St.

Paul University Philippines

Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

Perineal Care/ Straight Catheterization/ Midstream Clean Catch Urine

Collection

SCENARIO 1: Mrs. Lee Chun is bedridden for almost 2 years of her life after suffering a
series of stroke in 2022. Prior to admission, her temperature was 39.4C. Her physician
ordered Paracetamol 300mg/ml via IV. After 36 hours, her perform midstream clean catch
urine collection.

1. The ordered procedure is invasive. What will you secure before performing the
procedure?
-It is essential for us student nurses to gather and manage all specimens with caution,
following excellent hygiene procedures and donning the appropriate PPE, starting
with accurate patient identification. For female patients, postpone specimen collection
until menstruation has ceased and as student nurse, I can apply my knowledge about
the 10 rights of medication administration to always ensure specimens are collected at
the right time, minimizing contamination by utilizing aseptic technique and health
risks to all staff involved. Make sure to check the equipment to be used, transport the
specimen as soon as possible, and document clearly, in nursing ration no
documentation means that procedure is not merely done.

2. What measures/technique will you use during the procedure?

-During the procedure properly follow the given instruction of a doctor for the needed
specimen amount and monitoring the use of a correct equipment or tool in orde to
achieve the accuracy of results, for example, bacterial swabs contain a transport
medium that is incompatible with viruses.

3. Explain the importance of maintaining asepsis during the procedure.

-Microorganisms, viruses, and bacteria are prevalent everywhere. Aseptic technique is
a method that involves target-specific practices and procedures under suitably
controlled conditions to reduce.
contamination from microbes. When obtaining a midstream collection from a patient,
maintaining aseptic technique is of the utmost significance because we are obtaining a
specimen that needs to be tested for the confirmation of a diagnosis of a urine
infection, to determine the best antibiotic to administer, and to observe for other
abnormalities in the urine.

4. How is the procedure performed?

-The number-one role of a nurse is to be an educator for their patients. Stroke patients,
the elderly, and people with disabilities who have a hard time doing it alone may need
the assistance of a nurse. It is performed through observing the universal precaution,
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

start from washing your hands, open the commercial clean- catch urine specimen kit
and moisten the cotton balls with the antiseptic solution or open the prepare antiseptic
wipes, ask the patient to sit on the commode and separate her labia with her no
dominant hand, cleanse the perineum,washing from front to back, using a cotton ball
or wipe for only 1 strokes, then discard, and make sure that the patient is not touching
the inside of the container or cap and let the patient begin urinating, allow first urine
to flow then hold the container under urine stream to obtain specimen then remove
after approximately 10-20 ml has been obtained. Once obtained, advise the client to
remove the container, release her hand from her labia, and finish voiding into the
toilet. Tell the patient to cap the specimen container, wash hands, and bring it
immediately to the laboratory.

5. Why is it necessary to position the client in a dorsal recumbent/knee flex?

-In the dorsal recumbent position, the individual lies on their back with their knees
bent externally.
To carry out the positioncorrectly, an appropriate operating angle must be maintained,
and the patient's lower extremities might be covered by a sheet, blanket, or gown.
It hinders unintentional movement while providing care to the patient's body, gives
more comfort and privacy, makes it easier to observe the area during an examination
and helps lower the risk of infection and contamination by enabling nurses to follow
proper hygiene protocols while minimizing patient discomfort and guaranteeing
procedural efficacy.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

Assessment Nursing Background Goals and Objectives Nursing Evaluation

Diagnosis Knowledge Interventions and
Rationale
Subjective: Hyperthermia Core body NOC:Thermoregulation NIC:Temperature Goal Met:
History of related to temperature Regulation
stroke and suspected above the normal After 1 hour nursing STO
bedridden for infection. diurnal range due interventions, the client After 1 hour
2 years. to failure of will be able to: of effective
thermoregulation. nursing
(NANDA,15th intervention
Elevated Short Term:
Edition) the patient’s
temperature
temperature
of 39.4C Hyperthermia is Establish rapport with • Promotes patient
decreased
prior to defined as the patient’s guardian. and guardian
into 36.6 C
admission elevated body cooperation in the
to 37.7 F as
temperature due nursing care.
evidenced
Patients body to a break in -Promoting patient and
decreased
temperature thermoregulation guardian cooperation in
diaphoresis
nursing care ensures
remained that arises when a and calm
body produces or active participation in
elevated for breathing.
absorbs more treatment decisions,
at least 36 fostering trust and better
hours despite heat than it
dissipates. It is a health outcomes.
treatment.
sustained core
Understand of the • Monitor the
temperature
beyond the efficacy of the nursing patient for
normal variance, care. shivering and
usually greater modify cooling
Objective: than 39 °C (102.2 measures based on
Doctor’s °F). Such the patient’s
order of elevations range physical response.
straight from mild to -Excessive
cauterization extreme; body cooling or cooling
temperatures too rapidly may
for urinary.
above 40 °C (104 cause shivering,
elimination.
°F) can be life- which increases
threatening. metabolic rate and
Midstream temperature.
(Nurselab)
Clean Catch Shivering should
urine be avoided as it
collection. will hinder
cooling effort.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

Achieve understanding • Provide a tepid

of the importance of bath or sponge
sponge bath. bath.
A tepid sponge
bath is a non-
pharmacological
measure to allow
evaporative
cooling. Do not
use alcohol as it
can cool the skin
rapidly and may
cause shivering.

After 4 hours of nursing

intervention, the patient
will be able to:

Long Term:
• Educate patients LTO:
Acknowledge about the signs After 4
determining factors. and symptoms of hours of
heat exhaustion effective
nursing
or heat-related
intervention
illness.
the patient’s
-Heat-related illness vital sign
occurs when the body’s returned to
thermoregulatory system normal
fails. Heat exhaustion is limits.
characterized by elevated
body core temperature
(37ºC to 39.4ºC)
associated with
orthostatic hypotension
tachycardia, diaphoresis,
tachypynea weakness,
syncope,muscle aches,
headache, and flushed
skin.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

Recognize potential • Evaluate

complications. patient’s to
understanding
about the signs
and symptoms.
-Heatstroke occurs when
the body’s
thermoregulation fails and
is defined as elevated core
body temperature (above
39.4ºC) and central
nervous system
involvement.

Achieve behavior • Educate client

change. adequate oral
fluid intake and
nutritious
consumption.
-If the client is
alert enough to
swallow, provide
cool liquids to
help lower the
body temperature.
Additionally, if
the patient is
dehydrated or
diaphoretic, fluid
loss contributes to
fever and food is
necessary to meet
the increased
energy demands
and high
metabolic rate
caused by
accompanying
hyperthermia.
Food must be
appealing to the
patient because
lack of appetite is
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

common with
fever.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

Subjective: Self Care NOC: NIC: Goal Met:
Deficit related Self-Care: Activities Self
History of to of Daily Living Care Assistance: STO
stroke and cerebrovascular (ADLs) Bathing/Hygiene
bedridden for accident (CVA) Hygiene Self-Care Assistance:
2 years Fall Prevention Bathing/Hygiene LTO
Mobility Level Fall Prevention
Mobility Assistance
Elevated
temperature
of 39.4C
After 6 hours of
prior to
nursing interventions,
admission
the patient will be
able to:
Patients body
temperature
Short Term Provide education on adaptive
remained techniques and assistive
elevated for devices for ADLs.
Independently
at least 36 perform “basic” • canes, walkers and
hours despite activities of daily wheelchairs, as well as
treatment. living (ADLs) a wide variety of other
technologies for
Demonstrate accommodating the
improved ability to functional limitations.
maintain personal Assist patient with grooming
hygiene. and encourage participation in
self-care activities.
-The process begins by
helping them sit up in bed,
Objective: Verbalize
understanding of assisting them in putting on
Doctor’s
order of safety precautions to their clothes, proper posture
prevent injury. in performing oral care,
straight positioning properly to avoid
cauterization
Demonstrate increased bedsore , exercise regularly
for urinary. (playing board games can be)
independence in
elimination. mobility. and prioritizing their weaker
or paralyzed side first.
Midstream Educate patient and
Clean Catch family/caregiver on fall
urine prevention strategies and
collection environmental modifications.
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

-To enhance cooperation in

aily care activity, spiritual
activity, rehabilitation and
offering medicine, decision
making and financial support
Implement a progressive
mobility program, including
range of motion exercises and
ambulation with assistive
devices.
- To regain motor function
and prevent complications
like muscle contractures and
deep vein thrombosis,
exercises improve flexibility,
strength and enhance their
physical abilities quality of
life post-stroke.

• Collaborate with
occupational and
physical therapists to
develop a
comprehensive
rehabilitation plan
focusing on ADL
training, mobility
exercises, and
 St. Paul University Philippines
Tuguegarao City, Cagayan 3500
Tel: 078-846-4444;078-844-0073
Fax: 078-846-4305
www.spup.edu.ph

SCHOOL OF NURSING AND ALLIED HEALTH SCIENCES

strengthening
activities.
• Provide ongoing
education to the
patient and caregivers
on adaptive
After 6 months of techniques, proper
nursing interventions, body mechanics, and
the patient will be able the use of assistive
to: devices to enhance
Long Term: independence in self-
care activities.
Patient will • Monitor progress
independently perform regularly and adjust
all activities of daily interventions as
living (ADLs) without needed based on the
assistance. patient’s functional
status and goals.
Maintain optimal Implement a multidisciplinary
personal hygiene and approach involving nursing,
grooming habits. therapy, and other healthcare
professionals to address the
patient’s physical, cognitive,
and emotional needs
throughout the recovery
Adhere to safety process.
precautions to prevent •
falls and other
injuries.
Patient will achieve
improved mobility
and functional
independence.