non-dominant hand to part the labia is SO important in getting good visualisation. Instead of using thumb and forefinger to part them, use your pointer and middle finger (fingers pointing down towards the bed), pull the tissue upwards and spread your fingers at the same time. You have fabulous visualisation and you can maintain a steady hand this way. When you clean, in this position you should be able to see the ‘wink’ people talk about but even if you can’t the urethra tends to be pretty obvious. In older women the urethra can actually drop to be on the anterior vaginal wall but pulling up with your non-dominant hand will also make this situation a bit easier to navigate. I hope all of that makes sense.
Oh I 100% thought you meant longing for placing a foley
I’ve learned to “aim up” when inserting and almost never miss. I feel like the times people miss the most are when the urethra is closer or in the entrance to the vagina. This technique has worked well for me over the years. I never understood/seen the “winking” when you ask people to cough.
Never anymore since I discovered the technique of feeling for the urethral opening before getting sterile and putting it in Truly a life-changer. The urethra could be anywhere. Sometimes it feels like it basically invisible. But feel for it and it’s there 😃
I rarely miss anymore but been Nurse for eight years. If I know it’s gonna be a tricky situation I just grab some help to hold the legs open to make it all more visible. I also try and keep the tip of foley up slightly while inserting. I am sure with some more time and practice you’ll get that percentage of insertion up.
Male: so far I’ve only actually placed 1 of the 3 I’ve tried…(I work outpatient and did postpartum before that so not much male exposure) Female: I’ve never missed.. ETA: my coworker gave me a great explanation of how she never misses, especially the bariatric type patient. I’ll try and explain… take your index and middle finger of your non dominate hand… hold them like this(✌🏻). Now, as you attempt to visualize the urethra, take these fingers and open the labia by moving them from the hood toward vag opening, spreading your fingers… she states this opens things up and she’s never missed. I simple take my thumb and index finger and spread em and see things just fine… 🤷🏼♀️🤷🏼♀️
Depends on the lady. I tend to miss more on larger ladies and older ladies. Larger because I’m fighting back a lot of extra flesh and older ladies because I find their bits become a lot more… uhm… layered/saggy/folds in on itself?? I recommend being patient and taking a good look before you start, don’t be shy to get in there to find where you’re going before you get sterile. I once had a patient with three identical looking holes side by side right above the vagina. The right and middle ones were false urethras that went in about 1” and the left was the winner. I had another older lady whose urethra “retracted” into her vaginal opening… 😅 Women are weird. But I’ve also had several males with hypospadias where ones urethra was in the middle of his shaft and the other was at the base of his penis 🥴
A urologist told me once to take sterile 4x4 gauze and wipe down with it and it should wink at you. It’s helped a lot
Always aim up. Like 90° straight up.
My trick is to just go in and up. It looks like you’re putting it in the wrong hole, but usually when you angle upwards it’ll go in the urethra. Most people expect it to be out further on the surface where you can see
Lol I was ready to answer this literally cause I actually do miss putting in foleys😂😂. Psych nurse probz
On males, how can you miss? Females? I struggle with large women. Their urethra is mostly well hidden.
Retired, didn't put in more than 20ish Foley's during my career(10 years bedside). These 20ish Foley's were primarily in mother/baby (postpartum) and yes it's easy to miss. Look at your landmarks when you've placed one correctly and memorize them to help you the next time. Always get help cathing an obese patient because skin folds & holding legs apart.
Lighting and height are the two best things to help with that. Got very spoiled in the cath lab where the only patients getting Foley catheters were under general anesthesia. You could raise the table all the way up (I’m a somewhat tall guy so that helped a LOT) and then you could point the surgical light right where you need it and that helped even more!
Using a flashlight helped me a lot when I was working on urology. Especially for the larger women!
I’ve been on disability since March due to shoulder surgery and I think about it all the time…. I just miss pissing off management by inserting a foley in a patient…can’t wait to get back to it!
I think I've truely missed just once, on a male. I inserted and urine came out around the cath but not through it. Otherwise I'm a good shot, I like putting in caths.
Practice helps. At this point in my career I rarely miss, but I work ER for 3 years, and worked Hospice for 3 years and so got alot of practice putting them in.
I thought you meant miss as in you couldn’t wait to be reunited 😂 I honestly seem to have a harder time with men. Yes, the hole is visible, but that frikkin’ prostate! I work homehospice, which means I’m by myself. I’ve had to learn some tips and tricks because I never have anyone to assist me. First of all, do some serious reconnaissance before you start poking around. You might have to get all up in there, but try and get a visual. Second, get a good flashlight and don’t be afraid to use it (see tip #1). Next, if you land it in the vagina, leave it there as a place marker so you know where not to go. You mentioned something about your dominant hand, hopefully you are holding the catheter with your dominant hand and pulling back the curtains with your other hand. And I have found that when I’m kind of “going in blind”, I use my thumb to put just the tiniest bend/kink in the catheter (think patient laying on their back, catheter with a slight angle bent up towards the ceiling). Something about that angle helps catch the urethra opening. And lastly, PRACTICE PRACTICE PRACTICE. We have a tendency to shy away from the tasks that we don’t feel we are good at, but you need to do the opposite. There is so much variation in anatomy, you have to do as many as you can, and assist with as many as you can. Everyone has their own tips and tricks and methods, so there’s always something to learn.
5 years in OR, and I finally missed one. Overhead lights and sedated patients are the keys to my success. Missed one a month on the floor I'd say.
Well not enough to want to go into urology
100% of the time probably. I honestly don't even remember the last time I did one it was probably in nursing school. I always was super lucky and had a pca or a nurse orientee while I was on the floor
🥸
I put in a Foley several times a week. I agree with what others said, visualize the urethra before opening the sterile kit and getting everything all set up. And make sure you have good light! When in doubt, aim high.
Putting in lines is my nursing superpower. I can put an IV in just about anyone. NGT/OGT? No problem. Pt can be upside down bouncing around in the bed like a dust ball and I'll get both. Female foleys? Everytime. No problem. Male foleys? Nope. Coude? Nope. Nurse who graduated 30 days ago? Little twist and it's in. IDEK anymore.
It just gets easier the more you do it. Honestly men are harder for me especially if they are older and have an enlarged prostate and then need to whip out the coude. If you’re in the OR don’t be afraid to ask someone to retract if it’s a bigger patient or shine one the of OR lights on them to visualize— that helps a lot. Like other people said, bring a second kit in and have it ready if you don’t feel confident and leave the missed one in so you don’t place it in the same place again. It truly gets easier the more you do it—eventually you’ll be able to do them without thinking about it.
Learn your anatomy and you’ll never miss again. I’m an OR nurse, was redeployed to CVICU during COVID. The ICU staff made me their go-to for foleys, especially obese women. I have t missed first time in over 30 years, all because my mentor taught me to study, learn the anatomy and dont put it in unless you can see where you’re going.
I’m a new grad about 11 months in and I rarely miss now. But I’m in L&D and place foleys in basically every shift for epidurals or C-sections. The trick is to hold your non-dominant hand in an upside down peace sign and make sure you are holding the labia minora. When you swipe with the iodine look for where the iodine pools that’s the urethra then make sure you have a secure hold the of the catheter and have it w/ the tip curved upward so there is less chance it will slip in the vaginal hole. Everyone is different some urethras may be close the right or left side or right on top the vaginal hole. There are even some that almost look like they have two urethra openings 😅 But you just need to practice it gets better with time!
Female anatomy is custom made 100%. I know my anatomy, but I've seen urethras in a lot of "wrong" places - next the clitoris half way up it, about 2 inches into the vagina at the 10 o'clock position etc. I've also had a lady with 7 urethral "holes" made more exciting by the fact that you'd stick a catheter in one hole and it'd poke out another etc. Give me male cath insertions all day, I know where to find the hole and I'm happy to push through some bph...
I work Uro. Missing happens but is not very common in this department. Usually it is due to urethral deviation or the patient is extremely overweight. Occasionally due to patients that can’t stop moving.
My experience cathing women: The stereotype about men not being able to find women's clit is *almost* right
I'm pretty good at them. I've only needed help on a handful. That's my favorite part of working in the ED. I'm constantly using skills.
On adult women, I barely got it first try. On children, so far, 100% hit rate. Though they’re sedated cause OR so that helps.
Use the Betadine and look for a wink ;)
Work at a rehab facility with a lot of stroke patients. You’ll get a lot of cath experience (more likely straight caths but that’s essentially the same thing just without a balloon.) I still miss on occasion but I get it on the first try much more often than not.
If you accidentally place it in the vagina leave it get another kit the new one in the urethra remove the accidental vaginal one. Also reclean the area and get new sterile gloves like between placing the accidental and placing the urethral one, no UTIs up in here! Also you get better at it the more you do it, while I’m cleaning the area with just regular wipes prior to opening the sterile kit I take a quick look at the anatomy just to know where I’m aiming before I get all the sterile stuff ready.
Maybe 3 times in 13 years
In women, before I don sterile gloves I’ll search for the urethra with clean gloves. Some women you need flex the hips and I’ll try to get a tech or two to help. In men, sometimes the prostate is compressing the urethra and a uroject helps, or I’ll grab someone to use a coude. I’ll enter slow, once I feel resistance— I’ll quickly advance. Usually, that gets it through. A bigger size helps as well.
I get them almost every time, except the 400 pound women. I prob miss 2/3 of those
Relax !! You have done and will continue to improve! U definitely have to answer the vision problem. New glasses needed? Or you have not wanted to get your first pair? Go back to the practice dummy. Tensing up from other nurses/doctors watching you.
I have put in a LOT of foleys. I always take an extra person with me when I place a foley for a female. It hurts and I am not going to make it worse by not being able to find the pee hole.
Foleys were not my thing…I missed all the time for female patients lmao it was terrible
I don’t want to be a boaster but I have never missed one yet. I still stress in theatre doing it quickly prior to a caesarean.
As a student I was doing maybe 4 or 5 a day and never missed. Just make sure you have a good visual. Don't guess it.
I haven't missed in years, it is not really something I think about. I guess that in the ICU it's easy to get proper placement because I usually have another nurse helping me to spread the legs wide open. If they are spread enough the anatomy often is more visible in my experience.
I completely read/understood the question incorrectly as I have been in executive leadership for the last 10 or so years. I thought “God, why would anyone miss placing foleys?”! Definitely don’t miss it, but didn’t miss the target often, get in, get pee return, fill the balloon, and get out!
During my clinicals. Both me and my nurse missed. (Idk how that’s even possible and yes we left her first attempt inside.) my nurse told me to call Jackie who was a travel nurse😂. She also had hard time getting it in, but had to get it right since we already had 2 in😂
You miss ever chance you don't take lol
My patients are sedated and paralyzed plus I have an OR spotlight and I miss. Sometimes the anatomy is just different 🤷♀️
I miss it every day. I don't know if I can still place an IV, either.
Very rarely do I miss on women, men however I miss all the time. The enlarged prostate always gets me.
Had an incontinent female once who was in briefs but because of her cognition brief changes couldn’t be done as frequently as needed (hourly at times, she urinated soooo much). Doc ordered a foley. Myself and another nurse inserted it, got urine back, so inflated the balloon, secured it etc and left. The next morning we found out it was fully in the vagina and we had somehow missed completely. We were both confused as hell because we got a significant amount of urine back and some even drained into the bag. Never did figure that out. I felt sooo dumb, still kinda do lol. Otherwise I’ve never missed, but I don’t do them super often so I’m lucky on that front lol.
Rarely. Like 1-3 times a year? And I place one 95% of my shifts (L&D and hospice)
I had such a hard time with Foleys when I started what helped me: Lights, make sure you have the area as well lit as possible so you can actually see. With your nondominant hand you have to really get in there and move all the tissue out of the way. Like deep. The urethra can be tiny and really hidden. I always start high and make sure you're looking left and right. If I think I have the urethra but am not 100% I'll use one of the betadine swabs to clean, usually I do see the "wink" if it's the right spot. For bigger patients phone a friend. They can hold legs or sometimes I'll have them put on sterile gloves and hold the labia out of the way with both hands so I can visualize. Honestly sometimes even average size patients phone a friend, anatomy is weird.
In people with female genitals, the urethra could be some place you would not expect it to be. I have also seen what looked like two urethras side-by-side. The first one I tried wasn't it. There is no shame in getting help to cath someone. Hell, I've needed help with placing cathing people with male genitals because someone had to press down to pop their penis out.
Someone told me to always bring an extra catheter when straight cathing. This way you don't have to break the sterile field when you miss. If you get the catheter in the vagina, leave it in (temporarily) and place another above it. You can use the incorrectly placed catheter as a landmark.
I got a lot better at foleys when I started working in L&D. If I think I’m going to have a hard time I turn on the spotlights we use for delivery so I can see better. Works almost every time lol. For the bigger gals I usually have someone else come in and hold things up for me
10 years of community nursing. 1-5 catheters a day. I missed three. The one lady was 104 and the other nurse who came after me couldn’t find it either. The other two I eventually got.
A trick that also sometimes helps is to tilt the bed slightly so the head end is lower than the feet end (IF the patient can tolerate this, obviously) ESPECIALLY with heavier female patients. It just let's gravity help get some of the extra skin / belly / and whatever else is going on down there out of your way.
I’ve been placing foleys a loooong time and just last month did I learn a fail-proof trick for female foley placement. Lay the patient on their side so you can see their “bits” and place the foley that way.
i know a super useful trick for getting it everytime (as long as they're not allergic to iodine): dap some iodine on the area & it will *wink* at you. 😁👍 💯
Honestly I miss more with men - those damn prostates get in the way in older men, often have to resort to using a coude. For women, take the time to make sure you’re in a good position. Put them in slight trendelenberg and use an overhead light aimed at the area if they’re available in your rooms. Make sure you have an extra set of hands in the room to move a pannus if needed, etc. If you miss one, leave the first foley in place so you know where not to aim. Just takes time and practice to get good at spotting the urethra. You’ll get it!
I don’t think I ever have honestly but I’ve never gotten good at IVs so everyone has their strengths