UNIT 2 Clinical Pathology

🧪 EXAMINATION OF BODY CAVITY FLUIDS:

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🔹 1. Definition:

Body cavity fluids are serous fluids collected from normally closed body cavities. The main types include:

• Pleural fluid – from the pleural (lung) cavity
• Peritoneal fluid (Ascitic fluid) – from the abdominal cavity
• Pericardial fluid – from the sac surrounding the heart
• Synovial fluid – from joint cavities
• Cerebrospinal fluid (CSF) – from the subarachnoid space around the brain and spinal cord (sometimes grouped separately)

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🔹 2. Indications for Examination:

• Unexplained fever, chest pain, abdominal distention, or joint swelling
• Diagnosis of infections, malignancies, trauma, autoimmune disorders
• Monitoring response to treatment
• Evaluation of transudate vs. exudate

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🔹 3. Collection of Fluid:

Fluid Type	Procedure	Site	Needle Insertion
Pleural Fluid	Thoracentesis	Posterior chest wall (between ribs)	Intercostal space
Peritoneal Fluid	Paracentesis	Lower abdomen (usually left)	Midline or lateral
Pericardial Fluid	Pericardiocentesis	Below xiphoid process or intercostal	Under imaging
Synovial Fluid	Arthrocentesis	Affected joint	Directly into joint
CSF	Lumbar puncture	Lumbar spine (L3-L4/L4-L5)	Spinal canal

Note: Aseptic technique and local anesthesia are used; samples are sent in sterile containers to lab.

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🔹 4. Physical Examination of Fluids:

Feature	Observations
Color	Clear, straw, bloody, cloudy, chylous, greenish
Clarity	Transparent, turbid, milky, purulent
Volume	Measured in mL
Viscosity (for synovial)	String test (normal forms long string)
Odor	Foul smell may indicate anaerobic infection

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🔹 5. Biochemical Analysis:

Test	Purpose
Protein	Differentiates transudate (<3g/dL) vs. exudate (>3g/dL)
Glucose	↓ in infections (TB, bacterial), RA
LDH	↑ in infections, malignancy
pH	↓ in infection, cancer
Amylase	↑ in pancreatitis or GI perforation (esp. in pleural/peritoneal)
Albumin Gradient (SAAG)	>1.1 = portal hypertension; <1.1 = exudate

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🔹 6. Microscopic Examination:

Test	What It Shows
Cell count	WBC, RBC – ↑ WBC = infection, malignancy
Differential count	Neutrophils (acute), Lymphocytes (TB, cancer)
Cytology	Malignant cells in cancers
Gram stain	Bacteria presence (helps guide antibiotics)
AFB stain	For tuberculosis (Ziehl-Neelsen stain)
Culture and Sensitivity	Identifies organisms and antibiotic sensitivity
Crystals (Synovial fluid)	Gout (uric acid crystals), Pseudogout (calcium pyrophosphate)

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🔹 7. Special Tests:

• ADA (Adenosine Deaminase): High in TB effusion
• PCR/Genetic testing: For TB, viral, or autoimmune markers
• Tumor markers: CA-125 (ovarian), CEA (GI cancers), etc.
• Rheumatoid factor, ANA: In autoimmune effusions

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🔹 8. Interpretation – Transudate vs. Exudate:

Feature	Transudate	Exudate
Protein	<3 g/dL	>3 g/dL
LDH	<200 IU/L	>200 IU/L
Specific Gravity	<1.015	>1.015
SAAG	>1.1 g/dL	<1.1 g/dL
Causes	CHF, nephrotic syndrome, cirrhosis	TB, cancer, pneumonia, pancreatitis

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🔹 9. Nursing Considerations:

• Explain the procedure to the patient
• Ensure consent and prepare sterile equipment
• Position patient appropriately (e.g., sitting for thoracentesis)
• Monitor for complications: hypotension, bleeding, pneumothorax, infection
• Label and send samples to lab promptly
• Provide post-procedure care: rest, monitor vitals, watch for complications

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🔹 10. Complications of Procedures:

• Hemorrhage
• Infection
• Pneumothorax (in thoracentesis)
• Perforation of organs
• Hypotension
• Pain or discomfort
• Fluid leak (at puncture site)

🧠 CEREBROSPINAL FLUID (CSF): METHODS OF COLLECTION & EXAMINATION.

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🔷 1. What is CSF?

Cerebrospinal Fluid (CSF) is a clear, colorless fluid that surrounds the brain and spinal cord. It cushions the brain, removes waste, and circulates nutrients and hormones.

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🔷 2. Indications for CSF Examination:

• Suspected meningitis (bacterial, viral, fungal, TB)
• Subarachnoid hemorrhage
• Multiple sclerosis, Guillain-Barré syndrome
• Malignancies (CNS tumors, metastatic spread)
• Neurological symptoms with unknown cause (e.g., seizures, altered mental status)

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🔷 3. Methods of CSF Collection

🔹 A. Lumbar Puncture (Spinal Tap) – Most Common Method

✅ Procedure Overview:

Aspect	Details
Patient Position	Lateral decubitus (fetal) or sitting position with back curved
Site	Lumbar region (usually L3-L4 or L4-L5 interspace)
Needle	Lumbar puncture needle with stylet
Volume Collected	3–10 mL (divided into 3–4 sterile tubes)
Aseptic Technique	Strictly maintained
Contraindications	Increased intracranial pressure (risk of brain herniation), coagulopathy, infection at puncture site

✅ Steps:

1. Explain procedure and obtain informed consent.
2. Position the patient correctly.
3. Prepare and drape the lumbar area using aseptic technique.
4. Insert needle between L3–L4 or L4–L5 vertebrae.
5. Withdraw stylet; CSF flows out under normal pressure.
6. Collect CSF in 3–4 sterile tubes (1–2 mL each).
7. Withdraw needle, apply sterile dressing.
8. Instruct patient to lie flat for 1–2 hours.

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🔷 4. CSF Sample Handling:

Tube No.	Purpose
Tube 1	Chemistry & glucose
Tube 2	Microbiology (Gram stain, culture)
Tube 3	Cell count & differential
Tube 4	Special tests (PCR, serology, cytology, etc.)

🚨 Always label tubes properly and send to lab immediately.

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🔷 5. CSF Examination – Components

🔹 A. Physical Examination

Parameter	Normal	Abnormal Findings
Color	Clear, colorless	Cloudy (infection), bloody (hemorrhage), xanthochromic (old bleed)
Clarity	Transparent	Turbid (infection), oily (contrast), milky (TB/fungal)
Opening Pressure	90–180 mm H₂O (lying down)	↑ in meningitis, ↓ in shock
Volume	Total ~150 mL in body	Normally 3–10 mL withdrawn

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🔹 B. Chemical Analysis

Test	Normal Range	Clinical Significance
Glucose	45–80 mg/dL	↓ in bacterial/TB/fungal meningitis
Protein	15–45 mg/dL	↑ in infection, MS, tumor, GBS
Chloride	118–132 mEq/L	↓ in TB meningitis
Lactate	<2.1 mmol/L	↑ in bacterial meningitis
Albumin, Globulin	Normal trace	↑ in multiple sclerosis, infection

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🔹 C. Microscopic Examination

Test	Normal	Abnormal Findings
WBC count	0–5 lymphocytes/mm³	↑ in infection, inflammation
RBC count	0	↑ in hemorrhage or traumatic tap
Differential	Lymphocytes	Neutrophils (bacterial), Lymphocytes (viral/TB)
Cytology	No abnormal cells	Malignant cells (carcinomatous meningitis)

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🔹 D. Microbiological Examination

Test	Purpose
Gram Stain	Rapid detection of bacteria
AFB Stain (Ziehl-Neelsen)	Detects Mycobacterium tuberculosis
India Ink	Detects Cryptococcus neoformans (fungus)
Culture	Gold standard for identifying organisms
PCR/NAAT	For TB, herpes virus, CMV, enteroviruses

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🔹 E. Other Special Tests:

• Oligoclonal bands: Positive in multiple sclerosis
• VDRL test: Neurosyphilis
• Cryptococcal antigen: Fungal meningitis
• CSF IgG Index: Autoimmune diseases
• Tumor markers: In CNS metastasis

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🔷 6. Interpretation of CSF Findings (Simplified Table):

Condition	Pressure	Glucose	Protein	WBC Type
Bacterial Meningitis	↑	↓↓	↑↑	Neutrophils ↑
Viral Meningitis	Normal/↑	Normal	Mild ↑	Lymphocytes ↑
Tubercular Meningitis	↑	↓	↑	Lymphocytes ↑
Fungal Meningitis	↑	↓	↑	Lymphocytes ↑
Subarachnoid Hemorrhage	↑	Normal	↑	RBC ↑, Xanthochromia

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🔷 7. Nursing Responsibilities:

• Pre-procedure:
  • Explain procedure and reduce anxiety.
  • Obtain consent.
  • Ensure patient has voided before procedure.
• During:
  • Assist with patient positioning.
  • Maintain strict asepsis.
  • Monitor for pain, dizziness, or complications.
• Post-procedure:
  • Keep patient flat (supine) for at least 1–2 hours.
  • Monitor vitals and watch for headache or CSF leak.
  • Encourage fluid intake.
  • Send samples promptly with correct labeling.

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🔷 8. Complications of Lumbar Puncture:

• Post-lumbar puncture headache (common)
• Bleeding or hematoma
• Infection
• Brain herniation (if ICP elevated)
• Nerve damage (rare)
• CSF leak

🫁 SPUTUM COLLECTION AND EXAMINATION.

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🔷 1. What is Sputum?

Sputum is the thick mucus or phlegm that is coughed up from the lower respiratory tract (lungs and bronchi), not to be confused with saliva. It is analyzed to diagnose respiratory diseases such as tuberculosis, pneumonia, asthma, bronchitis, lung cancer, and others.

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🔷 2. Purposes of Sputum Examination:

• Diagnose infections (e.g., TB, pneumonia, bronchitis, fungal infection)
• Detect malignant cells (lung cancer)
• Identify allergic conditions (eosinophilia in asthma)
• Monitor treatment response
• Investigate hemoptysis (coughing blood)

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🔷 3. Methods of Sputum Collection

There are three main methods based on patient condition and sputum availability:

✅ A. Spontaneous (Self-expectorated) Sputum Collection

Most common method

Instructions to patient:

• Best done early morning before eating or drinking.
• Rinse mouth with water (not antiseptic) to remove food particles and oral bacteria.
• Take deep breaths and cough forcefully from deep in the chest.
• Collect 5–10 mL sputum in a sterile, wide-mouthed, screw-capped container.
• Ensure it is sputum (thick, mucoid) and not saliva (thin, watery).

✅ B. Induced Sputum Collection

For patients unable to cough up sputum spontaneously

Procedure:

• Patient inhales hypertonic saline (3–5%) via nebulizer for 10–20 minutes.
• This loosens secretions and induces coughing.
• Sputum is then collected in sterile container.

✅ C. Suctioned (Invasive) Sputum Collection

Used for critically ill, unconscious, or ventilated patients.

Methods include:

• Oropharyngeal or nasopharyngeal suction
• Endotracheal or tracheostomy suctioning

Using a sterile suction catheter, connected to vacuum apparatus.

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🔷 4. Precautions During Collection:

• Use sterile containers.
• Ensure adequate labeling (patient name, date, time).
• Avoid contamination with saliva.
• Wear gloves, mask, and gown (especially for TB cases).
• Collect in a well-ventilated or isolation room if infection is suspected.

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🔷 5. Physical Examination of Sputum:

Characteristic	Findings	Interpretation
Amount	Small, moderate, large	Large = infection or pulmonary edema
Color	Clear, white, yellow, green, rusty, pink	Green/yellow = infection, Rusty = pneumonia, Pink frothy = pulmonary edema
Consistency	Mucoid, purulent, frothy, bloody	Purulent = infection, Bloody = TB or cancer
Odor	Foul-smelling	Anaerobic infections
Presence of blood	Hemoptysis	TB, cancer, trauma

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🔷 6. Laboratory Examination of Sputum:

✅ A. Microscopic Examination

1. Gram Stain:

• Identifies bacteria (gram-positive/negative)
• Guides initial antibiotic therapy

2. Acid-Fast Bacilli (AFB) Stain – Ziehl-Neelsen:

• For Tuberculosis diagnosis
• 3 early morning samples on consecutive days are preferred

3. India Ink Preparation:

• Detects Cryptococcus neoformans (fungal infection)

4. Wet Mount or KOH Test:

• For fungal elements

5. Cytology:

• Identifies malignant cells in lung cancer or metastasis

6. Eosinophil Count:

• ↑ in asthma, parasitic infections, allergic bronchitis

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✅ B. Culture and Sensitivity (C&S):

• Sample is cultured on specific media (Blood agar, MacConkey, Lowenstein-Jensen for TB, Sabouraud agar for fungi).
• Identifies bacteria/fungi and tests for antibiotic sensitivity.
• Takes 2–3 days for bacteria, up to 6–8 weeks for TB culture.

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✅ C. Molecular Tests:

1. CBNAAT / GeneXpert:

• Rapid test for Mycobacterium tuberculosis and Rifampicin resistance.
• Results within 2 hours.

2. PCR-based Tests:

• Highly sensitive for viruses, TB, and certain fungi.

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🔷 7. Interpretation of Results:

Finding	Suggestive Diagnosis
Yellow/green, purulent with neutrophils and gram-positive cocci	Bacterial pneumonia
Blood-streaked sputum with AFB positive	Tuberculosis
Rusty sputum	Pneumococcal pneumonia
Foul-smelling, thick sputum with mixed flora	Anaerobic lung abscess
Pink frothy sputum	Pulmonary edema
Malignant cells on cytology	Lung cancer

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🔷 8. Nursing Responsibilities:

• Explain procedure and importance of proper collection
• Ensure privacy and comfort
• Use PPE (especially for TB patients)
• Encourage deep breathing before coughing
• Label and send samples to lab immediately
• Document the color, consistency, and amount of sputum
• Monitor for signs of respiratory distress during collection

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🔷 9. Common Errors to Avoid:

• Collecting saliva instead of sputum
• Delayed transport to lab (may kill pathogens)
• Using non-sterile containers
• Not instructing patient properly

🩹 WOUND DISCHARGE (EXUDATE): COLLECTION AND EXAMINATION.

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🔷 1. What is Wound Discharge?

Wound discharge, or wound exudate, is the fluid that leaks from wounds. It contains plasma, white blood cells, dead cells, bacteria, and proteins, and its nature gives vital clues about the type of infection, healing status, or complications.

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🔷 2. Purposes of Wound Discharge Examination:

• Identify type of infection (bacterial, fungal, MRSA, etc.)
• Determine healing stage of the wound
• Diagnose resistant organisms
• Guide antibiotic therapy
• Assess for malignancy in chronic wounds

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🔷 3. Types of Wound Discharge (Clinically Observed):

Type	Description	Indication
Serous	Clear, watery	Normal healing
Sanguineous	Bright red, bloody	Trauma, bleeding
Serosanguineous	Pale red, watery	Normal early healing
Purulent	Thick, yellow/green	Infection
Foul-smelling	May be green/brown	Anaerobic infection
Seropurulent	Watery + pus	Early/mild infection

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🔷 4. Methods of Collection of Wound Discharge

✅ A. Swab Technique (Most Common)

Used for superficial wounds or small ulcers.

Steps:

1. Clean wound with sterile saline (to remove surface contaminants).
2. Use a sterile cotton swab.
3. Rotate the swab gently over the wound base, targeting areas with visible pus or tissue slough (not just surface).
4. Place the swab into a sterile transport tube with medium (like Amies medium).
5. Label and send immediately to lab.

Note: Avoid swabbing dry or necrotic tissue.

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✅ B. Aspirate Collection (Wound Aspiration)

Used for deep or closed wounds, abscesses, or pockets.

Steps:

1. Clean skin with antiseptic.
2. Use a sterile syringe and needle.
3. Insert into the wound pocket and aspirate fluid.
4. Transfer into a sterile container or culture bottle.

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✅ C. Tissue Biopsy (In Special Cases)

Used when infection is deep, chronic, or unresponsive to treatment.

Steps:

1. Done by a physician or trained personnel.
2. A small piece of wound tissue is surgically removed.
3. Sent for histopathology, culture, and cytology.

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🔷 5. Transport & Lab Handling:

• Transport sample within 1–2 hours of collection.
• Avoid refrigeration unless instructed by the lab.
• Ensure correct labeling: patient name, date, wound site, clinical suspicion.

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🔷 6. Laboratory Examination of Wound Discharge

✅ A. Macroscopic (Physical) Examination:

Feature	Observation	Significance
Color	Yellow, green, red, brown	Green = Pseudomonas, Yellow = Staph, Brown = anaerobes
Consistency	Thin, thick, foul-smelling	Thick + foul = bacterial infection
Odor	Sweet, putrid	Sweet = Pseudomonas, Putrid = anaerobes

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✅ B. Microscopic Examination:

Test	Purpose
Gram Stain	Detects gram-positive or gram-negative bacteria, pus cells
KOH Mount	For fungal infections (Candida, Aspergillus)
AFB Stain (Ziehl-Neelsen)	Detects Mycobacterium tuberculosis in chronic wounds
Wet Mount	Parasitic or fungal elements if suspected

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✅ C. Culture and Sensitivity (C&S):

Purpose: To grow and identify the pathogen and determine its antibiotic sensitivity.

• Media used: Blood agar, MacConkey agar, Chocolate agar, Sabouraud’s (for fungi).
• Culture incubated 24–72 hours.
• Report shows:
  • Organism identified
  • Sensitive/Resistant antibiotics

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✅ D. Special Investigations:

Test	Use
MRSA Screening	Detect Methicillin-resistant Staphylococcus aureus
PCR Testing	For resistant genes, TB
Cytology	If malignancy suspected in chronic ulcers
Biopsy and Histopathology	For cancer, chronic granulomatous infection

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🔷 7. Interpretation of Results:

Finding	Suggestive Diagnosis
Pus cells + gram-positive cocci	Staph aureus infection
Pus cells + gram-negative rods	Pseudomonas, E. coli
Green discharge + sweet odor	Pseudomonas infection
Foul-smelling discharge + gas bubbles	Anaerobic infection
Chronic non-healing ulcer + abnormal cells	Malignant transformation (Marjolin’s ulcer)

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🔷 8. Nursing Responsibilities:

• Educate the patient about wound hygiene
• Use sterile technique during collection
• Ensure correct labeling and documentation
• Wear PPE during procedure
• Monitor for local signs of infection (redness, warmth, pain, swelling)
• Assist in wound cleaning and dressing post-collection
• Report lab results to medical team promptly

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🔷 9. Common Errors to Avoid:

• Swabbing before cleaning wound
• Collecting from slough or necrotic tissue
• Delayed transport to lab
• Using dry swab (use pre-moistened if needed)
• Poor labeling

🧪 EXAMINATION OF BODY CAVITY FLUIDS

👉 Including: CSF, Sputum, Wound Discharge

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🔷 I. CEREBROSPINAL FLUID (CSF)

✅ A. Collection Method – Lumbar Puncture

Feature	Details
Site	L3–L4 or L4–L5 interspace
Position	Lateral recumbent or sitting
Volume	3–10 mL (divided into 3–4 tubes)
Sterility	Strict aseptic technique
Contraindications	Increased intracranial pressure, bleeding disorders

✅ B. Examination of CSF

Test Type	Tests & Purpose
Physical	Color, clarity, pressure, volume
Biochemistry	Glucose, protein, chloride, lactate
Clinical Pathology	Cell count, differential count
Microbiology	Gram stain, AFB stain, India ink, culture, PCR (GeneXpert for TB, viruses), fungal studies
Special Tests	Cytology (for malignancy), oligoclonal bands (MS), VDRL (syphilis)

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🔷 II. SPUTUM (Respiratory Tract Secretion)

✅ A. Collection Methods

Method	Description
Spontaneous expectoration	Early morning, after rinsing mouth
Induced sputum	Nebulized hypertonic saline inhalation
Suction method	In ventilated or unconscious patients (tracheal aspiration or BAL)

✅ B. Examination of Sputum

Test Type	Tests & Purpose
Physical	Color, odor, volume, consistency
Biochemistry	Not commonly done unless for eosinophils in asthma
Clinical Pathology	Cytology (malignant cells), eosinophil count
Microbiology	Gram stain, AFB stain (for TB), KOH mount (fungi), Culture & Sensitivity, CBNAAT/GeneXpert, PCR (for viruses, TB)

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🔷 III. WOUND DISCHARGE (Exudate or Pus)

✅ A. Collection Methods

Method	Procedure
Swab technique	After cleaning wound, rotate sterile swab over base of wound
Aspirate	Using sterile syringe to aspirate pus from deeper tissue
Tissue biopsy	In chronic wounds or for malignancy detection

✅ B. Examination of Wound Discharge

Test Type	Tests & Purpose
Physical	Color, consistency, odor, amount
Biochemistry	Rarely performed unless for special wound healing studies
Clinical Pathology	Cytology (to detect cancer cells in chronic wounds)
Microbiology	Gram stain, AFB stain, KOH mount, Culture & Sensitivity, MRSA screening, PCR for resistant genes

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🔷 IV. EXAMINATION PARAMETERS AT A GLANCE

Specimen	Physical	Clinical Pathology	Biochemistry	Microbiology
CSF	Color, clarity, pressure	Cell count, cytology	Glucose, protein, chloride, lactate	Gram stain, AFB, culture, PCR
Sputum	Color, odor, consistency	Eosinophils, cytology	Rarely done	Gram stain, AFB, fungal stains, culture
Wound Discharge	Color, odor, type	Cytology	Rarely done	Gram stain, culture, AFB, fungal tests

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🔷 V. General Guidelines for Sample Collection

• Always use sterile containers and aseptic technique
• Collect adequate volume
• Label all specimens with patient name, date, time, and source
• Transport to lab immediately to avoid contamination or degradation
• Wear PPE when handling infectious samples
• Inform lab of any clinical suspicion (e.g., TB, fungal, malignancy)

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🔷 VI. Common Pathogens Detected in Each Fluid

Fluid	Common Pathogens
CSF	Streptococcus pneumoniae, Neisseria meningitidis, Mycobacterium tuberculosis, HSV, Cryptococcus
Sputum	Mycobacterium tuberculosis, Klebsiella, Streptococcus pneumoniae, Pseudomonas, Candida
Wound Discharge	Staphylococcus aureus (including MRSA), Streptococcus, Pseudomonas, anaerobes, TB, fungi

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🔷 VII. Nursing Responsibilities

• Explain the procedure and prepare the patient
• Maintain strict aseptic technique during collection
• Properly label and transport samples
• Document relevant clinical details
• Observe patient for complications (e.g., headache after LP, respiratory distress during sputum collection)

🧬 SEMEN ANALYSIS.

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🔷 1. Definition:

Semen analysis is a laboratory test to assess the quantity and quality of semen and sperm to determine male fertility potential or diagnose conditions affecting sperm production.

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🔷 2. Purposes / Indications:

• Evaluation of male infertility
• After vasectomy (to confirm absence of sperm)
• Investigation of urological or endocrine disorders
• Assessment of sperm count, motility, and morphology
• Donor sperm screening

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🔷 3. Preparation for the Test:

Instruction	Duration
Abstinence	2–7 days before the test (avoid ejaculation)
No alcohol/smoking	48–72 hours prior
Avoid hot baths/saunas	2–5 days prior
Avoid medications	Antibiotics, steroids, hormones (if advised by doctor)

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🔷 4. Method of Collection:

Step	Details
Sample Collection	By masturbation directly into a sterile, wide-mouthed container
Environment	Private room (clinic/lab) or at home (delivered within 30–60 mins)
Container	Sterile, non-toxic plastic container (no condoms unless approved for sperm collection)
Temperature	Kept at body temperature (~37°C) during transport

🚨 Avoid contamination with lubricants, saliva, water, or toilet paper.

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🔷 5. Time for Testing:

• The sample should be tested within 1 hour of collection for accurate motility and morphology evaluation.

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🔷 6. Semen Analysis Parameters:

Based on WHO (2021) Reference Values

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✅ A. Physical Characteristics

Parameter	Normal Value
Volume	1.5 mL or more
Color	Whitish-gray
Viscosity	Liquefied within 30 mins
pH	7.2–8.0
Odor	Distinctive chlorine-like
Liquefaction time	Within 15–30 minutes

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✅ B. Microscopic Analysis

Parameter	Normal Range	Significance
Sperm Count (Concentration)	≥15 million/mL	↓ = oligospermia; 0 = azoospermia
Total Sperm Count	≥39 million/ejaculate	Indicates fertility potential
Motility (progressive)	≥32% progressively motile	↓ = asthenozoospermia
Total Motility (all moving)	≥40% (progressive + non-progressive)
Vitality (Live sperm)	≥58% live	Dead sperm = necrozoospermia
Morphology (Normal forms)	≥4% (strict criteria)	Abnormal = teratozoospermia
WBCs	<1 million/mL	↑ = infection or inflammation

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✅ C. Additional Tests (If Indicated)

Test	Purpose
Fructose Test	Confirms seminal vesicle function (low = ejaculatory duct obstruction)
MAR or IgG Antisperm Antibody Test	Detects antisperm antibodies
Sperm DNA Fragmentation Test	Measures sperm genetic integrity
Culture and Sensitivity	Identifies infections
Hormonal Assays	FSH, LH, testosterone in abnormal cases
Ultrasound	For varicocele, obstruction, tumors

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🔷 7. Interpretation of Common Findings

Result	Interpretation
Low volume + acidic pH	Ejaculatory duct obstruction
No sperm + normal volume	Azoospermia (obstructive or non-obstructive)
Low motility + abnormal shape	Likely infertility
High WBC count	Seminal infection
Low fructose	Ejaculatory dysfunction or congenital absence of vas deferens

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🔷 8. Nursing/Collection Responsibilities:

• Explain purpose and procedure clearly
• Ensure patient privacy and comfort
• Provide labeled sterile container
• Educate on abstinence and sample transport
• Coordinate prompt delivery to lab
• Document relevant medical or medication history

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🔷 9. Repeat Testing:

• At least 2–3 samples, spaced 2–3 weeks apart, are recommended due to natural sperm fluctuations.

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🔷 10. Clinical Conditions Diagnosed via Semen Analysis:

• Infertility (primary or secondary)
• Azoospermia (no sperm)
• Oligospermia (low count)
• Asthenozoospermia (poor motility)
• Teratozoospermia (abnormal shape)
• Varicocele
• Obstructive pathologies
• Hormonal disorders

🧬 SEMEN ANALYSIS:

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🔷 1. Introduction

Semen analysis is the cornerstone of evaluating male fertility. The quality of sperm is assessed by analyzing:

• Sperm Count – the number of sperm
• Sperm Motility – the ability to move
• Sperm Morphology – the shape and structure

All three parameters must be evaluated together to assess a man’s fertility potential.

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🔶 2. SPERM COUNT (Sperm Concentration)

✅ Definition:

The number of spermatozoa present in 1 milliliter (mL) of semen.

✅ Normal Range (WHO 2021):

• ≥15 million sperm/mL
• ≥39 million per ejaculate (total sperm count)

✅ Clinical Interpretation:

Count	Term	Significance
≥15 million/mL	Normal	Good fertility potential
<15 million/mL	Oligospermia	Reduced fertility
0 sperm	Azoospermia	Complete absence of sperm; may indicate blockage or failure of sperm production

✅ Importance in Infertility:

• Low sperm count reduces the chance of sperm reaching the egg.
• A very low or zero count often necessitates further testing (e.g., hormonal profile, testicular biopsy, imaging).

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🔶 3. SPERM MOTILITY

✅ Definition:

The ability of sperm to move forward (progressive movement) through the female reproductive tract to reach the egg.

✅ Types of Motility:

Type	Description
Progressive	Moves actively in a straight line or large circles
Non-progressive	Moves but without forward progression
Immotile	No movement

✅ Normal Values (WHO 2021):

• Progressive motility: ≥32%
• Total motility (progressive + non-progressive): ≥40%

✅ Clinical Interpretation:

Condition	Description
Asthenozoospermia	Reduced sperm motility
Total immotility	Associated with infertility; may indicate genetic or structural defects

✅ Importance in Infertility:

• Without adequate motility, sperm cannot reach or penetrate the egg.
• Poor motility significantly decreases the chances of natural conception.

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🔶 4. SPERM MORPHOLOGY

✅ Definition:

The study of sperm shape and structure, including:

• Head (contains DNA)
• Midpiece (energy production)
• Tail (movement)

✅ Normal Value (WHO 2021 – Strict Kruger Criteria):

• ≥4% normal forms

(Only 4% or more of sperm need to have a normal shape for the sample to be considered normal)

✅ Abnormalities Include:

Area	Abnormalities
Head	Large, small, double heads, amorphous
Midpiece	Thick, irregular
Tail	Coiled, multiple tails, short tail

✅ Clinical Interpretation:

Term	Description
Teratozoospermia	High % of abnormally shaped sperm
Normal morphology with low count/motility	Still may result in infertility

✅ Importance in Infertility:

• Abnormal sperm may not penetrate the egg.
• Poor morphology is linked to failed fertilization in natural and assisted reproduction.

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🔶 5. Summary Table – Normal Values & Significance

Parameter	WHO Normal Value	Importance
Sperm Count	≥15 million/mL	Fertility potential; low count = reduced chance
Motility	≥40% total; ≥32% progressive	Required for sperm to reach egg
Morphology	≥4% normal forms	Required for fertilization

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🔶 6. Role in Infertility Diagnosis

• A man with abnormal values in one or more parameters may have subfertility or infertility.
• Causes of abnormalities may include:
  • Varicocele
  • Hormonal imbalances
  • Infections
  • Genetic conditions
  • Environmental/lifestyle factors (smoking, alcohol, heat exposure)
• Repeat testing and further investigations like hormonal profile, scrotal ultrasound, genetic testing, or testicular biopsy may be needed.

🚻 URINE EXAMINATION

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🔷 I. PHYSICAL CHARACTERISTICS OF URINE

These are macroscopic observations made immediately after collection:

Characteristic	Normal Findings	Clinical Significance of Abnormalities
Color	Pale yellow to amber	Red (hematuria), brown (bilirubin), cloudy (infection), dark yellow (dehydration)
Clarity	Clear	Turbid/cloudy in infection, crystals, mucus
Odor	Mild, aromatic	Foul (infection), fruity (ketones/diabetes), ammonia (old sample)
Volume	1–2 liters/day (normal adult)	Oliguria (<400 mL/day), Polyuria (>2.5 L/day), Anuria (<100 mL/day)
Specific Gravity	1.005–1.030	Low = dilute (diabetes insipidus); High = dehydration, proteinuria
pH	4.5–8.0	Acidic in diabetes, starvation; Alkaline in UTI, vegetarian diet

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🔷 II. URINE ANALYSIS (Routine/Microscopic/Biochemical)

✅ A. Chemical (Dipstick) Analysis:

Parameter	Normal	Abnormal Findings
Protein	Negative	Proteinuria – kidney disease, preeclampsia
Glucose	Negative	Glycosuria – diabetes mellitus
Ketones	Negative	Ketosis – diabetes, starvation
Blood	Negative	Hematuria – UTI, stones, trauma
Leukocyte esterase	Negative	Indicates WBCs – infection
Nitrites	Negative	Positive = gram-negative bacterial UTI
Bilirubin	Negative	Hepatic disease
Urobilinogen	Normal trace	Increased in hemolysis, liver dysfunction
pH & SG	As above	Evaluates acid-base and concentrating ability

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✅ B. Microscopic Examination (Centrifuged Sediment):

Element	Normal	Clinical Significance
RBCs	0–2/HPF	Hematuria – trauma, stones, glomerulonephritis
WBCs	0–5/HPF	Pyuria – UTI
Epithelial Cells	Few	Many = contamination or kidney disease
Casts	Occasional hyaline	RBC casts – glomerulonephritis, WBC casts – pyelonephritis
Crystals	Occasional	Excessive – kidney stones, metabolic disorder
Bacteria/Yeast	None	Infection, contamination

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🔷 III. URINE CULTURE AND SENSITIVITY (C&S)

Used to identify bacterial or fungal infections in the urinary tract and test which antibiotics are effective.

✅ A. Specimen Collection:

Type	Method
Midstream Clean-Catch	Most common; for adults
Catheterized sample	In catheterized patients
Suprapubic aspiration	In infants or sterile collection needs
Pediatric urine bag	For infants (non-invasive)

Container: Sterile, leak-proof container
Timing: Transport to lab within 1 hour or refrigerate up to 24 hours

✅ B. Procedure in Lab:

1. A small amount of urine is plated on culture media (blood agar, MacConkey agar).
2. Plates are incubated at 37°C for 18–24 hours.
3. Colony count is done to determine significance:
   • >10⁵ CFU/mL → Significant bacteriuria (infection)
   • 10³–10⁴ CFU/mL → Possible infection (repeat if asymptomatic)
   • <10³ CFU/mL → Contamination likely
4. Identified organisms are tested for antibiotic sensitivity using:
   • Kirby-Bauer Disc Diffusion
   • MIC testing (Minimum Inhibitory Concentration)

✅ C. Common Uropathogens Identified:

Organism	Common Infections
Escherichia coli	Most common UTI
Klebsiella pneumoniae	Nosocomial UTI
Proteus mirabilis	Alkaline urine, stones
Enterococcus faecalis	Complicated UTI
Staphylococcus saprophyticus	Young women, honeymoon cystitis
Candida albicans	Diabetics, catheterized, immunocompromised

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🔷 IV. Clinical Relevance in Diagnosing Conditions:

Finding	Associated Condition
Proteinuria + RBC casts	Glomerulonephritis
Pyuria + WBC casts	Pyelonephritis
Nitrites + leukocyte esterase	Bacterial UTI
Glycosuria + ketonuria	Uncontrolled diabetes mellitus
Hematuria	Stones, tumors, trauma
Acidic urine	Diabetic ketoacidosis, dehydration
Alkaline urine	UTI with Proteus or Klebsiella

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🔷 V. Nursing/Collection Guidelines:

• Explain and assist with clean-catch technique
• Use sterile container
• Label with patient name, time, date
• Send sample to lab promptly
• Document medications (e.g., antibiotics), recent symptoms, and fluid intake
• Encourage patient to drink water unless restricted

💩 FAECES (STOOL): CHARACTERISTICS.

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🔷 1. Normal Characteristics of Faeces

Parameter	Normal Value / Appearance
Color	Light to dark brown
Consistency	Soft, formed
Shape	Cylindrical, sausage-like
Amount	~100–200 grams/day (varies with diet)
Frequency	1–2 times/day to once in 2 days
Odor	Slightly offensive, characteristic fecal smell
pH	Slightly acidic to neutral (pH 6–7.5)
Mucus	Absent or minimal
Undigested food	Minimal if digestion is normal
Blood	Absent
Parasites	None visible or microscopically present

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🔷 2. Abnormal Faecal Characteristics & Clinical Significance

Characteristic	Abnormal Findings	Clinical Indication
Color	Black, tarry (melena)	Upper GI bleeding (e.g., ulcer, varices)
	Bright red	Lower GI bleeding (e.g., hemorrhoids, cancer)
	Clay/white	Bile duct obstruction (liver/gallbladder disease)
	Green	Rapid transit, spinach, antibiotics
	Yellow, greasy	Steatorrhea (fatty stool – malabsorption, pancreatitis)
Consistency	Watery	Diarrhea – infection, IBS
	Hard, dry	Constipation, dehydration
	Pasty, foul, bulky	Fat malabsorption, celiac disease
Odor	Foul-smelling	Putrefaction, infection, GI bleeding
	Acidic odor	Carbohydrate malabsorption (e.g., lactose intolerance)
Mucus	Excess mucus	Inflammatory bowel disease (IBD), infection
Blood	Visible red blood	Hemorrhoids, fissures, cancer
	Occult (hidden)	Detected in fecal occult blood test (FOBT) – GI bleeding
Parasites	Visible worms or eggs	Intestinal parasitic infestation (e.g., roundworms, hookworms)
Pus	Present	Dysentery, IBD, abscess

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🔷 3. Bristol Stool Chart (Clinical Reference Tool)

Used to assess stool form as an indicator of intestinal transit time:

Type	Description	Interpretation
Type 1	Hard lumps, separate	Severe constipation
Type 2	Lumpy and sausage-like	Mild constipation
Type 3	Sausage-shaped with cracks	Normal
Type 4	Smooth, soft sausage/snake	Ideal, healthy stool
Type 5	Soft blobs with clear edges	Lacking fiber
Type 6	Mushy, fluffy with ragged edges	Mild diarrhea
Type 7	Watery, no solid pieces	Severe diarrhea

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🔷 4. Nursing Responsibilities (Stool Observation)

• Observe and document color, consistency, odor, frequency
• Note presence of blood, mucus, pus, undigested food, or worms
• Use standard precautions when handling samples
• Collect sample in clean, dry, labeled container
• Send for lab examination promptly if ordered
• Educate patient on normal vs. abnormal stool

💩 STOOL EXAMINATION.

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🔷 1. PURPOSE OF STOOL EXAMINATION

• Detect digestive system disorders
• Diagnose infections (bacterial, parasitic, fungal)
• Detect GI bleeding, malabsorption, or inflammatory conditions
• Identify parasites and their life stages
• Evaluate enzymatic or carbohydrate digestion problems

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🔶 2. TYPES OF STOOL EXAMINATION

Type	Involves
Physical Examination	Color, consistency, odor, blood, mucus, parasites
Microscopic Examination	Cells, ova, cysts, parasites, crystals
Chemical Tests	Occult blood, reducing substances, pH, fats
Microbiological Tests	Culture & Sensitivity (bacteria/fungi), PCR
Special Tests	Enzyme levels, fat globules, antigen detection

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🔷 3. TESTS IN DETAIL

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✅ A. OCCULT BLOOD TEST (FOBT – Fecal Occult Blood Test)

🔹 Purpose:

Detects hidden (microscopic) blood in stool, used to screen for colon cancer, polyps, and GI bleeding.

🔹 Method:

• Guaiac-based test (gFOBT)
• Immunochemical test (iFOBT or FIT)

🔹 Instructions:

• Avoid red meat, iron, NSAIDs, vitamin C, aspirin for 2–3 days before the test (for gFOBT)
• Collect a small sample from multiple spots
• Repeat on 2–3 separate days if screening

🔹 Interpretation:

Result	Suggestion
Positive	Bleeding from polyps, ulcers, cancer, hemorrhoids, IBD
Negative	No detectable blood (may still require further tests)

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✅ B. OVA, PARASITES & CYSTS (O&P Test)

🔹 Purpose:

To detect intestinal parasites (protozoa, helminths) and their life stages.

🔹 Collection:

• Collect fresh stool sample in clean, dry container.
• For parasites, 3 samples on different days may be needed.
• Avoid contamination with urine or water.

🔹 Microscopic Examination:

Component	Seen in
Ova (eggs)	Ascaris, Hookworm, Trichuris, etc.
Cysts	Giardia lamblia, Entamoeba histolytica
Trophozoites	Active forms of protozoa – must be examined fresh
Larvae	Strongyloides, hookworm
Worms (whole)	Roundworms, pinworms may be visible

Saline and iodine wet mounts are used to visualize under microscope.

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✅ C. REDUCING SUBSTANCE TEST (Benedict’s Test)

🔹 Purpose:

Detects unabsorbed sugars in stool, used in infants to diagnose carbohydrate malabsorption (e.g., lactose intolerance).

🔹 Principle:

Reducing sugars (like glucose, galactose) reduce Benedict’s reagent, causing a color change.

🔹 Interpretation:

Result	Meaning
Positive	Unabsorbed carbohydrates (lactose intolerance, enzyme deficiency)
Negative	Normal sugar absorption

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✅ D. STOOL pH TEST

pH	Indication
<5.5 (acidic)	Carbohydrate malabsorption, bacterial fermentation
>7.5 (alkaline)	Bacterial overgrowth, high protein diet

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✅ E. FAT TEST (Sudan III Stain)

🔹 Purpose:

Detects undigested fat globules in stool, seen in malabsorption syndromes like:

• Celiac disease
• Pancreatic insufficiency
• Cystic fibrosis

Positive test shows orange-red fat globules under microscope.

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🔷 4. SUPPORTING MICROBIOLOGICAL EXAMINATIONS

Test	Purpose
Stool Culture	Identifies bacteria (Salmonella, Shigella, E. coli)
C. difficile toxin assay	Detects Clostridium difficile infection
PCR / ELISA	Detects viral/parasitic DNA or antigens
Fungal culture	For immunocompromised patients

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🔷 5. INTERPRETATION AT A GLANCE

Test	Positive Result Indicates
Occult Blood	GI bleeding, cancer, ulcer, IBD
Ova/Parasites	Intestinal parasitic infection
Reducing Substance	Lactose intolerance, enzyme deficiency
Fat Globules	Steatorrhea, malabsorption
WBCs in stool	Inflammation, infection (dysentery, IBD)
Mucus	IBD, infection, IBS

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🔷 6. Nursing Responsibilities for Stool Collection:

• Educate patient on collection method (especially for O&P test: no urine/water contamination)
• Use sterile, leak-proof containers
• Label sample with name, date, time
• Transport to lab within 30–60 minutes (especially for parasite or trophozoite identification)
• Wear gloves and follow infection control practices
• Document findings and any patient symptoms (diarrhea, pain, fever)

🚻💩 METHODS AND COLLECTION OF URINE & FAECES FOR VARIOUS TESTS.

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🟦 I. URINE COLLECTION METHODS FOR VARIOUS TESTS

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🔷 A. Routine Urine Analysis

✅ Purpose:

Detect infections, kidney disorders, glucose, protein, ketones, and other abnormalities.

✅ Method:

• Type: Random or early morning midstream clean-catch sample
• Container: Sterile, wide-mouthed, dry plastic container
• Instructions:
  • Wash genital area before collection
  • Discard the first stream of urine, collect midstream sample
  • Avoid contamination
• Volume Needed: 10–30 mL

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🔷 B. Urine Culture & Sensitivity (C&S)

✅ Purpose:

Detect and identify organisms (usually bacteria) causing urinary tract infection.

✅ Method:

• Type: Midstream Clean-Catch (MSCC)
• Sterile container with tightly sealed lid
• Avoid touching inside of container or lid
• Transport within 1 hour or refrigerate if delayed

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🔷 C. 24-Hour Urine Collection

✅ Purpose:

Evaluate kidney function, protein levels, creatinine clearance, hormone levels.

✅ Method:

• Discard first morning urine, then collect all urine for 24 hours, including the last morning sample
• Store in large clean container, sometimes with preservative
• Keep container cool (refrigerated or on ice) during collection
• Label start and end time

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🔷 D. Catheterized Urine Collection

✅ Purpose:

For patients unable to void; ensures sterile collection.

✅ Method:

• Use a sterile syringe to withdraw from catheter port (never from urine bag)
• Use aseptic technique
• Transfer into sterile container

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🔷 E. Specialized Tests (e.g., pregnancy test, protein, glucose, ketones)

Test	Sample Type	Notes
Pregnancy (hCG)	Early morning urine	Most concentrated
Glucose/Ketone	Random or fasting urine	Benedict’s or dipstick test
Protein	24-hour or random	Dipstick or sulfosalicylic acid test

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🟩 II. FAECES COLLECTION METHODS FOR VARIOUS TESTS

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🔷 A. Routine Stool Examination

✅ Purpose:

Check for color, consistency, blood, mucus, pus, undigested food, etc.

✅ Method:

• Container: Clean, dry, wide-mouthed container with tight lid
• Sample: 5–10 grams (about a teaspoon)
• Avoid contamination with urine or water
• Collect from freshly passed stool, preferably morning sample

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🔷 B. Stool for Ova, Parasites, and Cysts (O&P Test)

✅ Purpose:

Detect intestinal parasites (e.g., Giardia, Ascaris, Entamoeba histolytica)

✅ Method:

• Fresh stool collected in sterile container
• Often requires 3 samples on alternate days
• No urine or water contamination
• Sample should reach lab within 30 minutes for trophozoite detection
• For preserved samples, formalin or PVA preservatives may be used

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🔷 C. Stool for Occult Blood (FOBT)

✅ Purpose:

Screen for hidden blood in GI tract (polyps, cancer, ulcers)

✅ Method:

• Small sample from 2–3 different areas of stool
• Avoid red meat, NSAIDs, vitamin C 2–3 days before the test
• Use test kit or cards provided by the lab
• Usually 3 samples over 3 days

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🔷 D. Stool Culture and Sensitivity

✅ Purpose:

Detect bacterial infections (Salmonella, Shigella, E. coli, etc.)

✅ Method:

• Fresh stool in sterile container
• Transport to lab within 30–60 minutes
• May require special media or transport systems

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🔷 E. Stool for Reducing Substances (e.g., Benedict’s Test)

✅ Purpose:

Diagnose carbohydrate malabsorption (e.g., lactose intolerance in infants)

✅ Method:

• Fresh stool sample
• Test should be done immediately or refrigerated promptly

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🔷 F. Stool for Fat (Steatorrhea Test)

✅ Purpose:

Detect fat malabsorption in disorders like celiac disease, chronic pancreatitis

✅ Method:

• Collect 72-hour stool (in some cases) or a single large sample
• Use Sudan III stain in lab for fat globules

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🟨 3. GENERAL NURSING/CLINICAL GUIDELINES

✅ For All Samples:

• Educate patient on proper collection technique
• Ensure sample is not contaminated
• Label container with:
  • Patient’s name
  • Date & time
  • Type of test
• Use standard precautions (gloves, hand hygiene)
• Send samples to lab promptly (or store as required)