Specimen Collection, Catheter & Ostomy Care

Specimen Collection, Catheter & Ostomy Care

Nursing assistants frequently assist with diagnostic specimen collection and deliver essential non-sterile comfort applications. Precise specimen collection techniques ensure accurate laboratory analysis and prevent sample contamination. Concurrently, implementing effective non-sterile comfort measures—including hot and cold therapy and systematic pressure injury prevention—enhances resident physical comfort, promotes tissue healing, and maintains skin integrity.

Diagnostic Specimen Collection Protocols

Laboratory examination of body fluids and excretions provides critical diagnostic information regarding infections, metabolic functions, and organ diseases. The CNA must ensure proper labeling (resident name, date, time, specimen type), maintain container cleanliness, and transport samples promptly.

1. Routine Urine Specimen

• Purpose: Routine urinalysis checking for pH, specific gravity, protein, glucose, and blood.
• Procedure: Collected during normal voiding into a clean bedpan, urinal, or specimen collector hat placed in the toilet. Pour 120 mL (4 oz) into a clean specimen cup. Ensure specimen contains no toilet paper or stool.

2. Clean-Catch Midstream Urine Specimen

• Purpose: Bacterial culture and sensitivity testing for Urinary Tract Infection (UTI). Requires a sterile container free of external bacterial contamination.
• Procedure:
  1. Perform perineal hygiene first. Cleanse urinary meatus with antiseptic wipes:
     • Females: Cleanse front-to-back using a fresh wipe for each stroke (left side, right side, center meatus).
     • Males: Cleanse in a circular motion starting from the urethral meatus outward (retract foreskin if uncircumcised, and replace foreskin after collection).
  2. Instruct resident to begin urinating into toilet or bedpan to flush bacteria from outer urethra.
  3. Pause urine stream briefly. Place sterile collection container into stream without touching inside of container or rim.
  4. Collect 30 to 60 mL of the midstream portion of urine.
  5. Remove container before resident finishes voiding. Cap container tightly touching only outside of lid.

3. Stool (Fecal) Specimen

• Purpose: Testing for ova and parasites (O&P), occult (hidden) blood (Guaiac test), or pathogens like C. diff.
• Procedure: Collect stool from bedpan or specimen hat. Must not be contaminated with urine or toilet paper. Use a clean wooden tongue depressor to collect 1 to 2 tablespoons of stool from two different areas of the specimen (especially taking any visible blood, pus, or mucus). Place in stool container and transport to lab immediately.

4. Sputum Specimen

• Purpose: Microscopic analysis for respiratory infections such as pneumonia or tuberculosis.
• Definition: Sputum is thick mucus coughed up from the lungs and bronchi (it is not saliva from the mouth).
• Procedure: Best collected early in the morning upon awakening when secretions have accumulated overnight.
  1. Have resident rinse mouth with plain water only to remove food particles. (Never use mouthwash or toothpaste, which contain antibacterial agents that destroy sputum pathogens).
  2. Instruct resident to take 3 deep breaths, then cough deeply from deep within the chest/lungs.
  3. Expectorate (spit) sputum directly into a sterile sputum cup. Collect at least 1 to 2 teaspoons (5-10 mL).
  4. Secure lid, label, place in biohazard bag, and send to lab immediately.

Indwelling Urinary Catheter Care & Safety Protocols

An indwelling urinary catheter (Foley catheter) is a flexible tube inserted through the urethra into the bladder to continuously drain urine. Because catheters provide a direct pathway for micro-organisms to enter the urinary tract, Catheter-Associated Urinary Tract Infections (CAUTIs) represent a leading cause of healthcare-associated infections.

Catheter Cleansing Procedure

1. Perform standard perineal care using warm water (105°F) and cleanser.
2. Hold the catheter tubing near the urethral meatus with your non-dominant hand to prevent tension or painful pulling on the urethra.
3. Using a clean, moistened washcloth with mild soap, clean at least 4 inches (10 cm) of the catheter tubing starting from the urethral meatus outward (moving away from the body).
4. Use a clean surface of the washcloth for every stroke down the tubing.
5. Rinse and dry thoroughly.

Catheter Cleansing Direction:
Urethral Meatus [Hand Anchors Tubing]  ========================> Clean 4+ inches Outward
(NEVER wipe from tubing back toward meatus!)

Critical Catheter Safety Rules

1. Gravity Drainage: The urinary drainage bag must ALWAYS remain below the level of the resident's bladder. Placing the bag above bladder level causes stagnant, bacteria-laden urine to flow backward (reflux) into the bladder, causing infection.
2. Attachment Site: Fasten the drainage bag to the movable bed frame, NEVER to bed rails. Raising or lowering bed rails with a catheter attached can yank the balloon through the bladder neck, causing massive trauma and hemorrhaging.
3. Tubing Inspection: Check tubing continuously for kinks, twists, or dependent loops (sagging loops where urine pools). Urine must flow freely by gravity.
4. Floor Distance: Never allow the drainage bag or spigot to touch the floor.
5. Emptying Protocol: Empty the drainage bag at the end of each shift or when half full using a clean graduate container. Wipe the drainage spigot with an alcohol swab before and after reclamping.

Ostomy Care

An ostomy is a surgically created opening (a stoma) that diverts stool or urine into an external appliance. A colostomy diverts from the colon, an ileostomy from the small intestine, and a urostomy diverts urine.

In Rhode Island, "assist with ostomy appliance" is a routine nursing assistant duty, while colostomy irrigation requires direct supervision and any treatment to non-intact skin is excluded entirely.

What the nurse aide does

• Provide privacy and control odor. Empty the pouch when it is about one-third to one-half full — a heavier pouch pulls the appliance loose and leaks.
• Wear gloves and empty into the toilet or a graduate, measuring output if intake and output is ordered.
• Wash the skin around the stoma with mild soap and water and pat dry before a new appliance is applied. Do not use alcohol, lotions, or powders unless directed.
• Observe the stoma at every appliance change. A healthy stoma is pink or red, moist, and slightly raised. Report a stoma that is pale, dark, purple, black, dry, retracted, or bleeding more than a trace, and report redness, rash, or broken skin around it.
• Report an appliance that leaks repeatedly, absent output, watery output, or a resident's complaint of pain or cramping.
• Support the resident emotionally. An ostomy affects body image profoundly. Never grimace, never comment on odor, and never discuss it where others can hear.

Condom Catheters

A condom (external) catheter is a sheath applied over the penis and connected to drainage tubing. Applying one is a routine Rhode Island nursing assistant duty — unlike an indwelling catheter, which a nurse aide never inserts, removes, or changes.

• Wash and dry the area first, and provide perineal care at least daily and with every change.
• Roll the sheath on, leaving about an inch of space between the tip of the penis and the end of the catheter so urine drains freely.
• Apply the securing strap or adhesive snugly but never tightly — a constricting band cuts off circulation. You should be able to slide a finger underneath.
• Never use ordinary tape to secure it.
• Remove and replace every 24 hours or per facility policy, and check the skin at every change for redness, swelling, breakdown, or discoloration. Report any of these immediately.

Urinary Drainage Bags

Rhode Island permits a nursing assistant to change a urinary drainage bag, excluding any sterile procedures, and to empty the bag. The rules that keep this safe:

• Keep the bag below the level of the bladder at all times — including during transfers and ambulation — so urine cannot flow back.
• Never rest the bag on the floor.
• Keep tubing free of kinks and never let it loop below the level of the bag.
• Do not disconnect the closed system except where a bag change is permitted and directed.
• Empty into the resident's own graduate; do not let the drain spout touch the container or the floor.
• Use a leg bag for ambulation if ordered, and switch back to the larger bag at night.
• Report cloudy, foul-smelling, bloody, or absent urine, leaking at the insertion site, or any complaint of burning, urgency, or bladder pain.

Reinforcing a Simple Non-Sterile Dressing

Section 22.12.1(A)(2)(i) permits a nursing assistant to reinforce a simple non-sterile dressing — adding a layer of clean dressing material on top of an existing dressing that is loose or has some drainage.

What that does not authorize: removing a dressing, cleaning a wound, applying a sterile dressing, or applying anything at all to non-intact skin. If a dressing is saturated, has come off, or the wound beneath is visible, do not touch the wound — cover it if bleeding requires direct pressure, and get the nurse.

Always report the amount, color, and odor of drainage; increasing pain; redness or warmth spreading around a wound; and any dressing that will not stay in place.