collection of specimen assignment

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Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021.

Nursing Skills [Internet].

• About Open RN

Chapter 19 Specimen Collection

19.1. specimen collection introduction, learning objectives.

• Accurately collect specimens for blood glucose monitoring, nasal swabs, and oropharyngeal swabs
• Modify procedure to reflect variations across the life span
• Maintain standard and transmission-based precautions
• Select appropriate equipment
• Explain procedure to patient
• Document actions and observations
• Recognize and report significant deviations from norms

This chapter will describe specimen collection for blood glucose monitoring, nasal swabs, oropharyngeal swabs, sputum, and stool.

Additional information regarding obtaining wound cultures can be found in “ Wound Care ,” and information about obtaining urine cultures can be found in the “ Facilitation of Elimination .”

19.2. BLOOD GLUCOSE MONITORING

Blood glucose monitoring is performed on patients with diabetes mellitus and other conditions that cause elevated blood sugar levels. Diabetes mellitus is a common medical condition that affects the body’s ability to produce insulin in the pancreas and use insulin at the cellular level. There are two types of diabetes mellitus, type 1 and type 2. Type 1 diabetes mellitus is an autoimmune disease that damages the beta cells of the pancreas so they do not produce insulin; thus, synthetic insulin must be administered by injection or infusion. It typically begins in childhood or adolescence. Type 2 diabetes mellitus accounts for approximately 95 percent of all cases and is highly correlated with obesity and inactivity. During type 2 diabetes, the cells of the body become resistant to the effects of insulin, and the pancreas increases its production of insulin. However, over time, the pancreas may no longer be able to produce insulin. In many cases, type 2 diabetes can be managed by moderate weight loss, regular physical activity, and a healthy diet. However, if blood glucose levels cannot be controlled with healthy lifestyle choices, oral diabetic medication is prescribed and eventually, the administration of insulin may be required. [ 1 ]  Prediabetes is a medical condition where blood sugar levels are higher than normal, but not high enough yet to be diagnosed as type 2 diabetes. Approximately one in three American adults have prediabetes. Gestational diabetes is a type of diabetes that occurs during pregnancy in women who did not have diabetes before they were pregnant.

Diabetic patients require frequent blood glucose monitoring to administer customized medication therapy to prevent long-term complications from occurring. Hospitalized patients who do not have diabetes may also require frequent blood glucose monitoring due to elevations that can occur as a result of the stress of hospitalization, surgical procedures, and side effects of medications. Additionally, patients receiving enteral feedings typically have their blood glucose monitored every six hours. Health care providers prescribe the frequency of blood glucose monitoring; testing is typically performed before meals and at bedtime. For some patients, a  standardized sliding-scale insulin  protocol may be prescribed with instructions on the medication administration record (MAR) for administration of insulin based on their blood glucose results. [ 2 ],[ 3 ]  See Table 19.2 for an example of a sliding-scale insulin protocol.

Sample Sliding-Scale Insulin Protocol. Instructions: Check patient’s blood sugar before meals, at bedtime, and as needed for symptoms of hypoglycemia or hyperglycemia. Use the following table to administer insulin lispro PRN.

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Hypoglycemia

When caring for patients with diabetes mellitus and monitoring their blood glucose readings, it is important to continually monitor for signs of hypoglycemia.  Hypoglycemia  is defined as blood sugar readings less than 70 and signs and symptoms such as the following:

• Feeling nervous or anxious
• Sweating, chills, and clamminess
• Irritability or impatience
• Fast heartbeat
• Feeling light-headed or dizzy
• Color draining from the skin (pallor)
• Feeling sleepy
• Feeling weak or having no energy
• Blurred/impaired vision
• Tingling or numbness in the lips, tongue, or cheeks
• Coordination problems or clumsiness
• Nightmares or crying out during sleep
• Seizures [ 4 ]

A low blood sugar level triggers the release of epinephrine (adrenaline), the “fight-or-flight” hormone. Epinephrine causes the symptoms of hypoglycemia such as a rapid heartbeat, sweating, and anxiety. If a patient’s blood sugar level continues to drop, the brain has impaired functioning. This may lead to seizures and a coma. [ 5 ]

If a nurse suspects hypoglycemia is occuring, a blood sugar reading should be obtained and appropriate actions taken. Most agencies have a hypoglycemia protocol based on the “15-15 Rule.” The  15-15 rule  is to provide 15 grams of carbohydrate and recheck the blood glucose after 15 minutes. If the reading is still below 70 mg/dL, another serving of 15 grams of carbohydrate should be provided and the process continued until the blood sugar is above 70 mg/dL. Fifteen grams of carbohydrate includes options like 4 ounces of juice or regular soda, hard candy, or glucose tablets. If a patient is experiencing severe hypoglycemia and cannot swallow, a glucagon injection or intravenous administration of dextrose may be required. [ 6 ]

Hyperglycemia

Hyperglycemia  is defined as elevated blood glucose and often causes signs and symptoms such as frequent urination and increased thirst. Hyperglycemia occurs when the patient’s body does not produce enough insulin or cannot use the insulin properly at the cellular level. There are many potential causes of hyperglycemia, such as not receiving enough medication to effectively control blood glucose, eating more than planned, exercising less than planned, or increased stress from an illness, surgery, hospitalization, or other life events.

If a patient’s blood glucose is greater than 240 mg/dL, their urine is typically checked for ketones. Ketones indicate a condition called ketoacidosis may be occurring. Ketoacidosis occurs in patients whose pancreas is no longer creating insulin, so fats are broken down for energy and waste products called ketones are produced. If the kidneys cannot effectively eliminate ketones in the urine, they build up in the blood and cause ketoacidosis.  Ketoacidosis  is a life-threatening condition that requires immediate notification of the provider for treatment. Symptoms of ketoacidosis include fruity-smelling breath, nausea, vomiting, very dry mouth, and shortness of breath. Treatment of ketoacidosis often requires the administration of intravenous insulin while the patient is closely monitored in a critical care inpatient unit. [ 7 ]

For more information about diabetes mellitus, measuring blood sugar levels, and diabetic medications, visit the “ Endocrine ” chapter in Open RN  Nursing Pharmacology .

Glucometer use.

It is typically the responsibility of a nurse to perform bedside blood glucose readings, but in some agencies, this procedure may be delegated to trained nursing assistants or medical assistants. See Figure 19.1 [ 8 ]  for an image of a standard bedside glucometer kit that contains a glucometer, lancets, reagent strips, and calibration drops. Prior to performing a blood glucose test, read the manufacturer’s instructions and agency policy because they may vary across devices and sites. Ensure the glucometer has been calibrated per agency policy. [ 9 ]

Figure 19.1

Bedside Glucometer

Before beginning the procedure, determine if there are any conditions present that could affect the reading. For example, is the patient fasting? Has the patient already begun eating? Is the patient demonstrating any symptoms of hypoglycemia or hyperglycemia? Keep your patient safe by applying your knowledge of diabetes, the medication being administered, and the uniqueness of the patient to make appropriate clinical judgments regarding the procedure and associated medication administration. [ 10 ]

See the “ Checklist for Blood Glucose Monitoring ” for details regarding the procedure. It is often important to keep the patient’s hand warm and in a dependent position to promote vasodilation and obtain a good blood sample. If necessary, warm compresses can be applied for 10 minutes prior to the procedure to promote vasodilation. Follow the manufacturer’s instructions to prepare the glucometer for measurement. After applying clean gloves, clean the patient’s skin with an alcohol wipe for 30 seconds, allow the site to dry, and then puncture the skin using the lancet. See Figure 19.2 [ 11 ]  for an image of performing a skin puncture using a lancet.

Figure 19.2

Using a Lancet to Perform a Skin Puncture

If needed, gently squeeze above the site to obtain a large drop of blood. Do not milk or massage the finger because it may introduce excess tissue fluid and hemolyze the specimen. Wipe away the first drop of blood and use the second drop for the blood sample. Follow agency policy and manufacturer instructions regarding placement of the drop of blood for absorption on the reagent strip. See Figure 19.3 [ 12 ]  for an image of a nurse absorbing the patient’s drop of blood on the reagent strip. Timeliness is essential in gathering an appropriate specimen before clotting occurs or the glucometer times out.

Figure 19.3

Obtaining Drop of Blood

Cleanse the glucometer and document the blood glucose results according to agency policy. Report any concerns about patient symptoms or blood sugar results according to agency policy.

Life Span Considerations

Blood glucose samples should be taken from the heel of newborns and infants up to the age of six months. When obtaining a sample from the heel, the sample is taken from the medial or lateral plantar surface.

Video Review of Obtaining a Bedside Blood Sugar [ 13 ]

19.3. NASAL SPECIMEN COLLECTION

Specimen collections from a patient’s anterior nasal cavity and nasopharynx are used to test for multiple viral illnesses such as influenza and COVID-19. Nasal swabs can be performed by the nurse or the patient with proper education. It is vital to understand the anatomy of these areas to obtain an accurate sample so that patients receive the appropriate care they need. See Figure 19.4 [ 1 ]  for an image of the anatomy of the head and neck.

Figure 19.4

Anatomy of the Head and Neck

Review the “ Checklist for Obtaining a Nasal Swab ” for details about performing a nasal swab procedure.

Video review of nasopharyngeal specimens and covid-19 testing:.

Collection of Nasopharyngeal Specimens with the Swab Technique [ 2 ]

Introduction to COVID-19 Tests [ 3 ]

19.4. OROPHARYNGEAL SPECIMEN COLLECTION

The  oropharynx  is the part of the throat at the back of the mouth behind the oral cavity. It includes the back third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils. [ 1 ]  When obtaining a specimen from this area, it is important to avoid the tongue and teeth. Depending on the test ordered, the nurse may obtain the specimen from the tonsils alone or the posterior pharynx (throat) and the tonsils. Keep in mind that if you are ever unsure about how to accurately obtain a specimen, lab technicians are a great resource.

See the “ Checklist for Oropharyngeal Testing ” for additional details about performing the procedure.

Infants and Children

Specimen collection on infants and children may require the support of another health care provider or a parent. Educate the patient and the parent about the procedure and the expectations if the parent decides to assist with the specimen collection. During specimen collection, it’s important that the patient is immobile to prevent injury to the nasal cavity, nasopharyngeal, or oropharynx.

View Medscape’s YouTube video to review oropharyngeal testing: [ 2 ] How to Perform a Throat Swab

19.5. sputum specimen collection.

Sputum specimens collected by expectoration are commonly used for cytology, culture and sensitivity, and acid-fast bacilli (AFB) testing. Cytologic examination identifies abnormal cells such as cancer. Culture and sensitivity testing identifies specific infectious microorganisms and their sensitivity to antibiotics. Optimally, sputum samples used for culture and sensitivity testing should be collected before initiating antibiotic therapy because antibiotics affect the results. AFB testing, along with culture and sensitivity testing, is used to diagnose tuberculosis (TB). When testing for TB, at least three consecutive samples are collected, with at least one being an early morning sample.

Prior to implementing the procedure, it is helpful to ensure the patient is well-hydrated. Hydration helps thin and loosen sputum and increases the likelihood of obtaining an adequate sample. If the patient is prescribed nebulizer treatments, it is helpful to administer this treatment prior to the procedure to help mobilize secretions. It is also important to assess if the patient is experiencing pain related to coughing. For example, pain following chest or abdominal surgery can inhibit the patient from taking deep breaths and expectorating. In this case, pain medication should be provided prior to performing the procedure. Patients can also be encouraged to support surgical wounds with a pillow while coughing to provide additional support and comfort.

It is best to obtain sputum samples in the early morning because secretions accumulate overnight. The patient can rinse their mouth with water prior to the procedure, but avoid mouthwash or toothpaste because these products can affect the microorganisms in the sample. Remove dentures if they are present.

Be aware that droplets and aerosols may be generated when collecting sputum specimens, so use appropriate personal protective equipment when entering the room and during the procedure based on the patient’s condition. Explain the procedure to the patient, the type of specimen required, and the difference between oral secretions and sputum. Position the patient in a seated position in a chair or at the side of the bed, or place them in high Fowler’s position.

Instruct the patient to take three slow, deep breaths and then cough deeply. Repeat this process until the patient has produced sputum, with rest periods between each maneuver.

When the patient has mobilized sputum, instruct them to expectorate directly into a sterile specimen container without touching the inside or rim of the container. The specimen should be at least 5 mL (one teaspoon); ask the patient to continue producing and expectorating sputum until this amount is achieved. Assess the sputum specimen to ensure it is sputum and not saliva. Sputum appears thick and opaque, whereas saliva appears thin, clear, and watery.

Cap the specimen container tightly and ensure it is labeled with the patient’s name. Place the specimen in a transport bag and send it to the laboratory for analysis. Document the time and date the sputum specimen was collected and the characteristics of the sputum, including amount and color.

If a patient is unable to expectorate a sputum sample, other interventions may be required to mobilize secretions. It is often helpful to collaborate with a respiratory therapist for assistance in this situation. Interventions may include nebulizers, hydration, deep-breathing exercises, chest percussion, and postural drainage. If these interventions are not successful, a sputum sample may be obtained via oropharyngeal or endotracheal suctioning; these methods are used to obtain sputum samples for patients who are intubated. [ 1 ] , [ 2 ] , [ 3 ]

Read South Dakota Department of Health’s PDF with instructions for collecting a sputum sample: Sputum Collection Instructions

19.6. stool specimen collection.

Stool samples are collected from patients to test for cancer, parasites, or for occult blood (i.e., hidden blood). Follow specific instructions from the laboratory for collecting the sample.

The Guaiac-Based Fecal Occult Blood Test (gFOBT) is a commonly used test to find hidden blood in the stool that is not visibly apparent. As a screening test for colon cancer, it is typically obtained by the patient in their home using samples from three different bowel movements. Nurses may assist in gFOBT specimen collection during inpatient care.

Before the test, the patient should avoid red meat for three days and should not take aspirin or nonsteroidal anti-inflammatory drugs (NSAIDs), such as ibuprofen, for seven days prior to the test. (Blood from the meat can cause a false positive test, and aspirin and NSAIDS can cause bleeding, leading to a false positive result.) Vitamin C (more than 250 mg a day) from supplements, citrus fruits, or citrus juices should be avoided for 3 to 7 days before testing because it can affect the chemicals in the test and make the result negative, even if blood is present.

To perform a gFOBT in an inpatient setting, perform the following steps.

• Verify the patient has not consumed red meat for three days, has not taken aspirin or NSAIDs for seven days prior to the test, and has not had vitamin C greater than 250 mg daily for the past 3-7 days because these substances can affect the results.
• Explain the procedure to the patient. Instruct them to flush the toilet before defecating to remove any potential chemicals and to not place toilet paper in the toilet after defecating. Request they notify you when they have had a bowel movement.
• Review the manufacturer’s instructions because different test kits may have different instructions. Contact the laboratory with any questions.
• Label the card with the patient’s name and medical information per agency policy. Open the flap of the guaiac test card.
• Apply nonsterile gloves. Use the applicator stick to apply a thin smear of the stool specimen to one of the squares of filter paper on the card. Obtain a second specimen from a different part of the stool and apply it to the second square of filter paper on the card. (Occult blood isn’t typically equally dispersed throughout the stool.)
• Place the labeled test card in a transport bag and send it to the laboratory for analysis.
• If you are working in an agency where nurses apply the guaiac developer solution to the card, allow the specimen to dry for 3 to 5 minutes. Open the reverse side of the card and apply two drops of guaiac developer solution to each square. A blue reaction will occur within 60 seconds if the test is positive. The absence of a blue color after 60 seconds is considered a negative test.
• Document the date and time of the test and any unusual characteristics of the stool sample. [ 1 ] , [ 2 ]

19.7. SAMPLE DOCUMENTATION

Sample documentation of expected findings.

Patient alert and oriented x 3, sitting in a wheelchair and awaiting breakfast. Patient denies symptoms of hypoglycemia or hyperglycemia. Bedside blood glucose obtained with results of 135 mg/dL. 2 units of regular insulin given per sliding scale. Breakfast delivered to the patient.

Sample Documentation of Unexpected Findings

0730: Patient alert and oriented x 3, sitting in a wheelchair and awaiting breakfast. Denies symptoms of hypoglycemia and hyperglycemia. Bedside blood glucose obtained with results of 185 mg/dL. 6 units of regular insulin given per sliding scale along with 34 units of scheduled NPH insulin as breakfast tray was delivered to patient.

0900: Patient only ate 25% of breakfast and complains of headache, fatigue, and dizziness. Patient is shaking and irritable but alert and oriented x 3. Blood glucose was rechecked and results were 65 mg/dL. 4 ounces of orange juice was provided.

0915: Blood glucose rechecked and results were 95 mg/dL. Patient states, “I’m feeling much better and not dizzy anymore.” Shakiness has resolved. Provided a peanut butter sandwich per patient request. Will continue to monitor the patient for signs of hypoglycemia. Call light within reach.

19.8. CHECKLIST FOR BLOOD GLUCOSE MONITORING

Use the checklist below to review the steps for completion of “Blood Glucose Monitoring.”

Video Review of Blood Glucose Monitoring: [ 1 ]

Disclaimer: Always review and follow agency policy regarding this specific skill.

Prepare before completing the procedure:

• Note if the patient is receiving anticoagulant therapy. Anticoagulant therapy may result in prolonged bleeding at the puncture site and require pressure to the site.
• Assess the patient for signs and symptoms of hyperglycemia or hypoglycemia to correlate data to pursue acute action due to an onset of symptoms.
• Blood glucose monitoring is typically performed prior to meals and the administration of antidiabetic medications.

Gather supplies: nonsterile gloves, alcohol swab, lancet, 2″ x 2″ gauze or cotton ball, reagent strips, and blood glucose meter.

• Determine if the blood glucose meter needs to be calibrated according to agency policy to ensure accuracy of readings.
• Read and understood the manufacturer’s instructions and agency policy for the blood glucose meters.

Perform safety steps:

Perform hand hygiene.

• Check the room for transmission-based precautions.
• Introduce yourself, your role, the purpose of your visit, and an estimate of the time it will take.
• Confirm patient ID using two patient identifiers (e.g., name and date of birth).
• Explain the process to the patient and ask if they have any questions.
• Be organized and systematic.
• Use appropriate listening and questioning skills.
• Listen and attend to patient cues.
• Ensure the patient’s privacy and dignity.
• Assess ABCs.

Have the patient wash their hands with soap and warm water, and position the patient comfortably in a semi-upright position in a bed or upright in a chair. Encourage the patient to keep their hands warm. Washing reduces transmission of microorganisms and increases blood flow to the puncture site.

• Agency policy may require use of an alcohol swab to clean the puncture site.
• Ensure that the puncture site is completely dry prior to skin puncture.

Remove a reagent strip from the container and reseal the container cap to keep the strips free from damage from environmental factors. Do not touch the test pad portion of the reagent strip.

Follow the manufacturer’s instructions to prepare the meter for measurement.

Place the unused reagent strip in the glucometer or on a clean, dry surface (e.g., paper towel) with the test pad facing up, based on manufacturer recommendations.

Apply nonsterile gloves.

Keep the area to be punctured in a dependent position. Do not milk or massage the finger site:

• Dependent position will increase blood flow to the area.
• Do not milk or massage the finger because it may introduce excess tissue fluid and hemolyze the specimen.
• Warm water, dangling the hand for 15 seconds, and a warm towel stimulate the blood flow to the fingers.
• Avoid having the patient stand during the procedure to reduce the risk of fainting.

Select the appropriate puncture site. Cleanse the site with an alcohol swab for 30 seconds and allow it to dry. Perform the skin puncture with the lancet, using a quick, deliberate motion against the patient’s skin:

• The patient may have a preference for the site used. For example, the patient may prefer not to use a specific finger for the skin puncture. However, keep in mind their preferred site may be contraindicated. For example, do not use the hand on the same side as a mastectomy.
• Avoid fingertip pads; use the sides of fingers.
• Avoid fingers that are calloused, have broken skin, or are bruised.

Gently squeeze above the site to produce a large droplet of blood.

• Do not contaminate the site by touching it.
• The droplet of blood needs to be large enough to cover the test pad on the reagent strip.
• Wipe away the first drop of blood with gauze.

Transfer the second drop of blood to the reagent strip per manufacturer’s instructions:

• The test pad must absorb the droplet of blood for accurate results. Smearing the blood will alter results.
• The timing and specific instructions for measurement will vary between blood glucose meters. Be sure to read the instructions carefully to ensure accurate readings.

Apply pressure, or ask the patient to apply pressure, to the puncture site using a 2″ x 2″ gauze pad or clean tissue to stop the bleeding at the site.

Read the results on the unit display.

Turn off the meter and dispose of the test strip, 2″ x 2″ gauze, and lancet according to agency policy. Use caution with the lancet to prevent an unintentional sharps injury.

Remove gloves.

Assist the patient to a comfortable position, review test results with the patient, ask if they have any questions, and thank them for their time.

Ensure safety measures when leaving the room:

• CALL LIGHT: Within reach
• BED: Low and locked (in lowest position and brakes on)
• SIDE RAILS: Secured
• TABLE: Within reach
• ROOM: Risk-free for falls (scan room and clear any obstacles)

Document the results and related assessment findings. Report critical values according to agency policy, such as values below 70 or greater than 300, and any associated symptoms. Read more about hypoglycemia and hyperglycemia in the “ Blood Glucose Monitoring ” section of this chapter.

19.9. CHECKLIST FOR OBTAINING A NASAL SWAB

Use the checklist below to review the steps for completion of “Obtaining a Nasal Swab.”

Gather supplies: N95 respirator (or face mask if respirators are not available), gloves, gown, eye protection (goggles or disposable face shields that cover the front and sides of the face), and physical barriers (e.g., plexiglass) if needed.

Apply appropriate PPE: gown, N95 respirator (or face mask if a respirator is not available), gloves, and eye protection are needed for staff collecting specimens or working within 6 feet of the person being tested.

Open the sampling kit using clean technique on a clean surface. The kit should contain a biohazard bag, specimen container, and a nasal swab.

Remove the swab from the container being careful not to touch the soft end with your gloved hand or any other surface, which could contaminate the swab and either obscure the results or infect the patient.

Insert the swab into the nostril:

• Anterior Nasal Swab: Have the patient tilt their head back at a 70-degree angle. Do not insert the swab more than a half an inch into the nostril.
• Nasopharyngeal Swab: Insert until resistance is encountered or the distance is equivalent to that from the ear to the nostril of the patient, indicating contact with the nasopharynx.

Leave the swab in place as directed:

• Anterior Nasal Swab: Leave in place for 10 to 15 seconds.
• Nasopharyngeal Swab: Leave the swab in place for several seconds to absorb secretions.

Gently remove the swab:

• Anterior Nasal Swab: Gently remove the swab after repeating Steps 6 & 7 in the other nostril.
• Nasopharyngeal Swab: Slowly remove the swab while rotating it.

Place the swab in the sterile tube and snap the end off the swab at the break line. Place the cap on the tube.

Label the tube with the patient’s name, date of birth, medical record number, today’s date, your initials, time, and specimen type.

Place the specimen into the biohazard bag.

Remove the nonsterile gloves and place them in the appropriate receptacle.

Assist the patient to a comfortable position, ask if they have any questions, and thank them for their time.

Follow agency policy regarding transportation of the specimen to the lab. Report results appropriately when they are received.

19.10. CHECKLIST FOR OROPHARYNGEAL TESTING

Use the checklist below to review the steps for completion of “Oropharyngeal Testing.”

Gather supplies: testing kit or swab, gloves, tongue depressor, and mask. Other PPE such as a face shield, respiratory, or gown may be required based on the patient condition.

Apply nonsterile gloves. Inform the patient the procedure may be uncomfortable and cause gagging.

Open the supplies.

Ask the patient to open their mouth wide and tilt their head back.

Insert the tongue blade to depress the tongue. If the patient can depress their tongue so that it is out of the way of the swab, the tongue blade may not be needed.

Insert the swab into the posterior pharynx and tonsillar areas. Rub the swab over both tonsillar pillars and posterior oropharynx and avoid touching the tongue, teeth, and gums.

Place the swab in the sterile tube and snap the end off swab at the break line. Place the cap on the tube.

Remove nonsterile gloves and place them in the appropriate receptacle.

19.11. LEARNING ACTIVITIES

Learning activities.

(Answers to “Learning Activities” can be found in the “Answer Key” at the end of the book. Answers to interactive activity elements will be provided within the element as immediate feedback.)

You are caring for an elderly diabetic patient who requires a morning glucose check. You gather the calibrated glucometer and lancet, but have difficulty obtaining a capillary blood glucose from the patient’s fingerstick. What strategies might you use to facilitate blood flow?

Check your knowledge using this flash card activity:

Check your understanding of hypoglycemia with this activity:

• XIX. GLOSSARY

A rule in an agency’s hypoglycemia protocols that includes providing 15 grams of carbohydrate, then repeating the blood glucose reading in 15 minutes, and then repeating as needed until the patient’s blood glucose reading is above 70.

Elevated blood glucose reading with associated signs and symptoms such as frequent urination and increased thirst.

A blood glucose reading less than 70 associated with symptoms such as irritability, shakiness, hunger, weakness, or confusion. If not rapidly treated, hypoglycemia can cause seizures and a coma.

A life-threatening complication of hyperglycemia that can occur in patients with type 1 diabetes mellitus that is associated with symptoms such as fruity-smelling breath, nausea, vomiting, severe thirst, and shortness of breath.

The part of the throat at the back of the mouth behind the oral cavity. It includes the back third of the tongue, the soft palate, the side and back walls of the throat, and the tonsils.

Standardized instructions for administration of adjustable insulin dosages based on a patient’s premeal blood glucose readings.

Licensed under a Creative Commons Attribution 4.0 International License. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ .

• Cite this Page Open Resources for Nursing (Open RN); Ernstmeyer K, Christman E, editors. Nursing Skills [Internet]. Eau Claire (WI): Chippewa Valley Technical College; 2021. Chapter 19 Specimen Collection.
• PDF version of this title (449M)

In this Page

• SPECIMEN COLLECTION INTRODUCTION
• BLOOD GLUCOSE MONITORING
• NASAL SPECIMEN COLLECTION
• OROPHARYNGEAL SPECIMEN COLLECTION
• SPUTUM SPECIMEN COLLECTION
• STOOL SPECIMEN COLLECTION
• SAMPLE DOCUMENTATION
• CHECKLIST FOR BLOOD GLUCOSE MONITORING
• CHECKLIST FOR OBTAINING A NASAL SWAB
• CHECKLIST FOR OROPHARYNGEAL TESTING
• LEARNING ACTIVITIES

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Step-by-Step Guide to Specimen Collection

Learn the procedures, steps, risks, and requirements for collecting lab specimens..

Specimen collection is a common component of routine checkups for your health. It goes hand-in-hand with lab tests, allowing medical professionals to obtain tissue or fluids to look for any changes in your health. In addition, they help physicians diagnose medical conditions, plan treatments, and monitor diseases. Mastering this skill will lead to a much better experience for healthcare practitioners and their patients.

As you can see, specimen collection is an essential procedure used for many medical diagnoses. This fundamental skill may not be exciting for new healthcare professionals, but it is crucial in developing the correct diagnosis for each patient.  Therefore, it can be particularly beneficial for Medical Assistants to learn the proper method of collecting specimens.

This article provides an in-depth guide on the art and science of specimen collection, one of the most important healthcare procedures for medical staff.

(Click here to see our full list of the  most common Medical Assisting duties and responsibilities ).

Specimen Collection Definition

What is specimen collection.

Collecting specimens is the process of acquiring tissue or fluids for laboratory analysis. Some of the samples collected may include serum samples, virology swab samples, biopsy and necropsy tissue, cerebrospinal fluid, whole blood for PCR, and urine samples. Medical Assistants collect these samples and then place them in specific containers for successful processing in a lab.

What is the Purpose of Specimen Collection?

Specimen collection is vital for acquiring an accurate and timely laboratory test result. To properly collect specimens, they must be obtained through designated containers, correctly labeled, and promptly transported to the lab.

How Long Does it Take to Collect Specimens?

Most specimens can be collected in a matter of minutes . It normally only takes a few minutes to transport them to the lab as well. However, some specimen collection may require more steps. It often depends on the type of tissue or fluid the patient has provided.

Who Can Collect Specimens?

Nurses typically collect specimens like urine, stool, and sputum (saliva/mucus from the respiratory tract). In addition, they may perform venipuncture to obtain blood samples. Specimens can also be collected by a variety of other healthcare professionals, such as Medical Assistants.

Although the rules can vary by state, Medical Assistants are often allowed to collect specimens through non-invasive measures. They preserve specimens for testing, including urine, sputum, semen, and stool. This common task allows MAs to assist physicians and other healthcare professionals by allowing them to see more patients or perform other tasks.

(Click here to learn how to become a Medical Assistant ).

Training Requirements for Specimen Collection

Requirements for specimen collection can vary and depend on your location or profession. Aspiring nurses and other healthcare professionals will usually receive this training through their educational programs. However, others may pursue a job as specimen collectors. These individuals may need to meet other requirements in the SAMHSA handbook .

Some employers may prefer candidates with experience in healthcare. At Unitek College, we offer a Medical Assisting program that could give you a strong advantage when applying to nursing school or positions as a specimen collector for a federal agency program. Our courses include topics like specimen collection, pharmacology, medication administration, diagnostic imaging, and more.

Specimen Collection Procedure

With these steps, you can start to learn more about the process of collecting specimens. Of course, just like any other skill, specimen collection requires a little time and practice to get it right. Remember to follow the rules of your facility and ask for help whenever necessary.

Specimen Collection Preparation

While most collections don’t require much prep, there are some guidelines that must be followed. These include reviewing the appropriate information, such as the indicated specimen type, the volume, the procedure, the collection materials, patient prep, and storage instructions.

Specimen Collection Steps

Here are some of the general guidelines you should follow when collecting specimens from a patient:

• Verify the patient’s identity. Some examples of acceptable identifiers include the patient’s name, date of birth, and hospital number.
• Acquire a sample from the patient. Treat all biological material as potentially hazardous and follow your facility’s guidelines.
• Process the specimen as required by your facility or employer.
• Store the specimen. Appropriate storage is critical to maintaining the integrity of the specimen and, therefore, the test results.

After the procedure, the patient can usually resume their normal activities. There isn’t a recovery period for most types of specimen collection (i.e., urine, stool, etc.) If you are ever in doubt, consult the attending physician first.

Necessary Equipment for Specimen Collection

Typically, the suggested supplies for specimen collection include but are not limited to the following items:

• Hand sanitizer
• Specimen container
• Body material sample
• Refrigerator or freezer

Potential Risks or Complications of Specimen Collection

Specimen collection is often safe and relatively painless for patients. Although there may be pain associated with blood draws, it should not be significant or cause any lasting damage.

Pro Tips for Mastering the Art of Specimen Collection

Here are some pro specimen collection tips that may assist you in the future.

• Avoid frequent problems with attention to detail. Follow the guidelines of your facility to the letter.
• Use two patient identifiers or more before collecting the sample.
• Label containers for specimens while in the presence of the patient.
• Ensure you aren’t using any expired containers.
• Ensure that you are using the correct container. Some require preservatives, while others do not.
• Do NOT transfer/pour specimens from one type of container into another.
• Obtain a large enough quantity of the specimen to ensure the test can be performed (see the test’s requirements for more information).
• Tighten container lids to avoid any leakage or contamination.
• Keep the specimen at the recommended temperature as specified in the test requirements.
• Remember to add the preservative specified in the test requirements to the collection container before you ask for a sample.

Why Should Medical Assistants Learn How to Collect Specimens?

Although most facilities employ nurses and other healthcare professionals, it can be very beneficial for Medical Assistants to learn these skills as allowed per state law. This is because nurses may not always be available in smaller settings or even larger ones like hospitals.

While specimen collection isn’t always a job requirement, it is a valuable skill that can lead to greater opportunities. Therefore, it would be advantageous for MAs or aspiring Medical Assistants to pursue the proper training. Once they are prepared to perform certain specimen collection duties, an MA could become more indispensable to their employer and possibly gain greater responsibilities.

Start Your Career in Medical Assisting

The ability to collect specimens is an important skill that aspiring Medical Assistants should learn for their careers. It’s also an essential medical practice for several diagnoses and other procedures.

Think about it: Bodily specimens provide medical staff with critical information about a patient’s health. In order to determine the right diagnosis, they need to rely on accurate test results. This means that adequate specimen collection and handling are nothing short of essential to the success of a healthcare team.

If you’re feeling inspired and want to pursue a career in medicine, Unitek College offers various  healthcare programs , such as our  Medical Assisting program .

Contact us today to learn more about our programs and tuition assistance options. Take the first step toward a rewarding future in healthcare!

While this blog may occasionally contain information that relates to Unitek College's programs or courses, the majority of information provided within this blog is for general informational purposes only and is not intended to represent the specific details of any educational offerings or opinions of Unitek College.

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Introduction to Specimen Collection

Laboratory tests contribute vital information about a patient's health. Correct diagnostic and therapeutic decisions rely, in part, on the accuracy of test results. Adequate patient preparation, specimen collection, and specimen handling are essential prerequisites for accurate test results. The accuracy of test results is dependent on the integrity of specimens.

Safety and Disposal Considerations in Specimen Collection

In all settings in which specimens are collected and prepared for testing, laboratory and health care personnel should follow current recommended sterile techniques, including precautions regarding the use of needles and other sterile equipment. Treat all biological material as material that is potentially hazardous as well as contaminated specimen collection supplies. For all those who are involved in specimen collection and preparation, the responsibility to adhere to current recommendations designed to maintain the safety of both patients and health care workers does not end when the patient is dismissed.

There are four steps involved in obtaining a good quality specimen for testing: (1) preparation of the patient, (2) collection of the specimen, (3) processing the specimen, and (4) storing and/or transporting the specimen. Since information related to any of these areas may change as clinical laboratory technology changes, please refer to the latest edition of the Labcorp Directory of Services and Interpretive Guide for current instructions.

Preparation

Prior to each collection, review the appropriate test description, including the specimen type indicated, the volume, the procedure, the collection materials, patient preparation, and storage and handling instructions.

Preparing the Patient. Provide the patient, in advance, with appropriate collection instructions and information on fasting, diet, and medication restrictions when indicated for the specific test.

Preparing the Specimen. Verify the patient's identification. Proper identification of specimens is extremely important. All primary specimen containers must be labeled with at least two identifiers at the time of collection. Submitted slides may be labeled with a single identifier, but two identifiers are preferred. Examples of acceptable identifiers include (but are not limited to): patient's name (patient's first and last name exactly as they appear on the test request form), date of birth, hospital number, test request form number, accession number, or unique random number. A

location such as a hospital room number is not an appropriate patient identifier. If chain of custody documentation is necessary for the procedure, follow the appropriate protocol. All specimens should be labeled in the presence of the patient. Process and store the specimen(s) as required. Appropriate storage and handling are necessary to maintain the integrity of the specimen and, consequently, the test results.

Avoiding Common Problems

Careful attention to routine procedures can eliminate most of the potential problems related to specimen collection. Materials provided by the laboratory for specimen collection can maintain the quality of the specimen only when they are used in strict accordance with the instructions provided. To collect a sufficient quantity of each type of specimen indicated for the procedures to be performed, please consult the volume requirements published in this  Directory.

General Specimen Collection.  Some of the common considerations affecting all types of specimens:

• Please examine specimen collection and transportation supplies to be sure they do not include expired containers.
• Label a specimen correctly and provide all pertinent information required on the test request form. (See  Blood Specimens: Chemistry and Hematology − Blood Collection/Transport Containers .)
• Submit a quantity of specimen sufficient to perform the test and avoid a QNS (quantity not sufficient), as indicated in the test requirements. (See Quantity Not Sufficient.)
• Use the container/tube indicated in the test requirements for appropriate specimen preservation.
• Follow patient instructions prior to specimen collection Including the proper order of blood draw when multiple tubes are required. ( See Blood Specimens: Chemistry and Hematology – Consideration for Single and Multiple Sample Collection. )
• Carefully tighten specimen container lids to avoid leakage and/or potential contamination of specimens.
• Maintain and transport the specimen at the temperature indicated in the test requirements.
• Mix specimen with additive immediately after collection by inverting 5-10 times.

Serum Preparation.  The most common serum preparation considerations:

• Separate serum from red cells within two hours of venipuncture.
• Mix by inverting specimen with additive immediately after collection.
• Allow specimens collected in a clot tube (eg, red-top or gel-barrier tube) to clot before centrifugation. (See  Blood Specimens: Chemistry and Hematology − Preparing Serum  on clotting and gel-barrier tubes and red-top tubes.)
• Avoid hemolysis: red blood cells broken down and components spilled into serum. Causes and prevention are discussed under the section on hemolysis.
• Avoid lipemia: cloudy or milky serum sometimes due to the patient's diet (discussed under the section on lipemia).

Plasma Preparation.  The most common considerations in the preparation of plasma:

• Collect specimen in additive indicated in the test requirements.
• Avoid hemolysis or red blood cell breakdown.
• Fill the tube completely, thereby avoiding a dilution factor excessive for total specimen volume (QNS).
• Separate plasma from cells within two hours of venipuncture or as indicated in the test requirements.
• Label transport tubes as “plasma”
• Indicate type of anticoagulant (eg, “EDTA,” “citrate,” etc)

Urine Collection.  The most common urine collection considerations:

• Obtain a clean-catch, midstream specimen.
• Store unpreserved specimens refrigerated or in a cool place until ready for transport.
• Provide patients with instructions for 24-hour urine collection(s).
• Add the preservative (as specified in the test requirements) to the urine collection container prior to collection of the specimen if the preservative is not already in the container.
• Provide sufficient quantity of specimen to meet the minimum fill line on preservative transport container.
• Provide the proper mixing of specimen with urine preservative as specified in the test requirements.
• Use the collection container as specified in the test requirements, and refrigerate the specimen when bacteriological examination of the specimen is required.
• Carefully tighten specimen container lids to avoid leakage of specimen.
• Divide specimen into separate containers for tests with such requirements.
• Provide a complete 24-hour collection/aliquot or other timed specimen.
• Provide a 24-hour urine volume when an aliquot from the 24-hour collection is submitted.
• Preservatives vary for each test; refer to test information for the required preservative.

Collection Procedures

Collection of Vacuum Tubes Containing Additives (eg, anticoagulants, preservatives, clot activators, gel-barrier). When using vacuum tubes containing an additive:

•  Tap the tube gently at a point just below the top to release any additive adhering to the tube or top.
• Permit the tube to fill completely to ensure the proper ratio of blood to additive. There will be some dead space at the top of the tube.
• To allow for adequate mixing of blood with the anticoagulant or preservative, use a slow rolling wrist motion to invert the tube gently four to eight times. Failure to invert tubes may lead to the formation of microscopic clots.
• Rapid wrist motion or vigorous shaking may contribute to hemolysis.
• Check to see that all the preservative or anticoagulant is dissolved. If any preservative powder is visible, continue inverting the tube slowly until the powder is dissolved.
• If multiple samples are being drawn, invert each specimen as soon as it is drawn. Do not delay. Place the tube upright in a rack as quickly as possible after collection.
• The gel-barrier tube is an additive tube and should be inverted five to six times after collection. Allow the tube to stand for 30 to 60 minutes for complete clotting to occur prior to centrifugation.

Collection of Vacuum Tubes Without Anticoagulants. When using vacuum tubes containing no additives:

• Permit the tube to fill completely.
• Let the specimen stand for 30 to 60 minutes and (preferably) not longer than 60 minutes prior to centrifugation.
• Centrifuge the specimen at the end of the waiting period in accordance with the manufacturer's instructions for speed.

In general, grossly or even moderately hemolyzed blood specimens may not be acceptable for testing. Hemolysis occurs when the red cells rupture and hemoglobin and other intracellular components spill into the serum. Hemolyzed serum or plasma is pink or red, rather than the normal clear straw or pale yellow color.

Most cases of hemolysis can be avoided by observing the steps listed.

•  For routine collections, use a 21- to 22-gauge needle. (On occasion, however, it may be necessary to use a 23-gauge needle for patients from elderly and pediatric populations with small or difficult veins.)
• If there is air leakage around the needle or loss of vacuum in the tube, replace the vacuum tube.
• If you are using your own collection equipment instead of the vacuum tube technique, use only clean, dry, sterile needles, syringes, and tubes.
• Collect blood in room temperature containers unless the specimen requirement specifies otherwise.
• When there is difficulty accessing a vein or when a vacuum tube fills too slowly due to a difficult venipuncture, damage to the red blood cells may result. Address this problem by collecting a fresh tube when blood flow is established or select another puncture site and, using sterile/unused equipment, collect a second specimen. Also, use of a blood pressure cuff, in lieu of a tourniquet, will reduce trauma to fragile red blood cells.
• Do not remove the needle from the vein with the vacuum tube engaged. This applies to both the last tube collected during a routine venipuncture and to tubes collected during a difficult procedure.
• Premature removal of the tube causes a rush of air to enter the tube, which may result in damage to the red cells.
• Be as gentle as possible, drawing the blood evenly. Too much pressure in drawing blood into a syringe or forcefully ejecting blood into a collection tube from a syringe may damage red cells.
• Allow collection site to dry after cleaning with the alcohol pad. Alcohol used to clean the puncture site may cause contamination in a tube.
• Do not collect a specimen from or through a hematoma.
• Allow specimen to clot completely (for 30 to 60 minutes) before centrifuging.
• Do not centrifuge the specimen for more than 10 minutes unless otherwise specified by the collection instructions.

Lipemic Serum or Plasma (Turbidity)

Normal serum or plasma is a clear and light yellow to straw in color. Turbid serum or plasma appears cloudy or milky.

Serum or plasma may be cloudy due to bacterial contamination or chronic or transient high lipid levels in the patient's blood.

The primary dietary sources of lipids (fatty substances) are meats, butter, cream, and cheese. Patients who consume these foods within the 24-hour period immediately preceding collection of a blood specimen may have temporarily elevated lipid levels, which may be manifested by cloudy or lipemic serum. Lipemic serum or plasma may not be a true indicator of the patient's physiologic state. (See Figure 1.) Regardless of diet and length of fast, some patients may produce cloudy specimens.

To avoid dietary-induced high lipid levels prior to testing, many physicians require patients to exclude the high-fat foods from their diets or to fast for 12 to 14 hours prior to specimen collection. For morning specimen collection, the laboratory recommends that the patient be required to fast from 6 PM on the previous evening.

Quantity Not Sufficient

One of the most common problems in specimen collection is the submission of an insufficient volume of specimen for testing. The laboratory sends out a report marked QNS (quantity not sufficient), and the patient has to be called back for a repeat collection at an inconvenience to the patient and to the physician. To ensure an adequate specimen volume:

• Always draw whole blood in an amount 2½ times the required volume of serum required for a particular test.
• For example, if 2 mL serum are required, draw at least 5 mL whole blood. If there is difficulty in performing venipuncture, minimum volume may be submitted if it is indicated in the test description. For most profile testing, draw at least two 8.5-mL gel-barrier tubes.
• If pediatric tubes are used, be sure to collect an adequate volume of specimen to perform the test.
• Provide patients with adequate containers and instructions for 24-hour urine and stool collections.
• It is critical, especially for any specimen collection tube containing an additive, to allow the tube to fill to the "fill line" marked on the tube. This requirement is important in order to achieve the proper blood-to-additive ratio; otherwise, the specimen may be found to be QNS.

Specimen Storage and Shipping Temperatures

The definition of specimen temperatures for storage and shipping is as listed below:

Room Temperature: 10.1 – 40.0 o C

Refrigerated: 1.0 to 10.0 o C

Frozen: -1.0 to -80.0 o C Frozen Specimen Guide  

Outdoor Specimen Lockboxes

For clients whose specimen lockboxes must be placed outdoors, adding a frozen gel pack to the lockbox during warmer weather will help provide a moderate temperature inside the lockbox until specimens are collected by your Labcorp service representative. Labcorp also offers a different lockbox for use at locations that experience “extreme” temperatures. Contact your local representative for more information.

Refrigerant Bottles should be prepared for use by placing them in a freezer for four hours or longer. They should be frozen solid prior to being placed in the lockbox, and they should be frozen solid before each use, even though they may be used with specimens that are not frozen.

If it is not possible to avoid placing the specimen lockbox in direct sunlight, add 20°F to the temperatures listed above to determine how many frozen gel packs to use. For lockbox instructions and Q&A, select  Instructions for Use .

If a specimen that is frozen needs to be put into the lockbox, the Frozen Specimen Keeper can be used maintain that frozen state.  Instructions for Use .

Preparing the Patient

Patient instructions.

It is important to gain the patient's understanding and cooperation in obtaining an acceptable specimen.

Patient States

Basal State.  In general, specimens for determining the concentration of body constituents should be collected when the patient is in a basal state (ie, in the early morning after awakening and about 12 to 14 hours after the last ingestion of food). Reference intervals are most frequently based on specimens from this collection period.

The composition of blood is altered after meals by nutrients being absorbed into the bloodstream. Consequently, postprandial blood (blood drawn after a meal) is not suitable for some chemistry tests. An overnight fast is preferable (from 6 PM of the evening previous to collection) to ensure that the patient is in the basal state. This minimizes the effects of ingested substances on the test results. Before you collect

the specimen, ask the patient when he/she last ate or drank anything. If the patient has eaten recently and the physician wants the test to be performed anyway, you should indicate “nonfasting” on the test request form. In the clinical information/comments section of the test request form, indicate the time the patient ate. Fasting does not include abstaining from coffee, tea, or sugar-free liquids.

Fasting or diet restrictions, such as low-fat diets, should be explained in detail, particularly to aged or overanxious patients or their caregivers. Inform patients that fasting does not include abstaining from water. Dehydration resulting from water abstinence can alter test results.

When specimens are not collected in the basal state, the following additional effects should be considered when interpreting test results.

• Exercise.  Moderate exercise can cause an increase in blood glucose, lactic acid, serum proteins, and creatine kinase (CK).
• Emotional or Physical Stress.  The clinical status of the patient can cause variations in test results.
• Time of Day of Collection.  Diurnal variations and variations in circadian rhythm can also affect test results. For example, growth hormone peaks in the morning before waking and decreases throughout the day. Serum iron levels may change as much as 30% to 50%, depending on individual variation, from morning until evening.

Note:  For chemistry profiles, 12- to 14-hour fasting specimens are recommended.

Timed Specimens

There are two types of timed blood specimens: One is for a single blood specimen ordered to be drawn at a specific time. The other is for a test that may require multiple blood specimens to be collected at several specific times.

Single Specimens. Here are some instances in which timed single specimens may be required.

• Fasting plasma glucose alone or in conjunction with a random glucose determination, as recommended by the American Diabetes Association, to diagnose diabetes. Fasting here is defined as no caloric intake for at least eight hours.
• Postprandial glucose may be performed two hours after a meal for a timed test that is helpful in diabetes detection.
• Blood glucose determinations may be ordered at a specific time to check the effect of insulin treatment.
• Blood cultures may be ordered for a specific time if a bloodstream bacterial infection is suspected.
• Therapeutic monitoring of patients on medication.

Multiple Specimens.  Here are some instances in which timed multiple specimen tests may be ordered

• The most common timed procedure is a glucose tolerance test. First, a blood specimen is drawn from a fasting patient. Then, the patient is given glucose orally and blood specimens are drawn at fixed intervals. (See following illustration.) Note : The American Diabetes Association and the World Health Organization (WHO) have specific recommendations for glucose tolerance testing.
• The tolbutamide (Orinase®) test is similar to a glucose tolerance test, but the collection intervals vary.
• To test the effect of a certain medication, a physician may order the same test to be obtained on consecutive days, before, during, and after the patient has received a medication.
• Collection of an acute and convalescent serum to aid in the diagnosis of a viral infection when culturing is not feasible.
• Other examples include such tests as occult blood, ova and parasites, and blood cultures.

Sequential Sampling

Diagnosis of many endocrine diseases requires sequential sampling of blood and/or urine. Labcorp sometimes offers reduced fees for serial tests when the following conditions are met:

•  All sequential specimens are from the same patient and are sent to the laboratory at the same time.
• The specimens are clearly labeled with their chronological sequence (1 of 6, 2 of 6, time of drawn or Fasting, ½ hr, 1hr, etc) and with the patient's name, other unique identifier, and date of collection.
• Only one test request form accompanies the serial samples, and it is completed with all patient information, including any medications administered and the number of samples sent.
• The test request form and all specimens are sent in one container (box or plastic specimen transport bag).

Serial Monitoring

Monitoring a patient over time for a specific condition is a variation of sequential sampling. Many tumor markers (tests used to follow the patient's response to treatment for cancer) may be monitored over the course of several years. Specific instructions for serial monitoring are found in the test description for the applicable test being monitored.

Interference of Medications and Other Substances

Many common prescription and nonprescription (over-the-counter) medications can interfere with chemical determinations or alter levels of substances measured. Drug interference is complicated and often method-dependent such that only general recommendations can be stated here. Precautions to be observed must be determined by the physician, and the patient must then be told to avoid specified medications for the necessary periods of time prior to specimen collection.

If the patient cannot be taken off the medication in question, its presence should be noted on the test request form.

Summary: Interference of Medications and Other Substances

• Drugs or their metabolites are frequently concentrated in the urine in sufficient amounts to interfere significantly with urine assays. (See appendices or individual tests for specific information.)
• Thiazide diuretic therapy. The pharmacologic or toxic effect is hyperuricemia and hyperglycemia.
• Catecholamine assay. If a “24-hour drug abstinence period” for a patient is not possible, order VMA or metanephrines.
• Oral contraceptives cause a decrease in serum vitamin B12 levels that is often indistinguishable from vitamin B12 deficiency of any cause. They also cause an increase in total serum thyroxine-binding globulin. This results in increase in both total serum thyroxine and unsaturated thyroxine-binding globulin, but with no significant change in unbound (free) thyroxine.
• Many medications have been shown to have long-term residual effects that interfere with testing. (Biotin is one example of this that is often administered in high dosages.)
• Refer to individual test descriptions for specific information.

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Chapter 26 Specimen Collection and Processing for Microbiology

Nov 02, 2014

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Chapter 26 Specimen Collection and Processing for Microbiology. Wang Hui. General specimen collection and processing issue. First part of this chapter. Specimen Collection.

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Chapter 26Specimen Collection and Processing for Microbiology Wang Hui

General specimen collection and processing issue First part of this chapter

Specimen Collection Successful laboratory diagnosis of a microbial infection depends on many factors beginning with a well-collected sample. Proper specimen selection, collection, and transport are all essential to ensure that a specimen is representative of the disease process and minimally contaminated with microorganisms present in adjacent tissues.

Site and Timing Collect the sample from the correct anatomic site . eg. a superficial sample of a lesion is not useful in identifying the cause of a deep wound infection. The timing of sample collection is also important.eg, when submitting a specimen for bacterial culture, samples should be collected before the administration of antibiotics

Collection Techniques Sterile technique and equipment. Sufficient volume After collection, the specimen must be placed in an appropriately labeled leak-proof container.

Requisition slip Each specimen must be accompanied by a requisition slip to evaluate the specimen appropriately and relay the test results back to health care provider without delay. The requisition slip should contain these information : patient name, age, gender, identification number, location, name of health- care provider, time and date of collection, specimen type, diagnosis, and test(s) requested.

Transport of Specimens Rapid, optimally in less than 2 hours. For delays in transport, most specimens should be refrigerated. Exceptions: blood, cerebrospinal fluid (CSF), and specimens to be examined for anaerobes, fastidious organisms such as Neisseria gonorrboeae and Bordetella pertussis, and Trichomonas vaginalis, all of which should be maintained at room temperature.

Specimen rejection criteria(1) Improper transport temperature Improper transport container or medium Prolonged transport time Unlabeled or mislabeled specimen Broken or cracked container Leaking specimen

Specimen rejection criteria(2) Dried-out specimen Inappropriate specimen for test requested Inadequate volume Specimen in fixative (for culture) Duplicate sample in 24-hr period (for urine, sputum, feces culture)

Specimen rejection criteria(3) When specimens are rejected, the health care provider is notified so that another specimen may be properly submitted. If information on the requisition is incomplete, laboratory personnel should ask a responsible person to provide the information before processing the specimen further. If a specimen is mislabeled, the sample should be recollected. Relabeling of a specimen is acceptable only for difficult to collect specimens, such as tissue obtainedduring a surgical procedure or CSF.

Specimen not routinely accepted for anaerobic culture(1) Throat, nasopharyngeal, or gingival swabs Sputa Bronchial wash, lavage, or brush (except when collected with a protected double lumen catheter) Gastric and bowel contents

Specimen not routinely accepted for anaerobic culture(2) Ileostomy and colostomy effluent Voided or catheterized urine Female genital tract specimens collected through the vagina Surface swabs of ulcers, wound, and abscesses

Standard Precautions All specimens should be presumed to contain transmissible agents and therefore should be collected and handled using standard precautions. Use of gloves, gown, mask, and protective eyewear when there is a risk of coming in contact with the specimen In most clinical laboratories, a special area is designed for processing clinical samples for culture.

Clinical Diagnosis by Microbiology Laboratory method(1) Direct Examination Gram stain (general) acid-fast bacilli (AFB) (mycobacteria ) KOH and/or calcofluor white preparation (fungi ) wet mount (parasites), etc. Other techniques for directly examining specimens : direct fluorescent antibody stains (DFA), enzyme immunoassays (EIAs), DNA hybridization or amplification assays, etc.

Clinical Diagnosis by Microbiology Laboratory method(2) Isolate, Culture and Identification A combination of media types is used to isolate bacteria and fungi (include enriched, nonselective, selective, or differential media); Viruses can only be cultured within mammalian cells, three main categories:primary, low-passage finite and continuous cell lines Culture of parasites is generally not performed.

Clinical Dignosis by Microbiology Laboratory method(3) Lengths of culture time Most routine bacterial cultures are incubated for 2 to 3 days. Mycobacterial and fungal cultures are in-cubated for as long as 6 weeks. Viral cell cultures are incubated for varying lengths of time depending on the specimen source and the growth rate of the viruses that are typically recovered from that site

Clinical Dignosis by Microbiology Laboratory method(4) The condition of incubation 35℃ for bacteria and viruses 30℃for fungi Various atmospheric conditions may be utilized including ambient, CO2 enriched, microaerophilic and anaerobic.

Specific recommendations for each specimen type The second part of this chapter

Blood - specimen collection(1) In general, blood for culture should not be obtained using an intravascular device. When performing a venipuncture, the skin must be adequately disinfected to minimize contamination with normal skin flora. Blood should be collected and incubated into the blood culture bottles using the same needle.

Blood - specimen collection(2) Blood specimens should be collected before administering antimicrobial agents. Optimally, the specimen should be collected just before a fever spike; however, prac-tically, the specimen should be collected immediately after the spike. For adults, 20 to 30mL of blood should be collected per venipuncture. Less blood is required for children .

Blood - specimen collection(3) For adult patient, two sets of cultures should be collected per febrile episode to help distinguish probable pathogens from pos-sible contaminants No more than four sets should be submitted in a 24-hour period. Inoculated blood culture vials should be held at room temperature until they reach the laboratory.

Blood culture(1) Cultures for rapidly growing bacteria and yeast are usually incubated for 5 to 7 days. Cultures for mycobacteria and slowly grow-ing fungi are held for as long as 42 days. Many types of blood culture systems are a-vailable, including both manual and auto-mated.Each system utilizes a noninvasive method (i.e., colorimetric, fluorescent, or manometric methods for detecting CO2 or other gases) to monitor growth.

Blood culture(2) As soon as growth is detected from the blood specimen, a stain is performed (Gram, acid-fast, or Giemsa stain) to determine the type of microorganism present. Positive stain results are considered a critical value and called directly to the patient’s health care provider . Then the specimen should be subcultured to solid media.

Culture of catheter tips Performed to determine the source of a bacteremia. Semiquantitative catheter tip culture method : The segment is rolled across a blood agar plate four times Cultures yielding organisms present in more than 15 CFU are considered to be significant, potentially indicating a catheter-related in-fection.

Cerebrospinal fluid (CSF)(1) Cerebrospinal fluid (CSF) is submitted for microbiological analysis when meningitis or encephalitis is suspected. For meningitis, the likely infection agent differs depending on the duration of symp-toms.The most likely bacterial agent of acute meningitis will also vary with the age of the individual and whether the disease is comunity or nosocomially acquired.

Cerebrospinal fluid (CSF)(2) Most infectious cases of encephalitis are a result of viral infection, both arthropod and nonarthropod borne. Parasitic infections of the central nervous system also occur, with varying clinical presentations.

Probable infectious cause of meningitis Duration of symptoms Probable Pathogen < 24 hr Pyogenic bacteria 1-7 days Enteroviruses , Pyogenic bacteria ≥4 wk Mycobacterium tuberculosis Treponema pallidum Brucella spp , Candida spp Leptospira interrogans Borrelia burgdorferi Cryptococcus neoformam Coccidioides immitis Histoplasma capsulatum

CSF - specimen collection Obtained by lumbar spinal puncture Generally at least 0.5mL of CSF (smear, culture, antigen tests ) For mycobacterial culture,at least 3mL (greater volumes increase recovery)

CSF – transportation Transported to the laboratory promptly and processed as soon as possible. If a delay in processing is unavoidable, the specimen should be held at room temperature. If greater than 1.0mL of CSF is received for a given test the fluid is centrifuged to allow the test to be performed on the concentrate sediment

CSF-laboratory diagnosis Gram stain antigen tests India ink test (Cryptococcus neoformans ) dark-field microscopy of a concentrated specimen (Leptospires) acid-fast bacilli (AFB) (mycobacteria ) bacterial culture yeast and fungi culture viral culture

Gastrointestinal Tract(1) • Feces, and in some cases rectal swabs, are submitted to the laboratory primarily to determine the etiologic agent infections diarrhea or food poisoning. • Feces should be collected in a clean container with a tight lid and should not be contaminated with urine, barium, or toilet paper. Optimally be examined within 2 hours of collection.

Gastrointestinal Tract(2) Rectal swabs should be placed in a tube transport system containing modified Stuart-’s medium. Unpreserved stool specimens should be maintained at refrigerator temperature dur-ing storage and transport.

Gastrointestinal Tract(3) It is becoming standard practice to reject stool specimens for bacterial culture and parasite examination from patients who have been hospitalized longer than 3 days . For such patients, examination for the toxins produced by Clostridium difficile is recom-mended.

Gastrointestinal Tract -laboratory diagnosis Bacterial culture selective and differential medium (Mac Conkey agar, Hektoen enteric or xylose-lysine-desoxycholate agar,etc) Fungal culture of stool is not recommended. Viral culture To detect parasites, stool is examined microscopically for the presence of protozoa, helminth eggs, and larvae.

Genital Tract(1) Genital tract specimens are sent to the laboratory for determining the cause of vari-ous clinical syndromes, including vulvova-ginitis, bacterial vaginosis, etc. Many specimens will be contaminated with the normal microbiota of the genital tract or skin; therefore, the microbiologist must differentiate the normal flora from potential pathogens.

Genital Tract(2) Organisms such as N. gonorrhoeae, C. trachomatis, and Haemophilus ducreyi are always pathogenic, whereas organisms such as the Enterobacteriaceae, S. aureus, and group Bstreptococciare pathogenic only in some clinical situations.

Genital Tract -laboratory diagnosis(1) direct Gram stain (only a few situations ) eg., gram-negative diplococci within poly-morphonuclear leukocytes wet mount preparation of vaginal secretions clue cells :epithelial cells covered with small coccobacillary bacteria 3. vaginal pH normal≤4.5 4. whiff test positive :generation of a pungent, fishy odor on addition of 10% KOH to the specimen

Genital Tract -laboratory diagnosis(2) bacterial culture: depend on the source and the organisms likely to cause disease at that site Tissue and aspirates should be plated to media capable of recovering fastidious organisms. Specimens from the cervix, vagina, and urethra should at a minimum be evaluated for N. gonorrhoeae and C. trachomatis by culture or a direct detection method.

Genital Tract -laboratory diagnosis(3) Fungal culture of female genital tract specimens is not productive. Viral culture remains the gold standard for detection of HSV.

Lower Respiratory Tract primarily to determine the etiologic agent of pneumonia Specimen types: sputum (expectorated or induced), tracheal aspirates, transtracheal aspirates, bronchial washes, bronchial brushings, and bronchoalveolar lavage fluids. delivered promptly to the laboratory. if delays are unavoidable , refrigerated .

Lower Respiratory Tract -laboratory diagnosis(1) Gram-stained smear low-power magnification to determine the number of squamous epithelial cells and/or neutrophils present oil immersion to determine the relative amounts of organisms present Intracellular organisms should be specifical-ly noted. 2. culture ,selective and nonselective media, In addition, a medium capable of recovering fastidious organisms

Lower Respiratory Tract -laboratory diagnosis(2) bronchial brush specimens (0.01 to 0.001mL) a smear for Gram staining is prepared by cytocentrifugation, and 0.01mL of the speci-men is plated to appropriate media using a pipette or calibrated loop. 4. bronchoalveolar lavage (10 to 100mL ) a smear is prepared by cytocentrifugation and Gram stained (presence or absence of intracellular organisms), a 0.001-mL aliquot of the specimen is inoculated onto agar media

Upper Respiratory Tract Nasopharyngeal aspirates, washings, and swab specimens are primarily used for the diagnosis of viral respiratory infections but may also be submitted to diagnose pertussis, diphtheria, chlamydia infections, and candidiasis, as well as identify carriers of N. meningitidis or S. aureus. Throat swab specimens are generally collected to diagnose group A streptococcal pharyngitis or to detect shedding of viruses such as enteroviruses, HSV, or CMV.

Tissues procured at great expense and considerable risk to the patient; therefore, for optimal evaluation enough material should be collected to allow both histopathologic and microbiologic examination. After collection, tissues should be placed in a sterile container and transported rapidly to the laboratory to prevent drying.

Tissues -laboratory diagnosis homogenized by mincing with a sterile scalpel, grinding with a mortar and pestle or tissue grinder Gram stain or other stains examined for presence of microorganisms, leukocytes, and squamous epithelial cells routine culture,liquid medium and enriched agar medium bone marrow aspirates, in collection tubes for the lysis centrifugation blood culture system or in a sterile container

Urine Acceptable methods of urine collection in-clude midstream clean catch, catheterization, and suprapubic aspiration. Foley catheter tips should not be accepted for culture. promptly to the laboratory and processed within 2 hours of collection . If delays are unavoidable, refrigerated.

Urine -laboratory diagnosis Screening urine specimens Gram stain dipstick tests that combine nitrate reductase and leukocyte esterase Quantitative bacterial culture 0.001-mLplastic or wire calibrated loop blood and Mac-Conkey agars

Skin and Subcutaneous Lesions(1) Ideally, the infected material is aspirated with a needle and syringe.For transport, the material is expelled into sterile container that is tightly capped and promptly delivered to the laboratory. If an aspirate cannot be obtained, swab specimens of exudate collected from the deep portion of the lesion are acceptable. For bacterial and fungal cultures, swabs may be placed in tube transport system contain-ing modified Stuart’s medium.

Skin and Subcutaneous Lesions(2) To recover anaerobes, an additional swab specimen must be collected and placed in an anaerobic transport system. For viral culture, the specimen (aspirate or swab) should be placed in viral transport medium and kept on ice. If a delay in processing is unavoidable, specimens may be stored in the refrigerator, except those for recovery of anaerobes (room temperature )

Skin and Subcutaneous Lesions -laboratory diagnosis Gram-stain appropriate media for culture If detection of mycobacteria is requested, specimens should be decontaminated and concentrated.The sediment is used to prepare a smear for staining for AFB and to inoculate mycobacterial media.

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General Instructions

Over the 10-week progression of the term, you will collect and preserve specimens to create a collection that will be turned in at the end of the term for a significant portion of your lab grade. You will be given the tools to complete the collection, and we will have at least one day in class to collect as a group, and several days where time will be permitted for you to work on your collection with the aid of the lab instructor.

As you collect, you must take notes on the location, date, time, and ecological system in which you catch each specimen.

At the start of each week, you will be expected to bring in three new specimens and the associated field notes. It may be helpful to collect your notes in a single pocket-sized notebook; this information will be used to create the labels for your specimens.

Collection Requirements

• 25 individual families must be collected and correctly identified
• Field notes on each specimen will be recorded at time of collection
• Each specimen is to be properly curated with correct labeling

For each specimen in the collection, one point each will be awarded for correct Order ID and correct Family ID. One point will be awarded for each correct label as well, for a total of 4 points possible per specimen. Total points possible for the collection is 100 points.

Students may earn extra points per specimen by including a third “Applied” label noting ecological/life history information. This can denote gender (ONLY if externally discernible), separate life stages (up to three), parasitoid/prey relationships, caste (Hymenoptera and Isoptera only), and mimicry (must have mimic and model). For example, a collection may receive credit for two Dermaptera: Forficulidae specimens if they are labeled correctly as male/female, even though both specimens are the same family. At least TWO specimens with differing applied labels must be presented for the extra points.

Accepted Applied Labels

Gender: Male/Female

Life Stage: Eggs/Immature larvae/Mature Larvae/Pupae/Adult

Trophism: Prey/Parasitoid (must identify counterpart, i.e. Prey (of Braconidae); Parasitoid (of

     Aphididae))

Caste: Worker/Reproductive/Soldier

Mimicry: Mimic/Model (must identify counterpart, i.e. Mimic (of Apidae); Model (for Syrphidae)).

Correct Labeling

The applied label should be placed below the other two required labels (refer to Week 1 Reading). You will not be awarded extra points without the third label.

Entomology 311 Lab Manual Copyright © 2019 by Melissa Scherr is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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Chemical Science

State-of-the-art local correlation methods enable affordable gold standard quantum chemistry for up to hundreds of atoms †.

* Corresponding authors

a Department of Physical Chemistry and Materials Science, Faculty of Chemical Technology and Biotechnology, Budapest University of Technology and Economics, Műegyetem rkp. 3., H-1111 Budapest, Hungary

b HUN-REN-BME Quantum Chemistry Research Group, Műegyetem rkp. 3., H-1111 Budapest, Hungary

c MTA-BME Lendület Quantum Chemistry Research Group, Műegyetem rkp. 3., H-1111 Budapest, Hungary E-mail: [email protected]

In this feature, we review the current capabilities of local electron correlation methods up to the coupled cluster model with single, double, and perturbative triple excitations [CCSD(T)], which is a gold standard in quantum chemistry. The main computational aspects of the local method types are assessed from the perspective of applications, but the focus is kept on how to achieve chemical accuracy ( i.e. , <1 kcal mol −1 uncertainty), as well as on the broad scope of chemical problems made accessible. The performance of state-of-the-art methods is also compared, including the most employed DLPNO and, in particular, our local natural orbital (LNO) CCSD(T) approach. The high accuracy and efficiency of the LNO method makes chemically accurate CCSD(T) computations accessible for molecules of hundreds of atoms with resources affordable to a broad computational community (days on a single CPU and 10–100 GB of memory). Recent developments in LNO-CCSD(T) enable systematic convergence and robust error estimates even for systems of complicated electronic structure or larger size (up to 1000 atoms). The predictive power of current local CCSD(T) methods, usually at about 1 – 2 order of magnitude higher cost than hybrid density functional theory (DFT), has become outstanding on the palette of computational chemistry applicable for molecules of practical interest. We also review more than 50 LNO-based and other advanced local-CCSD(T) applications for realistic, large systems across molecular interactions as well as main group, transition metal, bio-, and surface chemistry. The examples show that properly executed local-CCSD(T) can contribute to binding, reaction equilibrium, rate constants, etc. which are able to match measurements within the error estimates. These applications demonstrate that modern, open-access, and broadly affordable local methods, such as LNO-CCSD(T), already enable predictive computations and atomistic insight for complicated, real-life molecular processes in realistic environments.

• This article is part of the themed collection: #MyFirstChemSci 2024

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State-of-the-art local correlation methods enable affordable gold standard quantum chemistry for up to hundreds of atoms

P. R. Nagy, Chem. Sci. , 2024, Advance Article , DOI: 10.1039/D4SC04755A

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