What should the nurse instruct the patient to do before obtaining the urine specimen for a urine culture?

The most important step in the recovery of pathogenic organisms responsible for infectious disease is the proper specimen collection, processing and handling by you, the healthcare professional. It is one way of knowing about the patient’s health status by identifying pathogens and analyzing urine, blood, sputum, and feces. One of the many responsibilities assigned to us, as nurses, is to collect and label specimen for analysis and to ensure their delivery to the lab. And knowing the proper way of gathering specimen is necessary for self-protection and to prevent the spread of disease.

• Objectives
• Concepts of Specimen Collection
• Importance of Specimen Collection
• Nurses’ Roles in Specimen Collection
• 1. Throat Swab Culture
• 2. Sputum Specimen and Culture
• 3. Stool Specimen and Culture
  • 3.1. Guaiac Fecal Occult Blood Test (gFOBT)
• 4. Urine Specimen and Culture
  • 4.1. Random Urine Sample
  • 4.2. Midstream “Clean-Catch” Urine Specimen
  • 4.3. Timed Urine Specimens (2-Hour, 4-Hour, 24-Hour)
  • 4.4. Pregnancy Urine Test
• 5. Blood Cultures

Objectives

• Specify most common specimen collection procedures
• Know the importance of various specimen collection for patient care and satisfaction
• Emphasize the importance of protecting yourself against exposure to bloodborne pathogens

Concepts of Specimen Collection

• Collect the specimen from the actual site of infection without contaminating adjacent tissues and secretions.
• Collect the specimen at the best time possible (e.g., early morning sputum for AFB culture)
• Collect ample amount of sample by using appropriate collection devices such as sterile, leak-proof specimen containers.
• Use appropriate transport media such as anaerobic transport vials, culturette for bacterial culture, and the like.
• Check expiration date before inoculating collection device.
• Collect specimens before administration of antimicrobial agents whenever possible.
• Label the specimen properly and fill out  test request form completely.
• Lessen transport time and maintain an appropriate environment between collection of specimens and delivery to the laboratory.

Importance of Specimen Collection

The following could affect the hospital’s reimbursement under recent healthcare reform laws and regulations:

• Poor specimen quality can affect key quality reporting requirements and metrics
• Reduced power to act upon infection
• Decreases patient satisfaction from improper collection technique
• Expanded cost-per-Medicare beneficiary due to repeated specimen collections and unnecessary treatment.

Specimen collection is also key to patient’s satisfaction and poor collection practice can lead to:

• Defective results and improper treatment
• Duplicated specimen collections and re-testing
• Vessel trauma and pain

Poor specimen collection may also affect nurses professionally and personally by:

• Decreased ability to provide up-to-date, proper patient care
• Exposure to bloodborne pathogens
• Unnecessary repeated specimen collection and patient dissatisfaction

Nurses’ Roles in Specimen Collection

• Patient interaction
• Suitable selection of supplies
• Appropriate and proper collection
• Precise sample identification
• Up-to-date transfer to the lab

1. Throat Swab Culture

A throat swab culture is a laboratory diagnostic test that evaluates for the presence of a bacterial or fungal infection in the throat. It is done to isolate and identify any pathogens, which may be medium. A sample of mucus and secretions from the back of the throat is collected on a cotton-tipped applicator and applied to a slide or a special cup that allows infections to grow. These infections can include strep throat, pneumonia, tonsillitis, whooping cough, and meningitis.

Purpose

Throat swab culture is done to detect the presence of organisms in the throat that could cause infection. For instance, the presence of group A streptococcus bacteria in your throat is a key sign that you may have strep throat.

Supplies and Equipment

The supplies and equipment required to obtain a sample for throat culture are:

• Sterile cotton-tipped applicator specimen collection tip (culturette)
• Tongue depressor
• Laboratory request form
• Flashlight

Procedure

1. Always observe proper hand hygiene prior to the test.
2. Have the patient sit comfortably either on bed or chair while explaining the procedure.
3. Allow the patient to tilt his head back and ask him to say “Ahhh.” Antiseptic mouthwash should be avoided before this test.
4. Make use of the flashlight to light up the back of the throat and check for presence of inflammation using the tongue depressor.
5. Swab the tonsillar areas from side to side and make sure to include any inflamed or purulent sites. The test may cause momentary gagging because the back of the throat is a sensitive area, but it should not be painful.
6. Refrain from touching the tongue, cheeks, or teeth with the applicator, due to possible contamination with oral bacteria.
7. Place the cotton-tipped applicator into the culture tube immediately.
8. Label the culture tube with the patient’s name, SSN, and ward number if applicable.
9. Fill out the request form completely with the following information:

• Patient’s name
• Patient’s rank or status
• Family member prefix and sponsor’s social security number
• Ward number if inpatient, or mobile number if outpatient
• Source of the specimen (e.g., throat)
• Any antibiotics the patient is taking
• Date and time the specimen was obtained
• Name of the physician who ordered the culture

10. The sample is then taken to the laboratory for culture.

2. Sputum Specimen and Culture

A sputum specimen is a sample of material expelled from the respiratory passages taken for laboratory analysis to determine the presence of pathogens. A specimen of mucus from the lungs expectorated through the mouth or obtained via tracheal suctioning with an in-line trap or bronchoscope. Specimens are often taken for three consecutive days because it is difficult for the patient to cough up enough sputum at one time, and an organism may be missed if only one culture is done.

Purpose

A sputum specimen is obtained for culture to identify the microorganism responsible for lung infections; identify cancer cells shed by lung tumors; or aid in the diagnosis and management of occupational lung diseases.

Supplies and Equipment

Supplies and equipment required to collect a sputum specimen are:

• Sterile container with tight-fitting lid
• Emesis basin
• Box of tissues
• Gloves
• Goggles
• Aerosol of 10% sodium chloride or sterile water (optional)
• Nebulizer (optional)
• Laboratory request form

Preparation

To prepare your patient, have him drink enough fluids on the night before the test, provided that he’s not on a fluid restriction. The additional intake will further increase sputum production overnight and assure that you’ll get a good sample.

For best results, obtain the sample first thing in the morning. If you can’t obtain the sample before the patient has breakfast, though, wait at least an hour after he’s eaten before trying. Before you begin, describe the procedure to him.

Ten to 15 ml of sputum is typically needed for laboratory analysis. A specimen will be rejected by the laboratory if it contains excessive numbers of epithelial cells from the mouth or throat or if it fails to show adequate numbers of neutrophils on gram staining. If the patient cannot cough up a specimen, the respiratory therapist can use sputum induction techniques such as heated aerosol (nebulization), followed in some instances by postural drainage and percussion.

Procedure

1. Observe proper hand hygiene and gather equipment.
2. Provide privacy for the patient and explain the entire procedure.
3. Position your patient in a chair or on the side of bed. If he is not capable of sitting alone, place him in a high-Fowler’s position. Remove dentures, if he has them.
4. Place the tissues nearby and have the patient rinse his mouth with clean water to remove any food particles. Don’t allow him to brush his teeth or use mouth wash. Doing so could kill bacteria in the sputum, rendering it useless.
5. Don gloves and goggles. Uncap the container but avoid touching the inside to ensure that it’s sterile.
6. Using the sterile collection container provided, instruct the patient to take three deep breaths, then force a deep cough and expectorate into a sterile screw-top container. To prevent contamination by particles in the air, keep the container closed until the patient is ready to spit into it.
7. If you don’t get an adequate sample on the first try, have him continue to cough until you’re able to collect a minimum of 15 ml. If the patient has trouble bringing up secretions, however, have him breathe into the nebulizer and try again.
8. Once you’ve collected the specimen, securely cap the container. Remove and discard your gloves and wash your hands thoroughly. Allow the patient to rinse out his mouth and provide a tissue.
9. Record the amount, consistency, and color of the sputum collected, as well as the time and date in the nursing notes.
10. Send the sample to the lab immediately, without refrigeration.

3. Stool Specimen and Culture

A stool culture is the process of growing or culturing organisms existing in feces to see if any of them cause disease. The most common is the ova and parasites test, a microscopic examination of feces for detecting parasites such as amoebas or worms. Stools specimen are often tested for blood. Guaiac or HemOccult test may be done in the laboratory but are sometimes done at the nursing station to test a stool for occult blood.

Purpose

Stool cultures play an important role in understanding and treating intestinal illness. It can confirm the presence of harmful bacteria. It may also show what treatments may work to kill an invasive organism. If no dangerous bacteria are present in the stool culture but symptoms still exist, other explanations like irritable bowel syndrome, a parasitic infection, or other diagnosis can be explored.

Supplies and Equipment

• Supplies and equipment required to collect a stool specimen are:
• Gloves
• Clean bedpan and cover (an extra bedpan or urinal if the patient must void)
• Specimen container and lid
• Wooden tongue blades
• Paper bag for used tongue blades
• Labels
• Plastic bag for transport of container with specimen to laboratory

Procedure

1. Discuss the test and the procedure with the patient. Ask him to tell you when he feels the urge to have a bowel movement.
2. Wear gloves when handling any bodily discharge.
3. Bedpan should be provided when the patient is ready. If the patient wants to urinate first, provide the urinal for a male patient or provide the extra bedpan for a female patient. Avoid mixing urine or regular toilet paper into the sample.
4. With the use of a tongue blade, transfer a portion of the feces to the specimen container. Don’t touch the specimen because it is contaminated. It is not necessary to keep the specimen sterile because the gastrointestinal tract is not sterile.
5. Immediately cover the container and label it with the patient’s name and other needed information.
6. Fill out the appropriate laboratory request form completely, noting any special examination ordered.
7. Take the specimen to the lab immediately; examination for parasites, ova, and organisms must be made while the stool is warm.
8. With regard to an infant patient, place the diaper in a leakproof bag, label it, and take the diaper and request form to the lab as soon as possible. However, it can be difficult to keep urine away from the stool sample.

3.1. Guaiac Fecal Occult Blood Test (gFOBT)

The stool guaiac test finds hidden (occult) blood in the stool (bowel movement). It is the most common form of fecal occult blood test (FOBT) in use today.

Purpose

This test uses guaiac as reagent to detect the presence of occult blood (blood that appears from a nonspecific source, with obscure signs and symptoms), which is not visible.

Supplies and Equipment

• Test kit (with detailed instructions)
• Test cards
• Brush or wooden applicator
• Gloves

Preparation

Do not allow the patient to eat red meat, any blood-containing food, cantaloupe, uncooked broccoli, turnip, radish, or horseradish for 3 days prior to the test. The patient may need to stop taking medicines that can interfere with the test. These include vitamin C and nonsteroidal anti inflammatory medicines such as ibuprofen and aspirin. However, never let the patient stop such medication without consulting the physician. There is no discomfort when the test is done since it only involves normal bowel function.

Procedure

1. Discuss the test and the procedure with the patient. And prepare himself when he feels the urge to have a bowel movement.
2. Tell the patient that he needs to collect a sample from his bowel by placing a sheet of plastic wrap or paper loosely across the toilet bowl to catch the stool or he can use a dry container to collect the stool.
3. Inform the patient to not mix the sample with urine. Tell him to flush the remaining stool down the toilet. Remind the patient not to take samples from the toilet bowl water.
4. Allow the patient to use the wooden applicator or a brush to smear a thin film of the stool sample onto one of the slots in the test card or slide.
5. Next, the patient needs to collect a specimen from a different area of the same stool and smear a thin film of the sample onto the other slot in the test card or slide.
6. Close the slots and put the name of the patient and the date on the test kit.
7. Instruct the patient to repeat the test on his next two bowel movements to improve the accuracy of the test.
8. Remove gloves and wash hands thoroughly.
9. Send the specimen to the laboratory.
10. Inform the patient that he may resume his usual diet and medications as ordered.

4. Urine Specimen and Culture

A urinalysis (UA), also known as routine and microscopy (R&M), is the physical, chemical, and microscopic examination of urine. It involves a number of tests to detect and measure various compounds that pass through the urine. It has been a useful tool of diagnosis since the earliest days of medicine. The color, density, and odor of urine can reveal much about the state of health of an individual.

Urine is assessed first for its physical appearance:

Color

Normal urine color ranges from pale yellow to deep amber in color, depending on the concentration of the urine. The amount and kinds of waste in the urine make it lighter or darker. Pigments and other compounds in certain foods and medications may change the color of urine. Blood in the urine colors it; if the amount of blood in the urine is great, the urine will be red. During a flare-up of chronic nephritis, the small number of red blood cells present in the urine give it a smoky appearance.

Odor

Urine normally doesn’t have a very strong smell. When urine stands, decomposition from bacterial activity gives it an ammonia-like odor. Consumption of certain foods, such as beets or asparagus can impart a characteristic odor to urine. UTI may also take on a foul-smelling odor. Refrigerate the urine sample if it is not to be examined at once.

4.1. Random Urine Sample

A sample of urine collected at any time of the day. This type of specimen is most convenient to obtain.

Purpose

This type of sample may be used to detect the presence of various substances in the urine at one particular point in the day. Often, no special handling is required with these samples.

Supplies and Equipment

• Clean, dry container with lid
• Cotton ball or towelette
• Laboratory request form

Procedure

1. Instruct the patient to use the cotton ball or towelette to clean urethral area thoroughly to prevent external bacteria from entering the specimen.
2. Let the patient void into the container.
3. Label the specimen container with patient identifying information, and send to the lab immediately. A delay in examining the specimen may cause a false result when bacterial determinations are to be made.
4. Wash your hands and instruct the patient to do it as well.
5. Note that the sample was collected.

4.2. Midstream “Clean-Catch” Urine Specimen

Midstream “clean-catch” urine collection is the most common method of obtaining urine specimens from adults, particularly men. This method allows a specimen, which is not contaminated from external sources to be obtained without catheterization. It is important to follow the “clean-catch” protocol in order to have accurate results from an uncontaminated sample.

Purpose

The clean-catch urine method is used to prevent germs from the penis or vagina from getting into a urine sample. It is a method of collecting a urine sample for various tests, including urinalysis, cytology, and urine culture.

Supplies and Equipment

• Sterile specimen cup
• Zephiran, a soap solution, or three antiseptic towelettes
• Three cotton balls (to use with zephiran or soap solution)
• Laboratory request form

Preparation

Explain to the patient that this kind of urine collection involves first voiding approximately one half of the urine into the toilet, urinal, or bedpan, then collecting a portion of midstream urine in a sterile container, and allowing the rest to be pass into the toilet. Discuss that this is done to detect the presence or absence of infecting organisms and, therefore, must be free from contaminating matter that may be present on the external genital areas.

Procedure

For female patients:

1. Wash hands with soap and water.
2. Instruct the patient to clean perineal area with towelettes or cotton balls.
3. Tell the patient to separate folds of urinary opening with thumb and forefinger and clean inside with towelettes or cotton balls, using downward strokes only; keep labia separated during urination.
4. Instruct the patient to void a small amount of urine into the toilet to rinse out the urethra, void the midstream urine into the specimen cup, and the last of the stream into the toilet. The midstream urine is considered to be bladder and kidney washings; the portion that the physician wants tested.
5. Fill out the laboratory request form completely, label the specimen container with patient identifying information, and send to the lab immediately. A delay in examining the specimen may cause a false result when bacterial determinations are to be made.
6. Wash your hands and instruct the patient to do it as well.
7. Note that the specimen was collected. Record any difficulties the patient had or if the urine had an abnormal appearance.

For male patients:

1. Wash hands with soap and water.
2. Instruct the patient to completely retract foreskin and cleanse penis with towelettes or cotton balls.
3. Instruct the patient to void a small amount of urine into the toilet to rinse out the urethra, void the midstream urine into the specimen cup, and the last of the stream into the toilet. The midstream urine is considered to be bladder and kidney washings; the portion that the physician wants tested.
4. Fill out the laboratory request form completely, label the specimen container with patient identifying information, and send to the lab immediately. A delay in examining the specimen may cause a false result when bacterial determinations are to be made.
5. Wash your hands and instruct the patient to do it as well.
6. Note that the specimen was collected. Record any difficulties the patient had or if the urine had an abnormal appearance.

Note: If the urine sample is being taken from an infant, the clean-catch kit consists of a plastic bag with a sticky strip on one end that fits over the baby’s genital area, as well as a sterile container. Use the same cleaning methods and the plastic bags for collecting the urine. Pour the urine into the sterile container.

4.3. Timed Urine Specimens (2-Hour, 4-Hour, 24-Hour)

For many urine chemistry procedures the specimen of choice is 24-hour urine. A 24-hour urine collection is performed by collecting a person’s urine in a special container over a 24-hour period. It always begins with an empty bladder so that the urine collected is not “left over” from previous hours. This specimen shows the total amounts of wastes the kidneys are eliminating and the amount of each.

Purpose

A 24-hour urine collection is noninvasive (the skin is not pierced). It is used to assess kidney (renal) function and detects disease.

Supplies and Equipment

• Large, clean bottle with cap or stopper
• Measuring graduate
• Bedpan or urinal
• Refrigerated storage area
• Gloves

Preparation

The test does not require anything other than normal urination. There are no risks involved. Generally, the patient will be given one or more containers to collect and store urine over a 24-hour time period.

Procedure

1. Label the bottle with patient identifying information, the date, and time the collection begins and ends.
2. Instruct the patient to urinate, flush down the urine down the toilet when he gets up in the morning.
3. Afterward, tell the patient to collect the rest of his urine in the special bottle for the next 24 hours, storing it in a cool environment. It can be kept cool in the refrigerator or on ice in a cooler.
4. Instruct the patient to drink adequate fluids during the collection period.
5. Emphasize proper hand hygiene before and after each collection. Record each amount on the intake and output (I&O) sheet.
6. Exactly 24-hours after beginning the collection, ask the patient to void. This will complete the specimen collection.
7. Instruct the patient to continue to keep the collection container refrigerated until transfer to laboratory.
8. Send the bottle and laboratory request form to the lab.

Example: Begin collecting the 24-hour urine specimen by voiding at 7:00 am and discarding the urine. Collect all urine voided during the next 24 hours. At 7:00 am the next morning, void and add the urine to the collection container. Keep the collection container refrigerated until delivery to the laboratory.

4.4. Pregnancy Urine Test

A pregnancy test measures a hormone in the body called human chorionic gonadotropin (HCG), a hormone produced during pregnancy. This hormone can be detected in small amounts in both the urine and the blood of a pregnant woman as early as 10 days after conception.

Purpose

Urine HCG tests are a common method of determining if a woman is pregnant. The best time to test for pregnancy is after the woman miss her period.

Supplies and Equipment

• Only a urine specimen cup is required.

Preparation

Allow patient to wait one to two weeks after her first missed period to get the most accurate results. Note: Irregular periods or miscalculations of when a period is due can affect the test. According to the FDA, 10 to 20 percent of pregnant women may not detect their pregnancy by testing on what they believe to be the first day of their first missed period.

Procedure

1. Advise the patient to use the test the first time she urinate after waking up. As this urine is the most concentrated, it will contain the highest hCG levels of the day. Urine will become more diluted as the patient drink liquids, so hCG levels may be harder to measure later in the day.
2. Label the specimen cup with the patient’s identifying information, complete a laboratory request form requesting an HCG test and send both to the lab.
3. Only the physician or a registered nurse should tell the patient the results of the test.

5. Blood Cultures

A blood culture is a fairly routine test that identifies a disease-causing organism in the blood, especially in patients who have temperatures that is higher than normal, for an unknown reason. The test is relatively simple for the patient and involves a simple blood draw.

Purpose

A blood culture is being done to determine which specific organism or bacteria is causing the problem and how best to combat it.

Supplies and Equipment

Supplies and equipment required for a blood culture are:

• Sterile syringe (20 cc) and three needles (usually 20 gauge)
• Two blood culture bottles (one for anaerobic and one for aerobic specimens)
• Betadine solution or alcohol swab
• Sterile cotton balls or gauze pads
• Gloves
• Tourniquet
• Band-aid
• Chux (to protect the bed)
• Laboratory request form

Preparation

The test requires little preparation for the patient. The patient will be asked what kind of medications he is taking, including prescriptions and nutritional supplements. The patient may be asked to stop taking certain medications that may alter the blood culture results.

Procedure

1. Discuss the procedure and the reason for doing it to the patient.
2. Bring together all supplies and equipment needed to patient’s bedside.
3. Assist the patient to comfortable position. Ask for someone within the team to assist if the patient is uncooperative.
4. Observe proper hand hygiene.
5. Clean the top of both culture bottles with betadine solution or alcohol swab.
6. Place the needle on the syringe.
7. Apply the tourniquet to allow the veins to fill with blood and become more visible.
8. Put on gloves and clean the drawing site with betadine solution or alcohol swab.
9. Draw at least 10 cc of blood from the patient (5 cc is needed for each bottle).
10. Unbind the tourniquet.
11. Remove the syringe and needle while applying pressure to the venipuncture site with the cotton ball or gauze pad. Have the patient apply pressure to the site.
12. Replace the needle on the syringe with another sterile needle.
13. Inject 5 cc of blood into the anaerobic bottle, not allowing air to enter the bottle.
14. Replace the needle on the syringe with another sterile needle.
15. Inject the remaining 5 cc of blood into the aerobic bottle and while the needle is still in the bottle, disconnect it from the syringe so that air enters the aerobic bottle.
16. Gently mix the blood with the solution in both bottles.
17. Label both bottles with the patient’s identifying information and the type of culture that is, aerobic or anaerobic.
18. Fill out the laboratory request form completely and send the specimens to the laboratory immediately.
19. Secure a band-aid or some gauze over the puncture site.

The role of nurses in collecting, labeling, and ensuring the timely and proper delivery of specimens to the laboratory plays a very important thing in the hospital setting. With this, nurses should be knowledgeable enough about the hospital’s policy and procedures for specimen collection. However, nurses should not only possess the right knowledge, but as well as the skill and understanding in performing necessary procedures in accordance with the organization’s protocols, policies, and guidelines.

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