Nonblood Body-Fluid Specimens

Urine
• most frequently analyzed nonblood body fluid
• readily available, easy to collect, and generally inexpensive to test
• Its analysis can provide information on many of the body's major metabolic functions.
• Analysis of urine can aid in monitoring wellness, the diagnosis and treatment of urinary tract
infections, the detection and monitoring of metabolic disease, and determining the
effectiveness or complications of therapy.
• Inpatient urine specimen collection is typically handled by nursing personnel.
• Outpatient urine specimen collection is often handled by phlebotomists, and should be
instructed correctly for the procedures.

Common Urine Tests

Routine Urinalysis (UA)

• the most commonly requested urine test because it screens for urinary and systemic disorders.
• A routine UA typically includes physical, chemical, and microscopic analysis of the urine
specimen.

1. Physical analysis
a) macroscopic observation and notation of color, clarity, and odor,
b) measurements of volume
c) specific gravity or osmolality

2. Chemical analysis
1. Can detect bacteria, bilirubin, blood (red blood cells and hemoglobin),
glucose, ketones, leukocytes, nitrite, protein, and urobilinogen, and
measure pH and specific gravity.
2. Commonly performed using a plastic reagent strip (often called a
dipstick) that contains pads impregnated with test reagents.
3. The strip is dipped into the urine and color reactions that take place
on the pads are compared to a color chart, which is usually found on
the label of the reagent strip container.
4. Special timing, which is not the same for all tests, is involved in reading
the results, which are reported in the manner indicated on the color chart.
Urine Culture and Sensitivity

➢ A urine culture and sensitivity (C&S) test may be requested on a patient with symptoms of
urinary tract infection (UTI).
➢ involves placing a measured portion of urine on a special nutrient medium that encourages the
growth of microorganisms, incubating it for 18 to 24 hours, checking it for growth, and
identifying any microorganisms that grow.
➢ Urine must be collected in a sterile container, following midstream cleancatch procedures to
ensure that the specimen is free of contaminating matter from the external genital areas

Urine Cytology Studies

➢ Cytology studies are performed to detect cancer, cytomegalovirus, and other viral and
inflammatory diseases of the bladder and other structures of the urinary system.
➢ Prepared from urinary sediment or filtrate.
➢ The smear is stained by the Papanicolaou (PAP) method and examined under a microscope for
the presence of abnormal cells.
➢ A fresh clean-catch specimen is required for the test.
➢ If a delay is unavoidable, the specimen can be preserved by the addition of an equal volume of
50% alcohol.

Urine Drug Specimen

➢ is performed to detect illicit use of recreational drugs, use of anabolic steroids to enhance
performance in sports, and unwarranted use of prescription drugs.
➢ it is also used to monitor therapeutic drug use in order to minimize withdrawal symptoms and
to confirm a diagnosis of drug overdose.
➢ A random sample in a chemically clean, covered container is required for the test.
➢ Specimens containing blood cells or having a high or low urine pH or a low specific gravity will
yield erroneous results and will require recollection of the specimen.

Other Urine Tests

➢ Numerous chemistry tests-including electrophoresis, tests for heavy metals, myoglobin

clearance, creatinine clearance, and porphyrins.
➢ Many of these tests require a pooled timed specimen, such as a 24-hour collection.

Types of Urine Specimens

1. Random
➢ Can be collected at any time.
➢ They are used primarily for routine urinalysis and screening tests. Random refers only to the
timing of the specimen and not the method of collection.

2. First Morning Urine/8-Hour Specimen

➢ Also called a first voided, overnight, or early morning specimen) is usually collected
immediately upon awakening in the morning after approximately 8 hours of sleep.
 ➢ This type of specimen normally has a higher specific gravity, which means that it is more
concentrated than a random specimen.
➢ Are often requested to confirm results of random specimens and specimens with low
specific gravity.
3. Fasting
➢ Typically used for glucose monitoring.
➢ It differs from a first morning specimen in that the specimen is the second specimen voided
after a period of fasting.
➢ This helps assure that the specimen will not be affected by food consumed prior to fasting.
4. Timed
➢ Some tests require individual urine specimens collected at specific times. Others require the
➢ collection and pooling of urine throughout a specific time period.

a. Tolerance Test Specimen

➢ Typically require collection of urine at specific times.
➢ The traditional standard glucose tolerance test (GTT) requires individual urine
specimens collected serially at specific times that correspond with the timing of
blood collection, such as fasting, 1/2-hour, 1 hour, and so on.
➢ Timing of the specimens is important in the interpretation of test results.
➢ For this reason, the specimens must be collected as close to the requested time
b. 2-Hour Postprandial Specimen
➢ Collected 2 hours after a meal and tested for glucose.
➢ It is primarily used to monitor the insulin therapy of patients with diabetes mellitus.
The patient is instructed to void shortly before consuming a normal meal and to
collect a specimen 2 hours later.
➢ Comparison of results with fasting urine and fasting blood glucose specimens'
results is done.
c. 24-Hour Urine Specimen

Is collected to allow quantitative analysis of a urine analyte.

Best time to begin is in the morning between 6 and 8 AM.

Requires a large, clean wide-mouth container capable of holding liters.

d. Double-voided Specimen
➢ Is one that requires emptying the bladder and then waiting for a specified amount
of time before collecting the specimen.
➢ Commonly used to test urine for glucose and ketone.
Urine Collection Methods

1. Regular Voided Urine

➢ -A regular voided urine collection requires no special patient preparation and is
collected by having the patient void (urinate) into a clean urine container.
2. Midstream Clean-Catch Specimen
➢ is collected in a sterile container and yields a specimen that is suitable for microbial
analysis or culture and sensitivity testing.
➢ Special cleaning of the genital area is required before the specimen is collected.
➢ Table 6.3 and 6.4 describe the proper procedures for Midstream Clean-Catch
3. Catheterized Specimen
➢ A catheterized urine specimen is collected from a sterile catheter inserted through
the urethra into the bladder.
➢ Catheterized specimens are sometimes collected on babies to obtain a specimen for
C&S, on female patients to prevent vaginal contamination of the specimen;
➢ and on bedridden patients when serial specimen collections are needed
4. Suprapubic Aspiration
➢ Involves inserting a needle directly into the urinary bladder and aspirating
(withdrawing by suction) the urine directly from the bladder into a sterile syringe
➢ The procedure normally requires the use of local anesthesia and is performed by a
physician.
➢ The specimen can also be collected from the catheter by a nurse using a sterile
needle and syringe.
➢ Used for samples for microbial analysis or cytology studies. It is sometimes used to
obtain uncontaminated samples from infants and young children.
5. Pediatric Urine Collection
➢ A plastic urine collection bag with hypoallergenic skin adhesive is used to collect a
urine specimen from an infant or small child who is not yet potty trained.
➢ The patient's genital area is cleaned and dried before the bag is taped to the skin.
The bag is placed around the vagina of a female and over the penis of a male. A
diaper is placed over the collection bag. The patient is checked every
➢ 15 minutes until an adequate specimen is obtained. The bag is then removed,
sealed, labeled, and sent to the lab as soon as possible.
➢ A 24-hour specimen can be obtained by using a special collection bag with a tube
attached that allows the bag to be emptied periodically.
Amniotic Fluid

➢ Clear, almost colorless to pale-yellow fluid that fills the membrane that surrounds and cushions
a fetus in the uterus.
➢ It is preferably collected after 15 weeks of gestation (pregnancy) and is obtained by a physician
through transabdominal amniocentesis.
➢ Amniotic fluid is normally sterile and must be collected in a sterile container.

Amniotic Fluid Analysis

• Genetic disorders
o can be detected by chromosome studies done on fetal cells removed from the fluid.
o Specimen must be kept at room temperature.
• Hemolytic disease
o can be detected by measuring bilirubin levels.
o The specimen should be protected from light to prevent breakdown of bilirubin and
delivered to the laboratory ASAP.
• Estimating gestational age
o amniotic fluid creatinine levels because these levels are related to fetal muscle mass.
• Measuring alpha-fetoprotein (AFP)
o an antigen normally present in the human fetus that is also found in amniotic fluid and
maternal serum.
o AFP testing is initially performed on maternal serum, and abnormal results are confirmed by
amniotic fluid AFP testing.
o Abnormal AFP levels may indicate problems in fetal development such as neural tube
defects or the potential for Down's syndrome.
o And gestational age of the fetus should be included due to AFP levels changes in each week
of gestation.
• Fetal lung maturity
o can be assessed by measuring the amniotic fluid levels of substances called phospholipids,
which act as surfactants to keep the alveoli of the lungs inflated.
o Results are reported as a lecithin-to-sphingomyelin (L/S) ratio.
o L/S ratio is less than 2 means that fetal lungs are likely to be immature.

Cerebrospinal fluid

➢ A clear, colorless liquid that surrounds the brain and spinal cord and has many of the same
constituents as blood plasma
➢ Primarily performed for the diagnosis of Meningitis.
➢ It is also used to diagnose other disorders such as brain abscess, CNS cancer, and multiple
sclerosis.
➢ Routine tests include cell counts, chloride, glucose, and total protein while other tests are
performed if indicated.
Cerebrospinal fluid collection

• Specimens are obtained most often through lumbar puncture (spinal tap) by a physician.
• The first tube is used for chemistry and immunology tests.
• The second for microbiology studies, and the third for cell counts.
• CSF should be kept at room temperature, delivered to the lab stat, and analyzed
immediately.

Gastric fluid

➢ A gastric analysis examines stomach contents for abnormal substances and measures gastric
acid concentration to evaluate stomach acid production.

Gastric Fluid Collection

• Basal Gastric analysis

o Sample of gastric fluid is aspirated by means of a tube passed through the mouth and throat
(oropharynx) or nose and throat (nasopharynx) into the stomach after a period of fasting.
o Tests are done to determine acidity prior to stimulation.
o After Basal Sample is collected, the patient is given a gastric stimulant (commonly histamine or
pentagastrin) intravenously and gastric samples are collected over timed intervals.
o The role of the phlebotomist in this procedure is to help label specimens and draw blood for
serum gastrin determinations.

Nasopharyngeal secretions

➢ Are cultured to detect the presence of microorganisms causing diphtheria, meningitis,

pertussis, and pneumonia.

Nasopharyngeal secretions collection

➢ NP specimens are collected using a sterile Dacron or cotton-tipped flexible wire swab.
1. The swab is inserted gently into the nose and passed into the nasopharynx.
2. There it is gently rotated, then carefully removed, placed in a sterile tube containing
transport medium, labeled, and delivered to the lab.

Saliva

➢ Used to monitor hormone levels and detect alcohol and drug abuse and its early detection
of drugs in saliva indicates recent drug use
➢ Hormone tests are typically frozen to ensure stability and sent to a laboratory for testing.

Semen

➢ Semen (seminal fluid) is the sperm-containing thick yellowish-white fluid discharged during male
ejaculation.
➢ It is analyzed to assess fertility or determine the effectiveness of sterilization following
vasectomy and is sometimes examined for forensic reasons.
Semen Analysis Collection

• Semen specimens are collected in sterile or chemically clean containers and must be kept warm,
protected from light, and delivered to the lab immediately.

Serous Fluid

➢ Is the pale-yellow, watery, serum-like fluid found between the double layered membranes
enclosing the pleural, pericardial, and peritoneal cavities.
➢ It lubricates the membranes and allows them to slide past one another with minimal friction.
➢ Its volumes increase when inflammation or infection is present or when serum protein levels
decrease.
➢ Effusion is an increase in fluid volume.

Types of Serous Fluids

1. Pleural fluid - aspirated from the pleural space, or cavity, surrounding the lungs.
2. Peritoneal fluid - aspirated from the abdominal cavity.
3. Pericardial fluid - aspirated from the pericardial cavity surrounding the heart.

Serous Fluid Collection

Serous fluids can be aspirated for testing purposes or when increased amounts are interfering with the
normal function of associated organs and a physician performs the procedure.

• EDTA tubes are used if cell counts or smears are ordered.

• Heparin or sodium fluoride tubes for chemistry tests.
• Nonanticoagulant tubes are used for biochemical tests.
• Sterile heparinized tubes for cultures.
• The type of fluid should be indicated on the specimen label.

Sputum

➢ Mucus or phlegm that is ejected from the trachea, bronchi, and lungs through deep coughing.
➢ Sometimes collected in the diagnosis or monitoring of lower respiratory tract infections such as
tuberculosis (TB), caused by Mycobacterium tuberculosis.

Sputum Collection

• First morning specimens are preferred, as secretions tend to collect in the lungs overnight
and a larger volume of specimen can be produced.
1. It is also best to collect the specimen at least 1 hour after a meal to minimize the risk
that the patient will gag or vomit.
2. The patient must first remove dentures if applicable, then rinse his or her mouth and
gargle with water to minimize contamination with mouth flora and saliva.
3. The patient is instructed to take three or four slow, deep breaths, inhaling to full
capacity and exhaling fully, then to cough forcefully on the last breath and expectorate
(cough up and expel sputum) into a special sterile container.
4. The process is repeated until a sufficient amount of sputum is obtained.
Sweat

➢ Analyzed for chloride content in the diagnosis of cystic fibrosis.

➢ Cystic fibrosis is a disorder of the exocrine glands that affects many body systems but primarily
the lungs, upper respiratory tract, liver, and pancreas.
➢ Patients with cystic fibrosis have abnormally high levels of chloride in their sweat, which can be
measured by the sweat chloride test.
➢ Sweat specimens can also be used to detect illicit drug use. Sweat is collected on patches placed
on the skin for extended periods of time and then tested for drugs.

Sweat Collection

• Test involves transporting a sweat-stimulating drug called pilocarpine into the skin by means
of electrical stimulation from electrodes placed on the skin, a process called iontophoresis.
• The forearm is the preferred site, but the leg or thigh may be used on infants or toddlers.
• Sweat is collected, weighed to determine its volume, and analyzed for chloride content.

Synovial fluid

➢ A clear, pale-yellow, viscous fluid that lubricates and decreases friction in

➢ movable joints that normally occurs in small amounts but increases when inflammation is
present.
➢ It can be tested to identify or differentiate arthritis, gout, and other inflammatory conditions.

Synovial Fluid Collection

• It is typically collected in three tubes:

o An EDTA or heparin tube for cell counts, identification of crystals, and smear
preparation
o A sterile tube for culture and sensitivity.
o Nonadditive tube for macroscopic appearance, chemistry, and immunology tests and to
observe clot formation.

Buccal swabs

➢ Collection of a buccal (cheek) swab is a less invasive, painless alternative to blood collection for
obtaining cells for DNA analysis.

Swab Collection:

• The phlebotomist collects the sample by gently massaging the mouth on the inside of the cheek
with a special swab.
• DNA is later extracted from cells on the swab.

Bone Marrow

➢ Aspirated and examined to detect and identify blood diseases.

➢ A bone marrow biopsy may be performed at the same time.
Bone Marrow collection

1. A physician inserts a special large-gauge needle into the bone marrow in the iliac crest (hip
bone) or sternum (breastbone).
2. Once the bone marrow is penetrated, a 10-ml or larger syringe is attached to the needle to
aspirate 1.0 to 1.5 mL of specimen. A laboratory hematology technologist is typically present
and makes special slides rom part of the first marrow aspirated. Additional syringes may be
attached to collect marrow for other tests such as chromosome studies or bacterial cultures.
3. Part of the first sample may be placed in an EDTA tube for other laboratory studies, remaining
aspirate is sometimes allowed to clot and placed in formalin or another suitable preservative
and sent to histology for processing and examination.
• In an alternate method, blood and particles from the EDTA tube are filtered through
a special paper. The filtered particles are then folded in the paper and placed in
formalin.
4. If a bone marrow biopsy is collected at the same time, the cylindrical core of material obtained
is touched lightly to the surface of several clean slides before being placed in a special
preservative solution. The slides are air-dried and later fixed with methanol and stained with
Wright's stain in the hematology department.
5. The biopsy specimen and several slides are sent to the histology department for processing and
evaluation. The remaining slides including biopsy touch slides are sent to the hematology
department for staining and evaluation under the microscope.

Breath Samples

➢ Are collected and analyzed for hydrogen content in one type of lactose tolerance test and to
detect the presence of Helicobacter pylori (H. pylori), a type of bacteria that secretes substances
that damage the lining of the stomach and causes chronic gastritis, which can lead to peptic
ulcer disease.

Breath Samples Analysis

1. C-Urea Breath Test

• A common test used to detect H. pylori is the C-urea breath test (C-UBT).
• This test is based on the fact that H. pylori produces urease, an enzyme that breaks down urea
but is not normally present in the stomach.
o To perform the test, a baseline breath sample is collected, after which the patient drinks a
special substance that contains synthetic urea. The synthetic urea contains a form of carbon
called carbon-13.
o If H. pylori organisms are present, the urease they produce will break down the synthetic
urea and in the process release carbon dioxide (CO2) that contain carbon-13.
o The CO2 will be absorbed into the bloodstream and exhaled in the patient's breath. The
patient breathes into a special Mylar balloon or other collection device at specified intervals.
The breath specimens are analyzed for carbon-13 content. If carbon-13 is found in amounts
higher than those in the baseline sample, H. pylori is present in the stomach.
2. Hydrogen Breath Test

• The hydrogen breath test helps identify problems with the digestion of carbohydrates such as
lactose (milk sugar) and fructose (fruit sugar) and is thought to be the most accurate lactose
tolerance test.
• It can also be used to detect bacterial overgrowth in the small intestine.
• The principle behind the test is that hydrogen gas is produced when intestinal bacteria ferment
carbohydrates such as lactose, fructose, or lactulose (used to detect bacterial overgrowth).
• Some of the hydrogen is absorbed into the bloodstream and transported to the lungs, where it
is exhaled during normal breathing
o To prepare for the test, the patient must not have taken antibiotics for at least 2 weeks
before the test and must avoid certain foods for 24 hours prior to the test.
o The patient must be fasting on the day of the test and is asked to refrain from vigorous
exercise and smoking for 30 minutes prior to and during the test.
o On the day of the test, a baseline breath sample is taken by having the patient exhale
into a special bag or device. Then the patient is given a drink that, depending on the
type of test, contains a measured amount of lactose, fructose, or lactulose. Additional
breath samples are collected at regular intervals, typically, every v30 minutes for up to 3
hours, depending on the amount of hydrogen detected in the samples.
• For those given lactose or fructose, increased hydrogen levels in the breath samples respectively
indicate increased lactose or fructose in the intestinal tract, most likely as a result of
metabolism.
o For those given lactulose, if bacterial overgrowth is present, increased hydrogen
levels appear twice; the first time when the lactulose reaches bacteria in the small
intestine and the second time when it reaches bacteria in the colon.

Feces (Stool)

➢ Examination of fecal specimens (feces or stool) is helpful in the evaluation of gastrointestinal

disorders.
➢ Stool specimens can be evaluated for the following:
o the presence of intestinal parasites and their eggs
o checked for fat and urobilinogen content
o cultured to detect the presence of pathogenic bacteria and viruses
o tested for the presence of occult (hidden) blood using the guaiac test.

Stool Collection

• Stool specimens are normally collected in clean, dry, wide-mouthed containers that should be
sealed and sent to the laboratory immediately after collection.
• For ova and parasite collection, special containers with preservatives
• Preserved specimens can usually be kept at room temperature. Large gallon containers, similar
to paint cans, are used for 24., 48., and 72-hour stool collections for fecal fat and urobilinogen;
these specimens must normally be refrigerated throughout the collection period.
 ➢ Hematest and Hemoccult Special test cards are used to stool specimens for fecal occult
blood testing (FOBT).
➢ The patient is usually instructed to follow a meat-free diet for 3 days prior to the test.
➢ Patients are then instructed to collect separate specimens for 3 successive days.

Hair

➢ Are sometimes collected for trace and heavy metal analysis and the detection of drugs of abuse.
➢ Easy to obtain and cannot easily be altered or tampered with.
➢ Hair shows evidence of chronic drug use rather than recent use.
➢ Despite of its rise in usage, there is a lack of standardization.

Throat Swabs

➢ Throat swab specimens are most often collected to aid in the diagnosis of streptococcal (strep)
infections.
➢ Nursing staff usually collect throat culture specimens on inpatients.
➢ Phlebotomists commonly collect throat culture specimens on outpatients.

Throat swab collection

• A throat culture is typically collected using a special kit containing a sterile polyester-tipped
swab in a covered transport tube containing transport medium.
• Throat swabs for rapid strep tests are collected in a similar manner.
Tissue Specimens

➢ Tissue specimens from biopsies may also be sent to the laboratory for processing. (A biopsy
➢ is the removal of a tissue sample for examination.) Most tissue specimens arrive at the
laboratory in formalin or another suitable solution and need only be accessioned and sent to the
proper department. However, with more biopsies being performed in outpatient situations,
➢ a phlebotomist in specimen processing may encounter specimens that have not yet been put
➢ into the proper solution. It is important for the phlebotomist to check the procedure manual
➢ to determine the proper handling for any unfamiliar specimen. (For example, tissues for genetic
analysis should not be put in formalin.) Improper handling can ruin a specimen from a
➢ procedure that is, in all probability, expensive, uncomfortable for thepatient, and not easily
➢ repeated.