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3/23/18 Types of Urine Specimens • Random- collected at any time without patient preparation • Most convenient • Hydration dependent Urinalysis Review • First Morning Void- patient voids before going to bed and collects a urine specimen immediately upon waKing in the morning CM Lauren Brandenburg, MS, MLS (ASCP) • Best for metabolite analysis • Inconvenient to obtain • Timed • 2 hour post prandial- specimen collected after a meal • 24 hour collection- patient voids and then collects all urine for a predetermined amount of time Urine Collection Techniques Collection Guidelines • Routine void- patient urinates into appropriate container • Container must be clean, dry, leak-proof, and made of translucent • Midstream clean-catch- Patient cleans external genital area, passes some disposable material urine into the toilet, collects some of the mid-portion of urine in an • Must be labeled before or immediately following collection (NOT ON appropriate container, then passes the remaining urine into the toilet LID) • Catheterized specimens- collect by inserting a sterile catheter through the • Name, ID #, date/time of collection, preservative used urethra into the bladder • Must be transported promptly to the lab or refrigerated • Suprapubic aspiration- collect by puncturing the abdominal wall and the • Preservative may or may not be added distended bladder using a needle and syringe • Varies depending on test methodology, how often the test is performed, time delays, • Pediatric collection- collect by securing a plastic bag to the external genital and transport conditions area using hypoallergenic sKin adhesive • Protect from light Changes in Unpreserved Urine Changes in Unpreserved Urine Physical Change Result Cause Physical Change Result Cause Color Change Oxidation or reduction of pH Increased Bacterial decomposition of urea to substances (bilirubin to biliverdin, ammonia; loss of CO2 hgb to met-hgb, urobilinogen to Decreased Bacterial or yeast conversion of urobilin) glucose to form acids Clarity Decreased Bacterial proliferation, solute Glucose Decreased Cellular or bacterial glycolysis precipitation (crystals and Ketones Decreased Bacterial metabolism of aceto- amorphous materials) acetate to acetone; volatilization of Odor Increased Bacterial proliferation/bacterial acetone decomposition of urea to ammonia Bilirubin Decreased Photo-oxidation to biliverdin and hydrolysis to free bilirubin Urobilinogen Decreased Oxidation to urobilin 1 3/23/18 Changes in Unpreserved Urine Urinalysis Physical Change Result Cause • Laboratory examination of urine consists of 3 components: Nitrite Increased Decreased bacterial production • Physical Examination following specimen collection Decreased Conversion to nitrogen • Color, clarity, odor, concentration (specific gravity or osmolality), volume and foam RBCs, WBCs and casts Decreased Disintegration of cellular and • Chemical Examination formed elements, especially in • pH, specific gravity, blood, leukocyte esterase, nitrite, glucose, protein, Ketones, dilute and alkaline urine urobilinogen, bilirubin Bacteria Increased Bacterial proliferation following • Microscopic Examination specimen collection • Blood cells, epithelial cells, casts, crystals, microorganisms, contaminants Color Color cont. • Normally different shades of yellow Abnormal Color Cause Clinical Correlation • Intensity of color is an indicator of urine concentration and body hydration DarK Yellow Concentrated specimen May be normal following strenuous exercise or in a first morning specimen. • Color can vary from colorless to amber, orange, red, green, blue, brown and even blacK Dehydration from fever or burns. Amber Large amt. of urobilinogen Does not produce yellow foam when shaKen. • Variations can indicate a disease process, metabolic abnormality, Orange Bilirubin Produces yellow foam when shaKen and positive strip ingested food or drug, or excessive physical activity/stress test for bilirubin. • Each laboratory should have an established list of terms for color to Phenazopyridine (Pyridium) Drug given for UTI. May have orange foam and pigment assure consistency in reporting. that interferes with strip tests. Nitrofurantoin Antibiotic given for UTIs. Color cont. Color cont. Abnormal Color Cause Clinical Correlation Abnormal Color Cause Clinical Correlation Brown/BlacK Methemoglobin Oxidized hemoglobin; Seen in acidic urine after standing, PinK/Red RBCs Cloudy urine, positive strip test for blood, RBCs seen positive strip test for blood microscopically Homogentisic acid (alKaptonuria) Seen in alKaline urine after standing Hemoglobin Clear urine, positive strip test for blood, intravascular Melanin or oxidized melanogen Urine darKens on standing; associated with malignant hemolysis melanoma Myoglobin Clear urine, positive strip test for blood, muscle damage Metronidazole (flagyl) DarKens on standing Porphyrins Negative strip test for blood, detect with Watson-Schwartz Yellow-green / Bilirubin oxidized to biliverdin upon Colored foam in acidic urine; false negative test strip test test or UV light Yellow-brown standing or improper storage result for bilirubin Beets/BlacKberries Certain people are genetically susceptible, pH dependent Green / Blue- Pseudomonas infection Positive urine culture green Amitriptyline Antidepressant Rifampin Medication for tuberculosis Methocarbamol (Robaxin) Muscle relaxant Clorets Breath mint Menstrual Contamination Cloudy specimen with RBCs, mucous and clots Indican Infection of the small intestine Methylene Blue Given for a number of conditions 2 3/23/18 Color cont. Foam • Normal- white foam that appears upon agitation and dissipates readily on standing • Large amounts of protein- thicK, long-lasting white foam produced when the urine is poured or agitated that does not dissipate • Bilirubin- yellow foam upon agitation that dissipates readily on standing • Not reported in routine urinalysis Clarity Clarity cont. • Describes the overall visual appearance (transparency) of a urine specimen • Normal- clear Non-pathologic Causes of Turbidity Pathologic Causes of Turbidity • Cloudiness is caused by suspended particulate matter that scatters light as is passes through Squamous epithelial cells Red blood cells the specimen Mucus White blood cells • Each laboratory should have an established list of terms for clarity to ensure Semen Bacteria consistency in reporting Amorphous phosphates, carbonates, urates Yeast • Abnormalities can be caused by: Fecal contamination Non-squamous epithelial cells • Bacterial growth Radiologic contrast media Abnormal crystals • Precipitation of amorphous solutes Talcum powder Lymph fluid • Excretion of fat or lymph Vaginal creams Lipids Odor Concentration • Normally the specimen is only faintly aromatic (not reported as part • A dilute urine has fewer solute particles present per volume of water, of routine urinalysis) whereas a concentrated urine has more solute particles present per • Abnormal odors can result from: volume of water • Allowing the specimen to stand at room temperature/age- smells liKe • ammonia because of bacterial conversion of urea to ammonia Color is a crude indicator of urine concentration • Severe urinary tract infections- smells pungent or fetid from pus, protein • Specific gravity is most often used to rapidly screen urine decay, and bacteria concentration in the clinical laboratory • Ingestion of certain foods/drugs- smell varies; caused by eating foods liKe asparagus or garlic or IV medications containing phenol derivatives • Osmolality is used to obtain more accurate and specific information • Metabolic disorders- diabetes leads to sweet or fruity smelling urine; maple about urine concentration syrup urine disease • Cleaning agents- if household containers are used to collect the specimen 3 3/23/18 Specific Gravity Osmolality • An expression of density • Ratio of the density of urine to the density of an equal volume of pure water (Range = 1.002 – 1.04) • Concentration of a solution expressed in mOsm/kg • Affected by the number of solutes present AND their molecule size • Temperature independent • Requires solutes to be DISSOLVED in the solution rather than particles floating in the solution to bring about a change in SG • Serum normal range = 275-300 mOsm/kg • Terminology • Urine normal range = 275-900 mOsm/kg • Varies greatly with the patient’s diet, health, hydration status and physical activity • Isosthenuric: SG = 1.010 • Hyposthenuric: SG = < 1.010 • Evaluates the renal concentrating ability of the Kidneys • Hypersthenuric: SG = >1.010 • Depends only on the number of solute particles present • If SG > 1.035, suspect the presence of radiographic contrast media • Measured by: • Direct measurements- determine true density of urine (all solutes detected and • Freezing point depression (most common method) measured) • Solvent vapor pressure depression • Urinometry or harmonic oscillation densitometric method; only of historical interest • Elevation of osmotic pressure • Solvent boiling point elevation • Indirect measurements • Refractometry and reagent strip chemical method; used in current clinical laboratory Volume Routine Urinalysis • Normal = 600-1800 mL/day with less than 400 mL excreted at night • Nocturia = >500 mL excretion at night • Polyuria = any increase in urine excretion • Excessive water intaKe, diuretic therapy, hormonal imbalance, renal dysfunction or drug ingestion • Oliguria = any decrease in urine excretion • Water deprivation, excessive sweating, diarrhea, vomiting or renal diseases • Anuria = lacK of urine excretion
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