Specimen Collection: Nose and Throat (Pediatric) - CE/NCPD

ALERT

Do not attempt to collect a throat swab specimen if acute epiglottitis is suspected because trauma from the swab may cause increased edema, resulting in airway obstruction.^{undefined#ref4">4}

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

OVERVIEW

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

Pathogenic organisms that may be identified by culture include group A beta-hemolytic streptococci, Bordetella pertussis, Corynebacterium diphtheriae, coronavirus, and Staphylococcus aureus. Other organisms, including Haemophilus influenzae, Streptococcus pneumoniae, and Candida albicans, are considered abnormal if found in large numbers. In children, Streptococcus pyogenes (strep throat), respiratory syncytial virus, and Bordetella pertussis are common pathogens. The test results help determine which antibiotic therapy or treatment is appropriate.

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

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 and family that the procedure is painless and lasts only a few seconds.
• Explain that obtaining a throat specimen may cause a tickling sensation or gagging and that obtaining a nasal specimen may cause an urge to sneeze.
• Discuss the patient’s and family’s role in collecting the specimen.
• Explain how and why the specimen is being collected.
• Discuss the relationship between the test results and the medication or treatment prescribed.
• Discuss the reason for the time delay in receiving test results.
• Encourage questions and answer them as they arise.

ASSESSMENT AND PREPARATION

Assessment

1. Perform hand hygiene before patient contact. Don appropriate personal protective equipment (PPE) based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient and family.
3. Verify the correct patient using two identifiers.
4. Assess the patient’s and family’s understanding of the purpose of the procedure and the patient’s ability to cooperate.
5. Assess the nasal mucosa and sinuses and observe for any drainage.
6. Determine if the patient experiences postnasal drip, sinus headache or tenderness, nasal congestion, or sore throat or if there was exposure to others with similar symptoms.
7. Assess the condition of the posterior pharynx.
8. Assess the patient for systemic signs of infection (e.g., fever, chills, and fatigue) and for indications for isolation precautions.

Preparation

1. Review the practitioner’s orders to determine if a nasal specimen, throat specimen, or both are needed.
2. Plan to collect the specimen before oral intake to avoid contamination.
3. Obtain assistance for collecting the specimen as needed.

PROCEDURE

Collecting a Throat Specimen (Table 1)

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. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Instruct the patient to sit erect in bed or in a chair and face the patient. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
5. Have the swab and sterile culture tube ready for use. If using a prepackaged swab in a tube, loosen the top so the swab can be removed easily.

   Rationale: Having the swab and sterile culture tube ready allows the nurse to grasp the swab easily without danger of contamination.

6. Instruct the patient to tilt the head back. If the patient is in bed, place a pillow behind the shoulders.
7. Ask the patient to open the mouth and say “ah.”
8. Depress the anterior third of the tongue with a tongue blade and observe for any inflamed areas of the pharynx or tonsils. Illuminate the area with a penlight as needed.

   Rationale: Depressing the tongue permits exposure of the pharynx, relaxes throat muscles, and minimizes the gag reflex. The area to be swabbed should be clearly seen.

   Do not place the tongue blade along the back of the tongue; doing so is likely to initiate the gag reflex. If the patient gags, remove the tongue blade and allow the patient to relax before reinserting it.

9. Insert the swab without touching the lips, teeth, tongue, cheeks, or uvula (Figure 1).

   Rationale: Touching the lips, teeth, tongue, cheeks, or uvula with the swab may cause contamination with organisms from the oral cavity.

10. Gently but quickly swab the tonsillar area from side to side, contacting any inflamed or purulent sites.

    Rationale: The inflamed or purulent sites in the tonsillar area contain the most microorganisms.

11. Carefully withdraw the swab without touching the oral structures.
12. Immediately insert the swab into the sterile culture tube (Figure 2) and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per the organization’s practice.³

    Rationale: Mixing the swab tip with the culture or transport medium helps ensure live bacteria or virus for testing.

13. Place the top securely on the culture tube.
14. In the presence of the patient, label the specimen(s) per the organization’s practice.⁵
15. Prepare the specimen(s) for transport.
    1. Place the labeled specimen(s) in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected (e.g., S. pyogenes, B. pertussis).
16. Immediately transport the specimen(s) to the laboratory.
17. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

18. Document the procedure in the patient’s record.

Collecting a Nasal Specimen (Table 1)

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. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Instruct the patient to sit erect in bed or in a chair and face the patient. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
5. Have the swab and sterile culture tube ready for use. If using a prepackaged swab in a tube, loosen the top so the swab can be removed easily.

   Rationale: Having the swab and sterile culture tube ready allows the nurse to grasp the swab easily without danger of contamination.

6. Ask the patient to occlude each nostril one at a time and exhale.

   Rationale: As the patient breathes through each open nostril, the nurse determines the nostril with the greater patency.

7. Position the patient with the head back and use a penlight to check the nasal passages for patency. If the patient is in bed, place a pillow behind the shoulders.
8. Carefully insert the swab into the nostril until it reaches the portion of mucosa that is inflamed or contains exudate. Rotate the swab slowly.

   Rationale: The swab should remain sterile until it reaches the area to be tested. Rotating the swab ensures that it touches all surfaces where exudate is present.²

9. Remove the swab without touching the sides of the nose.

   Rationale: Avoiding contact with the sides of the nose prevents contaminating the swab with resident bacteria.

10. Immediately insert the swab into the sterile culture tube (Figure 2) and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per the organization’s practice.³

    Rationale: Mixing the swab tip with the culture or transport medium helps ensure live bacteria or virus for testing.

11. Place the top securely on the culture tube.
12. Offer the patient a facial tissue to blow the nose if needed.
13. In the presence of the patient, label the specimen(s) per the organization’s practice.⁵
14. Prepare the specimen(s) for transport.
    1. Place the labeled specimen(s) in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected (e.g., B. pertussis).
15. Immediately transport the specimen(s) to the laboratory.
16. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

17. Document the procedure in the patient’s record.

Collecting a Nasal Specimen: Midturbinate Swab Method (Table 1)

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. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Instruct the patient to sit erect in bed or in a chair and face the patient. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
5. Have the swab and sterile culture tube ready for use.
   1. Use a flocked tapered swab for the midturbinate method.²
   2. If using a prepackaged swab in a tube, loosen the top so that the swab can be removed easily.
   3. If using a prepackaged swab in a paper wrapper, pull apart the two ends of the wrapper where it directs to peel open.

      Rationale: Having the swab and sterile culture tube ready allows the nurse to grasp the swab easily without danger of contamination. Only the handle is touched, not the tip.³

6. Ask the patient to occlude each nostril one at a time and exhale.

   Rationale: As the patient breathes through each open nostril, the nurse determines whether both nostrils have patency.

7. Position the patient with the head tilted back and use a penlight to check the nasal passages for patency. If the patient is in bed, place a pillow behind the shoulders.
8. While the patient’s head is tilted back, gently insert the swab into one nostril until the safety stopper touches the edge of the nostril (less than 2.5 cm [1 inch]).²
9. Gently twist the end of the swab in a circular motion for 15 seconds and remove the swab from the nostril.¹
10. Gently insert the same swab in the other nostril and twist the end of the swab in a circular motion for 15 seconds.¹ Remove the swab from the nostril.
11. Immediately insert the swab into the sterile culture tube (Figure 2) and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per the organization’s practice.³

    Rationale: Mixing the swab tip with the culture or transport medium helps ensure live bacteria or virus for testing.

12. Place the top securely on the culture tube.
13. Offer the patient a facial tissue to blow the nose if needed.
14. In the presence of the patient, label the specimen(s) per the organization’s practice.⁵
15. Prepare the specimen(s) for transport.
    1. Place the labeled specimen(s) in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected (e.g., B. pertussis).
16. Immediately transport the specimen(s) to the laboratory.
17. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

18. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen: Swab Method (Table 1)

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. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Instruct the patient to sit erect in bed or in a chair and face the patient. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
5. Have the nasopharyngeal swab (on flexible wire) and sterile culture tube ready for use. If using a prepackaged swab in a tube, loosen the top so the swab can be removed easily.

   Rationale: Having the swab and sterile culture tube ready allows the nurse to grasp the swab easily without danger of contamination. Use of a specially designed nasopharyngeal swab allows access to the difficult-to-reach nasopharyngeal area.

6. Position the patient with the head tilted back and use a penlight to check the nasal passages for patency.
7. Gently advance the swab to the nasopharynx until resistance is met.
8. Roll the swab and allow it to remain in place for several seconds. Remove the swab.

   Rationale: Leaving the swab tip in contact with the nasopharynx facilitates absorption of fluid into the swab.

9. Immediately insert the swab into the sterile culture tube (Figure 2) and push the tip into the liquid medium at the bottom of the tube or follow instructions specific to specimen collection per the organization’s practice.³

   Rationale: Mixing the swab tip with the culture or transport medium helps ensure live bacteria or virus for testing.

10. Place the top securely on the culture tube.
11. Offer the patient a facial tissue to blow the nose if needed.
12. In the presence of the patient, label the specimen(s) per the organization’s practice.⁵
13. Prepare the specimen(s) for transport.
    1. Place the labeled specimen(s) in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected (e.g., respiratory syncytial virus [RSV], B. pertussis).
14. Immediately transport the specimen(s) to the laboratory.
15. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

16. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen: Wash Method with Suction (Table 1)

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. Verify the correct patient using two identifiers.
3. Explain the procedure to the patient and family and ensure that they agree to treatment.
4. Instruct the patient to sit erect in bed or in a chair and face the patient. A patient who is acutely ill or a young child may lie back against the bed with the head of the bed raised.
5. Attach the suction catheter to the suction specimen trap. Attach the specimen trap to the suction connecting tubing and adjust the suction.
6. Draw up 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into a 3-ml syringe.³
7. Instruct the patient to tilt the head back. If the patient is in bed, place a pillow behind the shoulders.
8. Using the syringe, insert 1 to 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into each nostril.³
9. Insert the suction catheter into the nostril and suction secretions.
10. Repeat the procedure for the other nostril per the practitioner’s order.
11. Remove the specimen trap from the suction tubing and secure the ends per the manufacturer’s instructions.
12. Offer the patient a facial tissue to blow the nose if needed.
13. In the presence of the patient, label the specimen(s) per the organization’s practice.⁵
14. Prepare the specimen(s) for transport.
    1. Place the labeled specimen(s) in a biohazard bag.
    2. Record on the laboratory requisition if the patient is taking an antibiotic or if a specific organism is suspected (e.g., RSV, B. pertussis).
15. Immediately transport the specimen(s) to the laboratory.
16. Discard supplies, remove PPE, and perform hand hygiene.

    At the completion of the procedure, ensure that all choking hazards are removed from the patient’s linens and placed in the appropriate receptacle.

17. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Check the laboratory record for test results.
2. Report test results to the practitioner.
3. At the completion of the procedure, ensure that all choking hazards (e.g., culture tube caps) are removed from the patient’s linens and placed in the appropriate receptacle.

EXPECTED OUTCOMES

• Test results are consistent with presenting signs and symptoms.
• Patient does not experience nasal bleeding or throat trauma.
• Specimen is not contaminated.
• Patient and family understand purpose of collecting nose or throat specimens.
• Patient tolerates procedure without pain or discomfort.

UNEXPECTED OUTCOMES

• Test results are inconsistent with presenting signs and symptoms.
• Patient experiences nasal bleeding or throat trauma.
• Specimen is contaminated.
• Patient and family do not understand purpose of collecting nose or throat specimens.
• Patient complains of pain during procedure.

DOCUMENTATION

• Type, date, time, two patient identifiers, and disposition of specimen
• Appearance of nasal and oral mucosal structures
• Patient’s tolerance of procedure
• Education
• Unexpected outcomes and related interventions

REFERENCES

1. Audere. (2020). Swab instructions: Mid-turbinate self-swab nasal specimen collection. Retrieved July 25, 2023, from https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Self-SwabMid-turbinateCollectionInstructions.pdf (Level VII)
2. Centers for Disease Control and Prevention (CDC). (2022). Interim guidelines for collecting and handling of clinical specimens for COVID-19 testing. Retrieved July 25, 2023, from https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html (Level VII)
3. Centers for Disease Control and Prevention (CDC). (2023). Unexplained respiratory disease outbreaks (URDO): Specimen collection and handling. Retrieved July 25, 2023, from https://www.cdc.gov/urdo/specimen.html (Level VII)
4. Conlon, P. (2024). Chapter 26: The child with respiratory dysfunction. In M.J. Hockenberry, E.A. Duffy, K.D. Gibbs (Eds.), Wong’s nursing care of infants and children (12th ed., pp. 871-948). St. Louis: Elsevier.
5. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved July 25, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)

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

Clinical Review: Laurie Sands, RN, MSN, CPNP PC/AC

Published: September 2023