The Royal Marsden Hospital Manual of Clinical Nursing Procedures - Lisa Dougherty [431]
Indications
Obtaining a urine specimen is indicated:
when there are clinical signs and symptoms to indicate an UTI
if there are signs of a systemic infection or in patients with a PUO
on development of new patient confusion as toxicity from infection can cause alterations in mental status or impairments in cognitive ability (Pellowe 2009).
Principles of care
Urine may be collected using a midstream clean-catch technique or from a catheter using a sterile syringe to access the sample port (Pellatt 2007a). To minimize the contamination of a specimen by bacteria, which may be present on the skin, the perianal region or the external genital tract, good hand and genital hygiene should be encouraged. Therefore, patients should be encouraged to wash their hands prior to collecting a clean-catch midstream urine specimen and to clean around the urethral meatus prior to sample collection (Higgins 2007). The principle for obtaining a midstream collection of urine is that any bacteria present in the urethra are washed away in the first portion of urine voided and therefore the specimen collected more accurately represents the urine in the bladder (Dawson and Whitfield 1996).
Catheter-associated urinary tract infections (CAUTI)
The presence of a urinary catheter, and the duration of its insertion, are contributory factors in the development of a UTI. Some 60% of healthcare-associated UTIs are related to catheter insertion (DH 2007b). For every day the catheter remains in situ, the risk of bacteriuria is 5% so that 50% of patients catheterized for longer than 7–10 days will have bacteriuria (Pellowe 2009). Although often asymptomatic, 20–30% of patients with bacteriuria will develop a CAUTI and 1–4% will develop a bacteraemia, which has significant implications for patient morbidity, increased hospital stay and increased cost (Pellowe 2009).
Preprocedural considerations
Equipment
Specimen jars for urine collection must be sterile to ensure no contamination occurs which may lead to an incorrect diagnosis and treatment. The jars must close securely to prevent leakage of the sample.
Specific patient preparations
When collecting a midstream specimen of urine (MSU), the patient must pass a small amount of urine before collecting the specimen. This reduces the risk of contamination of the specimen with naturally occurring micro-organisms/flora within the urethra (Rigby and Gray 2005).
Procedure guideline 11.13 Urine sampling: midstream specimen of urine: male
Essential equipment
Cleaning solution (e.g. soap and water, 0.9% sodium chloride or disinfectant-free solution)
Sterile specimen container (with wide opening)
Gloves
Apron
Appropriate documentation/forms
Preprocedure
Action Rationale
1 Discuss need and indication for procedure with patient. To obtain valid consent (NMC 2008b, C).
2 Fully explain the steps of the procedure. The procedure requires the patient to fully understand the procedure in order to avoid inadvertent contamination of specimen and optimize the quality of the sample (Higgins 2008, C).
3 Ensure a suitable, private location. To maintain patient privacy and dignity (Gilbert 2006, E).
Procedure
4 Ask patient to wash hands with soap and water. To reduce risk of cross-infection (DH 2007a, C).
5 If practitioner’s assistance required: wash hands with bactericidal soap or decontaminate physically clean hands with alcohol rub and don apron. To prevent cross-contamination (DH 2007a, C).
6 Ask patient to retract the foreskin and clean the skin surrounding the urethral meatus with soap and water, 0.9% sodium chloride or a disinfectant-free solution. To optimize general cleansing and minimize contamination of specimen with other organisms. E
Disinfectant solutions may irritate the urethral mucous membrane (Higgins 2007, E).
7 Ask patient to begin voiding first stream of urine (approx. 15–30 mL) into a urinal, toilet or bedpan. To commence the flow of urine and avoid contamination of specimen with naturally