SPECIMEN COLLECTION 2005

1. SPECIMEN COLLECTION 2005 Adapted from the work of BRENDA QUARTLY, R.N., B.S.N. JUNE 23, 2004 , Can Costello, Infection Control Practitioner (NRGH) Spring, 2004; information from the Nurse’s Manual of Laboratory and Diagnostic Tests, 4e, by B.M. Cavanaught; F.A.Davis Co. and Handbook of laboratory & Diagnostic Tests with Nursing Implications (2005) 5th e; Joyce LeFever Kee

2. SPEC?!!!!! WHAT SPEC?!!!!! WHAT IS A SPECIMEN? NO, it is NOT an Italian Astronaut!

3. Examples of specs or tests Laboratory Blood, Serum, Plasma Breath Analysis Cerebrospinal(CSF) Feces -c. diff, O+P Urine -Routine, C+S Tissue (e.g.wound, vaginal smear) Diagnostic Angiography Biopsy “…oscopy” CT, CAT ECG GI series MRI etc.

4. Specimens that are NOTcollected & labeled correctly will be disposed of by the lab.

5. What types of specimens might you be asked to collect?

6. SPECIMEN TYPES Urine -> R+M; C+S Stool -> C+S;Virusor parasites Respiratory secretions -> Sputum, Nose & Throat Swabs for C+S, viral, TB or fungus Wound -> aerobic, anerobic swab/ aspirate ARO screening -> swab/other

7. Indications for UA Screening test during general physical examination Diagnosis of urinary tract infection (UTI) Detection of possible diabetes mellitus Detection of possible renal disease

8. Urinalysis tests Routine Physical exam, pre-op Diagnosing renal disease UTI and metabolic diseases Culture and Sensitivity Sensitivity to specific antibiotics (R, I, S) Timed -> 24 hour Hormones Drugs Renal function

9. Urine Formation Because urine results from filtration of blood, many substances in blood are also found in urine 25% of cardiac output perfuses the kidneys each minute 180 L of glomerular filtrate is produced each day, 90% of which is reabsorbed

10. Substances in Urine As with blood chemistry, urine can be screened for the following substances: Electrolytes Pigments Enzymes Hormones (PKU, Estrogens, FSH) Proteins (Albumin) Cells (epithelial) Drugs (legal, illegal)

11. Routine UA Diagnosing renal disease, UTI and metabolic disease (glycosuria + normal vs. abnormal urine components) Routine UA has two components: macroscopic analysis microscopic analysis

12. URINARY SPECIMENS What are some common S&S that your client would describe that could indicate a U.T.I.? Frequency, burning dysuria (painful void), odour, temp.-> C+S Asymptomatic

13. PROCEDURE FOR ROUTINE URINALYSIS (R+M) Specimen is considered clean and not sterile Supplies: sterile container, label, req., bactericidal soap, soap & water, gloves Cleanse perineum and void into clean container 50 mls or greater required – to lab in 30 min is ideal Could be refrigerated for 6-8 hrs No feces or toilet paper in spec. Early A.M. spec. while urine still concentrated for more accurate result Client’s chart: date/time spec type sent

14. Macroscopic urinalysis Colour, appearance/clarity; odour, Some places first use reagent strips – pH (slightly acidic, but can adjust to alkaline depending on systemic acid-base balance), protein (scant), glucose (neg), ketones (neg) and bilirubin (neg) Specific gravity (ability of kidney to concentrate urine - 1.010-1.035) Nitirite (neg) Leucocyte esterase (neg)

15. Microscopic analysis Microscopic for RBC, WBC, epithelial cells, casts, crystals, bacteria Detects normal/abnormal urine components ie electrolytes If WBC present or bacteria suspected then MSU for C&S required (how would you know?)

16. M.S.U. OR CLEAN CATCH Used to test for culture + sensitivity (C&S) Before antibiotic is started A midstream urine minimizes contamination of the spec. by organisms on the perineal skin and urinary meatus Takes 24hrs for bacteria to grow, and 48hrs for sensitivity to specific antibiotics

17. Procedure & Supplies for MSU Supplies: sterile container, label, req., bactericidal soap, soap & water, gloves Cleanse urinary meatus with bactericidal soap Initiate urine stream, then pass spec. bottle into stream and collect 30-50 mls Replace cap and clean outside of bottle Remove gloves and wash hands Apply label, put spec in bag and attach req. Client’s chart: date/time spec type sent

18. M.S.U. Continued Why initiate stream prior to collecting urine? To flush out the microorganisms that accumulate at the urinary meatus. Specimen should go to lab within 15 min. or be refrigerated to prevent falsely elevated bacteria counts. Females: hold labia open throughout voiding process to prevent contamination.

19. TIMED URINE SPECS 24hr. Urine (ie creatinine clearance) More accurate results than a one time random spec Client must be educated on procedure in order to assist

20. PROCEDURE for 24hr. URINE Large collection container with preservative in basin of ice Usually begin at 0600 with 1st void discarded.The next void goes into container with the correct date and time written on the label. The collection is stopped 24hrs. following the initial date and time and to lab immed. Start:Feb.10/04,0600 Stop:Feb.11/o4,0600

21. Tests of Renal Function Renal function tests are used to evaluate excretory, secretory, & osmolar regulation dynamics of the kidneys Broad categories for these tests include: clearance tests tubular function tests concentration tests

22. Creatinine Clearance Test A sensitive indicator of glomerular function and major diagnostic test for renal disease Creatinine clearance decreases with age Clearance is calculated by: C=UV/P C - creatinine clearance U - amount of creatinine in the urine V - volume of urine excreted in 24 hrs P - plasma creatinine level

23. Indications for Creatinine Clearance Tests Evaluation of nephron function (50% of functioning nephron units must be lost before values will be decreased) Evaluation of renal function and subsequent monitoring when ordering nephrotoxic drugs A 24-hr urine collection is necessary

24. Tubular Function Test (PSP) Assess the ability of the renal tubules to remove waste products and other substances from the blood PSP dye is injected intravenously, and urine samples are collected at 15 min-, 30 min-, 1 hr-, and 2-hr intervals

25. Concentration & Dilution Tests Assess the ability of the renal tubules to concentrate or dilute urine in response to water balance & circulating volume Appropriately, fluid is withheld, or additional fluid given, & output measurements are assessed

26. Summary Points As a filtrate of blood, UA can contribute significant information about the homeostasis of the body Care must be taken in the collection and storage of urine specimens as many alterations occur rapidly Creatinine clearance is the most sensitive test to determine renal function

27. STOOL SPECIMENS Occult Blood to detect colorectal ca. or GI bleeding Stool for O & P to detect parasites and their ova (intestinal Infection) Stool C & S to detect bacteria causing G.I. Disease

28. Indications for Fecal Analysis Diarrhea of unknown etiology Evaluation of fat in the stool Diagnosis of inflammatory bowel disease

29. Microscopic Analysis Leukocytes negative Qualitative fat <60 droplets per HPF Meat fibers negative Parasites & bacteria negative Occult blood negative

30. I AM MR. C. DIFFICILEcoming to a GI tract near you!!!! Stool for Clostridium Difficile Common in hospitalized clients taking lg. Doses of AB Bacterial infection Normal intestinal flora depressed by AB therapy

31. Nursing Considerations The patient should consume a normal diet for several days before the test Do not use laxatives for several days before the test Alterations in diet will be needed to test for occult blood and quantitative fat

32. Summary Points Analysis of fecal material can aid in diagnosis of lower intestinal disease Diet can influence the results of fecal analysis

33. Sample documentation for Urine/Fecal tests Mar2/05,0800 60mls of loose green/black foul smelling stool obtained and sent for clostridium difficile as ordered-Pea U RN. Mar2/05, 0700 M.S.U obtained with 80mls of cloudy, foul smelling urine, and sent as ordered. Client c/o dysuria and urgency.----------Bathroom Seeker, R.N. Mar 2/05,0600 24hr.urine collection for creatinine clearance initiated. First void discarded. Collection container on ice in B.R. Client independent with collection.----------------------------------U. Pee, R.N.

34. SPUTUM SPECIMENS Acid-fast Bacilli(AFB) If TB suspected-3 sputum specs tested over 3 separate days for Mycobacterium tuberculosis Early morning spec as this produces the most organism-concentrated sample Follow individual facility protocol

35. Sputum Specs Continued Sputum for Culture & Sensitivity Diagnose microorganisms causing resp. infection Identify appropriate antimicrobial sensitive to the pathogens

36. Sputum Production & Function Sputum is the material secreted by the tracheobronchial tree brought up by coughing 100 mL of mucus is produced each day to aid in bronchopulmonary cleansing The quantity of sputum produced in pathological states is roughly parallel to the severity of the problem

37. Common Tests Performed on Sputum Specimens Tests used to diagnose pulmonary infection Cytological testing of sputum specimens may also be done for abnormal cells, fungi, ova, and parasites

38. Gram Stain Sputum specimen is smeared on a slide and stained with dye This technique allows for morphological examination of any cells or bacteria Specimens may be obtained by expectoration or suctioning

39. Acid-Fast Bacillus (AFB) Smear and Culture Used to detect tubercle bacilli Cultures may be done to confirm positive and negative results of a smear

40. PROCEDURE For Sputum Specimens C & S-early a.m. spec. Brush teeth, rinse mouth Sterile container with lid (preservative prn) Client to cough 2-3X then provide deep cough so spec. comes from bronchi and delivered directly into container

41. Sputum Specimen Cont’d Be careful not to contaminate inside of lid 1-3mls sufficient Place correct label on spec container Place spec into plastic lab spec bag & seal Fill out appropriate req to send with spec. Refrigeration not nec., to lab asap Acid-fast bacilli-as above and according to agency protocol

42. How to Assist Your Client in Producing a Sputum Specimen Physiotherapy: percussion, positioning Normal Saline Nebulizer Suction if indicated Deep breathing Fluids

43. NOSE & THROAT SWABS by: Inspector Picker Client tilt head back and open mouth,tongue depressor to prevent contamination Swab back of throat left to right tonsillar area, one side Use culture tube with applicator stick

44. Summary Points Remember that production of sputum indicates some pathology Proper oxygenation must be maintained when obtaining a sputum specimen by suctioning technique

45. Skin and soft tissue Type Skin Surgical Other Why would we want to send a spec? Inflammation signs Infection signs Colonization suspect Chart:

46. Organisms Staphyloccocus aureus Group A streptoccocus (strep pyogenes) Coagulase negative staph & other resident flora Klebsiella E.Coli Anaerobes bacteroides etc. Candida

47. Skin and soft tissue Procedure Standard precautions + aseptic technique Cleanse wound of pus using sterile gauze and saline Insert swab tip into woulnd and brush or rotate Replace swab into medium, label and send to lab

48. Screening Cultures – ARO Determine carrier state for MRSA or VRE Moisten swab tip with medium or with sterile saline Swab # 1 – insert one cm. Into one nares and gently rotate, repeat other side Swab @2 – Insert 2 cm into rectum and gently rotate (stool must be on swab) Other – collect from other sites as requrired by policy – use aerobic culture collection method.

49. A bit about “Culture and Sensitivity”(C&S) Indicates the type and number of organisms present in a specimen & the antibiotics to which the organism is sensitive Growth of pathogens in a culture is more diagnostic than stain techniques

50. Culture Involves the introduction of material in an artificial growth medium that is liquid (broth) or solid (agar). These media are used to culture bacteria & fungi Cell cultures are done to identify viruses & chlamydiae

51. Sensitivity Measures a microorganism’s strength against certain antibiotics. Bacteria are classified as: resistant (growth not inhibited) sensitive (growth inhibited) intermediately sensitive (some inhibition)

52. Indications for Culture & Sensitivity Testing Any excreted or secreted body fluid, drainage, or tissue sample can be cultured for microorganism identification

53. Nursing Considerations Follow strict standard precautions in obtaining specimens Collect specimen from the site with the most viable and active microorganisms Specimens must be collected in sterile containers to avoid contamination

54. Summary Points Culture & sensitivity testing are extremely valuable in identifying the appropriate course of treatment for many infections Proper collection & care of the culture specimen is essential to avoid cross-contamination