2. CHAPTER © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47 Collecting, Processing, and Testing Urine Specimens

3. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-2 Learning Outcomes 47.1Describe the characteristics of urine, including its formation, physical composition, and chemical properties. 47.2Explain how to instruct patients in specimen collection. 47.3Identify guidelines to follow when collecting urine specimens. 47.4Describe proper procedures for collecting various urine specimens.

4. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-3 Learning Outcomes (cont.) 47.5Explain the process of urinary catheterization. 47.6List special considerations that may require you to alter guidelines when collecting urine specimens. 47.7Explain how to maintain the chain of custody when processing urine specimens. 47.8Explain how to preserve and store urine specimens.

5. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-4 Learning Outcomes (cont.) 47.9Describe the process of urinalysis and its purpose. 47.10Identify the physical characteristics present in normal urine specimens. 47.11Identify the chemicals that may be found in urine specimens. 47.12Identify the elements categorized and counted as a result of microscopic examination of urine specimens.

6. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-5 Introduction Routine analysis of a urine specimen –Noninvasive –Used to diagnose significant conditions Medical assistant –Learn about types of urine specimens –Instruct or assist patient in collection of a sample –Learn to process urine specimens –Learn about normal/abnormal components of urine

7. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-6 Role of the Medical Assistant Collect, process, and test urine samples Knowledge necessary –Anatomy and physiology of kidneys –How urine is formed –Normal components of urine

8. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-7 Role of the Medical Assistant Safety –Standard Precautions –PPE as needed –Handle and dispose of specimens properly –Dispose of used supplies and equipment properly –Sanitize, disinfect, and/or sterilize reusable equipment

9. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-8 Anatomy and Physiology of the Urinary System Organs –Kidneys – remove excess water and waste products –Ureters – drain urine into bladder –Bladder – stores urine –Urethra – drains urine to outside of the body

10. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-9 Formation of Urine Nephron –Functional unit of the kidney –Removes end products of metabolism –Allows for reabsorption of water and electrolytes –Maintains normal fluid balance Processes in urine formation –Glomerular filtration –Tubular reabsorption –Tubular secretion

11. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-10 Physical Composition and Chemical Properties of Urine 95% water 5% waste products Other dissolved chemicals –Urea –Uric acid –Ammonia –Calcium –Creatinine –Sodium –Chloride –Potassium –Sulfates –Phosphates Hydrogen ions Urochrome Urobilinogen A few RBCs A few WBCs

12. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-11 Apply Your Knowledge 1.What knowledge is needed by the medical assistant related to collecting, processing, and testing urine specimens? ANSWER: The medical assistant needs to know the anatomy and physiology of the urinary system, how urine is formed, and normal components of urine. 2.Components of normal urine include A. urea, uric acid, and ammonia. B. chloride, potassium, and sugar. C. red blood cells, sperm, and H 2 O 2 D. hydrogen ions, urochrome, and uranium. ANSWER:

13. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-12 Obtaining Specimens General collection guidelines –Follow the procedure for specified test –Use an appropriate specimen container –Label the specimen container correctly –Explain the procedure to patient –Wash your hands before and after the procedure; wear gloves during the procedure –Complete all necessary paperwork

14. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-13 Specimen Types Quantitative analysis – measures amount of a specific substance in the urine Qualitative analysis – simply determines if a substance is present in the urine Types vary in the method used to collect a specimen and in the time frame in which to collect a specimen

15. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-14 Specimen Types (cont.) Random urine specimen –Most common –Obtained any time during the day First morning specimen –Contains greater concentration of substances Clean-catch midstream –Used for culturing urine –External genitalia must be cleansed –Discard small amount of urine prior to collecting specimen –Can also obtain by catheterization

16. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-15 Specimen Types (cont.) Timed urine specimen –Discard first specimen –Collect all urine for specified time –Refrigerate 24-hour specimen –Collected as a timed specimen Both are used for qualitative and quantitative analysis

17. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-16 Catheterization Urinary catheter – a plastic tube inserted to provide urinary drainage Catheterization – procedure by which the catheter is inserted

18. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-17 Catheterization (cont.) Reasons for catheterization –Relieve urinary retention –Obtain a sterile urine specimen –Measure the amount of residual urine –Obtain a specimen if patient cannot void –Instill chemotherapy –Empty bladder before and during procedures

19. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-18 Catheterization (cont.) Drainage catheters –Indwelling urethral (Foley) catheter – bladder –Retention catheter – renal pelvis –Ureteral catheter – drainage through a wound into the bladder (cystostomy tube) –Straight catheter – bladder Splinting catheter – inserted after repair of ureter

20. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-19 Catheterization (cont.) Not a routine procedure due to risk of infection Not typically performed by medical assistants –Check scope of practice –Assemble supplies – catheterization kits

21. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-20 Special Considerations Male and female patients –Differences in collecting clean-catch midstream specimen –Questions during history Pregnant patients –Frequency –Prone to urinary tract infection –Urine checked for glucose and protein

22. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-21 Special Considerations (cont.) Elderly –Bladder muscles weaken –Uterine supports weaken – pulls on bladder –Loss of bladder control –May need assistance in obtaining a specimen –Repeat explanation as necessary Pediatric patients –Involve child if possible –Questions Diaper rash? Excessively thirsty? Difficulty urinating? Cry when urinating? How many diapers a day? Change in bladder control? Problems toilet training?

23. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-22 Establishing Chain of Custody Do not alter established procedure Positively identify patient Explain procedure and have patient sign a consent form Examine specimen and check temperature Complete documentation

24. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-23 Preservation and Storage Chemical, physical, and microscopic changes occur if urine is left at room temperature for more than 1 hour Preservation –Refrigeration Prevents growth for 24 hours Return to room temperature before testing –Chemical preservatives Specimens only

25. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-24 Apply Your Knowledge A patient has returned to the office and is complaining of not being able to empty her bladder fully after her hysterectomy. The physician has asked you measure the patient’s residual urine. How do you do this and why? ANSWER: A residual urine is done to measure the amount of urine in the bladder after voiding. You will ask the patient to empty her bladder and then perform a straight catheterization to measure any urine remaining in her bladder. Correct!

26. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-25 Urinalysis Evaluation of urine to obtain information about body health and disease Types of testing –Physical –Chemical –Microscopic

27. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-26 Urinalysis (cont.) Values –Negative or none, normal, or a range of concentration –Within normal limits indicate health and normality –Screening test – must have follow-up testing

28. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-27 Urinalysis (cont.) Average adult daily urine output is 1250 mL/24 hours Intake and output should be approximately the same Dysfunctions of other body systems can affect urinary function

29. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-28 Physical Examination and Testing of Urine Specimens Check label Check for visible contamination Check time since collection Visual examination –Color –Volume Normal Oliguria –Odor –Specific gravity

30. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-29 Physical Examination and Testing of Urine Specimens (cont.) Visual examination –Color/turbidity – pale yellow to dark amber; clear –Volume Normal range – 600–1800 mL/24 hours Oliguria – insufficient production of urine Anuria – absence of urine production

31. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-30 Physical Examination and Testing of Urine Specimens (cont.) –Odor Distinct, aromatic Standing at room temperature – ammonia Affected by disease and foods –Specific gravity 1.002 to 1.028 Fluctuates in response to fluid intake Methods –Refractometer –Reagent strips

32. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-31 Chemical Testing of Urine Specimens Check label on specimen Determine the status of –Carbohydrate metabolism –Liver or kidney function –Acid-base balance –Presence of drugs, toxins, or infections Reagent strip testing –Changes indicate presence of concentration of a substance –Follow instructions carefully

33. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-32 Chemical Testing of Urine Specimens (cont.) Ketone bodies –Normally none in urine –Presence Patient on a low- carbohydrate diet Starvation Excessive vomiting Diabetes mellitus pH –Normal 5.0 to 8.0 –Alkaline UTI Metabolic/ respiratory alkalosis –Acidic Phenylketonuria Acidosis

34. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-33 Chemical Testing of Urine Specimens (cont.) Blood –Hematuria Menstruation Infection Trauma –Hemoglobinuria – free hemoglobin in urine –Myoglobinuria Myoglobin in urine Injured or damaged muscles Bilirubin –From the breakdown of hemoglobin –Bilirubinuria – early sign of liver disease Urobilinogen –Elevated – increased RBC destruction –Lacking – bile duct obstruction

35. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-34 Chemical Testing of Urine Specimens (cont.) Glucose –Normally in small amounts –Glycosuria – diabetes Protein –Excess – renal disease –Proteinuria – common in pregnancy and after heavy exercise

36. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-35 Chemical Testing of Urine Specimens (cont.) Nitrite – suggests bacterial infection Leukocytes – urinary tract or renal infection Phenylketones –Presence indicates phenylketonuria (PKU) – genetic disorder –Blood testing is more routine for newborns

37. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-36 Chemical Testing of Urine Specimens (cont.) Pregnancy test –Detect human chorionic gonadotropin (HCG) Peak at 8 weeks Quick, easy to perform and interpret –Enzyme immunoassay (EIA) Newer technology Antigen/antibody reaction

38. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-37 Chemical Testing of Urine Specimens (cont.) Presence of STDs –Screening for chlamydia – 15- to 25-year-old sexually active females –Nucleic acid amplification tests (NAATs) Detect nucleic acid in urine Chlamydia and gonorrhea Advantage – highly specific, non-invasive Disadvantage – expensive, no organism remains for culture

39. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-38 Microscopic Examination of Urine Specimens View elements only visible with microscope Centrifuge –Obtain sediment –Spins fluid – heavier substances settle to the bottom of the tubes

40. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-39 Microscopic Examination of Urine Specimens (cont.) Cells –Epithelial cells –White blood cells –Red blood cells Casts –Cylindrical elements –Types Hyaline Granular RBC casts WBC casts Epithelial cell casts Waxy

41. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-40 Microscopic Examination of Urine Specimens (cont.) Crystals –Naturally produced solids of definite form –Common in urine –Determine pH before testing Yeast cells –May be confused with RBCs –Associated with genitourinary tract infection, diabetes

42. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-41 Microscopic Examination of Urine Specimens (cont.) Bacteria –A few are normal –Infection if urine also has Putrid odor WBCs Parasites –Infection or contamination –Trichomonas vaginalis – most common

43. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-42 Apply Your Knowledge 1. What is the specific gravity shown on this refractometer screen? ANSWER: The specific gravity shown here is 1.030.

44. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-43 Apply Your Knowledge 2. A urinalysis has detected that a patient has protein in his urine. Why is this important? ANSWER: Protein in the urine usually indicates renal disease.

45. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-44 In Summary 47.1Urine is formed during a filtration process that occurs in the nephron. It is made up of 95% water and 5% waste products and other dissolved chemicals, including urea, uric acid, ammonia, calcium, creatinine, sodium, chloride, potassium, sulfates, phosphates, bicarbonates, hydrogen ions, urochrome, urobilinogen, a few red blood cells, and a few white blood cells.

46. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-45 In Summary (cont.) 47.2Instructions for obtaining specific types of specimens will vary according to the test. The general instructions for urine specimen collection are: urinate into the container indicated by the laboratory; if the collection container contains liquid or powdered preservative, do not pour it out; always refrigerate the labeled collection container or keep it in a cooler or pail filled with ice; be sure to keep the lid on the container.

47. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-46 In Summary (cont.) 47.3The general guidelines for collecting a urine specimen include: follow the procedure that is specified for the urine test that will be performed; use the type of specimen container indicated by the laboratory; properly label the specimen container; explain the procedure to the patient when assisting in the collection process; wash your hands before and after the procedure and wear gloves during the procedure; and complete all necessary paperwork.

48. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-47 In Summary (cont.) 47.4Several types of urine specimens are collected in the medical office. Each specimen has a slightly different collection method. The various specimens include random, first morning, clean-catch midstream, timed, and 24-hour. 47.5Urinary catheterization involves inserting a plastic drainage tube into the kidney, the ureter, or the bladder. 47.6When the medical assistant obtains a urine specimen from a patient or takes a history of a patient who may have a urinary problem, she or he needs to consider the patient’s sex, condition, and age.

49. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-48 In Summary (cont.) 47.7When collecting a chain-of-custody specimen, the following safeguards should be used: positively identify the donor; have the donor remove outer clothing and empty pockets, displaying all items; add bluing agent to the water in the toilet and turn off other water sources; remain by the door while the specimen is being obtained; measure and record the temperature of the specimen within four minutes; have the donor witness the specimen transfer; complete additional information on the form; sign the CCF; give a copy of the CCF to the donor; place the specimen in a leak-proof bag with a copy of the form; and release the specimen to the courier service.

50. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-49 In Summary (cont.) 47.8Proper preservation and storage of specimens are essential. A specimen should not be left unpreserved for more than 1 hour. Refrigerate a specimen if it cannot be tested within an hour. Bring the specimen back to room temperature before testing. 47.9Urinalysis is the evaluation of urine by various types of testing methods to obtain information about body health and disease.

51. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-50 In Summary (cont.) 47.10The physical characteristics of normal urine include color and turbidity, volume, odor, and specific gravity. 47.11The chemicals that may be found in urine specimens include ketones, nitrite, bilirubin, glucose, and protein. 47.12During microscopic urine examination, elements that are categorized and counted include the cells, casts, crystals, yeast, bacteria, and parasites.

52. © 2011 The McGraw-Hill Companies, Inc. All rights reserved. 47-51 End of Chapter 47 A human being: an ingenious assembly of portable plumbing. ~ Christopher Morley, 1890-1957