Collection of Specimen And Nursing responsibilities

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• Many of the specimens needed for diagnostic examination of children are collected in much the same way as for adult.

• Older children are able to cooperate if given proper instruction regarding what is expected of them.

• Infants and small children are unable to follow directions and control body functions to help in collecting the specimens


Collection of Urine Specimen

• For infants and toddlers who are not toilet trained special urine collection devices are used. It is a clear plastic single use bags with self adhering material around the opening at the point of attachment.

• Older children will readily use the bedpan or urinal or can be trusted to follow directions for collection in the bathroom

• Children will better understand what is expected if the nurse uses the familiar terms

 

Other Types of urine Specimens

• From disposable diapers.

• Cellophane diaper.

• Clean catch specimens

• Twenty four hours collections

• Bladder catheterization

• Suprapubic aspiration

 

Techniques of Collection of Urine Specimen

• Clean catch urine in older children: Clean perineum in females and tip of penis in males using soap and antiseptic solution. In females perineum is wiped with a soaked cotton ball from front to back at least 3 times using a new cotton ball each time.

• The area is wiped with cotton ball soaked with sterile water to prevent contamination of urine with the antiseptic solution used for cleaning.

 

Urine collection bag

• Infants and toddlers : Use disposable urine collection bag.

Procedure: Wash and dry the genitalia, perineum and surrounding skin. Fix the bag first to the perineum and progress to the symphysis pubis. In little girls the perineum is stretched taut during application to that area to prevent leaking. For small boys place penis and scrotum inside the bag. Fix the adhesive portion well around the skin.

• Wipe the infant’s abdomen with alcohol and fan it dry. The cooling effect stimulates voiding in 2 minutes.

• Apply pressure over the suprapubic area or stroke the paraspinal muscles (along the spine) to elicit perez reflex resulting in urination.

• To get small amount of urine place some cotton balls inside the diaper and aspirate from it using a syringe without needle. This sample can be used for glucose, ketones, proteins, urea, pH and blood.

 

Suprapubic aspiration and bladder catheterization

• These techniques are used to obtain sterile urine sample from infants.

• Suprapubic aspiration: Bladder contents are aspirated by inserting a 20 or 21 G needle. Make sure the infant has not voided for at least 1 h. Clean the skin with an antiseptic. Palpate the bladder over the symphysis pubis and insert the needle.

• Catheterization: Catheterization is more frequently done now a days with small size (5 & 6 French) catheters to get sterile urine samples.

 

24 Hour Urine Collection

• Decide on the day and time to start the collection: Write on the bottle the date and time the collection is started.

• Starting the collection: Ask the child to empty bladder and discard the urine into the toilet. All urine passed in the next 24 hour period should be passed into the bottle. Collect all the urine for an entire 24 hour period, for example if the collection started at 8am on Sunday, then finish at 8am on Monday.

• Keep the bottle next to the toilet and on the toilet door to prevent the child forgetting.

• Exactly 24 hour after the collection started, ask the child to empty bladder, add this into the container, note this time on the container and ensure that the bottle is securely closed. 

• In case of infants and small children catheterization is needed to collect the 24 h sample.

 

After The Procedure

• Wash hands and dispose equipments.

• Record: Time specimen was collected

• Color of urine (cloudy, clear, any sediment) and consistency of stool (note any foul smell)

• Amount of urine voided

• Nature of the test which the specimen was collected

• Condition of the skin

 

Stool Specimens

• Stool specimens are frequently collected in children to identify parasites and other organisms that cause diarrhea to assess gastrointestinal function and to check for occult hidden blood

• It should be collected with out contamination with urine

• Investigations

– Routine and microscopy (For parasite and ova)

– Culture and sensitivity

– Occult blood

– pH (in watery diarrhea)

Collection

• From small infants collect from diaper after applying a urine collection bag.

•Toilet trained child: Make the child void first and then pass stool into a potty chair or bedpan.

 

Nursing Responsibilities

• Wash hands

• Prepare the needed equipments.( waxed jar with cover, tongue blade, label)

• Explain the procedure to the child or his/her parent.

• Provide privacy by closed curtains around the bed.

• Label the specimen and send it to the lab. Immediately. Label should include: – child’s name, Hospital number, pediatric unit, diagnosis, type of analysis required, and date and time of collection

 

After The Procedure

• Wash hands and dispose equipments.

• Record: Time specimen was collected

• Color , amount and consistency of stool (note any foul smell)

• Nature of the test which the specimen was collected

 

Blood Specimens

• The nurses are responsible for making certain that specimens are collected on time and properly

• Venous blood samples can be obtained by vein puncture or by aspiration from a peripheral or central access device

• Arterial blood samples are sometimes needed for blood gas measurements. It can be obtained by arterial puncture or from indwelling arterial catheters

• Capillary blood samples are taken from children by finger or earlobe puncture, as in adult

• For infant it can be obtained a heal stick

 

Equipment for blood sample drawing

• needles (preferably vacutainer needles), size 22G to 24G

• tubes

• tourniquet

• disinfection swabs

• micropore tape

• adhesive dressing

• rubber gloves

• pillow or other support

• separate stoppers for opened vacuum tubes and non-vacuum tubes

• needle disposal box

 

Nursing Responsibilities for blood sample drawing

Getting Ready

• Wash hands

• Prepare the needed equipments in an area not visible to the child. (23or 25 gauge butterfly catheter, gloves, alcohol swabs or pads, syringe, labels, tourniquet, collection container, and requisition form.

• Explain procedure to mother /child.

During The Procedure

• Select the venipencture site, the antecubital vein is commonly used for venipuncture in children.

•  Position and restrain the child according to his age and the venipencture site.

• Wear gloves and apply a tourniquet tight enough. A tourniquet should be left in place no longer than 2 minutes.

• Lightly pat or rub the sample site.

• Clean the site with alcohol using a circular motion, and allow drying.

• If the child is immunocompromised, use povidone-iodine (Betadine).

• Insert the needle of the butterfly catheter into the vein, beveled side up.

• When blood begins to the temptation to place the syringe on the end of the catheter attempt to speed up the blood flow by pulling back the plunger.

• Wait until the blood reaches the end of the catheter ,attach the syringe, and slowly draw the appropriate amount of blood into the syringe.

• After obtaining the required amount of blood, release the tourniquet, withdraw the needle, and apply pressure to the puncture site.

• Fill the appropriate specimen tubes or containers. Be sure to dispose of needles and apply pressure to the site.

• Comfort the child, and offer praise for cooperation.

• Adhesive bandages can be use to prevent bleeding from the puncture site.

• Label the specimen bottle and send it to the lab. Immediately. Label should include: – patient’s name pediatric unit, diagnosis, the site of puncture & type of analysis required.

 

LABELING THE SAMPLE

• A properly labeled sample is essential so that the results of the test match the patient. The key elements in labeling are:

– Patient’s surname, first and middle.

– Patient’s ID number.

– NOTE: Both of the above MUST match the same on the requisition form.

– Date and time

 

After The Procedure

• Wash hands and dispose equipments.

Record: The amount of blood collected, The site of puncture, Type of analysis required Reaction of the child

 

Contents of tubes

• The substances may include anticoagulants (EDTA, lithium citrate or heparin)

• A gel with intermediate density between blood cells and blood plasma. The gel enables the tube to be tipped upside-down, and transported without the blood cells remixing with the plasma.

 

Containers containing coagulants

Gold – A serum separating tube (SST). These contain particles that cause blood to clot quickly, as well as a gel to separate blood cells from serum. (Because the blood has clotted before it has been centrifuged, the liquid part is called serum not plasma.)

Orange – These tubes contain thrombin which makes the blood clot extremely rapid. This allows the serum to be analysed in a shorter time.

 

Containers containing anticoagulants

Green – Contains the lithium salt of heparin.

Purple or lavender – contains EDTA. Usually used for CBC and blood films. Can also be used for blood bank.

Grey – These tubes contain flouride and oxalate. Fluoride prevents enzymes in the blood from working, the glucose will not be gradually used up during storage. Oxalate is an anticoagulant. For blood sugar.

Light blue – Contain a measured amount of citrate. Citrate is a reversible anticoagulant, and these tubes are used for coagulation assays. Because the liquid citrate dilutes the blood, it is important the tube is full so the dilution is properly accounted for. Used for PT, PTT

Dark Blue – Contains the sodium salt of heparin, an anticoagulant. Also can contain EDTA as an additive or have no additive. These tubes are used for trace metal analysis.

Pink – Similar to purple tubes (both contain EDTA) these are used for ABO grouping and cross matching.

Red – Contains no additives. Tests for antibodies and drugs often require these.

Light yellow – Used in HLA antigen phenotyping. Also contains SPS, used for blood cultures.

Speckled top — no anticoagulant. Also called a "tiger top" tube. Contains clot activator.

 

ORDER OF DRAW

• Blood collection tubes must be drawn in a specific order to avoid cross-contamination of additives between tubes. The recommended order of draw is:

• First – blood culture tube (yellow-black stopper)

• Second – non-additive tube (red stopper or SST)

• Third – coagulation tube (light blue stopper). If just a routine coagulation assay is the only test ordered, then a single light blue stopper tube may be drawn. If there is a concern regarding contamination by tissue fluids or thromboplastins, then one may draw a non-additive tube first, and then the light blue stopper tube.

• Last draw – additive tubes in this order:

– SST (red-gray, or gold, stopper). Contains a gel separator and clot activator.

– Sodium heparin (dark green stopper)

– PST (light green stopper). Contains lithium heparin anticoagulant and a gel separator.

– EDTA (lavender stopper)

– ACDA or ACDB (pale yellow stopper). Contains acid citrate dextrose.

– Oxalate/fluoride (light gray stopper)

NOTE: Tubes with additives must be thoroughly mixed. Erroneous test results may be obtained when the blood is not thoroughly mixed with the additive.

 

SAFETY AND INFECTION CONTROL

• Because of contacts with sick patients and their specimens, it is important to follow safety and infection control procedures.

• PROTECT YOURSELF

– Practice universal precautions:

– Wear gloves and a lab coat or gown when handling blood/body fluids.

– Change gloves after each patient or when contaminated.

– Wash hands frequently.

– Dispose of items in appropriate containers.

– Dispose of needles immediately upon removal from the patient’s vein. Do not bend, break, recap, or resheath needles to avoid accidental needle puncture or splashing of contents.

– Clean up any blood spills with a disinfectant such as freshly made 10% bleach.

• PROTECT THE PATIENT

– Place blood collection equipment away from patients, especially children and psychiatric patients.

– Practice hygiene for the patient’s protection. When wearing gloves, change them between each patient and wash your hands frequently.

 

If you stick yourself with a  contaminated needle

• Remove your gloves and dispose of them properly.

• Squeeze puncture site to promote bleeding.

• Wash the area well with soap and water.

• Record the patient’s name and ID number.

• Follow institution’s guidelines regarding treatment and follow-up.

 

COLLECTION OF CAPILLARY BLOOD SPECIMENS

Nursing Responsibilities

• Wash hands

• Prepare the needed equipments .(disposable lancets or microlaricet, alcohol swabs, sterile gauze pads, gloves, warm washcloth, specimen container, labels, requisition forms

• Prepare the child using age- appropriate language.

• Select the site of capillary puncture, heel for infant under 2 years of age. Finger for older children

 

During The Procedure

• Warm the site before proceeding using the warm washcloth.

• Wear gloves.

• Cleanse the site of puncture with the across the fingerprint halfway, between the center of the ball of the finger and its side, use the third, or ring finger of the non-dominant hand.( don’t use a bruised , edematous or abraded finger and avoid any the previously used site.

• If using the heel

• Cleanse the heel with antiseptic solution and dry

• Encircle the heel with the thumb and index finger and blood is ‘milked’ centrally by gentle squeezing with the rest of the hand, the heel will appear ‘flushed’ when ready for capillary puncture

• Grasp a lancet firmly and introduce through the skin into the subcutaneous tissue and quickly remove from incision.

• Grasp a lancet firmly and introduce through the skin into the subcutaneous tissue and quickly remove from incision.

• Blot of the first drop of blood with a sterile gauze pad.

• Collect the blood into the capillary tube or container.

• Press the dry sterile gauze over the incision and hold firmly 2-3 minutes.

• Label the specimen with the child’s name, and send it to the lab. Immediately.

After The Procedure

• Wash hands and dispose equipments

Record: The amount of blood collected, The site of puncture, Type of analysis required Reaction of the child

 

COLLECTION OF SPUTUM SPECIMENS

Getting Ready

• Wash hands

• Prepare equipment needed (sterile waxed jar with cover or sterile test tube, cotton applicator in case of the young child.

• Explain procedure to the child and or his parent.

During The Procedure

• From a young child, when sputum is coughed up,

• Wipe the sputum with cotton applicator

• Dropped cotton applicator into a clean test tube

• Close the test tube with a cotton plug

 

From the older child

•  The child’s mouth is rinsed early in the morning

•Wash hands

• Allow child to cough deeply and expectorate his sputum into waxed jar and cover it. Not to get saliva

• Label the specimen with the child’s name, and send it to the lab. immediately

After The Procedure

• Wash hands and dispose equipments.

Record: The amount of the sputum Characteristics as color Reaction of the child

 

Throat swab

Equipment

• Tongue depressor

• 1 transport swab (blue top)

Specimen Collection

• Check the patient has not recently used an antiseptic mouthwash or lozenge. Mouth rinsing with water may be necessary before swabbing.

• Label the transport swab with the patient’s full name, age, Hospital number, date, time and site of collection.

• Using a tongue depressor, view the area to be swabbed (tonsillar surface and posterior pharyngeal wall).

• Areas of exudation, membrane formation or inflammation are preferred. All other areas should be avoided, including the tongue and teeth when withdrawing the swab.

• Firmly swab using the transport swab. Place the swab in transport medium.

• No slide/smear is necessary.

• State “throat swab” on the request slip and on the specimen.

• Store the swab in transport medium and deliver promptly to the laboratory (store at room temperature).

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Sputum collection

• If the child is unable to cough out sputum obtain a gastric washing (lavage).

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