Specimen Collection: Sputum (Home Health Care) - CE

ALERT

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

Bronchospasm or laryngospasm, as a result of suctioning, can be severe and prolonged, and, in some cases, can be life-threatening without intervention.

OVERVIEW

Sputum is produced by cells that line the respiratory tract. Although production is minimal in the healthy patient, disease processes can increase the amount or change the character of sputum. Examination of sputum aids in the diagnosis and treatment of many conditions such as bronchitis, bronchiectasis, tuberculosis (TB), pneumonia, and pulmonary abscess, or lung cancer.^{undefined#ref2">2}

In many cases, suctioning is indicated to collect sputum from a patient who cannot spontaneously produce a sample for laboratory analysis. Suctioning may provoke violent coughing, induce vomiting, and result in aspiration of stomach contents. Suctioning may also induce constriction of the pharyngeal, laryngeal, and bronchial muscles. In addition, suctioning may cause hypoxia or vagal overload, causing cardiopulmonary compromise and an increase in intracranial pressure.

Sputum for cytology, culture and sensitivity, and acid-fast bacilli (AFB) are three major types of sputum specimens.² Cytologic or cellular examination of sputum may identify aberrant cells or cancer. Sputum collected for culture and sensitivity testing can be used to identify specific microorganisms and determine which antibiotics are the most sensitive. The AFB smear is used to support a diagnosis of TB. A definitive diagnosis of TB also requires a sputum culture and sensitivity.²

Regardless of which sputum test is ordered, a sputum specimen should be collected first thing in the morning due to a greater accumulation of bronchial secretions overnight.

SUPPLIES

See Supplies tab at the top of the page.

EDUCATION

• Provide developmentally and culturally appropriate education based on the desire for knowledge, readiness to learn, and overall neurologic and psychosocial state.
• Explain to the patient, family, and caregivers how and why the specimen is being collected.
• Explain to the patient, family, and caregivers the need to obtain a specimen that is not contaminated with saliva or oropharyngeal secretions.
• Explain to the patient, family, and caregivers the difference between secretions and sputum.
• Instruct the patient not to clean teeth or use mouthwash before collecting an AFB specimen because this may kill the bacteria.
• Demonstrate the proper splinting technique for a postoperative patient or a patient with a weak cough.
• If an aerosol treatment is indicated, explain the purpose of the procedure, and inform the patient, family, and caregivers that the aerosol will stimulate coughing and sputum expectoration.
• Encourage questions and answer them as they arise.

PROCEDURE

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient, family, and caregivers.
3. Verify the correct patient using two identifiers.
4. Explain the procedure to the patient, family, and caregivers and ensure that the patient agrees to treatment.
5. Verify the practitioner’s order and assess the patient for pain.
6. Prepare an area in a clean, convenient location and assemble the necessary supplies.
7. Check the practitioner’s orders for the type of sputum analysis and specifications (e.g., amount of sputum, number of specimens, time of collection, method to obtain).
8. Assess the patient’s level of understanding of the procedure and its purpose.
9. Determine when the patient last ate a meal or had a tube feeding.

   Rationale: Suctioning or coughing up secretions can trigger the gag reflex. If a patient has recently eaten, this may also trigger vomiting.

10. Assess the patient’s respiratory status, including respiratory rate, depth, pattern, and color of mucous membranes.
11. Determine the patient’s ability to assist with the collection of the specimen.
12. Gather the necessary supplies, including the appropriate PPE.

    Take airborne precautions when caring for a patient who is suspected of having TB or other airborne transmissible diseases.

13. Position the patient in the high-Fowler or semi-Fowler position for specimen collection.

    Rationale: The high-Fowler or semi-Fowler position promotes full lung expansion and facilitates the ability to cough.

14. Instruct a patient who has an operative or invasive incision or localized area of discomfort to place hands firmly over the affected area or to place a pillow over the affected area (as applicable).

Sputum Collection Using the Coughing and Expectorating Method

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Provide the patient with the appropriate sterile specimen container. Instruct the patient not to touch the inside of the container.

   Rationale: Touching the inside of the sterile container may compromise the laboratory test results.

3. Instruct the patient to take a slow deep breath and to cough after a full inhalation.

   Rationale: Expectorant must come from the lungs. Saliva is not sputum.²

4. Instruct the patient to expectorate sputum directly into the sterile specimen container.
5. Instruct the patient to repeat coughing until a sufficient quantity, a minimum of 5 ml of sputum, is collected.²
6. Secure the top on the specimen container tightly.
7. Wipe any sputum present on the outside of the container with a disinfectant wipe.

   Ensure that the container is tightly closed before wiping to prevent contaminating the specimen.

8. Offer tissues after the patient expectorates. Dispose of the tissues in an appropriate waste receptacle.
9. Offer the patient mouth care, if desired.
10. In the presence of the patient, label the specimen per the organization’s practice.¹
11. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
12. Observe and monitor the patient’s respiratory status throughout the procedure, especially during suctioning.

    Rationale: Excessive coughing can alter the patient’s respiratory pattern and cause hypoxia.

13. Observe the patient for anxiety or discomfort.

    Rationale: The procedure can be uncomfortable. Anxiety may develop if the patient becomes short of breath.

14. Assess pain, treat if necessary, and reassess.
15. Discard or store supplies, remove PPE, and perform hand hygiene.
16. Document the procedure in the patient’s record.

Sputum Collection Using Suctioning

1. Perform hand hygiene and don gloves. Don additional PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.

   Take airborne precautions when caring for a patient who is suspected of having TB or other airborne transmissible diseases.²

2. Prepare the suction machine or device, if available, and ensure that the suction source is functioning properly.
3. Open a new flexible sterile suction catheter.
4. Connect the flexible sterile suction catheter to the rubber tubing on the sputum trap using aseptic technique.
5. Open and pour 0.9% sodium chloride solution or a water-soluble lubricant into the sterile tray of the suction catheter.
6. Remove gloves, perform hand hygiene, and don sterile gloves.
7. Apply 0.9% sodium chloride solution or water-soluble lubricant to the end of the flexible suction catheter.
8. Instruct the patient to breathe normally during the suctioning procedure to prevent hyperventilation. Explain to the patient that the catheter may trigger the cough reflex.

   Rationale: Entering the larynx and trachea triggers the cough reflex.

9. Gently insert the tip of the flexible suction catheter through the patient’s nasopharynx, endotracheal tube, or tracheostomy tube without applying suction.

   Rationale: Inserting the tip of the flexible suction catheter without applying suction minimizes hypoxia and trauma to the patient’s airway as the catheter is inserted.

10. Advance the flexible suction catheter into the trachea gently and quickly.
11. Apply suction to the catheter by placing the thumb of the nondominant hand over the suction port of the flexible suction catheter for 10 to 15 seconds as the patient coughs.³ Collect 5 to 10 ml of sputum.²
12. Apply suction only while withdrawing the catheter from the insertion site. Maintain sterility when suctioning the endotracheal or tracheostomy tube site.

    Limit the duration of each suction pass to less than 15 seconds and limit the number of passes to a maximum of three to help minimize hypoxia, airway trauma, and cardiac arrhythmias.³

    If the patient becomes hypoxic during the suctioning procedure, discontinue suctioning immediately and provide supplemental oxygen.

13. Release the suction and withdraw the suction catheter.

    Rationale: Suction can damage mucosa if applied during withdrawal.

14. Turn off the suction source.
15. Evaluate the patient immediately after the suctioning procedure. Note if the patient has any dyspnea or signs of hypoxia.
16. Detach the suction catheter from the specimen trap. Dispose of the flexible suction catheter in an appropriate receptacle.
17. Detach the suction tubing and connect the rubber tubing on the sputum trap to the plastic adapter (Figure 1).
18. Wipe off any sputum present on the outside of the sputum trap with a disinfectant wipe.

    Ensure that the sputum trap is tightly sealed before wiping to prevent contaminating the specimen.

19. Offer tissues to the patient after suctioning. Dispose of the tissues in an appropriate waste receptacle.
20. Offer the patient mouth care, if desired.
21. In the presence of the patient, label the specimen per the organization’s practice.¹
22. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
23. Observe the patient for anxiety or discomfort.

    Rationale: The procedure can be uncomfortable. Anxiety may develop if the patient becomes short of breath.

24. Assess pain, treat if necessary, and reassess.
25. Discard or store supplies, remove PPE, and perform hand hygiene.
26. Document the procedure in the patient’s record.

EXPECTED OUTCOMES

• Patient’s respirations are the same rate and character as before the procedure.
• Patient is relaxed and able to answer questions.
• Sputum is not contaminated by saliva or oropharyngeal flora.
• Patient tolerates procedure without pain or discomfort.

UNEXPECTED OUTCOMES

• Patient becomes hypoxic.
• Patient has increased respiratory rate and effort.
• Patient feels short of breath.
• Oxygen saturation levels drop after procedure and do not improve after procedure is completed.
• Patient remains anxious or complains of discomfort from the suction catheter.
• Inadequate amount of sputum is collected.
• Specimen contains blood, pathogenic organisms, or abnormal cells.
• Patient complains of pain when coughing to produce sputum.

DOCUMENTATION

• Education
• Patient’s progress toward goals
• Unexpected outcomes and related interventions
• Assessment of pain, treatment if necessary, and reassessment
• Method used to obtain specimen
• Type of test ordered
• Date and time of collection
• Characteristics of sputum specimen
• Patient’s tolerance of procedure

REFERENCES

1. Joint Commission, The. (2022). National Patient Safety Goals for the home care program. Retrieved October 18, 2022, https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2022/npsg_chapter_ome_jan2022.pdf (Level VII)
2. Pagana, K.D., Pagana, T.J., Pagana, T.N. (2022). Chapter 7: Microscopic studies and associated testing. In Mosby’s manual of diagnostic and laboratory tests (7th ed., pp. 661-746). St. Louis: Elsevier.
3. Stacy, K.M. (2022). Chapter 20: Pulmonary therapeutic management. In L.D. Urden, K.M. Stacy, M.E. Lough (Eds.), Critical care nursing: Diagnosis and management (9th ed., pp. 499-529). St. Louis: Elsevier.

Elsevier Skills Levels of Evidence

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