4.6 Therapeutic & Technical Procedures: Elastic Stockings, Oxygen, Specimens & Ostomy Care

4.6 Therapeutic & Technical Procedures

Quick Answer: Therapeutic/Technical Procedures is one of the four sub-areas inside Basic Nursing Skills, the single largest block on the 2024 NNAAP written outline (35%, 21 of 60 scored items). It covers the procedures that sit between plain personal care and licensed nursing: anti-embolism stockings, oxygen support, specimen collection, ostomy care, warm and cold applications, and non-sterile dressing support. One of these — Applies One Knee-High Elastic Stocking — is a testable South Carolina skill, and its bold critical element is finishing with no twists or wrinkles and the heel correctly positioned.

Every procedure below has a bright line running through it. Learn the line, not just the technique.

---

1. Anti-Embolism (Elastic) Stockings — a Tested NNAAP Skill

Anti-embolism stockings — also called elastic stockings, TED hose, or compression stockings — apply graduated external pressure to the legs to promote venous return and reduce the risk of deep vein thrombosis (DVT) in residents with limited mobility.

The NNAAP Skill: Applies One Knee-High Elastic Stocking

• Explain the procedure, speaking clearly, slowly, and directly, maintaining face-to-face contact.
• Provide privacy with a curtain, screen, or door.
• The client is in the supine position (lying down in bed) while the stocking is applied.
• Turn the stocking inside out, at least to the heel.
• Place the foot of the stocking over the toes, foot, and heel.
• Pull the top of the stocking over the foot, heel, and leg.
• Move the foot and leg gently and naturally, avoiding force and over-extension of limbs and joints.
• Bold Critical Element Step: finish the procedure with no twists or wrinkles, with the heel of the stocking (if present) over the heel and the toe opening (if present) either over or under the toe area. If a mannequin is used, the candidate may state that the stocking needs to be wrinkle-free.
• Leave the signaling device within reach and the bed in the low position.
• After completing the skill, wash your hands.

Why the Rules Are the Rules

• Applied before the resident gets out of bed, ideally in the morning before the legs become dependent and swell. Once the legs have been down, venous pooling has already occurred.
• Wrinkles and twists are dangerous, not untidy. A rolled band acts as a tourniquet, concentrating pressure in a narrow ring, obstructing venous return, and creating both a pressure injury and a clot risk — the exact opposite of the stocking's purpose.
• Never fold or roll the top down to "shorten" a stocking that is too long. Get the correct size.
• Report immediately: cold, pale, blue, or mottled toes; numbness or tingling; new or worsening leg pain, redness, or warmth in the calf; or any skin breakdown found when the stocking is removed. Stockings are removed at least once per shift for skin inspection and hygiene per care plan.

---

2. Oxygen Therapy — the CNA's Narrow Lane

Oxygen is a prescribed drug. A CNA supports its safe use and never manages its dose.

Within the CNA scope: reposition a displaced cannula or mask; pad the tubing behind the ears; report a kinked line; keep the humidifier bottle filled to the marked line per facility policy; report a low cylinder; provide frequent oral and nasal care, because oxygen dries mucous membranes; and report shortness of breath, confusion, restlessness, or cyanosis.

Outside the CNA scope: starting or stopping oxygen; changing the liter flow rate; deciding to give PRN oxygen based on a pulse-oximeter number; adjusting concentrator settings.

Oxygen fire safety — oxygen does not burn, it makes everything else burn faster:

• No smoking, open flames, candles, matches, or lighters in the room; post "Oxygen in Use" signage.
• Avoid petroleum-based products (petroleum jelly) on the lips or nares — use water-soluble lubricant instead.
• Avoid wool and synthetic fabrics that generate static; cotton is preferred for linens and clothing.
• Keep electric razors, heating pads, and equipment that can spark away from the oxygen source.
• Never store cylinders near heat sources, and never allow a cylinder to fall.

---

3. Specimen Collection

CNAs collect many routine specimens. The universal rules: wear gloves, label the container before or immediately after collection with the resident's full name and the date and time, never touch the inside of the container or lid, place the specimen in a biohazard transport bag, and deliver it promptly.

• Routine (random) urine specimen: ask the resident to void into a clean specimen pan (a "hat") placed in the toilet, or a bedpan or urinal. Do not collect urine that contains toilet paper or stool. Pour into the container and label.
• Clean-catch / midstream urine specimen: the one most commonly tested.
  1. Perform perineal cleaning first — for a female, separate the labia and clean front to back with each wipe; for a male, clean the meatus in a circular motion outward (retracting the foreskin first if uncircumcised, then replacing it).
  2. Have the resident void a small amount into the toilet and stop.
  3. Collect the middle of the stream in the sterile container without letting the container touch the body.
  4. Allow the last portion to pass into the toilet. Cap without touching the inside of the lid.
  • The first portion flushes organisms out of the distal urethra, so the middle portion better represents bladder urine.
• 24-hour urine specimen: the resident voids and that first specimen is discarded, and the clock starts then. Every void for the next 24 hours is saved in the collection container, usually kept on ice or refrigerated. If a single void is accidentally discarded, tell the nurse — the collection must be restarted. Post signage so no one flushes a specimen.
• Stool specimen: the resident defecates into a clean specimen pan; the specimen must not be contaminated with urine or toilet paper. Transfer with a tongue blade to the container.
• Sputum specimen: best collected first thing in the morning before eating, drinking, or oral care; the resident takes several deep breaths and coughs deeply from the lungs. Saliva is not sputum.

---

4. Ostomy Care

An ostomy is a surgically created opening (a stoma) that diverts stool or urine to the abdominal wall. A colostomy drains from the colon; an ileostomy drains from the small intestine and produces more liquid, more constant, and more enzymatically irritating output; a urostomy drains urine.

CNA responsibilities within scope (per facility policy and the care plan):

• Empty the pouch when it is one-third to one-half full — a heavier pouch pulls the seal loose and leaks.
• Measure and record output as part of I&O for an ileostomy or urostomy.
• Wash the peristomal skin with warm water and mild soap, rinse, and pat dry completely before a new appliance is applied; moisture defeats the adhesive.
• Apply skin barrier products as directed and ensure the appliance opening fits the stoma without pinching it.
• Provide privacy and manage odor without commenting on it. Ostomies carry enormous body-image weight; the resident is watching your face.

Report immediately: a stoma that is dusky, purple, black, or bleeding (normal is beefy red and moist), skin excoriation or rash around the stoma, no output for an extended period, or output that changes markedly in color, consistency, or odor. Irrigation, appliance changes involving the stoma itself, and any assessment of stoma viability belong to the licensed nurse.

---

5. Warm and Cold Applications

Both are ordered treatments. Both carry burn and tissue-damage risk, and older adults, residents with diabetes or neuropathy, residents with paralysis, and residents who are confused are the highest-risk groups because they may not feel injury occurring.

Universal rules: never apply directly to bare skin — always use a cover, towel, or barrier; check the skin every 5 minutes; stop and report immediately if the skin becomes pale, blue, mottled, blistered, or bright red, or if the resident reports numbness or pain; and never let a resident lie on top of a heat source, which traps heat and multiplies burn risk. A CNA does not decide to apply heat or cold — the nurse conveys the order.

---

6. Non-Sterile Dressings and Admission, Transfer & Discharge

Dressings: in facilities that allow it, a CNA may apply a clean, non-sterile dry dressing to a minor closed abrasion per policy — nothing more. Sterile dressing changes, medicated dressings, wound packing, wound measurement, and pressure-injury staging are licensed nursing functions. What the CNA contributes is observation: report drainage amount, color, and odor; increasing redness or warmth; a dressing that is loose, saturated, or missing; and any resident complaint of new wound pain.

Admission: greet the resident by name, orient them to the room, the call light, the bathroom, and mealtimes; obtain baseline height, weight, and vital signs; and complete a personal property inventory — including eyeglasses, hearing aids, dentures, jewelry, and electronics — which protects both the resident and you.

Transfer and discharge: gather all belongings against the inventory list, obtain final vital signs and weight if ordered, transport the resident safely and never leave them unattended in a hallway, and report to the nurse before the resident leaves the unit. Federal law requires that a resident be transferred or discharged only for permitted reasons, and S.C. Code Ann. § 44-81-40(D) requires written notice of not less than thirty days, except when the health, safety, or welfare of other residents would be endangered by waiting.