Urine Specimen Management Procedure



Canberra Hospital and Health ServicesClinical ProcedureUrine Specimen ManagementContents TOC \h \z \t "Heading 1,1" Contents PAGEREF _Toc414977292 \h 1Purpose PAGEREF _Toc414977293 \h 2Alerts PAGEREF _Toc414977294 \h 2Scope PAGEREF _Toc414977295 \h 2Urinalysis PAGEREF _Toc414977296 \h 224 Hour Urine Collection PAGEREF _Toc414977297 \h 4Urine Specimen - Midstream PAGEREF _Toc414977298 \h 6Urine Specimen – Catheter Specimen of Urine (CSU) PAGEREF _Toc414977299 \h 8Implementation PAGEREF _Toc414977300 \h 10Related Policies, Procedures, Guidelines and Legislation PAGEREF _Toc414977301 \h 10References PAGEREF _Toc414977302 \h 10Search Terms PAGEREF _Toc414977303 \h 11PurposeThe purpose of this procedure is to outline the safe and effective management of urine specimen collection and testing for patients that are being cared for under the direction of ACT HealthScopeAlertsHand Hygiene: healthcare workers will comply with ACT Health hand hygiene practices in order to support the reduction of infection caused by the transmission of harmful pathogens.Patient Identification Pathology Specimen Labelling: defines the correct process that Health Directorate staff must comply with when identifying a patient and accurately labelling Pathology specimens collected from that patient.ScopeThis procedure provides information for clinicians about the care of patients that require urine testing in clinical and community settings.This procedure applies to all registered nurses, midwives or medical staff with competency recognised by ACT Health. New nursing or medical staff, assistants in nursing, or students (if within their defined scope of practice) will be required to perform these skills under the direct supervision of a credentialed and competent practitioner.Urinalysis Equipment Personal Protective Equipment (PPE) including clean gloves and gogglesRelevant reagent strips for urinalysis test:N Multistix for routine urinalysis including specific gravity, protein, ketones, blood,urobilinogen, pH, glucose, bilirubin, nitrite testingAlbustix for protein testingClinistix for glucose testingKetodiastix for glucose and acetone testingClean specimen jar (yellow top), bedpan, urinal, paediatric urine collection bag, or, uridome and catheter bagWatch or clock with second hand for timing the testAlcohol hand rub.Procedure Explain to the patient the reason for the test and the need to collect a urine specimenCheck patient identificationEnsure privacyDon PPE (goggles and gloves)Collect urine sample in clean specimen jar, bedpan, urinal, paediatric urine collection bag, or uridome and catheter bag. Note: please confirm appropriateness of a first morning urine specimenwith pathologyDiscard waste as contaminated wasteEnsure patients comfortDon PPE (gloves)Assess the urine sample for colour, clarity and odourSelect correct reagent stripsCheck the expiry date on bottleRemove the cap from the reagent strip bottleRemove reagent strip ensuring you do not touch the test end of the strip. Note: where reagent strips are discoloured do not useReplace cap on bottleInsert the reagent strip into the urineRemove strip from urine sample and tap the strip on the side to drain excess urineKeep strip horizontal and compare the test results with the chart provided on the bottle. Note: Strict adherence to timing requirements (as stated on the specimen strip container) is essential for accurate results. Where available an electronic analyser can be usedDiscard waste as contaminated wasteAttend hand hygieneUrinalysis InterpretationGlycosuria is an abnormal condition associated with diabetes, Cushing's syndrome or stress. It may also signify elevated serum glucose or reduced renal re-absorption.Bilirubin results may be falsely positive if the specimen is stale or if the patient has been prescribed certain medications. A valid positive result may indicate hepatic or biliary disease.Ketones are associated with the metabolism of fatty acids and dehydration if present suggest malnutrition, carbohydrate free diets, pregnancy or diabetesBlood may be pre-renal, renal or post-renal in origin. Stale urine or contamination with bleaches may give a false positive result.Nitrites are indicative of the presence of gram-negative bacteria, the organisms most commonly associated with UTIs.Leucocyte esterase indicates the presence of active WBCs in the urine and provides a good guide as to when a specimen should be sent to the laboratory.Urine specific gravity can act as an indicator of hydration status or the kidney's ability to concentrate urine. Urinary pH can detect renal disease, infection or calculi.Proteinuria may be transient and indicate such conditions as dehydration, stress, congestive heart failure, fever and exercise. Persistent proteinuria may indicate renal impairment, systemic disorders, or malignancies.Urine colour, clarity and odourColour changes may result from the influence of exogenous or endogenous pigments, or red blood cells.Cloudiness is secondary to particle suspension and may represent renal tubular cells or white blood cells.Normal urine has very little odour but if left to stand, the scent of ammonia becomes noticeable. Infected urine has an offensive smell that worsens when the specimen is left standing.A sweetish/ acetone scent indicates ketoacidosis, a condition usually associated with diabetic patients or with starvation.Strongly flavoured food and medications can also affect the odour or colour of urine.Back to Table of Contents 24 Hour Urine CollectionTo obtain a 24 hour collection of urine for the purpose of diagnostic measurements on excreted urine.A 24 hour urine collection for diagnostic purposes is ordered by a medical officer.Equipment PPE including clean gloves and gogglesA large labelled collection container specific to the test required. This is obtained from the appropriate laboratory. Note: The container may contain acid. Do not discard this as it acts as a preservativeClean bedpan or urinalClean jug for decantingAlcohol hand rub.Additional equipment where the patient experiences incontinencePaediatric Urine Collection Bag, feeding tube and syringeUridome and Catheter Bag.Additional equipment where the patient is catheterisedCatheter Bag.Procedure Explain to the patient the reason for the test and the need to retain all urine for 24 hours. Note: there are ACT Pathology Patient Fact Sheets available on 24 Hour Urine Collection and 24 hour Acid Urine Collection available via the intranetCheck patient identification, and label the collection container with the patient’s first and last names, date of birth, and UR number. Refer to: Patient identification and Pathology Specimen Labelling ProcedureRequest the patient to void upon waking in the morning. Note: For paediatrics begin following the first morning voidDiscard this urine. Note: The first specimen is considered old urine or urine in the bladder before the test began. Collection begins with empty bladderWrite on the container the time the urine was discarded. Note: This is the commencement time of the 24 hour urine collectionNote: Where a patient experiences incontinence or is catheterised, a new urine collection device and/ or new catheter bag is applied at the time the urine collection is commenced.Alert: Ensure that all nursing staff are aware that a 24 hour urine collection is in progress. Document on clinical worksheet. Post an ‘Alert Sign’ in an appropriate place. For example on the Catheter Bag and in the Dirty Utility.Document the time the urine collection commenced in the patient's clinical record and Fluid Balance ChartEnsure that a clean bedpan or urinal is available at all timesDon PPE (goggles and gloves) to collect every urine specimenEnsure patient comfort following collectionNote: Where paediatric urine collection bag is in use, ensure secure attachment and drain urine intermittently using feeding tube and syringeSlowly transfer urine specimens (using clean jug where decanting is required) into the collection containerEnsure the lid of the collection container is firmly in place post decantingDiscard waste as contaminated wasteOn the following morning at the same time as the first specimen from the previous day was discarded, request that the patient void their bladder and collect all urine passed into the collection container. For paediatrics collection is complete at 24 hoursAdd this final urine specimen to the collection containerDiscard waste as contaminated wasteRecord on the container the time that 24 hr urine collection was completedContact Central Equipment and Courier Service on (02) 6204 7171 and request a courier to collect specimenRecord the relevant details in the patient's clinical record.Alert: If a sample of urine is accidentally discarded during the 24 hour period, then the collection must be started again with a new specimen container.Where repeat specimen collection is required, that is unrelated to ongoing diagnostic requirements; these are to be entered via RISKMAN reporting system.Back to Table of Contents Urine Specimen - MidstreamTo obtain a midstream collection of urine for the purpose of laboratory microbiological analysis. A Midstream Specimen of Urine (MSU) for diagnostic purposes is ordered by a medical officer.Equipment PPE including clean gloves and gogglesClean specimen jar (yellow top)Sterile collecting dish - optionalGauze swabsSoap and water or Normal SalineClean bedpan or urinal where the patient is unable to ambulate to the toiletAlcohol Based Hand Rub (ABHR).Procedure Explain to the patient the reason for the test and the need to collect a urine specimen. Gain consent for procedure and check patient identification. Refer to: Patient identification and Pathology Specimen Labelling ProcedureAssess what level of assistance the patient may require. Some patients will need supervision throughout the procedureIf independent provide fact sheet (ACT Pathology Patient Fact Sheet available on Mid Stream Urine Collection via the intranet) and advise to wash perineal area with soap and waterEnsure privacyFemale Midstream Urine Specimen:Alert: Please exercise vigilance to procedure when collecting urine specimens from female patients as a large proportion of specimens are incorrectly collected/ contaminated.Where the patient is not able to wash independently with soap and water.Don PPE (goggles and gloves)Cleanse the perineal area with soap and water or normal saline. Ensure a new gauze is used for each swab:Separate the folds of the labia using a moist swab, wipe from front to back on one side then the other side then discard swabWipe down the middle from front to back and then discardUrination should begin, passing the first portion into the bedpan, urinal or toiletAfter the flow of urine has started, the clean specimen jar is placed under the patient collecting the mid portion (mid stream ‘clean catch’) without contaminating the container. Note: A sterile collecting dish can also be used and urine transferred to the clean specimen jarRemove clean specimen jar and allow patient to complete voidingEnsure the lid of the specimen jar is firmly in place, being careful not to touch the inside of the container or lidDiscard waste as contaminated wasteEnsure patient comfortApply patient specimen label or label the specimen jar with the patient’s first and last names, UR number, date of birth, time, date and type of collection (MSU)Complete pathology request form with your signature, time, date and type of collection (MSU)Place specimen and pathology request form in zip lock bag, and send to Pathology. Note: Specimens must be received within two hours of collectionRecord the relevant details in the patient's clinical record.Male Midstream Urine Specimen:Where the patient is not able to wash independently with soap and waterDon PPE (goggles and gloves)Cleanse the head of the penis with normal saline swabs using a circular motion (If a male is not circumcised the foreskin is retracted for cleaning (and when voiding)Discard the swabsUrination should begin, passing the first portion into the bedpan, urinal or toilet (If a male is not circumcised the foreskin is retracted when voiding)After the flow of urine has started, the clean specimen jar is placed under the patient collecting the mid portion (mid stream ‘clean catch’) without contaminating the container. A sterile collecting dish can also be used and urine transferred to the clean specimen jarRemove the clean specimen jar and allow patient to complete voiding (If a male is not circumcised ensure the patient’s foreskin is repositioned so as not left retracted)Ensure the lid of the specimen jar is firmly in place, being careful not to touch the inside of the container or lidDiscard waste as contaminated wasteEnsure patient comfortApply patient specimen label or label the specimen jar with the patient’s first and last names, UR number, date of birth, time, date and type of collection (MSU)Complete pathology request form with your signature, time, date and type of collection (MSU)Place specimen and pathology request form in zip lock bag, and send to Pathology Note: Specimens must be received within two hours of collectionRecord the relevant details in the patient's clinical record.Urine Specimen - Clean Catch Urine in non toilet trained children:Note: Clean catch urine collections are the preferred method of urine collection in non toilet trained children. Paediatric bag urine collections are not suitable for diagnostic testing. Cultures of urine obtained by bag have contamination rates of over 50%. As an alternative method of urine collection for diagnostic testing in non toilet trained children, a medical officer may perform supra pubic aspiration or request an in out catheter specimen.Don PPE (goggles and gloves)Remove nappyCleanse the genitalia and perineal area of the non toilet trained child with soap and water or normal salineAfter the flow of urine has started, the clean specimen jar is used to collect the ‘clean catch’ without contaminating the container. A sterile collecting dish can also be used and urine transferred slowly to the clean specimen jarEnsure the lid of the specimen jar is firmly in place, being careful not to touch the inside of the container or lidDiscard waste as contaminated wasteEnsure patient comfortReapply nappyApply patient specimen label or label the specimen jar with the patient’s first and last names, UR number, date of birth, time, date and type of collection (clean catch)Complete pathology request form with your signature, time, date and type of collection (clean catch)Place specimen and pathology request form in zip lock bag, and send to Pathology Note: Specimens must be received within two hours of collectionRecord the relevant details in the patient's clinical record.Note: Where repeat specimen collection is required, that is unrelated to ongoing diagnostic requirements, these are to be entered via RiskMan. Examples include spillage or incorrect labelling of specimens.Back to Table of Contents Urine Specimen – Catheter Specimen of Urine (CSU)To obtain a urine specimen via an existing urinary catheter, for the purpose of microbiological laboratory analysis. A Catheter Specimen of Urine (CSU) for diagnostic purposes is ordered by the medical officer.Alert: Where a patient has had a recent Prostatectomy; Removal/Exchange of IDC can only be on a written senior Medical Officer’s order.Note: If a CSU is required for the purpose of the diagnosis of a UTI and the catheter has been insitu for less than two weeks a urine specimen can be obtained by using the catheter sampling port. If the catheter has been insitu for greater than two weeks then a new catheter should be inserted before a specimen is obtained. Equipment PPE including clean gloves and gogglesClean Specimen Jar (yellow top)Alcohol swabs x twoSyringe 10ml (Slip Tip)ClampABHRProcedure Explain to the patient the reason for the test, the need to collect a urine specimen and gain consent from the patient to proceedCheck patient identification. Refer to: Patient identification and Pathology Specimen Labelling ProcedureEnsure privacyClamp the drainage bag collection tubing below the aspiration port for approximately 30 minutesAttend hand hygiene by either hand washing or using alcohol hand rubDon PPE (goggles and gloves)Disinfect the aspiration port on the catheter drainage bag with an alcohol swab, and allow to dryInsert syringe into the aspiration port. Note: Catheter bags contain needle free aspiration portsAspirate 10mL of urine. Note: for Paediatrics collect 2-5mL of urineWithdraw the syringeSlowly transfer the urine into clean specimen jar. A sterile collecting dish can also be used and urine transferred slowly to the clean specimen jarEnsure the lid of the specimen jar is firmly in place, being careful not to touch the inside of the container or lidDisinfect the aspiration port with an alcohol swab Unclamp the drainage bag collection tubingDiscard waste, as contaminated wasteEnsure patient comfortApply patient specimen label or label the specimen jar with the patient’s first and last names, UR number, date of birth, time, date and type of collection (CSU)Complete pathology request form with your signature, time, date and type of collection (CSU)Place specimen and pathology request form in plastic zip lock bag, and send to Pathology.Note: Specimens must be received by the laboratory within two hours of collectionRecord the relevant details in the patient's clinical record.Note: Where repeat specimen collection is required, that is unrelated to ongoing diagnostic requirements, these are to be entered via the RISKMAN reporting system. Examples include incorrect labeling of specimens.Back to Table of ContentsImplementation This procedure will be communicated to all staff via the clinical policy register and as a news item on the HUB.Back to Table of ContentsRelated Policies, Procedures, Guidelines and LegislationPolicies/ProceduresACT Health Infection Prevention and Control PolicyAseptic Non-Touch Technique.Consent and Treatment Policy and Procedure.Infection Control- Personal Protective Equipment ProcedureNursing and Midwifery Continuing Competence Policy Patient Identification and Procedure Matching Procedure. Patient Identification: Pathology Specimen Labelling Procedure. Waste Management Policy Back to Table of ContentsReferencesACT Health Urine Specimen; Midstream Specimen of Urine (MSSU) Female. Acute Care Practice Manual ?. The Joanna Briggs Institute, 2009.Al-Orifi F, McGillivray D, Tange S, Kramer MS. Urine culture from bag specimen in young children: Are the risks too high? Journal of Pediatrics, 2000. 137, 2, 221-226.Dolan J. Urologic Nursing:? Urine Specimen Collection Urol Nurs.; 33(5(:249-256) 2013. Greene L, Marx J, Oriola S. APIC Guide: Guide to the Elimination of Catheter-Associated Urinary Tract Infections (CAUTIs). 2008.Hand Hygiene Australia 5 Moments of Hand Washing S, Duell D & Martin B. Clinical Nursing Skills, 7th Edition, Pearson Education Inc, New Jersey, 2008.Toward Optimized Practice: Diagnosis and Management of Urinary Tract Infection in Long term Care Facilities;. 2015 Clinical Practice Guidelines.World Health Organisation (WHO) Guidelines on Hand Hygiene in Healthcare. to Table of ContentsSearch Terms UrineSpecimenUrinalysisUrination24 hour urine collectionLaboratoryPathologyBack to Table of ContentsDisclaimer: This document has been developed by Health Directorate, Canberra Hospital and Health Services specifically for its own use. Use of this document and any reliance on the information contained therein by any third party is at his or her own risk and Health Directorate assumes no responsibility whatsoever.Date AmendedSection AmendedApproved ByEg: 17 August 2014Section 1ED/CHHSPC Chair ................
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