COLLEGE OF HEALTH SCIENCES

Module Number 1
Duration 4 weeks
Course Number NCM 109- B
Care of Mother and Child (Related Learning
Course Title/ Description
Experience)
Class Schedule M/T/W (7-3)
Module Developer/
JORDANA KHADIJA C. SADJAIL, R.Ph.,R.N., M.N.
Course Coach
LOU NORMAN H. FLORES, MAN, RN
FATIMA SHELLAINE T. AKMAD, RN, MAN
Contributors: ARMINA E. AKBARA, RN, MAN
FERKIYA A. ABDUWA, RN, MAN
SAIMA D. HAMAD, RN MAN

Second Semester, Academic Year 2020-2021

BaSC, Sumagdang, Isabela City, Basilan, 7300
www.Bassc.edu.ph
 NCM 109-B Module 1

Table Of Contents
Lesson 1 DOCUMENTATION ..........................................................................................................................................2
I. Activation of Prior Knowledge. ...................................................................................................................................2
II. Engagement in Relevant Content and Appropriate Learning Activity/Activities. ..................................................2
DOCUMENTATION ...........................................................................................................................................................2
How Do Healthcare Providers Use Documentation?....................................................................................................2
What Forms Do Nurses Use to Document Nursing Care? ...........................................................................................3
1. Nursing Admission Data Forms ............................................................................................................................3
2. Discharge Summary .............................................................................................................................................3
3. Flowsheets and Graphic Records.........................................................................................................................4
4. Medication Administration Records ......................................................................................................................5
5. Kardex or Patient Care Summary .........................................................................................................................6
6. Integrated Plan of Care ........................................................................................................................................6
7. Occurrence Reports .............................................................................................................................................6
III. REFLECTION AND RESPONSE/ACTION ..................................................................................................................7
IV. SUMMATIVE ASSESSMENT ......................................................................................................................................7
V. FEEDBACK TO IMPROVE LEARNING AND TEACHING ...........................................................................................7
Lesson 2 INSERTION AND REMOVAL OF A RETENTION CATHETER .......................................................................8
I. Activation of Prior Knowledge. ...................................................................................................................................8
II. Engagement in Relevant Content and Appropriate Learning Activity/Activities. ..................................................9
Urinary Catheterization ...................................................................................................................................................9
What Is It? .....................................................................................................................................................................9
Indwelling catheterization ..............................................................................................................................................9
Clean intermittent catheterization (CIC) ........................................................................................................................9
What It is Used For......................................................................................................................................................10
Patient anxiety.............................................................................................................................................................12
Routine urethral catheter removal.......................................................................................................................13
The procedure................................................................................................................................................................14
INSERTING A FOLEY CATHETER ON A FEMALE PATIENT/SKILL DEMO .................................................................16
https://www.youtube.com/watch?v=Il0iJUNnq7k .............................................................................................................16
INSERTING A FOLEY CATHETER ON A MALE PATIENT/SKILL DEMO......................................................................16
https://www.youtube.com/watch?v=A493yBJtiQ0 ...........................................................................................................16
III. REFLECTION AND RESPONSE/ACTION ................................................................................................................16
Lesson 3 OBTAINING A URINE SPECIMEN FROM AN INDWELLING URINARY CATHETER .................................17
I. Activation of Prior Knowledge. .................................................................................................................................17
II. Engagement in Relevant Content and Appropriate Learning Activity/Activities. ................................................18
SKILL 3 ...........................................................................................................................................................................18
III. REFLECTION AND RESPONSE/ACTION ................................................................................................................22
IV. SUMMATIVE ASSESSMENT ....................................................................................................................................23
V. FEEDBACK TO IMPROVE LEARNING AND TEACHING .........................................................................................23

1
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Lesson 1 DOCUMENTATION
Course Code NCM 109- B Week/Day 1,2
Course Description Care for Mother and Child at Risk or Duration 16 hours
with Problem (Acute and Chronic)
Lesson/ Topic Documentation Lesson No. 1

Learning Outcome/s At the end of this lesson the students can follow documentation guidelines to
accurately record patient health status, nursing interventions, and patient
outcomes. through case study
Value Integration Compassion- Being sensitive to the needs of your patients and your patients' families.
Reference/s Fundamentals of Nursing
Course Coach Jordana Khadija Sadjail, RPh, RN, MN
Email: jordanakhadijac@gmail.com
Fb: Jordana Khadija Sadjail Castillo
Contact #:09052428221

I. Activation of Prior Knowledge.

To My students:
✓ You are now about to start the first lesson for Week 1. Read the learning materials below then
answer the comprehension check questions that follow and do Activity No. 1.

Activity 1. When you imagine yourself working as a nurse, what do you think of?

II. Engagement in Relevant Content and Appropriate Learning Activity/Activities.

Read and Ponder

(This content is taken from Fundamentals of Nursing page 179-

DOCUMENTATION
✓ Documentation is the act of recording patient status and care in written or electronic form, or in a
combination of the two forms.
✓ Documentation is not limited to “writing nursing notes,” but is the act of making a written record. The terms
documenting, recording, and charting are often used to mean the same thing.
✓ Historically, the collection of documentation, orders, and other care information for a patient had been
called the medical record or chart. However, with the present emphasis on health promotion, the medical
record is now more commonly referred to as the health record.
✓ A patient’s health record permanently documents:

■ Care, in chronological order, provided by all healthcare providers

■ The patient’s responses to interventions and treatments
■ Important facts about a client’s health history, including past and present illnesses, examinations, tests,
treatments, and outcomes
✓ As a nurse, you are responsible for managing and implementing the interdisciplinary plan of care.
✓ That responsibility includes documenting the care provided and the progress made toward goals.

How Do Healthcare Providers Use Documentation?

✓ Clear, complete, concise, comprehensive, and correct documentation in a client health record serves the
following purposes:

2
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

• Communication One important function is communication. Members of the interdisciplinary team use
the health record to communicate about the patient’s status and care. For example, if it is not possible
to speak directly to the respiratory therapist on your shift, you can at least review the progress notes.
Documentation enables healthcare professionals to plan and evaluate treatment and monitor health
status over time.

• Continuity of Care Communication promotes continuity of care. For example, if you are concerned
that the patient is at high risk for developing an infection, you can include a nursing diagnosis of Risk
for Infection on the written or electronic interdisciplinary plan of care. You would then initiate nursing
orders for other nurses to regularly observe for and document signs of infection.

• Quality Improvement Healthcare organizations and other agencies perform manual chart audits
(directed reviews of client medical records) of written documentation. In electronic health record (EHR)
systems, reports are run to analyze large amounts of data. Results are used to formulate strategies to
improve care, decrease length of stay, control costs, and identify knowledge and practice gaps that
can be addressed through Inservice and continuing education. Accrediting agencies, such as The Joint
Commission, review written and electronic records to ensure delivery of quality care and public safety.

• Planning and Evaluation of Patient Outcomes Documentation enables physicians, nurses, and
other healthcare professionals to plan and evaluate treatment and monitor health status over time.

• Legal Documentation The health record will be scrutinized by legal experts if a dispute about a client’s
care arises. In court, the health record is legal evidence of the care given to a client, and is used to
judge whether the interventions were timely and appropriate. Expert reviewers look for documentation
of the client’s baseline status, changes in status, interpretation of the changes, interventions
implemented, and the client’s responses to those interventions.

• Professional Standards of Care The American Nurses Association (ANA) Scope and Standards of
Practice (2nd ed.) (2010) includes documentation in many of its standards. By the ANA standards and
competencies, the registered nurse:

What Forms Do Nurses Use to Document Nursing Care?

Documentation forms vary by purpose, institution, and unit. However, regardless of the system or forms
used, nursing documentation reflects the nursing process. You record assessments, diagnoses,
planning, implementation (what you did), and evaluation of client responses. This section discusses the
most used paper and electronic forms that are used in addition to the nursing progress notes discussed
in the preceding sections.

1. Nursing Admission Data Forms

✓ A separate nursing admission form or a combined interdisciplinary form is completed at the time the patient
enters the healthcare system. A baseline assessment is essential because it:
(1) may be used as a benchmark to monitor change;
(2) provides information about the client’s support system and helps forecast future needs;
(3) contains critical information (e.g., presenting illness or reason for admission, vital signs, allergy
information, current medications, activities of daily living (ADL) status, physical assessment data, and
discharge planning information).

2. Discharge Summary
✓ Discharge data are obtained with the admission assessment but are often recorded on a separate form.

3
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Key Point:
✓ A general principle in nursing is that discharge planning begins on admission. Therefore, discharge
needs should be evaluated when the patient first enters a healthcare facility, especially in acute care
facilities. Ask yourself what this patient would need if he were to go home in the next few days.
For example would he need help with food preparation? Does he understand how to use his medicines?
✓ A discharge summary is the last entry made in the paper chart.
✓ In the electronic chart, the discharge summary can be started any time after admission and revised
throughout the hospitalization.
✓ A summary is completed when the patient is transferred within the same organization, to another
facility, or discharged to home.
✓ The discharge summary may be a multidisciplinary document, or each discipline may write a separate
summary.
✓ The forms are different in each organization, but they contain similar data.

3. Flowsheets and Graphic Records

✓ You will use flowsheets and graphic records to document assessments and care that are performed
frequently, on a recurring schedule, or as a part of unit routines.

For example, most hospital units require that vital signs be taken every 8 hours for all patients. How
often you perform, and document care activities depends on your patient’s condition and the unit policy.
In the first hour after surgery, for example, you would probably record vital signs every 15 minutes;
then every 30 minutes for 1 hour; and then every hour for 4 hours.

✓ The simplest paper forms are organized with time in columns across the top and the activities or patient
assessment parameters in rows down the side.
✓ On electronic forms, the areas (fields) to enter the time and activities are arranged close together.
✓ Flowsheets and graphic records allow you to see patterns of change in patient status. For instance,
you may view a steady increase in the line representing a patient’s blood pressure compared to his
pain score on an electronically generated graph.
✓ On a paper form, you may scan across a row to see that your patient has not had a bowel movement
for several days. Other types of information recorded on flowsheets include intake and output (I&O),
weight, hygiene measures, ADLs, and medications administered. For examples of a paper graphic
record and an electronic flowsheet,

Checklists
✓ Assessments and care may also be recorded on paper and electronic checklists.
✓ Common normal and abnormal findings are usually organized according to body systems.
✓ Using a paper form, the nurse checks the box that reflects the current assessment findings.
✓ Some checklists include nursing actions, such as wound care, treatments, or IV fluid administration.
Essentially these forms are comprehensive charting documents.
✓ Exceptions, patient care activities, and patient responses are recorded in the narrative note section of
the paper form.
✓ Using an electronic field-based checklist, the nurse enters values or text in the appropriate fields and
saves the documentation.
✓ Electronic flowsheets typically contain content similar to paper checklists, but also include a greater
range of potential documentation areas that can be opened as needed. This allows for a more
comprehensive record of a patient’s assessment, treatments, IV fluid administration, and many other
parameters.

Intake and Output Records

✓ You will sometimes use separate intake and output (I&O) paper records to document data about the
patient’s fluid balance.
✓ Electronic systems have flowsheet sections or I&O forms to enter I&O and save it into the patient’s
EHR.

4
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

✓ Usually these documentation forms contain data totaled by shift and by 24-hour periods.
✓ Paper forms must be totaled manually, whereas electronic systems usually automatically total I&O
figures for you.
✓ For a paper I&O record, I&O paper graphics may be kept at the bedside. If your patient or a family
member can assist with measuring his I&O, teach him how to record data on the paper form.
✓ You might also complete electronic I&O documentation at the bedside using a portable or stationary
computer. When appropriate, patients can still track their own intake and output on paper, but you will
need to enter the patient’s I&O data into the EHR.

4. Medication Administration Records

✓ Medication administration records (MARs) contain information about the medications that have been
prescribed for the client. The information and format vary by setting, with significant differences
between outpatient and inpatient facilities.
▪ Inpatient facilities: Inpatient medication records not only contain a list of prescribed
medications, but also track medication administration and usage for the agency.

▪ Outpatient facilities(e.g., include clinics, primary care offices, and treatment facilities). Because
patients do not stay at the facility, usually the MAR primarily contains information about how
the patient is to use the medications prescribed. Patients retain responsibility for administering
their own medications either independently or with the help of family or caregivers.

✓ Some electronic MARs allow care providers to look up detailed information about the medication,
including indications, contraindications, expected and adverse effects, and safe dosage ranges based
on routes of administration.

Terminology for Medication Administration Times.

You will document medications according to the times they are given: scheduled, unscheduled, continuous,
prn, STAT, and so on.
▪ Scheduled medications are medications that are to be given on a regularly scheduled basis.
▪ Unscheduled medications are medications that are to be given on call at the appropriate time.
An example of an unscheduled medication is a preoperative medication to be administered immediately
before the patient goes to the surgical holding area.
▪ Continuous infusions are IV fluids that are running consistently unless stopped for a blood
transfusion or to give an IV medication that is not compatible with the IV fluid running
▪ Prn means “as needed.” It is an abbreviation of the Latin term pro re nata. Medications administered
prn are given only when the patient meets certain conditions that were established in the
medication prescription. Typically, medications are prescribed prn for relief of pain, fever, nausea,
and constipation. You should administer a prn medication when you assess that the patient needs
it or when the patient requests it. Document immediately after you administer the medication.
▪ A STAT medication is given and charted immediately and only once.
▪ A single-order medication is given once at a prescribed time, but not necessarily immediately.

Charting Additional Information About Medications.

✓ For scheduled medications, you may only have to initial and make a checkmark in the column that
corresponds with the preprinted times at the top.
✓ In the circumstances following, you will often need to record additional. information on the MAR and
sometimes even in the Progress Notes.

▪ Injections. If you administer an injection, you must chart the type and the site of administration to protect
the patient from repeated injections in the same location.

5
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

▪ Assessment Required Before Administration. Some medications require you to make a specific
assessment before administering the drug, to ensure that it is safe to give it. You must document that
assessment data on the MAR, along with the time of administration and other required information.

As an example, most protocols instruct you to not give digoxin (a cardiac medication) if the heart rate
is below 60 beats/min., so you must auscultate the rate before giving the drug. Blood pressure and
pain medications, insulin, and anticoagulants also require assessments before administration.

Drug Allergies. Drug allergies are always noted on the paper or electronic MAR. This makes them easily
visible for caregivers who are prescribing or administering medication. If the patient has an allergic
reaction to a medicine, you must record this response on the MAR and in the nurses’ notes. Of course
you would also report this to the prescriber.

5. Kardex or Patient Care Summary

✓ Kardex is a special kind of paper form or folding card that briefly summarizes a patient’s status and
plan of care.
✓ Paper Kardex and electronic patient care summaries typically pull patient data from multiple areas of
the health record (medical and nursing diagnoses, orders, treatments, results).
✓ Paper Kardexes are usually kept together in a portable file in a central location in the nurses’ station to
allow all team members access to patients’ summary information. Each patient has a separate screen
in an electronic summary. All authorized members of the care team can access the electronic care
summary at the same time, even if they are away from the patient or outside the organization in a
remote location, depending on the institution’s permission for access. Neither the paper Kardex nor
the electronic care summary is a permanent part of the patient’s health record

6. Integrated Plan of Care

✓ Integrated plans of care (IPOCs) are a combined charting and care plan form. They exist in both
paper and electronic formats.
✓ An IPOC maps out day-by-day patient goals, outcomes, interventions, and treatments for a specific
diagnosis or condition from admission to discharge.
✓ Lab work, diagnostic testing, medications, and therapies are all included in the pathway, as well
as standardized interventions captured in the plan.
✓ IPOCs help administrators predict length of stay, monitor costs of care, and can assist with staffing.
✓ They also eliminate duplicate charting, increase team effort, and enhance the nurse’s teaching
about what the patient can expect during the hospital stay.
✓ Multiple patient diagnoses can be captured easily in an electronic IPOC. However, in special
situations, you may need to individualize the paper IPOC by commenting on special issues in the
space provided for narrative comments.

7. Occurrence Reports
✓ An occurrence report, or incident report, is a formal record of an unusual occurrence or accident.
✓ This is an organizational report that is used to analyze the event, identify areas for quality improvement,
and formulate strategies to prevent future occurrences.
✓ The overall goal is to create safer processes and procedures for clients and staff.

Key Point:
✓ An occurrence report is not part of the client’s health record and thus should never be referenced in the
nurses’ notes or in other sections of the health record.
✓ The paper report should be sent to risk management, according to agency protocol, while the electronic
form is completed on the organization’s secure internal network.
✓ You should report all errors, even if there was no adverse impact on the client.
✓ This is important from a safety standpoint for improving your institution’s quality of care and from a legal
perspective to provide defensible information.

6
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

✓ When completing an occurrence form, be sure to clearly identify the client, date, time, and location. Briefly
describe the incident in objective terms.
✓ Quote the client or persons involved if possible.
✓ Identify any witnesses to the event, equipment involved, and environmental conditions.
✓ Avoid drawing conclusions or placing blame.
✓ You should document actions taken and the patient response to the

III. REFLECTION AND RESPONSE/ACTION

Now that you have learned and understood the content on this unit you may start doing the
activities prepared for you.

Activity 2 – Case Study ( will be given on separate file)

Accomplish the task and complete the patient’s chart found at Annex.

IV. SUMMATIVE ASSESSMENT

This activity will be at the end of the unit.

V. FEEDBACK TO IMPROVE LEARNING AND TEACHING

Kindly fill in the feedback at the answer sheet provided at Annex D for any issues you are facing, and you may
suggest ways to improve your learning.

7
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Lesson 2 INSERTION AND REMOVAL OF A RETENTION CATHETER

Course Code NCM 109- B Week/Day 3
Course Description Care for Mother and Child at Risk or Duration 16 hours
with Problem (Acute and Chronic)
Lesson/ Topic INSERTION AND REMOVAL OF A Lesson No. 2
RETENTION CATHETER
Learning Outcome/s At the end of this lesson the students can demonstrate the nursing skill
through guided practice skills
Value Integration Compassion
Reference/s Fundamentals of Nursing
Course Coach Jordana Khadija Sadjail, RPh, RN, MN
Email: jordanakhadijac@gmail.com
Fb: Jordana Khadija Sadjail Castillo
Contact #:09052428221

I. Activation of Prior Knowledge.

Welcome to Lesson 2 of NCM 109-B (RLE).

Please take the pre-test to evaluate your expectation of this lesson. Write your answer
on the answer sheet provided at Annex
Activity 3
1. Catheterization is used for (List all correct):

A.) sterile urine specimen

B.) opening bladder for surgical/diagnostic purposes
C.) to prevent or treat over-distention of the bladder and urinary retention when other measures have
not corrected the problem.
D.) Residual urine-
E.) Bladder irrigations
F.) medication administration

2. This is end-dwelling or retaining catheter. It is known as a Foley catheter. It's going to stay in the
bladder for a period of time. It has two lumens, one that drains urine and the other one that inflates
balloon that is found at the tip of the catheter. Once you inflate tip of balloon, this holds catheter in
place. Balloon is inflated with 5 mL of fluid.

a.) single lumen

b.) double lumen
c.) triple lumen
d.) multi-lumen

3. these are used to immediately drain the bladder. Sometimes we use it for a urine sample and to
check for residual urine. This is known as a non-retaining, straight catheter.

a.) single lumen

b.) double lumen
c.) triple lumen
d.) multi-lumen

8
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

4. This has three different lumens. The purpose is to be an End-dwelling catheter. They will use this
when they do bladder irrigations, usually after a prostatectomy or something like that. 1 lumen will
drain urine from bladder, 2nd lumen will used to instill fluids so that balloon expands, 3rd lumen is
used to instill irrigating fluid into the bladder.

a.) single lumen

b.) double lumen
c.) triple lumen
d.) multi-lumen

5. True or False:

Once you have touched patient with non-dominant hand, you cannot remove that hand from patient.
It must stay there, for that hand will no longer be considered sterile.

II. Engagement in Relevant Content and Appropriate Learning Activity/Activities.

Let us start with our lesson.

( The content of this lesson is taken from https://www.nursingtimes.net/clinical-

archive/continence/urinary-catheters-6-removing-an-indwelling-urinary-catheter-15-05-
2017)

Urinary Catheterization
What Is It?

✓ In urinary catheterization, a catheter (hollow tube) is inserted into the bladder to drain or collect urine.
There are two main types of urinary catheterization: indwelling catheterization and clean intermittent
catheterization (CIC).

Indwelling catheterization
✓ In this type of catheterization, one end of the catheter remains inside the bladder. A small, inflated
balloon at the tip of the catheter inside the bladder keeps the end of the catheter from slipping out.

✓ Urine flows from the bladder through the catheter and collects in a drainage bag.

✓ If the patient is not bedridden, this drainage bag can be worn on the leg, where it can be hidden
under a skirt or slacks.

✓ If the patient is bedridden, the drainage bag usually is attached to the lower portion of the hospital
bed (near the floor). This position allows gravity to help the urine drain.

An indwelling catheter can be used for short-term or long-term care.

Clean intermittent catheterization (CIC)

✓ In CIC, the urinary catheter does not remain inside the bladder. It is inserted into the bladder only
long enough to allow the bladder to drain.

✓ Then, it is removed. CIC can be done by the patient or by the patient's caregiver.

9
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

What It is Used For

Urinary catheters are used to remove urine from the bladder in the following situations:

• To relieve a physical obstruction to urine flow, such as a urinary-tract stone, a bladder tumor or an
enlarged prostate.
• To drain urine when the bladder's muscles or nerves are not working properly. This can be caused by
a spinal cord injury, multiple sclerosis or some other nerve problem. Also, certain medications can
interfere with the bladder's normal emptying.
• To treat incontinence (difficulty holding in urine until you reach the toilet) when other methods have
failed.
• To drain urine in patients who are unconscious. This includes patients who are in a coma or under
general anesthesia.
• To measure urine output in infants and children who are not toilet trained.
• To measure urine output in adults who are incapacitated because of critical illness or surgery.
• To obtain a clean urine sample for tests to detect bacteria infections in the urine. A clean urine
sample is one that is not contaminated by bacteria from the patient's hands, genitals or rectum. With
a catheter, a clean urine sample can be obtained directly from inside the bladder.
• To collect urine during diagnostic studies of the urinary tract.

❖ Urinary catheterization is associated with a number of complications including catheter-associated

urinary tract infection (CAUTI), tissue damage, and bypassing and blockage. The risk of
complications means catheters should only be used after considering other continence management
options, and should be removed as soon as clinically appropriate (Loveday et al, 2014).

✓ It is important to understand the reason for removal and whether the catheter is being removed
permanently or in a planned or unplanned change due to problems encountered by the patient, such
as a blocked catheter. The procedure differs depending on whether the insertion site is urethral or
suprapubic.

✓ The removal of a urinary catheter should be a simple, uncomplicated procedure but there are
recognized competencies. Nurses removing a catheter must be aware of:

• Local policies and procedure;

• Anatomy and physiology of the genitourinary system (Figs 1 and 2);
• Care of the patient before, during and after removal;
• What action to take if they encounter a problem;
• Infection prevention and control issues relating to catheter care;
• The balloon mechanism used to retain catheters in the bladder (Box 1 and Fig 3a).

10
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

11
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Box 1. Foley catheters

Foley catheters have an inflatable balloon that anchors the catheter in the bladder. The catheter has two
channels – one drains urine while the other is used to inflate and deflate the balloon.
Balloons are inflated with sterile water/or using liquid in syringes supplied by manufacturers. The water is
usually inserted and removed using a syringe that is attached to a valve on the catheter.
Balloons vary in size but adults usually require a 5-10ml balloon. Always check manufacturers’ instructions.
Balloons must not be overinflated as they can rupture, leaving fragments in the bladder (Dougherty and
Lister, 2015).

Patient anxiety
✓ Patients may be anxious about pain and discomfort during the procedure, and about passing urine
afterwards.

✓ Those who have previously failed a trial without their catheter may be concerned about passing urine
independently.

✓ Some may also be anxious about bladder control and urinary incontinence. These concerns may be
heightened if the catheter has been in place for a long period of time.

✓ They should also ensure patients know who to contact if they experience problems. Box 2 lists the
complications that can occur following catheter removal.

12
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Box 2. Complications following catheter removal

Urinary retention (inability to pass urine) - Symptoms include:
Abdominal discomfort and pain
A palpable bladder
Anuria (no urine output) or passing small and frequent amounts of urine
A weak stream
Hesitancy
Straining, feelings of incomplete emptying and after-dribble (Abrams et al, 2002).
If retention is suspected, it is important to perform a bladder ultrasound (Yates, 2016) and catheterize the
patient if indicated.

Dysurea (pain when passing urine) - Stinging and burning may occur when passing urine; symptoms can
last for a few days. It is important that patients drink 2-3L of fluids a day to dilute their urine.

Frequency (need to urinate more often than usual) and urgency (sudden and compelling urge to
urinate) - These symptoms can occur immediately after catheter removal. It is important that patients can
reach the toilet or are supplied with appropriate aids, such as a urinal, and are able to call for assistance if
required. Symptoms usually resolve in a few days but if they persist or are accompanied by signs of urinary
tract infection or urinary retention, they will require further investigation. Patients with frequency and/or
urgency may be reluctant to drink but should be advised that concentrated urine can irritate the bladder and
cause unwanted contractions/spasms. Drinking fluids, especially water, will dilute the urine so the bladder will
become less irritable and tolerate holding urine for longer periods.

Haematuria (bloodstained urine) - This can occur following catheter removal but if it persists or gets worse,
the patient should report it to a heath professional for further assessment.

Incontinence - Patients may experience continence problems immediately after catheter removal; these may
settle within a few days or take longer, depending on how long the catheter has been in situ. Patients may
need management aids such as absorbent pads temporarily to help them remain dry; however, this should
not be considered a long-term solution.

If symptoms persist the patient should be assessed and referred for specialist support. If the catheter has
been in situ for a long period of time, the patient may need bladder retraining instruction.

Routine urethral catheter removal

Timing of catheter removal

Catheters are routinely removed early in the morning. This means that any problems, such as urinary
retention, will normally present during the day and can be dealt with by appropriate health professionals
(Dougherty and Lister, 2015).

Equipment
• Dressing pack containing paper towel, swabs and gallipot;
• Kidney dish to receive the catheter;
• Syringe for deflating the balloon (usually a 10ml syringe);
• Disposable gloves and apron (Dougherty and Lister, 2015);
• Cleansing solution, for example 0.9% sodium chloride.

13
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

The procedure
1. Ensure the patient understands the procedure and gain consent to remove the catheter. Explain
any symptoms that may occur after removal, such as urgency, frequency and discomfort, and
what action to take if these occur.
2. Check the patient’s records to see how much water was used to inflate the catheter balloon. The
same volume should be removed to completely deflate the balloon, before attempting to remove
the catheter.
3. Assemble the relevant equipment. Screen the patient to maintain privacy and protect bed linen
using protective covering.
4. Ask the patient to lie in a supine position so the catheter is easily accessible and the patient can
relax.
5. Release any catheter fixation devices to allow easy removal (Fig 3b).
6. Empty the patient’s catheter bag or drain the bladder via a catheter valve to prevent any spillage
of urine during removal (Fig 3c).
7. Wash your hands and put on non-sterile gloves to reduce the risk of cross infection.
8. Place the paper towel under the patient and a kidney dish between the patient’s legs to receive
the used catheter and to catch any urine spillage.
9. If necessary, clean around the meatus and catheter using an appropriate solution (usually 0.9%
sodium chloride – check local policy). Always swab away from the urethral opening to reduce the
risk of introducing infection into the urethra. In women, never clean from the perineum or vagina
towards the urethra as this can transfer bacteria and potentially cause urinary tract infection
(Dougherty and Lister, 2015).
10. Following the manufacturer’s instructions, attach the syringe to the inflation/deflation valve to
deflate balloon. Do not pull on the syringe but allow the solution to flow back naturally as the
balloon deflates (Fig 3d).
11. Check that the volume of fluid in the syringe is equal to the volume inserted; this indicates that
the balloon is completely deflated (although silicon catheters may not give back the same
volume as fluid can be lost from the balloon by osmosis).
12. Ask the patient to relax, and to breathe in and out as this relaxes the pelvic floor muscles
(Dougherty and Lister, 2015).
13. Ask the patient to exhale and gently remove the catheter using continuous traction (Dougherty
and Lister, 2015) (Fig 3e). In male patients, extend the penis as this straightens the urethra. Men
should be warned about potential discomfort as the deflated balloon passes through the prostatic
urethra. Women can experience a stinging sensation and discomfort.
14. Clean and dry the meatus if necessary and make the patient comfortable.
15. Inspect the removed catheter for any signs of encrustation, especially if a new catheter is to be
inserted. This can affect how often the catheter is replaced.
16. Dispose of equipment according to local policy (Fig 3f).
17. Remove gloves, and wash and dry hands. Ensure the patient is able to walk to the toilet or has a
call bell to ask for help.
18. Patients often experience symptoms of urgency and frequency so calls for assistance should be
responded to promptly.
19. Document the date and time of the catheter removal.
20. Record urine output until the frequency and voided volumes are satisfactory.

14
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

21. Encourage the patient to drink 2-3L of fluid a day (Dougherty and Lister, 2015). This helps to
flush out any bacteria that may be present in the urinary tract and prevent infections, which in
turn will prevent burning/pain on passing urine. Concentrated urine can also irritate the bladder
and cause unwanted contractions and spasms.
22. Ask the patient to observe for any signs of voiding difficulties and report these immediately.

15
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

You may check on the skills below;

INSERTING A FOLEY CATHETER ON A FEMALE PATIENT/SKILL DEMO

https://www.youtube.com/watch?v=Il0iJUNnq7k

INSERTING A FOLEY CATHETER ON A MALE PATIENT/SKILL DEMO

https://www.youtube.com/watch?v=A493yBJtiQ0

III. REFLECTION AND RESPONSE/ACTION

Activity 4. Now that you have learned the nursing skill of insertion and removal of catheter, did you encounter
difficulties in performing the skill?
Activity 5. MAKE A RECORDED VIDEO OF YOURSELF DEMONSTRATING THE SKILL.
Refer to your Nursing Manual Procedure or Annex for the checklist
Activity 6. DOCUMENT THE SKILLS PERFORMED (USE SAME SCENARIO FROM THE
DOCUMENTATION)
Things to consider on guided skills practice.
1. Use your RLE uniform during demonstration.
2. Verbalize the checklist or atleast the thought in English.
3. No notes allowed.
4. Avoid unnecessary audience during the demonstration.
5. Use available resources at home for tools and equipment. Use equipment that will serve as the same
functions. We discourage to buy new things.
6. Do not upload your video on social or another platform. The video will be exclusive for BaSC- CHS-
Department of Nursing.
7. Focus the camera on the skills being demonstrated.

16
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Lesson 3 OBTAINING A URINE SPECIMEN FROM AN INDWELLING URINARY CATHETER

Course Code NCM 109- B Week/Day 4
Course Description Care for Mother and Child at Risk Duration 16 hours
or with Problem (Acute and
Chronic)
Lesson/ Topic OBTAINING A URINE SPECIMEN Lesson No. 3
FROM AN INDWELLING URINARY
CATHETER
Learning Outcome/s At the end of this lesson the students can demonstrate the nursing skill
through guided practice skills
Value Integration Compassion
Reference/s Fundamentals of Nursing
Course Coach Jordana Khadija Sadjail, RPh, RN, MN
Email: jordanakhadijac@gmail.com
Fb: Jordana Khadija Sadjail Castillo
Contact #:09052428221

I. Activation of Prior Knowledge.

Welcome to Skill 3 of NCM 109-B (RLE). This lesson will introduce you to OBTAINING
A URINE SPECIMEN FROM AN INDWELLING URINARY CATHETER .
Please take the pre-test to evaluate your expectation of this course.

Activity 7.

Write your answer on the answer sheet provided at Annex

1. Why does the nurse need to keep the urine sterile while obtaining a sample from an indwelling urinary
catheter?

A. Sterile technique protects the patient from microorganisms in the urine.

B. Sterile technique protects the nurse from microorganisms in the urine.
C.Sterile technique reduces the amount of pain caused by the procedure.
D. Sterile technique ensures that microorganisms in the specimen are from the urine, and not the
result of contamination.

2. Which statement might the nurse make to nursing assistive personnel (NAP) before delegating the
collection of a routine urine sample from a patient with an indwelling urinary catheter?

A. "Does the patient understand why the specimen is needed and why we cannot obtain it from the
Foley bag?"
B. "See if the catheter is causing the patient any problems and if he is having any pain."
C. "Please get two sterile urine collection containers from the utility room."
D. "Let me know if the urine contains blood or sediment or appears cloudy."

3. Which measure may be taken to minimize the staff's risk for infection from a urine specimen?

A. Firmly securing the lid of the urine specimen container

B. Using a sterile urine specimen container
C. Using a sterile syringe to access the sampling port
D. Placing the urine specimen container in the refrigerator until the laboratory comes to get it

17
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

4. When collecting a urine specimen from an indwelling urinary catheter, which action is most likely to
ensure that sufficient urine is collected?

A. Checking the patency of the indwelling catheter tubing

B. Placing the urinary collection bag below the level of the bladder
C. Clamping the catheter tubing for 15 minutes before collection
D. Asking the patient to drink a glass of water 30 minutes before the collection

5. Which action will ensure that a sterile urine specimen is handled properly in order to help obtain
reliable results?

A. Placing the specimen in a biohazard bag

B .Having someone take the specimen to the lab immediately
C. Cleaning the outside surface of the container
D. Ensuring that a stock of sterile urine collection kits is available

II. Engagement in Relevant Content and Appropriate Learning Activity/Activities.

Let us start with our lesson.

SKILL 3

(This content is taken from Shepherd E (2017) Specimen collection 2: obtaining a catheter
specimen of urine. Nursing Times 113 8:20-21. www.nursingtimes.net/clinical-
archive/assessment-skills/specimen-collection-2-obtaining-acatheter-specimen-of-urine-10-07-2017,
https://www.cmqcc.org/system/files/resources/Sepsis%20Appendix%20E.pdf)
(https://www.specimencare.com/main.aspx?cat=711&id=6235#:~:text=Urine%20has%20a%20long%20history,status%
20and%20detection%20of%20drugs.)

Urine Specimens
an overview of collection methods, collection devices, specimen
handling and transportation

✓ Urine has a long history as a specimen for analysis in clinical laboratories.

✓ After blood, urine is the most commonly used specimen for diagnostic testing, monitoring
of disease status and detection of drugs.
✓ Urine testing, using both automated and traditional manual methods, is growing rapidly.
✓ As with all clinical laboratory specimens, preanalytical error in urine specimens is often
difficult to detect.
✓ Because of this, it is important for laboratories to have processes in place to ensure
compliance with best practice in specimen collection, handling and transport – including the use
of preservatives where appropriate.

Types of Urine Collection Methods

Urine specimens may be collected in a variety of ways according to the type of specimen
required, the collection site and patient type.

Randomly Collected Specimens are not regarded as specimens of choice because of the
potential for dilution of the specimen when collection occurs soon after the patient has consumed
fluids.

18
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

First Morning Specimen is the specimen of choice for urinalysis and microscopic analysis,
since the urine is generally more concentrated.

Midstream Clean Catch Specimens are strongly recommended for microbiological culture and
antibiotic susceptibility testing because of the reduced incidence of cellular and microbial
contamination.

Timed Collection Specimens may be required for quantitative measurement of certain analytes,
including those subject to diurnal variation. Analytes commonly tested using timed collection
include creatinine, urea, potassium, sodium, uric acid, cortisol, calcium, citrate, amino acids,
catecholamines, metanephrines, vanillylmandelic acid (VMA), 5-hydroxyindoleacetic acid, protein,
oxalate, copper,17-ketosteroids, and 17-hydroxysteroids.

Collection from Catheters (e.g. Foley catheter)using a syringe, followed by transfer to a

specimen tube or cup. Alternatively, urine can be drawn directly from the catheter to an evacuated
tube using an appropriate adaptor.

Supra-pubic Aspiration may be necessary when a non-ambulatory patient cannot be

catheterized or where there are concerns about obtaining a sterile specimen by conventional
means.

Pediatric Specimens present many challenges. For infants and small children, a special urine
collection bag can be adhered to the skin surrounding the urethral area.

Urine Collection Devices

An extensive array of urine collection products is available on the market. Information on features,
intended use and instructions for use should be obtained from the device manufacturer and
reviewed before being incorporated into a specimen collection protocol.

Urine Collection Containers (cups for collection and transport)

Urine collection container cups are available in a variety of shapes and sizes with lids that are
either ‘snap-on’ or ‘screw-on’. Leakage is a common problem with low quality products. To protect
healthcare workers from exposure to the specimen and protect the specimen from exposure to
contaminants, leak-proof cups should be utilized. Some urine specimen containers have closures
with special access ports that allow closed-system transfer of urine directly from the collection
device to the tube.

Urine Collection Containers for 24-hour Collection

Urine collection containers for 24-hour specimens commonly have a 3 liter capacity. As for the
urine collection cups above, closure types vary with some containers featuring an integrated port
for transfer of an aliquot of the specimen to an evacuated urine collection tube. This provides the
option for the laboratory to receive only the aliquot tube and specimen weight (with the large 24-
hour container and contents discarded at the point of collection). Additional precautions need to
be taken when a preservative is required.

19
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Urine Specimen Tubes

Urine specimens may be poured directly into tubes with ‘screw-on’ or ‘snap-on’ caps. Additionally,
evacuated tubes, similar to those used in blood collection, are available.

Urine Specimen Collection and Transportation Guidelines

As for any type of clinical laboratory specimen, certain criteria for collection and transportation of
urine specimens must be met to ensure high quality specimens free of preanalytical artifact are
obtained consistently. Without this, accurate test results cannot be guaranteed.

Urine Specimen Preservation

For urinalysis and culture and sensitivity testing, recommend testing within two hours of collection.
Different time limits may apply to specimens required for molecular testing of infectious agents
(e.g. testing forNeisseria gonorrhoeae, Chlamydia trachomatis). For this type of testing,
laboratories should ensure they are able to comply with specimen transportation conditions
prescribed by the assay manufacturers. Where compliance with these and/or CLSI
recommendations is not possible, consideration should be given to the use of a preservative.
Specimen collection tubes with preservatives for chemical urinalysis and culture and antibiotic
susceptibility are available.

Urine Specimen Reception in the Laboratory

In addition to routine checks and precautions taken for all specimens received in the
clinical laboratory, the following additional ‘check items’ apply to urine specimens.

• Labels
• Volume
• Collection Date and Time
• Collection Method
• Specimen Preservation
• Light Protection

Collecting a Urine Specimen from a Foley Catheter

✓ Indwelling urinary catheters are attached to a drainage bag to create a closed system.
✓ Breaking this closed system by disconnecting the catheter from the drainage device can increase the risk
of a patient developing a catheter-associated urinary tract infection (CAUTI).
✓ Samples should not be collected from the drainage bag, as the specimen may be contaminated.
✓ Ideally, samples should be collected before antibiotics are administered as they may affect the laboratory
result.
✓ A catheter specimen must be obtained from the sampling port on the catheter bag.
✓ Sampling ports are designed to be accessed directly using a Luer Lock syringe and do not require a needle.

20
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

Equipment
• Personal protective equipment (i.e. gloves)
• Sterile 10ml Luer Lock syringe
• Non-traumatic clamp (if catheter does not have a slide clamp)
• Sterile specimen container
• Prep wipes Procedure
(See Figure 1 on next page)
1. Introduce yourself to the patient and verify the correct patient using two identifiers.
2. Explain the procedure to the patient and gain informed consent to obtain the specimen. Explain why the specimen is
being collected, when the results will be available, and implications for treatment.
3. Ensure the patient is comfortable and that privacy and dignity is maintained throughout the procedure.
4. Wash your hands, prepare equipment, and apply personal protective equipment.
5. If taking a specimen from a sampling port (
Fig 1a), check first whether there is urine in the catheter tubing. If the tubing is empty, apply a clamp approximately 3
inches below the level of the sampling port
(Fig 1b). This allows urine to collect above the clamp so that a sample can be obtained.
6. Clean the sampling port with a prep wipe according to policy and allow to dry (Fig 1c).
7. Stabilize the tubing by holding it below the level of the sampling port.
8. Insert the syringe tip into the sampling port (following manufacturer’s instructions) (Fig 1d). Be careful to protect the
sterile syringe tip and disinfected sampling port from contamination.
9. Aspirate at least 10 mL of urine and disconnect the syringe.
10. Put the urine into a sterile specimen container, avoiding contact between the syringe and the cup (Fig 1e). Ensure
the top of the specimen container is secured to prevent leakage and contamination of the specimen.
11. Wipe the sampling port with a prep swab and allow it to dry. This reduces the risk of cross infection and contamination.
12. If a clamp was used, release it to allow urine to drain freely. Failure to do this will cause the bladder to fill and can
result in discomfort.
13. Remove and dispose of personal protective equipment, and perform hand hygiene.
14. Label the specimen and place in a specimen bag following policy.
15. Send the sample to the laboratory immediately or refrigerate until it can be transported to ensure accurate results are
obtained.
16. Document the date and time the sample was collected.

21
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

You can watch the skills at the link below or type nursing skill
How to take urine sample from catheter

https://www.youtube.com/watch?v=jW_GNTEbmiw

You may refer to the checklist provided at Annex B

III. REFLECTION AND RESPONSE/ACTION

Activity 8. As a nurse, what must you consider in collecting a urine specimen from foley catheter?
Activity 9. MAKE A RECORDED VIDEO OF YOURSELF DEMONSTRATING THE SKILL.
Activity 10. Document the procedure from the same case scenario
Refer to the checklist provided at Annex

Things to consider on guided skills practice.

1. Use your RLE uniform during demonstration
• Hair cut for boys
• Hair colors not allowed
• Use only black tarha
2. Verbalize the checklist or atleast the thought in English.
3. No notes allowed.

22
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21
 NCM 109-B Module 1

4. Avoid unnecessary audience during the demonstration.

5. Use available resources at home for tools and equipment. Use equipment that will serve as
the same functions. We discourage to buy new things.
6. Do not upload your video on social media or another platform (facebook, youtube, IG, tweeter
or any other alike). The video will be exclusive for BaSC- CHS- Department of Nursing.
7. Focus the camera on the skills being demonstrated.
8. No video editing
9. Performance of the skills will be time limit.

IV. SUMMATIVE ASSESSMENT

This activity will be at the end of the unit.

V. FEEDBACK TO IMPROVE LEARNING AND TEACHING

Kindly fill in the feedback at the answer sheet provided at Annex D for any issues you are facing, and you may
suggest ways to improve your learning.

23
NCM-109B- Care for Mother and Child at Risk or with Problem (Acute and Chronic) BaSC AY 2020-21