COALINGA STATE HOSPITAL NURSING POLICY AND PROCEDURE MANUAL SECTION Diagnostic Procedures POLICY NUMBER: 605 Effective Date: August 31, 2006 SUBJECT: OBTAINING STOOL SPECIMENS FOR LABORATORY ANALYSIS 1. PURPOSE: Laboratory examination and analysis of stool provides useful information about the nature of elimination. Stool specimens are collected to determine pathologic conditions such as tumors, hemorrhage, infection, and mal-absorption problems. These conditions can be detected by the presence of blood, bile, urobilinogen, fat, nitrogen content, ova, parasites, protozoa, and bacteria. Guidelines are provided to aid in specimen collection. 2. POLICY: 1. All laboratory orders are to be transcribed from the physician s order onto the DIAGNOSTIC MAR: LAB CSHxxxx (Diagnostic MAR: Lab, Diagnostic MTR: Consult & Radiology ). 2. Pre-label the specimen container and lab slip. Using Miscellaneous Lab slip document Individual s name, CSHxxxx, unit, test requested, nature and source of specimen, collection date and time, name of the ordering physician, physician s diagnosis or suspected diagnosis. 3. Any licensed nursing employee may obtain a stool specimen for laboratory analysis when ordered by a physician. 4. Nursing personnel, having direct or the potential for contact with exposure to blood, body fluids, or other potentially infectious material of Individuals, are expected to practice STANDARD PRECAUTIONS according to guidelines established by the CSH Infection Control Program. Personal Protective Equipment (PPE) and engineering controls shall be used as needed. 3. GENERAL INFORMATION: 1. If more than one stool specimen is needed, allow one or two days between collection and number each stool specimen accordingly on lab slips. -1-
2. Place stool for culture in container with C&S preservative (available from lab) and keep at room temperature. Stool for O&P should always be placed into the specimen container with O&P fixative (available in lab), cap tightly and mix well. Specimens obtained for ova and parasites do not need to be refrigerated. Do Not send fresh stool for culture or O&P. 3. During business hours (Monday - Friday, 0800-1630) collected specimens are sent to the designated specimen collection site refrigerator prior to the 0800 pickup, and to the main lab if specimens have already been picked up. This should be done within (30) minutes of collecting the specimen. 4. During non-business hours, weekends, and holidays, contact the NOD so that arrangements can be made through the ACNS office for the Contract Lab to pick up the specimen from the Central Sally Port. (Do Not place stool specimen(s) in refrigerator.) 5. Do not obtain specimen from toilet. Do not use specimen that has been urinated on. Do Not have Individual pass the specimen directly into the vial. 4. STOOL FOR OVA AND PARASITE (O&P): 1. Collect specimens in a clean, waxed cardboard container or sterile screw-capped plastic vial that may have a spoon attached to the lid. Transfer to O&P fixative. Fill to line on vial, Do Not Overfill. Cap tightly and mix well. 2. Collect early in the disease and before antibiotic treatment if possible. Care must be taken to not contaminate the specimen with urine or any residual soap, detergent or disinfectant. Those portions of the stool that contain pus, blood or mucus are best. 3. Specimen should be brought to the lab ASAP. 4. Collect prior to radiology studies, i.e. Barium Sulfate - must wait 5-7 days. 5. Individual should not receive laxatives, mineral oil, magnesium, bismuth, and antidiarrheal meds, certain antibiotics for at least 48 hours prior to collection. 6. Stool must be free of water or urine. 7. Must use fixative kit. Place into O&P Stool Fixative vial ASAP - no more than 30 minutes if liquid or one hour otherwise. Once in kit, its good for an indefinite time. 8. No more than one specimen per day. 9. Never incubate or freeze. Room temperature only. 5. STOOL FOR WBC: Stool for WBC can also be done from Stool Preservative Kit vial if ordered with an O&P exam. Otherwise collect specimen in a clean, waxed cardboard container. -2-
6. STOOL FOR PINWORM: Obtain special pinworm collector from the Lab. Use for perirectal sample. 7. STOOL FOR OCCULT BLOOD: To reduce both false positive and false negative results the following guidelines should be observed. I. The individual to be tested should: 1. Be placed on a meat-free, high bulk diet two days prior to the test and continue through the test period 2. Avoid all blood-containing foods (meats) 3. Avoid foods rich in peroxidase-like substances (turnips, horseradish) 4. Be restricted, for 48 hours prior to the test, from some medications which may cause false positives: aspirin, iron preparations, Butazolidin, as well as drugs that may be associated with increased GI blood loss (steroids, colchicine, indomethacin). Discuss with physician. 5. Not take more than 500 mg of Vitamin C per day, as this may cause false negative results. 6. Not be tested if bleeding hemorrhoids are present or, for females, during menstrual periods. 7. Not be tested if diarrhea is present. II. The licensed nursing staff obtaining the stool specimen should: 1. Consult with the physician if any of the above (in I.) are applicable. Follow orders as directed. 2. Inform the dietician of the testing so any foods that may affect testing can be avoided. 3. Obtain and test three (3) consecutive stool specimens to increase probability of detection of occult blood. 4. Collect specimen in a clean, waxed cardboard container, or sterile, screwcapped plastic vial that may have a spoon attached to the lid. 8. STOOL CULTURE: Stool culture is for Shigella, Salmonella and Campylobacter. Any other bacterial pathogen needs to be indicated with the physician s order. Leave at room temperature and transport ASAP to lab for processing. Use C&S (culture and sensitivity)media as preservative. Specimen still needs to be processed promptly for best results. Shigella, in particular, is difficult to recover if delays occur. Shigella is delicate. They will not survive the drop in ph that occurs when the stool is refrigerated and therefore the specimen should be left at room temperature. -3-
9. PRECAUTIONS: Medical aseptic technique should be followed during collection of any stool specimen. Feces contain a variety of microorganisms that can easily be transmitted if specimens are handled incorrectly. 1. The fluid blood and moist body substances of all Individuals shall be treated as though they were infectious. Refer to Administrative Directive 3 Standard Precautions. 2. Hand Hygiene before and after procedure. Follow Biohazardous Waste Procedure for proper disposal. 3. The Solutions in the vials are poisonous. Keep out of reach of Individuals. 10. EQUIPMENT: 1. Sanopan stool collection pan (also called Pilgrim s Hat); 2. Clean disposable gloves; 3. Waxed cardboard or plastic specimen bottle with lid, or sterile culture transport tube with swab for cultures (C&S collection, culture swabs are obtained from the Lab); 4. Other personal protective equipment as required; 5. Tongue blades (Use sterile tongue blades for cultures); 6. Toilet paper and bag; 7. Completed laboratory requisition form Miscellaneous Lab Slip 8. Stool Preservative Kit for ova and parasites; pinworm collectors (obtain from Lab). 9. Appropriate receptacle. See Biohazardous Waste Procedure. 11. ASSESSMENT: NURSING ACTION A. Determine purpose of stool specimen and correct method of obtaining and handling specimen. B. Determine if Individual should have dietary modifications or restrictions before test. KEY POINTS A. Prevents collection of specimen at time when laboratory cannot test it. Consult with the CSH Laboratory or Contract Lab for any questions regarding collection procedures. B. Prevents invalid test results on stool specimen. Appraise the dietician of the testing so that dietary modifications can occur. -4-
C. Assess Individual s understanding of reason for collection of stool specimen. D. Determine normal defecation pattern of Individual. E. Assess Individual for gastrointestinal dysfunction, such as abdominal pain, nausea, vomiting, excessive flatus, diarrhea. C. Reveals Individual s ability and willingness to cooperate in collection of specimen. D. Allows for more effective planning. E. May indicate specific physical problem. 12. PROCEDURE: NURSING ACTION KEY POINTS A. Check physician's orders. A. To prevent error. B. Hand hygiene with soap and water. B. Reduces spread of infection. C. Identify Individual by photo ID and explain the procedure to Individual. Assess Individual s understanding of purpose and ability to cooperate. D. Assemble equipment needed. C. Provides basis to determine need for health teaching and need for assistance. Individual teaching assists with gaining Individual s cooperation. E. Label specimen container with date and time of collection, Individual name, CSH number, and unit location. Prelabel Lab slip to include date and time of collection, Individual name, CSH number, unit, test requested, nature and source of specimen, name of the ordering physician, physician s diagnosis or suspected diagnosis. F. Instruct Individual to void into toilet before defecating. E. This is recorded on Miscellaneous Lab slip (MH 6075). Contract Lab requires that the source of the specimen, and physician s diagnosis or suspected diagnosis needs to be identified on the lab slip including the name of the ordering physician. F. Feces should not be mixed with urine or toilet tissue. Urine inhibits fecal bacterial growth. Toilet tissue contains bismuth, which interferes with test results. -5-
G. Place collection pan on toilet. G. Collection pan must be clean. H. Put on disposable gloves and remove a small portion of feces (2 cm X 2 cm) from the bedpan with the tongue blade and place in C&S preservative specimen container. Fill to line. Do Not Overfill. Cap tightly and mix well. I. Ova and parasites: Use The spoon built into the vial cap and transfer small samples from areas that appear bloody, slimy, or watery. Continue adding samples until the liquid level in the vial reaches the red fill line. Avoid over or under filling. Mix specimen in the solution using the spoon provided. Recap the vial, making sure the lid is tight. Shake the vial until the contents are well mixed. J. Using a new single glove to handle specimen, place it into a specimen transport bag using the clean hand to handle the bag. Follow by thorough hand washing. H. Follow appropriate hand hygiene protocols. I. Specimen must be taken to specimen collection site. J. Outside of bag should not be touched by the hand contaminated by specimen prior to handwashining. K. Cleanse all equipment or dispose appropriately, in Biohazardous waste container. L. Leave area clean and neat. Use aerosol-deodorizing spray in area if necessary. M. Note character of stool while preparing specimen for lab. Document in IDN, lab slip, and on Individual s Diagnostic MAR LAB. Document Individual teaching on the Wellness and Recovery Individual and Family Health Education Record CSHxxxx N. Place completed lab slip in pouch of the specimen transport bag. K. Refer to A.D. Biohazardous Waste procedure. L. To provide for unit comfort and dispel odor. M. Staff member who collected the specimen will record on the Lab slip and the Diagnostic MAR: LAB the exact date and time the specimen was collected. Its disposition will also be reflected in the ID notes. N. Send specimen in specimen transport bag to designated specimen -6-
collection site within 30 minutes. O. Immediate evaluating, sorting, ands logging begins when the lab reports arrive on the unit. Promptly report significant test results to physician. Provide all lab results to the Med/Surg physician for review. O. As the lab report arrives on the unit, the Med Room person and/or Shift Lead is responsible for notifying the RN of its arrival. The RN is expected to promptly review all incoming lab results then date and initial the Diagnostic MAR: LAB. If the results of the lab are out of therapeutic parameters, the RN shall notify the physician off these results and reflect this on the Diagnostic MAR: LAB by checking the YES box, followed by identifying same action in the IDN including action taken. -7-