RETIRING - Specimen Collection: Nose and Throat - 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 occlusion.^{undefined#ref6">6}

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

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, and Staphylococcus aureus. Other organisms, including Haemophilus influenzae, Streptococcus pneumoniae, and Candida albicans, are considered abnormal if found in large amounts. The test results help determine which antibiotic therapy or treatment is appropriate.

Several techniques are used depending on the type of specimen obtained. Incorrect technique may result in an inaccurate result.² The length of the swab stick and the material used in manufacturing vary. Ensure the correct swab is used depending on the technique applied and the type of specimen ordered.

An anterior nasal swab specimen is obtained by inserting the swab stick into the nostril no more than 1.5 cm (approximately 0.6 inch).¹ The swab is rotated for a total of 15 seconds.¹ The same swab is then used in the same manner in the other nostril. A nasal midturbinate specimen is obtained by inserting the specimen swab straight back into the nostril approximately 2 cm (0.8 inch), or until resistance is felt.³ The same swab is then used in the same manner in the other nostril.³

Obtaining a simple nasopharyngeal swab is completed by inserting the specimen swab into the nostril approximately half the distance between the patient’s nostril and ear.⁴ The swab should be left in the nostril for several seconds to absorb as much moisture as possible. A nasopharyngeal specimen may also be obtained using a wash method. Several drops of sterile 0.9% sodium chloride are placed into the nostril. A sterile suction catheter is attached to a specimen container and light suction is applied while rotating and removing the catheter.⁴ Nasal washing may provide an effective, more comfortable alternative to swabbing, when necessary.

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.

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 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 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 PPE based on the patient’s need for isolation precautions or the risk of exposure to bodily fluids.
2. Introduce yourself to the patient.
3. Verify the correct patient using two identifiers.
4. Assess the patient’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 the patient has been exposed 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 mealtime to avoid contamination.
3. Obtain assistance for collecting the specimen as needed.

PROCEDURE

Collecting a Throat Specimen

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 and ensure that the patient agrees to treatment.
4. Instruct the patient to sit erect in bed or in a chair. 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 appropriate swab and the 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 patient’s 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.

    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 per the organization’s practice.⁵
15. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
16. Discard supplies, remove PPE, and perform hand hygiene.
17. Document the procedure in the patient’s record.

Collecting a Nasal Specimen

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 and ensure that the patient agrees to treatment.
4. Instruct the patient to sit erect in bed or in a chair. 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 appropriate 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 patient’s shoulders.
8. Carefully insert the swab into the nostril no more than 1.5 cm (0.6 inch).¹ Rotate the swab in a circular manner at least four times, taking approximately 15 seconds to collect as much nasal discharge as possible.¹

   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.¹

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.

    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 per the organization’s practice.⁵
14. Place the labeled specimen in a biohazard bag and transport it immediately to the laboratory per the organization’s practice.
15. Discard supplies, remove PPE, and perform hand hygiene.
16. Document the procedure in the patient’s record.

Collecting a Nasal Specimen: Midturbinate Swab 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. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Instruct the patient to sit erect in bed or in a chair. 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 appropriate swab and sterile culture tube ready for use.
   1. Use a flocked tapered swab for the midturbinate method.³
   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.²

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

   Rationale: As the patient breathes through each open nostril, the health care team member determines that both nostrils have patency.

7. Position the patient with the patient’s 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 patient’s shoulders.
8. While the patient’s head is tilted back and the patient is looking up at the ceiling, gently insert the swab straight back into one nostril approximately 2 cm (0.8 inch), or until resistance is felt.³
9. Gently rotate the swab in a circular motion against the nasal wall several times and remove the swab from the nostril.²
10. Gently insert the same swab in the other nostril and rotate the swab in a circular motion against the nasal wall several times.² 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.

    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 per the organization’s practice.⁵
15. Place the labeled specimen in a biohazard bag and transport it to the laboratory immediately per the organization’s practice.
16. Discard supplies, remove PPE, and perform hand hygiene.
17. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen: Swab 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. Verify the correct patient using two identifiers.
3. Explain the procedure and ensure that the patient agrees to treatment.
4. Instruct the patient to sit erect in bed or in a chair. 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 appropriate nasopharyngeal 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. 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. Rotate the swab during removal.⁴

   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.

   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 per the organization’s practice.⁵
13. Place the labeled specimen in a biohazard bag and transport it immediately to the laboratory per the organization’s practice.
14. Discard supplies, remove PPE, and perform hand hygiene.
15. Document the procedure in the patient’s record.

Collecting a Nasopharyngeal Specimen: Wash Method with Suction

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 and ensure that the patient agrees to treatment.
4. Instruct the patient to sit erect in bed or in a chair. 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.²
7. Instruct the patient to tilt the head back. If the patient is in bed, place a pillow behind the patient’s shoulders.
8. Using the syringe, insert 1 to 1.5 ml of sterile nonbacteriostatic 0.9% sodium chloride solution into each nostril.²
9. Insert the suction catheter into the nostril and rotate the suction catheter while removing 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 per the organization’s practice.⁵
14. Place the labeled specimen in a biohazard bag and transport it immediately to the laboratory per the organization’s practice.
15. Discard supplies, remove PPE, and perform hand hygiene.
16. Document the procedure in the patient’s record.

MONITORING AND CARE

1. Check the laboratory record for test results.
2. Report unusual test results to the practitioner.
3. Check the patient’s nasal or throat passage for evidence of trauma, such as bleeding.
4. Assess, treat, and reassess pain.

EXPECTED OUTCOMES

• Test results do not reveal bacterial or viral growth.
• Patient does not experience nasal bleeding or throat trauma.
• Specimen is not contaminated.
• Patient understands purpose of collecting nose or throat specimens.
• Patient tolerates procedure without pain or discomfort.

UNEXPECTED OUTCOMES

• Test results reveal pathogen growth.
• Patient experiences nasal bleeding or throat trauma.
• Specimen is contaminated.
• Patient does not understand purpose of collecting nose or throat specimens.
• Patient complains of pain during procedure.

DOCUMENTATION

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

PEDIATRIC CONSIDERATIONS

• It is important to develop rapport and trust with a pediatric patient before beginning any invasive procedure. The family should be included; if the family demonstrates trust, the patient will be less anxious.
• Taking the time to include age-appropriate distraction helps to manage pain and anxiety.
• A developmentally appropriate approach and explanation of the procedure should be used.
• The family should be encouraged to remain present during the procedure.
• Showing the tongue blade and penlight to the pediatric patient and demonstrating how to say “ah” helps to decrease anxiety.
• A school-age and older child may be more cooperative if given an opportunity to ask questions about the procedure and results.
• Stabilizing the patient’s head and arms in a firm, gentle, and kind manner may be needed when collecting nose or throat specimens. If necessary, another health care team member may need to assist.

OLDER ADULT CONSIDERATIONS

• Some older adults need help keeping the mouth open during specimen collection.
• Some older adults have poor dentition. Caution should be used to not break a tooth. Denture removal should be considered, when appropriate.
• If the patient is confused, someone may need to hold the patient’s hands while the specimen is collected.

REFERENCES

1. Centers for Disease Control and Prevention (CDC). (2021). How to collect an anterior nasal swab specimen for COVID-19 testing. Retrieved October 31, 2023, from https://www.cdc.gov/coronavirus/2019-ncov/downloads/testing/QuickieAnteriorSwab.pdf (Level VII)
2. Centers for Disease Control and Prevention (CDC). (2022). Interim guidelines for collecting and handling clinical specimens for COVID-19 testing. Retrieved October 31, 2023, from https://www.cdc.gov/coronavirus/2019-ncov/lab/guidelines-clinical-specimens.html (Level VII)
3. Centers for Disease Control and Prevention (CDC). (n.d.). How to collect a nasal mid-turbinate specimen for COVID-19 testing. Retrieved October 31, 2023, from https://www.cdc.gov/coronavirus/2019-ncov/testing/How-To-Collect-NMT-Specimen-for-COVID-19.pdf (Level VII)
4. Centers for Disease Control and Prevention (CDC). (n.d.). Influenza specimen collection. Retrieved October 31, 2023, from https://www.cdc.gov/flu/pdf/freeresources/healthcare/flu-specimen-collection-guide.pdf (Level VII)
5. Joint Commission, The. (2023). National Patient Safety Goals for the hospital program. Retrieved October 31, 2023, from https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2023/npsg_chapter_hap_jan2023.pdf (Level VII)
6. Sokolovs, D., Tan, K.W. (2017). Ear, nose and throat emergencies. Anaesthesia and Intensive Care Medicine, 18(4), 190-194. doi:10.1016/j.mpaic.2017.01.004

ADDITIONAL READINGS

Audere. (2020). Swab instructions: Mid-turbinate self-swab nasal specimen collection. Retrieved October 31, 2023, from https://www.doh.wa.gov/Portals/1/Documents/1600/coronavirus/Self-SwabMid-turbinateCollectionInstructions.pdf

Centers for Disease Control and Prevention (CDC). (2023). Unexplained respiratory disease outbreaks (URDO): Specimen collection and handling. Retrieved October 31, 2023, from https://www.cdc.gov/urdo/specimen.html

Adapted from Perry, A.G. and others (Eds.). (2022). Clinical nursing skills & techniques (10th ed.). 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

Clinical Review: Martha Beck, MA, BSN, RB, CNOR
Published: December 2023