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Mar.26.2020

Elsevier Clinical Skills

Specimen Collection: Nose and Throat (Home Health Care) - CE

ALERT

Don appropriate personal protective equipment (PPE) based on the patient’s signs and symptoms and indications for isolation precautions.

Do not attempt to collect a throat specimen for culture if acute epiglottitis is suspected because trauma from the swab may cause increased edema resulting in airway occlusion.3

Collect oropharyngeal and nasopharyngeal specimens within 3 days of symptom onset if possible but no later than 7 days of symptom onset and before the start of antimicrobial therapy.1

OVERVIEW

A nose-throat swab specimen is used to detect pathogenic microorganisms in the nose and throat. To determine the degree of infection, laboratory personnel place the specimen on a culture medium and determine if pathogenic organisms grow.

Pathogenic organisms that may be identified by this culture include group A beta-hemolytic streptococci, Bordetella pertussis, Corynebacterium diphtheriae, and Staphylococcus aureus. Other organisms, including Haemophilus influenzae, Streptococcus pneumoniae, and Candida albicans, are considered abnormal if found in large amounts. The culture results help determine which antibiotic therapy is appropriate.

A nose-throat swab may cause discomfort to sensitive mucosal membranes. Collecting a throat specimen for culture sometimes causes gagging. The patient’s clear understanding of the specimen collection techniques may minimize anxiety or discomfort. Nasal washing may provide an effective, more comfortable alternative to swabbing, when necessary.

SUPPLIES

Click here for a list of supplies.

EDUCATION

  • Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
  • Explain to the patient, family, and caregivers that the procedure is painless and lasts only a few seconds.
  • Explain that obtaining a throat specimen may cause a tickling sensation or gagging and that obtaining a nasal specimen may cause an urge to sneeze.
  • Discuss the patient’s role in collecting the specimen.
  • Explain how and why the specimen is being collected.
  • Discuss the relationship between the culture results and the medication prescribed.
  • Discuss the reason for the time delay in receiving culture results.
  • Encourage questions and answer them as they arise.

PROCEDURE

  1. Perform hand hygiene and don gloves and appropriate PPE based on the patient’s signs and symptoms and indications for isolation precautions.
  2. Introduce yourself to the patient, family, and caregivers.
  3. Verify the correct patient using two identifiers.
  4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
  5. Verify the practitioner’s order and assess the patient for pain.
  6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
  7. Assess the patient’s understanding of the purpose of the procedure and his or her ability to cooperate.
  8. Assess the nasal mucosa and sinuses and observe for any drainage.
  9. Determine if the patient experiences postnasal drip, sinus headache or tenderness, nasal congestion, or sore throat or if he or she has been exposed to others with similar symptoms.
  10. Assess the condition of the posterior pharynx.
  11. Assess the patient for systemic signs of infection (e.g., fever, chills, fatigue).
  12. Review the practitioner’s orders to determine if a nasal specimen, throat specimen, or both are needed.

Collecting a Throat Specimen for Culture

  1. Plan to collect the specimen before mealtime to avoid contamination.
  2. Obtain assistance for collecting throat specimens from confused or combative patients.
  3. Have the swab and the culture tube ready for use. If using a prepackaged culture swab in a tube, loosen the top so that the swab can be removed easily.
    Rationale: Having the swab and the culture tube ready allows the nurse to grasp the swab easily without danger of contamination.
  4. Instruct the patient to sit erect in bed or in a chair. Face the patient.
  5. Instruct the patient to tilt the head back. If the patient is in bed, place a pillow behind the shoulders.
  6. Ask the patient to open his or her mouth and say “ah.”
  7. Depress the anterior third of the tongue with a tongue blade and observe for any inflamed areas of the pharynx or tonsils. Illuminate the area with a penlight as needed.
    Rationale: Depressing the tongue permits exposure of the pharynx, relaxes throat muscles, and minimizes the gag reflex. The area to be swabbed should be clearly seen.
    Do not place the tongue blade along the back of the tongue; doing so is likely to initiate the gag reflex. If the patient gags, remove the tongue blade and allow him or her to relax before reinserting it.
  8. Insert the swab without touching the lips, teeth, tongue, cheeks, or uvula (Figure 1)Figure 1.
    Rationale: Touching the lips, teeth, tongue, cheeks, or uvula with the swab may cause contamination with organisms from the oral cavity.
  9. Gently but quickly swab the tonsillar area from side to side, contacting any inflamed or purulent sites.
    Rationale: The inflamed or purulent sites in the tonsillar area contain the most microorganisms.
  10. Carefully withdraw the swab without touching the oral structures.
  11. Insert the swab into the culture tube and push the tip into the liquid medium at the bottom of the tube (Figure 2)Figure 2.
    Rationale: Mixing the swab tip with the culture medium helps ensure live bacteria for testing.
  12. Place the top securely on the culture tube.
  13. In the presence of the patient, label the specimen per the organization’s practice.2
  14. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
  15. Check the patient’s throat for evidence of trauma, such as bleeding.
  16. Check the laboratory record for culture results.
  17. Report unusual test results to the practitioner.
  18. Assess pain, treat if necessary, and reassess.
  19. Discard or store supplies, remove PPE, and perform hand hygiene.
  20. Document the procedure in the patient’s record.

Collecting a Nasal Specimen for Culture

  1. Have the swab and the culture tube ready for use. If using a prepackaged culture swab in a tube, loosen the top so that the swab can be removed easily.
    Rationale: Having the swab and the culture tube ready allows the nurse to grasp the swab easily without danger of contamination.
  2. Instruct the patient to sit erect in bed or in a chair. Face the patient.
  3. Ask the patient to occlude each naris and exhale.
    Rationale: As the patient breathes through each open naris, the nurse determines the naris with the greater patency.
  4. Position the patient with the head back and use a penlight to check the nasal passages for patency. If the patient is in bed, place a pillow behind the shoulders.
  5. Carefully insert the swab into the naris until it reaches the portion of mucosa that is inflamed or contains exudate. Rotate the swab quickly.
    Rationale: The swab should remain sterile until it reaches the area to be cultured. Rotating the swab ensures that it touches all surfaces where exudate is present.
  6. Remove the swab without touching the sides of the nose.
    Rationale: Avoiding contact with the sides of the nose prevents contaminating the swab with resident bacteria.
  7. Insert the swab into the culture tube and push the tip into the liquid medium at the bottom of the tube (Figure 2)Figure 2.
    Rationale: Mixing the swab tip with culture medium helps ensure live bacteria for testing.
  8. Place the top securely on the culture tube.
  9. Offer the patient a facial tissue to blow his or her nose if needed.
  10. In the presence of the patient, label the specimen per the organization’s practice.2
  11. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
  12. Check the patient’s nares for evidence of trauma, such as bleeding.
  13. Check the laboratory record for culture results.
  14. Report unusual test results to the practitioner.
  15. Assess pain, treat if necessary, and reassess.
  16. Discard or store supplies, remove PPE, and perform hand hygiene.
  17. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen for Culture: Swab Method

  1. Have the nasopharyngeal swab (on flexible wire) and the culture tube ready for use. If using a prepackaged culture swab in a tube, loosen the top so that the swab can be removed easily.
    Rationale: Having the swab and the culture tube ready allows the nurse to grasp the swab easily without danger of contamination. Using a specially designed nasopharyngeal swab allows access to the difficult to reach nasopharyngeal area.
  2. Instruct the patient to sit erect in bed or in a chair. Face the patient.
  3. Gently advance the swab to the nasopharynx until resistance is met.
  4. Roll the swab and allow it to remain in place for several seconds.
    Rationale: Leaving the swab tip in contact with the nasopharynx facilitates absorption of fluid into the swab.
  5. Insert the swab into the culture tube and push the tip into the liquid medium at the bottom of the tube (Figure 2)Figure 2.
    Rationale: Mixing the swab tip with the culture medium helps ensure live bacteria for testing.
  6. Place the top securely on the culture tube.
  7. Offer the patient a facial tissue to blow his or her nose if needed.
  8. In the presence of the patient, label the specimen per the organization’s practice.2
  9. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
  10. Check the patient’s nasal passage for evidence of trauma, such as bleeding.
  11. Check the laboratory record for culture results.
  12. Report unusual test results to the practitioner.
  13. Assess pain, treat if necessary, and reassess.
  14. Discard or store supplies, remove PPE, and perform hand hygiene.
  15. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen for Culture: Wash Method with Suction

  1. Instruct the patient to sit erect in bed or in a chair. Face the patient.
  2. If suction equipment is available, attach the suction catheter to the suction specimen trap. Attach the specimen trap to the suction connecting tubing and adjust the suction.
  3. Draw up 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into a 3-ml syringe.1
  4. Instruct the patient to tilt his or her head back. If the patient is in bed, place a pillow behind the shoulders.
  5. Using the syringe, inject 1 to 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into each naris.1
  6. Insert the suction catheter into the naris and suction secretions.
  7. Repeat the procedure for the other naris per the practitioner’s order.
  8. Remove the specimen trap from the suction tubing and secure the ends per the manufacturer’s instructions.
  9. Offer the patient a facial tissue to blow his or her nose if needed.
  10. In the presence of the patient, label the specimen per the organization’s practice.2
  11. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
  12. Check the patient’s nasal passage for evidence of trauma, such as bleeding.
  13. Check the laboratory record for culture results.
  14. Report unusual test results to the practitioner.
  15. Assess pain, treat if necessary, and reassess.
  16. Discard or store supplies, remove PPE, and perform hand hygiene.
  17. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

  • Cultures do not reveal bacterial growth.
  • Patient does not experience bleeding of nasal mucosa.
  • Specimen is not contaminated.
  • Patient understands purpose of collection of nose and throat specimens for culture.

UNEXPECTED OUTCOMES

  • Cultures reveal pathogen growth.
  • Patient experiences nasal bleeding.
  • Patient experiences throat trauma.
  • Specimen is contaminated by adjacent skin or tissue.

DOCUMENTATION

  • Type, date, time, and disposition of specimen
  • Appearance of nasal and oral mucosal structures
  • Patient’s tolerance of procedure
  • Unexpected outcomes and related interventions
  • Education
  • Patient’s progress toward goals
  • Assessment of pain, treatment if necessary, and reassessment

OLDER ADULT CONSIDERATIONS

  • Some older adults need help keeping the mouth open during specimen collection.
  • Some older adults have poor dentition. Caution should be used to not break a tooth. Denture removal should be considered, when appropriate.
  • If the patient is confused, someone may need to hold his or her hands while the specimen is collected.

REFERENCES

  1. Centers for Disease Control and Prevention (CDC). (2020). Unexplained respiratory disease outbreaks (URDO): Specimen collection and handling. Retrieved March 24, 2020, from https://www.cdc.gov/urdo/specimen.html (Level VII)
  2. Joint Commission, The. (2020). National patient safety goals. Home care accreditation program. Retrieved March 24, 2020, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/npsg_chapter_ome_jan2020.pdf (Level VII)
  3. Sokolovs, D., Tan, K.W. (2017). Ear, nose and throat emergencies. Anaesthesia and Intensive Care Medicine, 18(4), 190-194. doi:10.1016/j.mpaic.2017.01.004

ADDITIONAL READINGS

Gomez, S., Prieto, C., Folgueira, L. (2016). A prospective study to assess the diagnostic performance of the Sofia® Immunoassay for influenza and RSV detection. Journal of Clinical Virology, 77, 1-4. doi:10.1016/j.jcv.2016.01.018

Elsevier Skills Levels of Evidence

  • Level I - Systematic review of all relevant randomized controlled trials
  • Level II - At least one well-designed randomized controlled trial
  • Level III - Well-designed controlled trials without randomization
  • Level IV - Well-designed case-controlled or cohort studies
  • Level V - Descriptive or qualitative studies
  • Level VI - Single descriptive or qualitative study
  • Level VII - Authority opinion or expert committee reports

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