CENTRO ESCOLAR UNIVERSITY

Manila * Makati * Malolos

SCHOOL OF NURSING

PROCEDURE CHECKLIST

Collecting A Sterile Specimen from an Indwelling Catheter

Name of Student Score

Year/Section/Group/Number

Rate the student's performance by checking the appropriate box using the following criteria:

5 - Excellent (Carries out procedures efficiently, systematically and

independently/Personality trait is observed at all times)

4 - Very Satisfactory (Carries out procedures efficiently and systematically but requires
minimal guidance and supervision/Personality trait is observed at all times)

3 - Satisfactory (Carries out the procedures efficiently and systematically but requires
moderate guidance and supervision/Personality trait is observed at all times)

2 - Fair (Carries out the procedures efficiently and systematically but requires close
guidance and supervision/Personality trait is observed at all times)

1 - Poor (Carries out the procedures inefficiently, unsystematically even under close
guidance and supervision/Personality trait is observed at all times)

0 - Not done

Criteria 5 4 3 2 1 0

ASSESSMENT

1. Determine how long catheter has been in place.

2. Observe any discharge or encrustation around
urethral meatus. Assess for complaints of pain or
discomfort.

PLANNING

Prepare the materials needed.

1. 3 mL syringe with 1inch needle (21-25 gauge) for

culture or 20 mL syringe with 1inch needle (21-25
gauge) for routine urinalysis

2. Metal clamp or rubber band

3. Alcohol, povidone-iodine, or other disinfectant

swab

4. Specimen container: non-sterile for routine

urinalysis, sterile for culture

5. Specimen label

6. Completed laboratory requisition with patient’s

name, date and time of collection

7. Clean, disposable gloves

IMPLEMENTATION

1. Wash your hands. Wear gloves and follow

standard precautions if contact with blood or body
fluids cannot be avoided.

2. Identify the person, and greet him or her by name.

3. Explain the procedure and encourage the person
to participate as appropriate.

4. Provide privacy by showing any visitor where they

should wait, if necessary, until you have completed
the procedure. Close the door and the curtain.

5. Clamp the drainage tubing with clamp or rubber

band for 30 minutes.

Criteria 5 4 3 2 1 0

6. Return to room and inform patient that the

procedure to collect specimen from the catheter will
begin.

7. Wash hands again or an alcohol and don gloves.

8. Cleanse entry port for needle with disinfectant

swab.

9. Insert the needle at 30-degree angle just above

where the catheter is attached to drainage tube or
built-in sampling port.

10. Draw urine into 30 mL syringe for culture or draw

urine into 20 mL syringe for urine urinalysis.

11. Transfer urine from syringe into specimen

container.

12. Place lid tightly on container.

13. Unclamp catheter and allow urine to flow into
drainage bag.

14. Secure attached properly completed identification

label and laboratory requisition specimen.

15. Send specimen to laboratory immediately or

place in specimen refrigerator.

16. Dispose of soiled supplies and wash hands.

EVALUATION

1. Check laboratory report for results.

2. Record collection of specimen on nurse’s notes;

note time and date, appearance and odor.

Total Score:

Comments/Suggestions:

Computation: Total Score divided by (number of items) x 20 (factor) =

_________________

*Total points shall be transmuted using the table for 100 pts. Passing cut-off point is 65.

Equivalent Numeric Grade: _______________

 Interpretation: __________________________

Evaluator: Conforme:

Clinical Instructor's Student’s Signature Date:

Printed Name & Signature