STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH … · STATE OF WEST VIRGINIA ... glomerular...

BUREAU FOR PUBLIC HEALTH

OFFICE OF LABORATORY SERVICES

167 11th Avenue

South Charleston, West Virginia 25303-1134

Phone: (304) 558-3530 FAX: (304) 558-2006

STATE OF WEST VIRGINIA

DEPARTMENT OF HEALTH AND HUMAN RESOURCES

SESSION I – REAGENT STRIP URINALYSIS

COURSE INSTRUCTIONS

1. If you have not already registered and paid for the course, you must complete the registration form at the end of the chapter exams. Submit the form with your payment and the completed exams.

2. Write your name on the designated area of each chapter exam. Unidentified exams

will not be graded.

3. The exams are generally made up of four sections. Follow the instructions given in each section:

A. Multiple Choice C. Matching B. True or False D. Short Answer

4. Complete all questions of the examination. Participants are reminded that this is an

individual self-study course. Taking the examination is not meant to be a group effort. Credits are based on individual merit. Therefore, participants will be on the honor system when completing this examination. Group study can be done after the exams are graded and returned.

5. The Training and Evaluation Section has no regulated deadline. To avoid “urgent”

requests and to allow you to meet any program deadlines for which you may be planning to use the CEUs, we ask that you return completed exams in plenty of time to allow for grading. Return completed exams to:

West Virginia Office of Laboratory Services Training & Evaluation Section 167 11th Avenue South Charleston WV 25303

6. A final exam that covers the material of all three chapters is also enclosed and should be

completed and returned with the other exams.

Thank you for your cooperation.

Joe Manchin III

Governor Patsy A. Hardy, FACHE, MSN, MBA

Cabinet Secretary

URINALYSIS SESSION I COURSE OUTLINE

Chapter Topic Page 1 Introduction to Urinalysis 1

2 Safety in the Urinalysis Laboratory 12

3 Chemical Reagent Strip Examination of Urine 23

Exams 40

W V O L S | T & E | 2 0 1 0 U R I N A L Y S I S – S E S S I O N I P a g e | 1

URINALYSIS - SESSION I

REAGENT STRIP URINALYSIS

CHAPTER 1

INTRODUCTION TO URINALYSIS

Welcome to all participants in the Urinalysis Correspondence course. This is Session I of a two-part course, designed to meet the needs of individuals performing waived or moderate complexity urinalysis. It also serves as a review for all laboratorians. COURSE GOAL The goal of both courses is to provide participant with the information needed to improve the quality of urinalysis performed at each testing site. COURSE OBJECTIVES At the conclusion of Session I, participants can expect to know or accomplish the following:

o Evaluate the quality of a urine sample

o Develop safe laboratory work practices

o Know urine composition, normal and abnormal volumes, types of specimen

collection and common terms involved with urinalysis

o Correlate color, appearance and odor with disease states

o Review urine dipstick procedure and update if necessary

o Incorporate quality control as a routine part of the testing process


IMPORTANCE

Humans have been curious about urine as far back as the caveman. Drawings on cave

walls indicate a study of urine started then. The color, cloudiness, volume, thickness,

odor and whether or not it attracted ants could all be studied. Today urinalysis is still

an integral part of most patient examinations. It is the most commonly performed

laboratory test. Two characteristics can account for its popularity:

o urine is readily available and easily collected (i.e. without pain to patient)

o urine contains information about the body’s metabolic functions and thus

information can be obtained by simple laboratory tests

These characteristics fit well with the current trends of preventive medicine and lower

medical costs. Urinalysis can screen large numbers of people for renal disease and

asymptomatic beginnings of diabetes melitis and liver disease with relatively low cost.

URINE COMPOSITION

Urine consists of water (96%) and dissolved substances from foods eaten or waste

products of metabolism (4%). Variation can occur due to dietary intake, physical

activity, metabolism, and endocrine function.

Urine is essentially a solution of salt (sodium and potassium chloride) and urea (a

metabolic waste product) dissolved in water. Besides urea, the principal organic

substances include uric acid and creatine which are wastes of protein metabolism.

Creatinine is related to the muscle mass of the body and not influenced by diet.

Because creatinine is excreted at this constant rate, it may be used to assess the

completeness of a timed (24 hr) specimen. An increase in creatinine indicates impaired

glomerular filtration.

Other substances that make up urine composition to a lesser degree are hormones,

formed elements (e.g. cells, crystals), and of ingested vitamins and medications.


WARNING: DON’T LET THE SIMPLICITY OF A URINALYSIS TEST FOOL YOU. TESTING MUST BE STANDARDIZED AND CARE MUST BE TAKEN TO FOLLOW PROCEDURES EXACTLY.

Urinalysis should not be ordered indiscriminately. NCCLS guidelines define the

following purposes for urinalysis:

o to aid in the diagnosis of disease;

o to screen a population for asymptomatic, congenital, or hereditary diseases (to

monitor wellness);

o to monitor the progress of disease;

o to monitor the effectiveness or complications of therapy.

Urinalysis is defined as the testing of a urine sample with standardized procedures

which include the following:

o Visual evaluation (appearance) - The first observance made on a urine

specimen is appearance. Careful attention to details can provide clues to the

substances in the urine specimen. Note color, clarity, and odor.

o Physical measurements (volume and specific gravity) - Urine volume in a 24-

hour period is important when quantifying measurement of urinary chemicals, or

volume over a 24-hour period. For routine urinalysis, it is not critical.

o Specific gravity should be measured as part of routine urinalysis. It is helpful in

determining urine concentration.

o Chemical reagent strip or tablet testing - Chemical measurement of a urine

specimen.

o Microscopic examination - Examination of the urine sediment for cells, casts,

crystals and bacteria.

o Confirmation of screening tests - Confirmatory tests include Clinitest® for

reducing sugars, Ictotest® for bilirubin, and sulfosalicylic acid (SSA) for protein.


ROUTINE REAGENT STRIP URINALYSIS PROTOCOL Physical Color: straw yellow dark yellow / amber red brown other (specify): Appearance: clear hazy cloudy turbid

Odor: normal abnormal (specify):

Chemical Screen (Reagent Strip) Glucose: negative 1+ (250 mg/dl) 3+ (>2000 mg/dl) tr (100 mg/dl) 2+ (1000 mg/dl)

Bilirubin: negative 2+ (mod) 1+ (small) 3+ (large)

Ketone: negative sm (15 mg/dl) lg (80 mg/dl) tr (5 mg/dl) mod (40 mg/dl)

Specific gravity: Blood: negative tr small (1+) mod (2+) lg (3+) non-hemolyzed

pH: 5.0 7.0 8.0 6.0 7.5 8.5

Protein: negative 1+ (30 mg/dl) 3+ (300 mg/dl) trace 2+ (100 mg/dl) 4+ (>2000 mg/dl)

Urobilinogen: normal 2 mg/dl 4 mg/dl 8 mg/dl

Leukocyte: negative sm (1+) mod (2+) lg (3+)

Nitrite negative positive

A back-up test, when available, should be performed on all questionable tests. The result of the dipstick test, if confirmed, is the one reported; and the back-up test performed is recorded on the log sheet.


URINE VOLUME

Urine volume is dependent upon the amount of water excreted by the kidneys.

Therefore, the amount excreted is usually determined by the body’s state of hydration or

individual’s fluid intake. Normal urine output in a 24-hour period ranges from 600 -

2000 ml. The average volume is about 1500 ml. Factors influencing urine volume

include:

o fluid intake

o fluid loss from non-renal sources, e.g. perspiration, vomiting, climate

o variations in the secretion of antidiuretic hormone

o necessity to excrete solids, such as glucose or salts

URINE VOLUME TERMS

Oliguria is a decrease in normal daily urine volume (<200 ml/24 hrs). It is commonly

seen when the body is in a state of dehydration. Physiological form of water loss may

be due to vomiting, diarrhea, or excessive perspiration. Pathological oliguria can be

due to renal shut-down from nephritis or mechanical obstruction to the urinary flow.

Severe burns, poisoning and cardiac insufficiency could also result in oliguria.

Anuria is a total lack of urine flow. It is indicative of severe damage to the kidneys. A

decrease in blood flow to the kidneys also may result in anuria.

Nocturia is an increase in the urine output at night. Normally two to three times more

urine is excreted during the day than during the night. It is arbitrarily defined as the

excretion by an adult of more than 500 ml of urine with a specific gravity of 1.018 at

night. This is characteristic of chronic glomerulonephritis and is due to the kidney’s

inability to concentrate the urine.

Polyuria is an increase in the daily urine volume. It is mostly influenced by the intake of

water and other fluids. The use of diuretics and consuming caffeine or alcohol will also

cause polyuria. Polyuria is a characteristic of diabetes melitis and diabetes insipidus.


SPECIMEN COLLECTION AND HANDLING

In order for urinalysis to be meaningful, the urine must be properly collected. Improper collection invalidates the results of the laboratory no matter how skillfully the tests are performed. NCCLS recommends that the urine specimen for routine urinalysis be a well-mixed, first morning specimen (8 hours concentrated) which is tested at room temperature. Ideally, the specimens should be tested within 30 minutes of voiding - but must be tested within 2 hours of collection (unpreserved) to avoid specimen deterioration. Types of Specimens First morning: or eight-hour specimen is the ideal screening specimen. It

is concentrated and bladder incubated - which helps to assure detection of chemicals and formed elements that may not be present in a dilute random specimen. The patient must be given instruction to collect the specimen immediately upon rising. It is best for nitrite, protein and microscopic examination.

Random Specimen: Adequate for urinalysis. This is the most commonly received

specimen due to the ease of collection and the lack of inconvenience to the patient. It may produce erroneous results due to:

dietary intake

physical activity

inadequate volume

non-symptomatic low-grade kidney & bladder infections

lack of concentration

Glucose Tolerance: Specimens are collected to correspond with blood of

samples drawn during a glucose tolerance test. The number of specimens varies from fasting to 3-hour specimens. Urine is tested for glucose and possibly ketones.

2-Hour Postprandial: Patient voids shortly before eating and 2 hours after eating.

Specimen is tested for glucose.


Fasting: Eliminates dietary interference used for testing chemicals such as glucose. A fasting specimen is the second voided specimen after a period of fasting. This specimen will not contain metabolites from ingested food.

Catherized specimen: Requires the actual participation of trained personnel. The

specimen is used for bacterial culture or function of individual kidneys. It is collected by passing a hollow tube through the urethra into the bladder.

Pediatric specimen: This is a challenge! Safe, clean bags with adhesive to

attach to the genital area are available for routine specimens. Specimens for culture may be obtained by the clean-catch cleaning procedure and a sterile bag. Check bag every 15 minutes for the specimen.

Clean-catch (midstream) specimens:

The mid-stream clean-catch specimen is collected primarily for bacterial culture or when a specimen may be contaminated from vaginal discharge. It is an excellent routine screening specimen. The specimen is more representative and less contaminated than random specimens from external sources (vaginal, skin). Patients are provided with appropriate cleansing material and a sterile cup. The procedure is outlined below.

Clean Catch Collection Procedure

1. Provide patient with instructions, sterile cleansing towelette or equivalent and a sterile container with lid.

2. Instruct patient to wash hands thoroughly before beginning procedure. 3. Cleanse the urogenital area with the cleansing solution towellette wiping from front to

back to remove external contamination from adjacent areas. To cleanse properly, females should spread the labia, males should retract the foreskin.

4. Remove lid from container - Do not touch inner side of lid. 5. Urinate by passing the first portion into the toilet, collecting the midportion in the sterile

container without contaminating the container (clean catch) and passing the last portion into the toilet.

6. Place lid tightly on container. 7. Label the specimen container. (Volume less than 15ml should be noted as short

samples.)


GENERAL PATIENT INSTRUCTION

A simple instruction sheet with drawings posted in the restroom along with verbal instructions will assist in assuring a properly collected sample. Many times specimens are collected at home where it is out of control of the laboratory. To help to assure better specimen quality, the following points must be emphasized to patients, both verbally and in writing.

o Thorough hand washing and general cleanliness collecting the specimen.

o The importance of a clean, properly rinsed, leak proof container - preferably clear. Whenever possible, the container should be provided by the laboratory.

o The specimen must be brought to the lab within 2 hours of collection. (Some

sources state 1 hour). If this is not possible, refrigerate the specimen. ACCEPTABILITY OF SPECIMENS A quality test result starts with a good specimen. To ensure suitability for a urinalysis, follow the rules outlined in the section.

o Correct specimen labeling - The specimen container must be labeled with the patient name, time and date of collection. Do not write this information on the lid because when the lid is removed, the identity is lost.

o Urine specimen collected preferably within one hour, but will accept up to two

hours standing at room temperature. According to NCCLS, unpreserved specimens older than the 2 hours should not be tested.

o Note urine preservative - The most common type of urine preservative is

refrigeration at 2-8 C. Urine can be refrigerated up to 4 hours but not more than 8 hours. Commercially made preservative tablets and chemicals such as boric acid are available. Preservatives may interfere with specific parts of the urinalysis. Urine preservatives are listed in Table 1 - 2.

o Container suitability - Container should have a capacity of at least 50ml with a large opening. It must be clean, leak proof, and particle free. Small specialized containers should be used for children. The label on the container should adhere during refrigeration.


o Adequate volume - A minimum sufficient urine quantity for testing is considered to be 12ml but around 50ml is preferred.

o Absence of contaminating material - Inspect urine and container for free

particulate matter (e.g. feces, toilet paper, food matter, or oily film). Note if patient is menstruating. Preferably collect it at another time after menstruation or recollect with patient using a tampon and collecting clean catch method. Menstruation should be noted on report.

o NEVER extract urine from a diaper!

Preservation Refrigeration is the most commonly used preservative. Ideally, urine specimens should be tested within 30 minutes of voiding. If it is impossible to test the specimen

immediately, it should be refrigerated at 2-8 C as soon as possible after collection. Specimens can be maintained for up to 8 hours with refrigeration. Refrigeration will reduce the growth of bacteria, the primary cause for decomposition of urine. The growth of bacteria will cause an increased pH as urea is converted to ammonia. Glucose, if present, is also used by the bacteria to feed which may cause a false lowering or negative glucose result. Other changes are summarized in Table 1-1.


TABLE 1-1 Changes that begin to occur in unpreserved urine left at room temperature for longer than 1 hour.

Constituent Change Why it changes

pH increased bacterial breakdown of urea to ammonia

glucose decreased bacterial metabolism

nitrite increased bacterial growth

ketones decreased evaporation

bilirubin decreased exposure to light

urobilinogen decreased oxidized

Table 1-2 URINE PRESERVATIVES Preservatives

Advantages

Disadvantages

Additional Information

Refrigeration

Does not interfere with chemical tests

Raises specific gravity by hydrometer Precipitates amorphous phosphates and urates

Will prevent bacterial growth for 24 hours

Thymol

Preserves glucose and sediments well

Interferes with acid precipitation tests for protein Large amounts will interfere with 0-toluidine glucose tests

Boric acid

Preserves protein and formed elements well Does not interfere with routine analyses other than pH

Large amounts may cause precipitation of crystals

Keeps pH at about 6.0 Bacteriostatic (not bacteriocidal) at 18 g/L; can be used for culture transport Interferes with drug and hormone analyses

Sodium fluoride

Prevents glycolysis Good preservative for drug analyses

Inhibits reagent strip tests for glucose, blood, and leukocytes

Will not interfere with hexokinase tests for glucose Sodium benzoate instead of fluorid may be used for reagent strip testing

Phenol Does not interfere with routine tests

Causes an odor change

Use 1 drop per ounce of specimen

Commercial preservative tablets

Convenient when refrigeration is not possible Concentration is controlled to minimize interference

May contain one or more of the above preservatives including sodium fluoride

Check tablet composition to determine possible effects on desired tests

Urine C + S

Transport Kit

(Becton

Dickinson,

Rutherford, NJ,

07070)

Urinalysis and culture can

be run on same specimen

Decreases pH

Preservative is boric acid

Adapted from Susan King Strasinger, Urinalyses and Body Fluids, Edition 3, F. A. Davis


URINALYSIS TERMS

anuria complete stoppage of urine flow

catheter hollow tube for draining urine from the bladder on kidneys

diuretic an agent that increases the production of urine

dysuria painful urination

glycosuria glucose in the urine

hematuria occult blood in the urine

ketonuria ketone in the urine

nephritis inflammation of the kidney

nocturia excessive urination during the night

oliguria marked decrease in urine flow

polydipsia excessive thirst

polyuria marked increase in urine flow

proteinuria protein in the urine

pyuria WBCs in the urine

renal pertaining to the kidney

refractometer instrument used for determining specific gravity

renal calculi kidney stones

renal dialysis removal of waste products from the blood when kidneys are not functioning

uremia presence of increased urea in the blood

urinalysis the physical, chemical, and microscopic analysis of urine

urinometer instrument used for directly measuring the specific gravity of urine


SAFETY IN THE URINALYSIS LABORATORY

CHAPTER 2

CHAPTER OBJECTIVES

Participants will be provided with information to:

o Develop safety awareness in the urinalysis laboratory o Know how to organize a urinalysis laboratory o Discuss the significance of urine color and appearance o Know what odor suggests o Define specific gravity and methods of measurement

This chapter discusses the basic principles for laboratory safety. Before performing any laboratory test, including urinalysis, it is essential that a safety program for your site is in place. Safety rules, no matter how burdensome, are for your benefit.

The Occupational Safety and Health Administration (OSHA) Standard on Exposure to Blood-borne Pathogens states that any body fluid that is visibly contaminated with blood should be treated as if infectious and that includes urine. Letting down your guard can be risky. Urine that contains blood and/or bilirubin should be treated as hazardous. Because it is often impossible to know which urine might be infectious, NCCLS recommends that persons responsible for the collection and analysis of urine specimens be aware of potentially biohazardous specimens and practice Universal Precautions. The term Universal Precautions is defined as treating all specimens as if they carry an infectious agent(s).

A biohazard is a potential health risk of persons working in the area from contact, either directly or through the environment, with an infectious agent. The word or symbol should be posted throughout the laboratory to denote biohazardous areas. Labels should be fluorescent orange or orange-red with the word “biohazard.” Some examples of the various types of labels available are shown below.


The Biohazard label should be placed on:

o biohazard waste receptacles

o refrigerators and freezers that hold specimens

o containers used to ship specimens

o doors leading to biohazard areas where specimens are tested

o contaminated equipment such as a centrifuge or reagent strip reader

Computers, telephones, and desk areas in the laboratory section should be considered “clean.” Keep all specimens away from these areas and remove lab coat, gloves and other personal protective equipment while working in these areas. If it is necessary to use one of these items while working with specimens, label it as a biohazard.

PERSONAL PROTECTIVE EQUIPMENT (PPE)

Wearing personal protective equipment (PPE) is a method of infectious disease control

that creates a barrier between the employee and the biohazard. PPE is mandated by OSHA to provide personnel with safer working conditions.

o protective clothing that should be used in the urinalysis section: (at a minimum)

o latex gloves

o laboratory coat or apron, closed front

o goggles or glasses with side protection during activities where splashing can

occur (e.g. pouring or centrifuging tubes)


Hand Washing The single most important safety work practice for preventing the spread of disease is hand washing. Hand washing cannot be stressed enough in the laboratory. It interrupts the transmission of infectious agents. Hand washing should be done:

o if a specimen comes in contact with the skin

o after completion of laboratory work

o before leaving the laboratory

o after removing gloves

o before & after every patient contact

Hand Washing Procedure

1. Wet both hands and wrists with warm water.

2. Apply soap from a dispenser to the palms first (about 1 tsp)

3. Lather well and wash hands, wrists, fingernails and between the fingers. Do this for a minimum of 5 seconds.

4. Rinse well with warm water and dry completely.

5. Use a paper towel to turn off faucet to avoid contamination of clean hands.

HOUSEKEEPING The laboratory workplace must be kept clean. Cleaning and disinfecting work surfaces after contact with body fluids are of primary importance. At the completion of the work day or once per shift, it is important to decontaminate workbenches where specimens are processed. Spilled fluids should be cleaned with a disinfectant (e.g. 10% bleach solution) and disposable paper towels. The bleach solution should be made fresh daily to ensure its germicidal activity. Other commercially available intermediate level disinfectants are available. The manufacturer’s information will list the pathogens for which the disinfectant will be effective.


GENERAL LABORATORY SAFETY POLICIES

1. Smoking, eating, drinking and applying cosmetics are not permitted in the laboratory area.

2. Food must not be stored in the laboratory refrigerators or any other laboratory

area where specimens are stored or processed. 3. Wearing contact lenses is discouraged while working in the laboratory. Lenses

should never be inserted while in the laboratory. If a splash occurs, the eyes should be flushed with water immediately and lenses removed.

4. Laboratory coats or gloves worn in the laboratory are to be removed when

leaving the laboratory. 5. Open-toe and penetrable shoes should not be worn while working in the

laboratory. 6. Personal items such as glasses, purses, etc., must not be placed in work areas

where infectious materials are handled. Designate “clean” areas for their storage.

7. Pens and pencils used in the laboratory must remain in the laboratory. They

should not be put to the face, mouth or behind the ear. 8. Hair should be worn in a style that does not impair vision or come in contact

with work surfaces or specimens. 9. Cuts on hands should be bandaged. 10. Mouth pipetting is prohibited. Pipetting devices should be available. 11. Broken glass must not be picked up by hand. To prevent injury use a brush

and/or forceps and dustpan to pick up glass. 12. Chairs should never be used as step-stools. 13. Exits and aisles must not be obstructed. 14. Urine can be disposed of down the toilet or sink with plenty of water. The sink

should be soaked with 10% bleach solution daily. Dispose of containers in the regular trash unless grossly contaminated with blood or the urine has a positive bilirubin.

15. Each work site should have a written safety manual with the documentation that

all employees have read it.


16. When using a centrifuge:

make sure the centrifuge is balanced before using

never operate without being covered and latched

never stop by hand

cap all specimens

disinfect interior surface with 10% bleach at least weekly or if a spill occurs

17. Have an eyewash available at all times. (Don’t forget eyewash maintenance.)

18. Keep a multi-purpose fire extinguisher mounted on the wall in the laboratory ORGANIZATION OF THE URINALYSIS LABORATORY Another preliminary part of urinalysis is the organization of the laboratory. Are supplies readily at hand? Do you have the proper lighting and equipment? These are all items to think about before performing a urinalysis. A well organized laboratory will produce better results.

o work area should have good lighting o sink and running water should be within easy reach o the testing counter top or bench should be made of nonporous material that can

be easily disinfected and cleaned. The top should have a light neutral color so that test colors can be seen easily

o there should be adequate storage area for reagent strips and other supplies in

an area free of moisture o a daily cleaning routine should be established in the work area with

documentation o for microscopics, there should be:

a centrifuge capable of 1500 rpm

a good quality binocular microscope conveniently located, with low and high

power objectives

wall charts and/or color atlas with urine microscopic photographs


have an easily accessed area for storage of personal protective equipment an area should be reserved for the urinalysis procedure manual, reference

materials and control charts have a refractometer to measure specific gravity

distilled/deionized water must be available for reconstituting controls

VISUAL EXAMINATION OF URINE The visual (sometimes referred to as physical) examination of urine is the assessment of urine color, appearance and specific gravity. The presence of abnormal odor should also be noted. The visual examination is especially important if a microscopic examination of urine sediment is not part of everyday urinalysis. For example, increased cloudiness may be the only indication of the presence of yeast or abnormal epithelial cells. Abnormalities in the visual examination must be explained and correlated with urine reagent strip results as well as the microscopics. This is part of a good quality assurance program. Urine Color Terminology used to describe normal urine color may differ slightly among laboratories. In general, some shade of yellow or amber is considered normal. It is good to rate whether the color is pale yellow (straw) or dark yellow. It could help in determining the concentration of the urine specimen and patient diagnosis. The color of normal urine is due largely to urochrome - a yellow pigment. Uroerythrin and urobilin are present in a lesser amount. Each laboratory should establish specific color guidelines for reporting. Keep it simple!

Color Description Possible Cause

Colorless, straw Very dilute urine from increased fluid intake or diabetes mellitus. Very dilute urine may cause false negative results.

Amber, Dark yellow Concentrated urine, decreased fluid intake, bilirubin (liver disease) vitamins, dehydration, medications

Dark Amber Brown Bilirubin or biliverdin (shake an aliquot vigorously and note if yellow foam appears - bilirubin)


Black (Black/brown) Blood, drugs, methyldopa, old urine, melanin and homogentisic acid (after standing)

Orange Urobilin Pyridium compounds - Medications

Pink to Red Blood, infections, myoglobin, beets, menstrual flow, chemicals, foods, muscle damage

Clear cherry red Cloudy red

Dark red Red - Purple

Hemoglobin Red blood cells Myoglobin Porphyries

Green

Bilirubin, liver disease Pseudomonas bacterial infection Drugs Clorets *Bilirubin will be oxidized to biliverdin in acidic urine. The reagent strip test will be negative for bilirubin. Important to note color!

*Deeply colored urine masks reagent strip results. Do not report. Send to reference lab or use

back-up tests.

Urine Appearance (Clarity) Appearance is a general term that refers to the clarity of a urine specimen. Always observe the appearance of the urine specimen under good lighting. It is helpful to note urine clarity in a clear container. Many disposable plastic containers are made of nontransparent plastic. It may be necessary to transfer the specimen to a clear one. The degree of clarity ranges from clear to turbid. Freshly voided urine is normally clear; however, a white cloudiness may be caused by precipitation of amorphous material. The degree of cloudiness should be noted and supported by reagent strip and microscopic analysis. Keep it simple and consistent! Appearance Terminology and Grading

o Clear - Can read print and see colors through it clearly. No visible particulate matter.


o Hazy - Can still see print and color through it but a little harder to read. Some

visible particulate matter. o Cloudy - Print can be seen through the urine but letters are distorted or blurry. o Turbid - Cannot see print or color at all.

Common Causes of Urine Cloudiness

Generally Normal Possibly Pathologic (Abnormal)

Amorphous phosphates (alkaline urine)

Normal crystals Amorphous urates (acidic urine) Squamous epithelial cells (in large numbers

could mean a poorly collected specimen)

Mucus Powders X-Ray Contrast

Abnormal crystals Red Blood Cells White blood cells Casts Fat Renal and Transitional Epithelial cells Bacteria in fresh urine Yeast Parasites Fungi

NOTE: Refrigerated specimens often become cloudy due to precipitation of amorphous

materials. When analyzing a refrigerated urine specimen, warm the specimen first by placing it in a container of warm tap water. This forces the precipitation back into solution.

ODOR

Although the odor of the urine specimen should be observed as part of the urinalysis, it is commented on or reported only if abnormal. It is not necessary to specifically smell each specimen. If there is an abnormal odor, you will detect it as soon as you remove the lid from the container.

ODOR DESCRIPTION POSSIBLE CAUSE

Aromatic to very little odor Ammonia Putrid or foul

Sweet or fruity

Normal Breakdown of urea by bacteria. Indication of an old specimen unsuitable for testing. Urinary tract infection

Ketone bodies, diabetes


SPECIFIC GRAVITY Specific gravity is defined as the density of a substance compared with the density of

distilled water at a certain temperature (usually 20 C) or around room temperature. As described in Chapter 1, urine is water which contains dissolved chemicals, and specific gravity is a measure of the density of the dissolved chemicals. Specific gravity will detect the kidney’s selection ability to reabsorb essential chemicals, an important function of the kidney. Specific gravity will detect possible dehydration or abnormalities in antidiuretic hormones. It also is used to determine whether specimen concentration is adequate to ensure the accuracy of chemical tests. Methods to Measure Specific Gravity: Refractometer: The refractometer is the most commonly used instrument to measure a specific gravity. NCCLS refers to the refractometer as the instrument of choice to determine specific gravity. The refractometer measures the velocity of light as it passes through different liquids compared to the velocity of light as it passes through air. It requires a very small volume of specimen and there is no correction needed for temperature. The refractometer is simple to operate and gives reliable results. Results are valid up to a specific gravity of 1.035. Above this, results should be reported only as greater than 1.035. Specific gravity greater than 1.035 suggests the presence of a large number of very dense chemicals such as glucose or radiographic compounds.

Instrument Prism Cover plate

A TYPICAL HANDHELD REFRACTOMETER

Note that in the sample view screen above, the specific gravity is measured on the far right, not on the middle scale. Information displayed in the view screen will vary depending on the brand of the instrument and what that instrument has been designed to measure (e.g. salt water, animal urine, etc.)

S.P. = total serum protein nD = refractive index U.G. = urine specific gravity


PROCEDURE FOR SPECIFIC GRAVITY BY REFRACTOMETER

1. Clean surface of instrument prism and cover by rinsing with water. Wipe dry with lint-free tissue or cloth.

2. Close the cover plate of the instrument. 3. Apply a drop of urine to the exposed portion of the prism at the notched bottom using a

disposable pipette. The liquid will be drawn automatically into the space between the prisms.

4. Hold the instrument up to a light source so that light passes over the chamber. 5. Looking through the eye piece, take the reading of the specific gravity scale at the

point where the dividing line between the bright and dark fields crosses the scale. 6. Rinse the chamber and cover with water and wipe dry.

According to NCCLS, the refractometer should be checked for calibration each day of use with distilled water. The water should read 1.000 ± 0.001. In addition, a control solution of known specific gravity should be tested. Commercially made controls, as well as solutions of 5% w/v saline (1.022 ± 0.001) or 9% w/v sucrose (1.034 ± 0.001), can be used for controls. All control values must be recorded. The Reagent Strip specific gravity method or colorimetric test is based on a chemical reaction that will cause an indicator to change color in the presence of sodium and chloride ions. Reagent strip specific gravity is easier and faster to perform than the refractometer or urinometer methods. There is no instrument to maintain and it requires less skill. Be aware that problems can occur. The reagent strips specific gravity method is based on ionization. Some substances do not ionize yet contribute to specific gravity. The specimen must be at room temperature. Very alkaline urine (high pH) may indicate a slightly lower specific gravity than the reagent strip indicates. These substances will read significantly lower with the reagent strip than the refractometer. The reagent strip specific gravity method is performed by dipping the reagent strip which contains a specific gravity portion in the urine sample and reading the color change. The color change corresponds to the values listed on the reagent strip bottle label. Specific Gravity Normal Values Newborn: 1.002 - 1.004 (random specimen) Adults: 1.005 - 1.030 (highest in morning) Middle Age and Over: Progressive decrease in specific gravity


Normally, specific gravity is proportional to color - the higher the specific gravity, the deeper the color. Exception: If a pale color appears with a high specific gravity, check for the presence of glucose. Specific Gravity Terms: Isothenurea: Urine with a specific gravity equal to the 1.010 specific gravity of

the plasma filtrate. This indicates the loss of the kidney’s concentrating and diluting functions.

Hyposthenuria: Urine with a specific gravity less than the 1.010 specific gravity of

the plasma filtrate. Hypersthenurea: Urine with a specific gravity greater than 1.010 specific gravity of

the plasma filtrate. Urinometer The Urinometer is another instrument that measures specific gravity. It is the most time-consuming method for specific gravity measurement. The Urinometer consists of a weighted float attached to a scale that has been calibrated for specific gravity. The float displaces disperses a volume of liquid equal to the weight and has been designed to sink to a level of 1.000 in distilled water. Accordingly, it will sink to the level influenced by the dissolved substances in the urine. Three major disadvantages occur by using the Urinometer method:

o It requires a large volume of specimen (at least 10-15 ml of specimen)

o The container in which the urinometer is floated must be large and wide enough to float without touching sides and bottom and the volume of urine varies with the size of the container.

o It is necessary to correct the Urinometer for temperature. Urinometers are

calibrated with distilled water at 20 C. If a specimen is cold 0.001 must be

subtracted from the reading for every 3 C that the specimen is below the calibrated temperature. On the other hand, 0.001 must be added to the reading for every 3 degrees that the specimen measures above the calibrated temperature.

Because of the above disadvantages, NCCLS considers the Urinometer an inaccurate method and discourages its use.


CHEMICAL REAGENT STRIP EXAMINATION OF URINE

CHAPTER 3

CHAPTER OBJECTIVES

Chapter 3 will focus on improving the quality of the urine reagent strip procedure:

o Know the proper care of reagent strips

o Review reagent strip technique and procedure

o Describe the test principle, results, and clinical significance of each chemical analyte

o Incorporate quality control as part of daily testing protocol

o Know the process of troubleshooting out-of-control results

REAGENT STRIP The invention of the reagent strip (dipstick) technology revitalized urinalysis. Reagent strips are convenient, cost effective, and relatively easy to use. Dipsticks contain from one to ten chemical test sites, each on an absorbent pad. When the dry reagents come in contact with urine, the reagents are activated and a chemical reaction occurs. The chemical reaction results in a specific color change. The color change is noted visually and compared with a color chart located on the side of the reagent strip bottle. The color intensity also may be measured by instruments manufactured to read reagent strips. The intensity of the color change is generally proportional to the amount of constituent present in the urine specimen. Some test areas are reported simply as positive or negative; other test areas semiquantitate the amount of constituent present.


USE AND CARE OF REAGENT STRIPS

o Store and use according to the manufacturer’s requirements.

o The small amounts of chemicals on the reagent strip are very susceptible to

moisture and light. Always replace the cap tightly on the strip bottle after removing a strip and do not remove desiccant packet from bottle.

o Reagent strips can absorb volatile fumes such as alcohol and bleach. This can

occur in the process of cleaning or disinfecting the counter top. Do not lay the strip pad side down on countertop.

o Do not touch the test pads with your fingers.

o Do not use reagent strips if the pads appear discolored.

o Never use expired reagent strips.

o Use strips within the time specified by the manufacturer after they are opened

(usually within 6 months). Write the date of opening on the bottle when it is opened.

o Reagent strips should be stored at room temperature. Do not refrigerate or

freeze.

o Keep strips in their original container; do not mix strips from different bottles.

o Remove only the number of strips needed at a time. Do not store them outside of the bottle.

o Never cut strips in half or alter them in any way.

PROPER TECHNIQUE AND PROCEDURE Although urine dipsticks are easy to use, errors can still occur due to faulty technique. Persons using reagent strips should:

o Understand the principle and specificity of each chemical test area.

o Be aware of precautions or interferences that can occur.

o Know the significance of positive or negative results.

o Follow procedures as designated by manufacturer.


All of the information listed above can be found in the manufacturer’s package insert provided with each bottle of strips. It is important to read this information thoroughly at least with each new lot of reagent strips. Each package insert has a revision date at the bottom right corner of the insert. If the revision date has changed, read the package insert carefully because there has been some type of change either with the procedure or the strips. It is important to save for record purposes one package insert from each lot and/or revision date to justify any changes in a procedure. During an inspection, a surveyor may ask to see source information on a specific lot of strips. General Procedure for Urine Reagent Strips Remember these key words for good technique:

mix dip remove excess

timing compare to color chart

Reagent Strip Procedure

1. Use a freshly voided, well mixed, uncentrifuged urine specimen at room temperature.

2. Remove one strip from the bottle and replace cap. Do not touch the test areas of

the reagent strip.

3. Dip the strip completely, but briefly into urine (not over 1 second). Remove immediately to avoid dissolving out of the reagent areas.

4. While removing, run the edge of the strip against the rim of the urine container to

remove excess urine. Avoid mixing of chemicals (run off) from adjacent reagent strip pads.

5. Compare reagent areas to the corresponding color chart on the bottle label.

Observe the specified time for reading each test result. Do this procedure in good lighting and hold the strip close to the bottle color chart to match colors carefully.

6. Record the following information on the patient report log and report form:

patient identification

test results in consistent units as established by your laboratory

date test was performed

time specimen was collected and time tested

initials of person performing test


Routine reagent strip tests include one or more of the following chemical screens: pH glucose specific gravity ketones protein bilirubin blood urobilinogen nitrite leukocyte esterase Tables I - X describe the test principle, test results, confirmatory tests (if any) and clinical significance of each chemical test pad.

TABLE I. PROTEIN

PRINCIPLE

1. “Protein-error-of-indicators” - Based on the ability of proteins to alter the color of some acid-base indicators without altering the pH.

At a constant pH, the development of any green color is due to the presence of protein.

2. Color change: Negative-yellow

Positive - green to blue

NORMAL

Negative or trace (less than 10 mg/dl)

RESULTS

FALSE POSITIVE 1. Skin cleansers containing chlorhexidine 2. Alkaline medications 3. Stale urine 4. Ammonia compounds (e.g. antiseptics &

detergents) 5. Highly buffered alkaline urine

CONFIRMATORY TESTS

Sulfosalicylic acid (Bumitest®)

NEEDED WHEN:

1. Globulin is suspected 2. Urine is highly colored 3. pH is alkaline 4. Results of strip are positive

CLINICAL SIGNIFICANCE

1. Glomerular membrane damage - albuminuria 2. Impaired tubular reabsorption 3. Bence-Jones protein-multiple myeloma 4. Diabetic nephropathy 5. Pre-eclampsia 6. Benign proteinuria – orthostatic-- strenuous

exercise 7. Hemoglobinuria 8. Leukocytosis 9. Leukemia


TABLE II. GLUCOSE

PRINCIPLE

1. Double sequential enzyme reaction 2. Reaction based on glucose oxidase that is specific for glucose-

will not detect other sugars 3. Color change blue to brown 4. Timing critical

RESULTS

Normal urine - negative

FALSE POSITIVES 1. Strong oxidizing agents (bleach, hydrogen peroxide)

2. Sensitivity is increased with very dilute urine 3. Reagent strips with improper storage

FALSE NEGATIVES 1. High specific gravity (> 1.020) especially if pH is also high 2. Ketone bodies 40 mg/dl or greater w/ a small amount of glucose 3. Aspirin 4. Ascorbic acid (Vitamin C) - 50 mg/dl or greater 5. Levadopa 6. 5-hydroxyindoleacetic acid 7. Homogentisic acid 8. Cold, refrigerated specimens

CONFIRMATORY TESTS

Clinitest®

NEEDED WHEN: 1. Ketone bodies are 40 mg/dl or greater 2. Glucose results to confirm and quantify 3. Pediatric specimens are screened (less than 2 years of age) to

check for galactose - a metabolic error resulting in physical toxemia and mental deterioration

4. Lactase intolerance is suspected 5. Other reducing sugars are suspected


1. Diabetes mellitus 2. Impaired tubular absorption due to advanced kidney failure 3. Latent diabetes mellitus discovered during 3rd trimester of

pregnancy 4. Central nervous system damage


TABLE III. KETONE

PRINCIPLE

1. Sodium nitroprusside reaction 2. Ketones produce a violet-to-purple colored complex 3. Does not react with β-hydroxybutyric acid 4. Ketones are products of fat metabolism. The test strip method

detects acetone, acetoacetic & β-hydroxybutyric-acid.

RESULTS


FALSE POSITIVES 1. Highly pigmented urine 2. BSP or PSP dye injection 3. Some urine preservatives 4. Levadopa metabolites 5. Mesna (2-mercapto-ethene sulfonic acid) FALSE NEGATIVES 1. Evaporation due to standing at room temperature


1. Management of diabetes mellitus 2. Development of acidosis in diabetics 3. Monitoring weight loss when fasting is involved


TABLE IV. BILIRUBIN

PRINCIPLE

1. Diazo reaction in which bilirubin is coupled with a diazonium salt in an acid medium to form azobilirubin.

2. Produces a tannish, purple-colored azobilirubin compound 3. Bile pigment from degradation of hemoglobin

RESULTS


FALSE POSITIVES 1. Urobilinogen (>4 Ehrlich units) 2. Chloropromazine (large doses) 3. Metabolites of phenazopyridine 4. Metabolites of iodine

FALSE NEGATIVES 1. Stale specimen exposed to light 2. Ascorbic acid (>25 mg/dl) 3. Presence of nitrites

CONFIRMATORY TEST

Ictotest®

NEEDED WHEN: 1. Positive results are obtained from the reagent strip 2. Urobilinogen is positive (4 or more Ehrlich units) 3. Red color is observed on the reagent strip 4. In doubt, due to color of urine 5. Physician is suspecting early phase of hepatitis and very small

amounts of bilirubin is sought (more sensitive than strip)


1. Bile duct obstruction 2. Liver disease - hepatitis 3. Gall bladder disease


TABLE V. BLOOD

PRINCIPLE

1. Reaction based on the liberation of 02 from H202 by the peroxidase-like activity of heme.

2. Color change: orange green blue 3. Intact red blood cells in urine - speckled green pattern on test strip.

Hemoglobin - solid color change. More sensitive to hemoglobin than to intact cells.

4. Timing is CRITICAL

RESULTS


FALSE POSITIVES 1. Oxidizing contaminants such as bleach (hypochlorite) 2. Contamination from provodine-iodine, which is used in surgical

procedures 3. Microbial peroxidase associated with urinary tract infections 4. Menstrual contamination

FALSE NEGATIVES 1. Captopril ingestion 2. Ascorbic acid ingestion (vitamin C) greater than 3 mg/dl 3. High specific gravity or high protein decreases the sensitivity of the

test 4. pH below 5 inhibits hemolysis of red blood cells 5. Menstrual contamination


1. Hematuria

a. renal calculi b. pyelonephritis c. glomerulonephritis d. tumors e. trauma f. toxic chemicals g. drugs h. strenuous exercise

2. Hemoglobinuria

a. hemolytic anemia b. transfusion reaction c. severe burns d. infection e. strenuous exercise

3. Myoglobin - acute destruction of muscle fibers. Possible cause:

strenuous exercise in an untrained person or trauma energy


TABLE VI. NITRITE

PRINCIPLE

DIAZO REACTION - based on the Griess test. 1. Some bacteria use nitrates, converting them to nitrite. (e.g. Escherichia coli or Pseudomonas sp.) 2. Nitrites react with p-arsanilic acid to form a diazonium

compound 3. Diazonium compound couples with 3-hydroxy-1, 2, 3, 4

tetrahydrobenz-(h)-quinoline 4. Positive test with any degree of uniform pink color

RESULTS


FALSE-POSITIVES 1. Stale urine 2. Pink spots or pink edges interpreted as positive

FALSE-NEGATIVES 1. Dilute urine 2. Random specimens 3. Ascorbic acid levels > 25 mg/dl 4. Urine retained in bladder less than 4 hours that has not had enough time or the reduction from nitrate to nitrite 5. Lack of sufficient dietary nitrate 6. Reduction of nitrite to nitrogen which is not detectable by the test pad 7. Inhibition of the metabolism of bacteria due to antibiotic therapy 8. Infections with non-nitrate reducing bacteria (e.g. Enterococcus faecalis). 9. Yeast infections


1. Cystitis 2. Pyelonephritis 3. Monitor antibiotic therapy 4. Screen high risk patients 5. Screen urine culture specimens 6. Asymptomatic urinary tract infections


VII. UROBILINOGEN

PRINCIPLE

1. Reaction is based on the Ehrlich aldehyde reaction

2. Color change: tan orange brown 3. Reported as Ehrlich units 4. A bile pigment that results from degradation of hemoglobin

TEST RESULTS

Normal urine - up to 1 Ehrlich unit

FALSE-POSITIVES 1. Substances known to react with Ehrlich’s reagent:

p-aminosalicylic acid & sulfonamides 2. High concentrations of p-aminobenzoic acid 3. Drugs containing azo dyes 4. Methyldopa (Aldomex) 5. Urine tested at body temperature

FALSE-NEGATIVES 1. Use of stale urine that has been exposed to light 2. Formalin preservative


1. Liver function

2. Hepatitis

3. Cirrhosis

4. Hemolytic disorders that produce red blood cell destruction

such as hemolytic anemia and megaloblastic anemia.

5. Porphobilinogen - requires confirmation with Hoesch test before reporting


TABLE VIII. LEUKOCYTE ESTERASE

PRINCIPLE

1. Reaction is enzymatic, using the esterase present in the granules of granulocytic white blood cells. Granulocytic white blood cells are present in response to a bacterial infection.

Indoxyl carboxylic acid ester esterase indoxyl

oxidation indigo blue

RESULTS


FALSE POSITIVE

1. Strong oxidizing agents - Vaginal contamination

FALSE NEGATIVE 1. Elevated glucose levels (>3g/dl) - Decreased sensitivity 2. High levels of ascorbic acid and protein 3. High specific gravity - decreased sensitivity 4. White blood cells other than granulocyte - (e.g. lymphocytes) 5. Antibiotics - cephalosporin and tetracycline


Urinary tract infections


TABLE IX. SPECIFIC GRAVITY

PRINCIPLE

1. Measures ionic concentration.

Reaction based on the change in pKa (dissociation constant) of methyl vinyl-ether-maleic anhydride.

2. The polyelectrolytes dissociate in proportion to the number

of ions in solution. Hydrogen ions produce a pH change that is detected by the indicator bromthymol blue.

3. As specific gravity increases, bromthymol blue changes

from blue-green to green and finally to yellow-green. 4. Assuming the kidney is functioning normally, when urine

volume is high, specific gravity is low and vice versa.

RESULTS

Normal random specimens may range from 1.005 to 1.030 depending upon the patient’s degree of hydration. Causes of lower readings relative to the refractometer or urinometer methods: 1. Highly buffered urines (urine pH of 6.5 or over may

interfere with strip). Therefore, it is recommended that 0.005 be added to specific gravity readings in this pH range.

2. Substances that do not ionize (e.g. X-ray contrast, glucose)

CONFIRMATORY TEST

Refractometer

Urinometer

When urine appearance and amount of constituents do not correlate with reagent strip reactions.


1. State of patient hydration and dehydration 2. Loss of renal tubular concentration ability 3. Diabetes insipidus 4. Determination of unsatisfactory specimens due to low

concentration


TABLE X - pH

PRINCIPLE

1. Double-indicator system using methyl red and bromthymol

blue

2. Color change: pH 5 (yellow) through pH 9 (blue)

NORMAL VALUES

Must be considered in conjunction with other patient information

Random samples - 4.5 - 8.0

First morning - 5.0 - 6.0

Improperly preserved specimen - 9.0

FALSE POSITIVE

“Runover” phenomenon between pH testing area and the adjacent, highly acidic protein testing area produces a false acidic reading in alkaline urine.


1. Respiratory acidosis 2. Metabolic alkalosis 3. Defects in renal tubular secretion and reabsorption of acids

and bases 4. Helps identification of crystals 5. Management of urinary tract infections- maintenance of an

acidic urine 6. Determination of unsatisfactory specimens 7. Persistently alkaline - fresh voided specimen - is indicative of

a urinary tract infection


QUALITY CONTROL (QC)

It is part of good laboratory practice to ensure the reliability of laboratory test results. Quality control (QC) validates the testing process which incorporates testing technique, color interpretation and the integrity of the strip. If a facility uses a reagent strip instrument that analyzes the strip reactions (another variable), it is required by federal laboratory regulations (CLIA-88) to perform QC each day of testing. Proficiency testing (external QC) is also a requirement if the automated readers are used. There are specific personnel requirements for moderate complexity laboratories.

The Ames Multistix package insert states:

“For best results, performance of reagent strips should be confirmed by testing known negative and positive specimens or controls whenever a new bottle is first opened, randomly, or if questionable results are obtained. Each laboratory should establish performance standards and should question handling and testing procedures if these standards are not met.”

The laboratory must be sure that the results it reports for any analysis are clinically correct. This is done primarily through the use of a QC program. The program makes use of control specimens. The control specimen is similar in composition to patient specimens. A negative and positive control ideally should be run once per day of testing. The control must be carried through the entire test procedure and treated in the same manner as patient specimens. Accurate control results indicate an overall reliability of the patient results tested during that time period.

Controls are usually purchased commercially. They can be ready to use or in dried (lyophilized) form. Care must be taken in reconstituting dried material to add the correct amount of distilled or deionized water and then to make certain that the material is completely dissolved and well mixed.

For small laboratories such as health departments or physician office laboratories, it is recommended that the control material be purchased premixed. Small laboratories may not have pipettes or deionized/distilled water available which is required for reconstitution of dried control material.

DOCUMENT! DOCUMENT!! DOCUMENT!!! All QC results must be documented immediately on a log or chart or in a computer. The chart, whether it is manually recorded or computerized, should include the following information: Name and location of laboratory site Control Material Information: Test title (e.g. Urinalysis Control Chart) Control level - Normal and Abnormal Date tested Manufacturer Time collected or (Time In) / Time out Lot number Initials of who tested control Expiration Date Control Results Control Ranges

Corrective Action (may be separate form) Reagent Strip information:

Name Manufacturer Lot Number Expiration Date


The above information is necessary for regulatory purposes, but more importantly, it is necessary for troubleshooting errors before they affect patient results. Taking action on shifts and trends before the test results are out-of-control can be a time and money saver. This information will also serve as proof for reimbursement of faulty reagent strips or controls. Example of chart format:

URINALYSIS QUALITY CONTROL LOG

CLINIC SITE:

TEST USED QUALITY CONTROL MATERIALS

Product:

Manufacturer:

Lot No.:

Opened Date:

Expiration Date:

Product:

Manufacturer:

Lot No.:

Opened Date:

Expiration Date:

RESULTS

mg/dl

100-500 sm – 1g tr – 1g

1.010 - 1.020

sm – 1g 6.0 – 7.5 tr – 100 1 – 8 mg/dl

Pos sm – 1g

Date Tested

Glucose Bilirubin Ketone SP/gr Blood pH Protein URO Nitrite Leuk Init

QUALITY CONTROL CORRECTIVE ACTION

DATE

PROBLEM

ACTION

FOLLOW UP


TROUBLE SHOOTING OUT-OF-CONTROL RESULTS If the control specimen is not within an acceptable range (as stated by the manufacturer or determined by each site statistically) it must be assumed that the values obtained for patients are clinically incorrect. The test procedure must be reviewed for errors. This is called troubleshooting. All patient testing must stop until the error(s) are found and corrected. All laboratories should develop a written protocol for troubleshooting problems that eliminates each variable one at a time.

Common Sources of Error: 1. Allowing the strip to remain in the urine for an extended period of time may cause

dissolving of reagents from the test areas. 2. Excess urine remaining on the strip after its removal from the specimen can

produce run-over between chemicals on adjacent pads which can distort the colors. This happens particularly with pH and protein.

3. Lack of attention to timers: Timing is critical to the chemical reactions and so

often is ignored. Follow the manufacturer’s recommendations for timing. Generally the timing ranges from immediate, up to 2 minutes.

4. Different interpretations of color from one person to another. A good light source

is essential. 5. Interpreting test results on deeply colored urine. 6. If a cap is left off the reagent strip bottle, reagent strips will become faulty.

Always take out only what is needed and seal bottle with a tight snap. 7. Urine tested immediately after refrigeration without allowing time to come to room

temperature. 8. Inconsistent reporting (e.g. 1+, 1/4 g/dl, 250 mg/dl). It is confusing to the health

care providers if employees at a site do not report in the same units. 9. Use of outdated or deteriorated reagent strips on patient specimens.

10. Faulty instrument or equipment.

11. Transcription errors. Patient identity must be maintained throughout the testing process.

Remember to document the problem and all action taken to find and correct the problem, and any necessary follow-up. Inspectors know that problems occur in the best of laboratories. It is how the problem is solved that is important. The diagram below is a general laboratory troubleshooting protocol.


OUT-OF-CONTROL PROTOCOL

1. RUN MATERIAL

In Control Out of Control

Proceed with patient testing STOP. Go to Step 2.

2. INSPECT CONTROL: outdate, proper storage, lot number, signs of contamination

Problem found No obvious problem

Obtain new control bottle and retest Retest same control


Proceed with testing Go to Step 3

3. OBTAIN NEW CONTROL BOTTLE AND RETEST


Discard old control and proceed with patient testing

Go to Step 4

4. INSPECT REAGENT STRIPS: outdate, proper storage, lot number, signs of contamination

Problem found No obvious problem

Open new bottle and retest with new control

Proceed to Step 5

5. OPEN NEW BOTTLE OF STRIPS AND RETEST WITH NEW CONTROL


Discard bad reagent strips and proceed with testing

Obtain a different lot number of

strips and retest


Discard bad lot of strips, notify manufacturer and

proceed with testing.

Notify supervisor.

Do not proceed with testing.

NAME: ________________________________


INTRODUCTION TO URINALYSIS

Chapter 1

MULTIPLE CHOICE: CIRCLE THE LETTER CORRESPONDING TO THE BEST ANSWER

1. The primary chemical constituents of normal urine are:

a. water, protein, sodium b. water, urea, protein c. water, urea, chloride d. water, urea, bilirubin

2. A non-preserved specimen is delivered to the lab at 1:00 P.M. It is not tested until 4:00

P.M. Without refrigeration, which of the following problems may occur?

a. pH decreased b. glucose decreased c. bilirubin increased d. nitrite decreased

3. The most routinely used method of urine preservation is:

a. commercial preservation tablets b. freezing c. refrigeration d. boric acid

4. Which of the following are rules that apply to urine specimen acceptability:

1. specimen must be labeled with name, date and time of collection on the container lid 2. urine specimen collected preferably within one hour but will accept up to 2 hours without

preservation 3. urine preservative should be noted in case there is an interference with the urinalysis

results 4. a minimum acceptable quantity of urine specimen is 30 ml 5. container should be clean, leak proof and free of particulate matter

a. all are correct

b. 1, 2, 4, and 5

c. 2, 3, and 5

d. 2, 3, and 4


5. Which of the urine specimens listed below is preferred for a urine culture?

a. random b. clean catch (midstream) c. first morning d. 2-hour postprandial

6. The urine specimen of choice for routine urinalysis is:

a. random b. first morning c. 2-hour postprandial d. 1 hour postprandial

7. Caffeine consumption can expect to produce:

a. proteinuria b. polyuria c. pyuria d. oliguria

MATCHING: WRITE THE APPROPRIATE LETTER(S) IN THE SPACES PROVIDED

8. Match the following terms with the definition nocturia

a. occult blood in urine

anuria

b. increase in urine output at night

dysuria

c. WBC's in urine

glycosuria

d. stoppage of urine flow

pyuria

e. painful urination

__ hematuria

f. glucose present in urine

__ diuretic

g. agent that increases the formation of

urine urinalysis

h. physical, chemical and microscopic

analysis of urine

SHORT ANSWER: COMPLETE THE BLANK

9. The text lists four factors that influence urine volume. List three of these factors.

a.

b.

c.


10. A decrease in the normal urine volume is termed: _

Give two causes of decreased urine volume: a.

b.

11. Explain why a first morning urine specimen is preferred over a random urine specimen.

12. Which specimen type does the text give as an excellent routine screening specimen?

Describe the collection procedure for this type of specimen:

13. What is the primary cause of decomposition of urine after 1 hour at room temperature?

NAME: ________________________________


BIOHAZARDOUS SAFETY/PHYSICAL EXAMINATION OF THE URINE

Chapter 2 MULTIPLE CHOICE: CIRCLE THE LETTER CORRESPONDING TO THE BEST ANSWER 1. The yellow color of urine is due to:

a. urobilinogen

b. urochrome

c. hemoglobin

d. bilirubin

2. Specimens that contain intact red blood cells can be visually distinguished from those that contain hemoglobin, because:

a. hemoglobin produces a much brighter red color

b. hemoglobin produces a cloudy-pink specimen

c. red blood cells produce a cloudy specimen

d. red blood cells lyse and are converted to hemoglobin

3. The observation of a strong ammonia odor of a urine specimen is caused by:

a. diabetes mellitus

b. improper handling & storage

c. urinary tract infection

d. ingestion of certain food

4. A means of handling blood, body fluids or any specimen containing visible blood as if it were infectious is referred to as:

a. universal prudence

b. universal precautions

c. contamination control

d. exposure determination

5. If a urine specimen received by a laboratory yields a specific gravity reading of 1.000, you should:

a. proceed with urinalysis

b. recollect specimen

c. report results to physician immediately


6. Which specific gravity would most likely correlate with dark yellow urine?

a. 1.005

b. 1.010

c. 1.020

d. 1.030

7. Area of the laboratory where potentially infectious specimens are tested or stored should be identified with:

a. barium protection

b. red/orange biohazard symbol

c. NCCLS guidelines

d. MSDS Chart

8. Urine with a specific gravity of less than 1.010 is referred to as:

a. hypersthenuria

b. hyposthenuria

c. isosthenuria

d. hypotonic

9. The appearance of urine in which print can be seen but letters are blurry is reported as:

a. opaque

b. hazy

c. cloudy

d. turbid

10. Which of the following is considered a generally normal cause of urine cloudiness:

a. casts

b. amorphous phosphates

c. renal epithelial

d. yeast

11. When leaving the laboratory after working with specimens:

a. disposable gloves should be washed so they can be reused

b. keep disposable gloves on if you are immediately returning to the lab

c. properly discard disposable gloves and wash your hands


TRUE OR FALSE: CIRCLE THE CORRECT RESPONSE 12. A fruity odor of a urine specimen is indicative of a Pseudomonas infection. a. True b. False 13. A ten-to-one ratio of water to household bleach can be used for the cleaning of a urine

spill. a. True b. False 14. In general, computers, telephones, and desk areas of the urinalysis section should be

considered “clean.” a. True b. False 15. Refrigerated urine specimens should be tested while still at a cold temperature to

preserve any formed elements. a. True b. False


16. Match the following urine colors with the most likely cause:

Causes bilirubin

Color a. straw

red blood cells b. dark yellow

melanin c. brown (with yellow foam)

dilute urine d. cloudy red

pyridium e. green

Pseudomonas infection f. orange

concentrated urine g. clear cherry red

porphyrines h. red/purple

hemoglobin i. brown-black (upon staining)



17. The density of a substance compared with the density of a similar volume of distilled water at a similar temperature is called:

18. List two types of personal protective equipment that should be worn while working in the urinalysis laboratory:

a.

b.

19. List 6 general laboratory safety policies mentioned in this Chapter. Then, in your opinion, rate them in importance to you. (1 - Most important; 6 - Least important)

a.

b.

c.

d.

e.

f.

20. The instrument which measures the velocity of light as it passes through different liquids and compares it to the velocity of light through air is called a:

NAME: ________________________________


CHEMICAL EXAMINATIONS OF THE URINE

Chapter 3

MULTIPLE CHOICE: CIRCLE THE LETTER CORRESPONDING TO THE BEST ANSWER

1. The pH of normal random urine samples can range from:

a. 4.5 - 8.0

b. 5.0 - 6.0

c. 3.0 - 9.0

d. 6.0 - 8.0

2. Which of the following is not a reason for the measurement of urine pH?

a. assessment of specimen acceptability for examination

b. indication of urinary tract infection

c. crystal identification

d. indication of proteinuria

3. Which of the following proteins is associated with proteinuria due to glomerular damage?

a. albumin

b. gamma globulin

c. hemoglobin

d. Tamm-Horsfall

4. Reagent strips should be discarded in all of the following situations, except:

a. one day after the expiration date

b. unexpired bottle opened for one month kept tightly capped

c. strips stored outside the bottle

d. reagent strips appearing damp

5. A urine specimen is received in the laboratory with a pH of 9.0. What does this indicate?

a. the patient is in metabolic acidosis

b. a fresh specimen needs to be collected

c. the patient is on a medication which raises urine pH

d. the patient drank a large quantity of cranberry juice

6. Which of the following is not detected by reagent strip test for blood?

a. hemosiderin

b. hemoglobin

c. myoglobin

d. red blood cells


7. Finding leukocyte esterase in the urine is most useful in the detection of:

a. early renal transplant rejection

b. immunosuppression

c. malignancy

d. urinary tract infection

8. Children under 2 years of age should be screened with Clinitest® along with the reagent

strip method because:

a. pediatric specimens have smaller amounts of glucose than is detectable on

the reagent strip

b. the presence of ascorbic acid having a greater effect on children’s urine

specimens

c. screen for galactosuria

d. sucrose overdose in young children

9. Urine screen tests for bilirubin is primarily used to detect:

a. hormone production

b. red cell destruction

c. liver disease

e. uremic poisoning

10. Tests for urobilinogen may be used to assess:

a. hormone production

b. kidney function

c. liver function

d. red cell destruction

e. c and d

11. Ascorbic acid can interfere with all of the following reactions, except:

a. glucose

b. occult blood

c. protein

d. bilirubin

e. nitrite

12. Which of the following breakdown products of hemoglobin appears normally in the urine

at a concentration of 1 mg/dl?

a. porphobilinogen

b. urobilinogen

c. uroporphyrin

d. coproporphyrins


13. If a patient is put on a high protein or fasting diet, what urine test would most likely be positive to prove the patient is cooperating with the diet?

a. urobilinogen b. ketones c. protein d. glucose

14. If a urine specimen has a dark yellow or amber color and foam appears when it has been shaken, what would you suspect to appear positive on the reagent strips?

a. occult blood b. bilirubin c. urobilinogen d. protein

15. If a urine specimen is found to have a 4+ glucose on the reagent strip, what other test will most likely be positive?

a. blood b. urobilinogen c. bilirubin d. ketones

16. In the routine urinalysis, the term ketones refers to all of the following, except:

a. acetone b. acetoacetic acid c. phenylketones d. beta-hydroxybutyric acid

17. According to this chapter, the reactivity of reagent strips should be checked:

1. at least daily when urinalysis is performed 2. when a new bottle is opened 3. using positive controls 4. using positive and negative controls

a. 1, 2, and 3 b. 3 and 5 c. 1, 2, and 4 d. 2 only

18. Which of the following variables could cause a quality control result to be out-of-range?

a. contaminated control specimen b. bottle of reagent strips c. the entire lot of reagent strips d. dipping technique e. a, b, and d f. all of the above


19. The urine reagent strip package insert contains information on which of the following:

a. chemical principles

b. urinalysis procedure

c. quality control

d. storage

e. interfering substances

f. all of the above

g. a, d, and e


20. Match the following chemical reactions with the corresponding urine constituent.

(Letters may be used more than once).

_____ double indicator system

a.

glucose

_____ double sequential enzyme reaction based on glucose oxidase

b.

blood

_____ Ehrlich’s reaction

c.

ketones

_____ “protein error of indicators”

d.

pH

_____ reaction with sodium-nitroprusside

e.

bilirubin

_____ diazo reaction

f.

nitrite

_____ granulocyte esterase

g.

urobilinogen

_____ Griess reaction

h.

leukocyte esterase

_____ peroxidase activity of heme

i.

protein

TRUE OR FALSE: CIRCLE THE CORRECT REPONSE

21. Always replace the cap of the urine strip bottle and remove the packet of desiccant.

a. True b. False

NAME: ________________________________


FINAL EXAMINATION

SESSION I

REAGENT STRIP URINALYSIS

MULTIPLE CHOICE: CIRCLE THE LETTER CORRESPONDING TO THE BEST ANSWER 1. Which of the following analytes would be suspected in a urine specimen with a red color

and clear appearance?

a. bilirubin b. red blood cells c. hemoglobin d. porphobilinogen

2. Loss of the kidney’s ability to concentrate and dilute urine will result in a fixed specific

gravity of:

a. 1.005 b. 1.010 c. 1.015 d. 1.020

3. What is the term that describes the above condition? _________________________ 4. According to OSHA, urine is considered to be a biohazard if it contains:

1. blood 2. urobilinogen 3. bilirubin 4. nitrite

a. 1 b. 1 and 3 c. 1, 3, and 4 d. all are correct

5. Which of the following organic urine constituents is excreted daily at constant amount

and is not related to diet?

a. urea b. creatinine c. uric acid d. ammonia

6. A total lack of urine flow is called:

a. polyuria b. oliguria c. nocturia d. anuria


7. A specimen is received by the laboratory from a patient collected at home with what appears to be an oily film. You should:

a. perform the urinalysis and report results b. perform the urinalysis noting the oily film c. recollect the specimen. It may be contaminated d. remove the oily film, then perform urinalysis procedure

8. A well organized urinalysis laboratory should have which of the following: (Choose the

best response.)

1. work area with good lighting 2. a microscope 3. running water at easy reach 4. counter top constructed of nonporous material with neutral color 5. urine centrifuge 6. distilled water available

a. 1, 2, 3, 5, and 6 b. 1, 2, 3, and 4

c. 1, 2, 4, and 5 d. all are correct

TRUE OR FALSE: CIRCLE THE CORRECT REPONSE

9. A urine specimen can be stored in the health facilities refrigerator that contains the

employees’ lunches only if it is clear and yellow. a. True b. False

10. Disposable latex gloves and a buttoned lab coat (at a minimum) should be worn while working with urine specimens. a. True b. False

11. An unlabeled specimen should be accepted for testing if it is accompanied with a test requisition. a. True b. False

12. Timing is a critical part of the urine reagent strip procedure. a. True b. False

13. While removing the reagent strip from the specimen, run the edges of strip against the rim to remove excess urine. This helps to prevent chemicals from coming in contact with each other (run off). a. True b. False


MATCHING: WRITE THE APPROPRIATE LETTER(S) IN THE SPACES PROVIDED 14. Match the following concerning the methods of specific gravity measurement.

(More than one letter may go in a blank.) measures all dissolved substances a. urinometer measures only substances that ionize b. refractometer values affected by temperature of the urine specimen c. reagent strip values affected by the presence of radiographic contrast media measurement requires relatively large urine volume NCCLS method of choice

15. Match the chemical test pad with the substances that could produce a false test reaction. (Letters may be used more than once.)

protein a. protein test pad run over

urobilinogen b. substances that do not ionize

glucose c. high levels of ascorbic acid

pH d. skin cleansers containing chlorhexidine

bilirubin e. levadopa metabolites

ketone f. bleach

specific gravity g. formalin preservative

blood

nitrite


16. List 4 requirements for preserving integrity of the reagent strips.

17. According to NCCLS, the specimen of choice for a routine urinalysis is:

18. Why is refrigeration a good urine preservative?


CASE STUDY

19. A routine urinalysis is performed on urine from a 40-year old woman as part of a physical required for employment. The results are as follows:

PHYSICAL APPEARANCE CHEMICAL SCREENING

Color: Amber pH: 9.0

Appearance: Cloudy Specific gravity: 1.005

Odor: Ammonia-like Protein: Trace

Glucose: Negative

Ketones: Negative

Bilirubin: Negative

Occult blood: Negative

Nitrite: Positive

Leuk. Est.: Negative

Results are reported to the physician and the patient is prescribed an antibiotic for a urinary tract infection.

Did the patient, most likely, need the antibiotic prescribed?

( ) Yes ( ) No In two sentences or less, explain why:

20. List the nine categories of information that should be included on a quality control log or chart.

PARTICIPANT REGISTRATION FORM

Please complete the following information and return to Training & Evaluation with payment and completed exams.

REQUIRED INFORMATION

1. Name of participant:

2. Home address: Street:

City: State: Zip:

3. Home phone: Email:

4. Professional title: ____ MT ____ MLT ____ CLA(CLT) ____ RN ____ LPN

____ PAC-C ____ MED. ASST. ____ RT ____ DO ____ MD

5. Facility (current employer):

6. Facility address: Street:

City: State: Zip:

7. Facility phone: Fax:

8. Type of facility (check one): ____ Reference lab ____ POL/Group practice ____ Health Dept

____ Hospital ____ Primary care ____ Rural health clinic ____ Other (specify):

VOLUNTARY INFORMATION (REQUESTED FOR RESEARCH AND TRAINING PURPOSES)

9. Formal education (check highest level completed):

____ High school ____ Some college (# of yrs ____ ) ____ Master’s degree

____ Hospital training program ____ Associate degree ____ Other (specify):

____ Vocational training program ____ Bachelor’s degree

10. Length of laboratory experience: months / years

11. Clinical laboratory practitioner’s license: Number: Category:

12. Does your facility have a CLIA-88 certificate to perform laboratory testing? ( ) YES ( ) NO

In what complexity category?

____ High ____ Moderate ____ Other accreditation (specify):

____ Waived ____ Physician performed microscopy

13. Does your facility have a procedure manual designed for your facility? ( ) YES ( ) NO

14. Do you currently have a written QA plan or policy? ( ) YES ( ) NO

15. Does your laboratory have any QA monitoring activities either in progress now or in the past? ( ) YES ( ) NO

If “Yes”, list the QA monitoring activities:

WV OFFICE OF LABORATORY SERVICES

TRAINING & EVALUATION SECTION

COURSE EVALUATION

URINALYSIS – SESSION I

(COMPLETION IS VOLUTNARY – REQUESTED FOR RESEARCH AND TRAINING PURPOSES)

How did you find out about this course?

PLEASE RATE EACH OF THE ITEMS BELOW USING THE FOLLOWING SCALE: Excellent Good Acceptable Marginal Poor

5 4 3 2 1

HOW SUCCESSFUL WAS THIS COURSE IN:

Increasing you knowledge and/or skills in the subject matter presented? 5 4 3 2 1

Providing material that is directly applicable to your work? 5 4 3 2 1

Meeting the stated objectives? 5 4 3 2 1

How worthwhile was this program in terms of time and money invested? 5 4 3 2 1

Overall, I consider this course: 5 4 3 2 1

1. What would you add to this course to make it more beneficial to you?

2. What would you delete from this course?

3. Based on what you learned in this course, do you intend to make any changes in your laboratory practices? ( ) YES ( ) NO

4. Which type of course do you prefer? ( ) Correspondence ( ) One day workshop/seminar held at various locations throughout the state

5. Suggestions for topics of future courses:

OPTIONAL INFORMATION

Name:

Clinical laboratory practitioner category (CLP) (please check one): ( ) MT ( ) MLT ( ) POCT ( ) CYTO

CLP license number: If not CLP licensed, other:

STATE OF WEST VIRGINIA DEPARTMENT OF HEALTH … · STATE OF WEST VIRGINIA ... glomerular...

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