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Urine samples and urinalysis

Article in Nursing standard: official newspaper of the Royal College of Nursing · January 2008
DOI: 10.7748/ns2007.12.22.14.42.c6303 · Source: PubMed

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art & science clinical skills: 29
Urine samples and urinalysis
Steggall MJ (2007) Urine samples and urinalysis. Nursing Standard. 22, 14-16, 42-45.
Date of acceptance: October 1 2007.
Summary
Urinalysis is a routine screening and diagnostic tool that can be used
to identify infections and diseases. This article discusses methods of
collecting and testing urine using reagent strips and provides a guide
for interpreting the results.
Author
Martin J Steggall is head of Department of Applied Biological
Sciences, City University, and clinical nurse specialist, Barts and the
London NHS Trust, London. Email: m.j.steggall@city.ac.uk
Keywords
Reagent strips; Urinalysis; Urinary tract infection
These keywords are based on the subject headings from the British
Nursing Index. This article has been subject to double-blind review.
For author and research article guidelines visit the Nursing Standard
home page at www.nursing-standard.co.uk. For related articles
visit our online archive and search using the keywords.
URINE TESTING OR URINALYSIS can provide
the health professional with valuable information
about the patient’s health status, including
indications of renal, urological and liver disease,
diabetes mellitus, urinary tract infection (UTI)
and general hydration. Urinalysis can be used to
screen for substances that would not usually be
expected to be present in urine, for example,
glucose, leucocytes, nitrite and blood. If these
substances are present, further analysis of urine
and/or blood may be required. Although
urinalysis is an effective screening tool it should
not be used in isolation to guide treatment
because false positives, for example, nitrites, and
false negatives, for example, glucose, can occur if
the sample is contaminated or left to stand for too
long (Simerville et al 2005).
Patient assessment
Urinalysis is an important part of patient
assessment and could potentially indicate the
presence of a serious disease. For this reason, it is
essential that patients receive appropriate
counselling before providing a urine sample.
Patients should be made aware that further tests
and investigations may be required if the urine
sample provided indicates any abnormality. This
has to be balanced against the harm that a missed
42 december 12 :: vol 22 no 14-16 :: 2007
diagnosis can have. For example, the estimated
number of undiagnosed individuals with diabetes
mellitus in England is one million (Chiasson et al
2003) and without treatment these people are at a
higher risk of developing complications of diabetes
mellitus, including hypertension, accelerated
atherosclerosis, renal dysfunction, neuropathy and
sexual dysfunction. Patients should be informed if a
positive result is identified and further
investigations will be required to confirm diagnosis.
Preparation of the patient
The patient should be mobile and dextrous enough
to ‘catch’ the urine sample. Although only
approximately 50ml of urine is required for
urinalysis, patients will need to void more than this.
The usual voided volume in an adult is 200-400ml.
Patients should be asked to catch the middle part of
the void where possible (Smith et al 2004).
In adults, a mid-stream specimen of urine
(MSU) is collected or a catheter-specimen of urine
(CSU) if the patient has a catheter in situ. The
accuracy of any test and subsequent diagnosis can
be influenced by a number of factors including the
amount of bacterial contamination present when
urine is collected. MSU is collected to reduce the
possible contamination of the sample from debris
in the urethra, which may give rise to inaccurate
results. However, contamination of MSU samples
is estimated at around 30% (Lifshitz and Kramer
2000) and care should be exercised to avoid
contaminating samples (Getliffe and Dolman
2003). The effectiveness of urethral cleansing to
minimise contaminants is a matter of debate.
Lifshitz and Kramer (2000) identified that
contamination rates were similar in specimens
obtained with and without initial cleansing
(Simerville et al 2005), while Kozier et al (2000)
and Smith et al (2004) recommend cleaning of the
genital and perineal region, therefore, local
procedures should be followed.
Once the urine sample has been collected it is
sent to the laboratory for microscopy, culture and
sensitivity testing, to identify the presence of
infection and the most effective treatment. Urine
may also be collected for cytology, which involves
the study of cells for possible abnormalities,
indicating, for example, the presence of cancer
(Brewster 2001).
NURSING STANDARD
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Procedure for urine collection
Urine collection from infants and young
children It is particularly difficult to obtain an
uncontaminated sample of urine from infants or
young children as they are unable to void ‘on
demand’ like adults. There are four main ways to
obtain a urine sample from babies and young
children (Steggall 2007):

‘Bagged’ sample – obtained by attaching a
sterile perineal collecting bag. This is the least
favoured method because of the high degree of
contamination of the sample from the
perineum and rectum.

‘Clean catch’ – for non-emergency urinary
specimens the baby or child can be sat over a
sterile receptacle and the urine collected and
tested.

Mid-stream void – is the most reliable method,
but it is not always possible in young children.
Women should be encouraged to part the labia
and in older males the foreskin should be
retracted to prevent contamination.

Suprapubic bladder aspiration – is only
performed when a sample is required urgently
in children less than two years of age. Needle
aspiration can be uncomfortable and
distressing for the child and there is a risk of
puncturing the rectum if the needle passes
through the bladder.
Urine collection from adults Collecting an MSU
Before collecting an MSU it is important to
obtain verbal consent from the patient and
ensure that the individual’s dignity is respected
and maintained. The following steps should be
adhered to when obtaining an MSU:

Equipment and the environment should
be prepared in advance of the procedure. This
should include access to a lavatory, urinal or
bed pan and the availability of a sterile
specimen pot, soap and water, paper towels
and gauze swabs.

If assisting the patient, the nurse should ensure
that his or her hands are washed and dried,
and ensure non-sterile gloves and a plastic
apron are worn.

In older boys and men the foreskin should be
retracted. Local procedures relating to meatal
cleansing should be followed.

The patient should start to pass enough urine
to ‘flush’ the urethra. Approximately 30-50ml
of urine should be collected in a sterile pot.
A funnel may be used if the urine sample pot
has a narrow opening.
NURSING STANDARD

After the sample has been obtained, the
patient should be offered handwashing
facilities.

The specimen should be labelled with the
patient’s details and placed in a plastic
specimen bag, along with the laboratory
request form. It should then be kept in a
specimen fridge ready for transportation to
the laboratory.

The date, time and type of sample taken
should be documented in the nursing notes.
Collecting a CSU Before collecting a CSU for
bacteriological investigation it is important to
obtain verbal consent from the patient and
ensure that the individual’s dignity is respected
and maintained. The following steps should be
adhered to when obtaining a CSU:

Equipment and the environment should be
prepared in advance of the procedure.
Equipment should include a 20ml sterile
syringe, a sterile specimen container with
screw-top lid, an alcohol swab and portable
sharps bin.

The nurse should wash and dry his or her
hands and wear non-sterile gloves and a
plastic apron.

The section of the catheter bag tubing with the
sampling port should be exposed. The port
should be swabbed with the alcohol wipe and
left for 30 seconds to allow the alcohol to dry.
If there is no urine in the tubing, the catheter
bag tube should be clamped to allow
collection of urine.

The sterile syringe should be inserted into the
port. If a needle is used it is important to
ensure that the needle does not perforate the
catheter tubing. Approximately 10-20ml of
urine should be withdrawn from the catheter
tubing. The syringe should then be removed.
The contents of the syringe should be
transferred into the specimen container
slowly to prevent spillage. The used needle
and syringe should be discarded into the
sharps box.

The specimen container should be labelled
with the patient’s details.

If the sample is to be sent for investigation it
should be placed in the specimen fridge or in a
sample pot containing boric acid if a fridge is
unavailable, along with the laboratory request
form ready for transportation to laboratory as
soon as possible.

The date, time and type of sample taken
should be documented in the nursing notes.
december 12 :: vol 22 no 14-16 :: 2007 43
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art & science clinical skills: 29
Urinalysis using reagent strips
Routine urinalysis is an important screening tool
for abnormalities and possible disease. The urine
used for urinalysis should be a fresh MSU. Urine
must be tested within a few hours of voiding as
urinary constituents can become unstable and
may affect test results. If a delay in testing the
urine is anticipated, the sample should be kept in
a fridge to limit the speed at which the
constituents become unstable, particularly if the
sample is sent to a laboratory where an
automated testing system is used (Froom et al
2000). Because of urine stasis in the bladder
samples should not be the first void of the day
unless the urine is being tested for renal
tuberculosis (Nicholls 1997). Before using a
reagent strip to analyse a sample of urine the
following visual observations should be made:

Colour – urine can range from a pale straw
colour to deep amber depending on the
concentration. Dark urine may indicate
dehydration, blood in the urine (haematuria)
can be bright red or can give the urine a
red/brown or smoky appearance. Bilirubin
can turn the urine a brown/green or a strong
yellow colour, or the urine may even be frothy.
Certain foods or drugs may also influence
colour, for example, eating beetroot can
produce ‘pinkish’ urine. The drug rifampicin
can turn urine orange-red (Steggall 2007).

Clarity – cloudiness or debris can indicate
the presence of pus, protein or white cells and
may require further investigation (Simerville
et al 2005).
BOX 1
Urine testing: reagent strip procedure

Wear non-sterile gloves and an apron.

Check the expiry date on the container of the reagent strip and make sure
it has been stored according to the manufacturer’s recommendations.

Dip the reagent strip into the urine so that all the reagent areas are
covered. Remove the test strip from the urine. Remove excess urine
by tapping the strip against the inside of the urine container.

Wait for the recommended time to elapse according to the
manufacturer’s instructions. Compare the test strip against the colour
reference guide on the outside of the container. Remember the results.

If the sample is not being sent for laboratory investigation, discard the
urine into the lavatory and put the used strip and specimen bottle in the
clinical waste bin.

Remove gloves and wash hands.

Record the results.
(Steggall 2007)
44 december 12 :: vol 22 no 14-16 :: 2007

Odour – freshly voided urine may have a slight
but inoffensive odour. A ‘fishy’ smell may
indicate an infection and a ‘pear-drop’ smell
may indicate the presence of ketones in the
urine. Certain foods, such as asparagus,
produce a characteristic odour, as can other
strongly flavoured foods.
Urinalysis using a reagent test strip is a quick and
simple method of assessing renal function,
hydration and nutritional state. Box 1 provides
advice on reagent strip procedure. Urine reagent
strips usually test for specific gravity (SG), pH,
protein, blood, glucose, ketones, urobilinogen
and bilirubin. Some reagent strips also include a
test for nitrite and leucocytes which, if present,
may indicate bacteruria and UTI respectively. In
such cases an MSU will need to be sent to the
laboratory for microbiology, culture and
sensitivity testing (Brewster 2001). Test kits differ
between manufacturers and it is important to
review their guidelines before use.
Specific gravity Specific gravity (SG) is a
measure of the total solute concentration in a
fluid. The normal SG range of urine is 1.001-
1.035 (Marieb 2001), depending on the solutes
contained in the urine. A high SG value
represents concentrated urine and may indicate
that the individual is dehydrated. High levels of
glucose or other abnormal substances can also
result in a high SG value. A low SG value
represents dilute urine, found when an individual
has a high fluid intake, diabetes insipidus or
hypercalcaemia. When assessing SG, the
environmental temperature should be considered
as individuals may, for example, dehydrate at a
much faster rate in hot conditions. It should also
be noted that children are generally unable to
concentrate their urine efficiently and this may
affect SG values (Kozier et al 2000).
pH The pH of urine is normally acidic. A pH
range of 5.0-8.0 is considered normal (Higgins
2007). High acidity may indicate urinary stone
formation. Alkalinity may indicate a UTI with
certain types of bacteria such as Proteus
mirabilis, Klebsiella or Pseudomonas (Higgins
2007). Urinary pH is also influenced by dietary
intake. A protein-rich diet can give rise to acidic
urine and a diet high in vegetables or dairy
products can give rise to alkaline urine.
Protein Albumin protein molecules are generally
too large to pass through the glomerular
filtration barrier. Therefore, the presence of
albumin in the urine may indicate the increased
permeability of the glomerular barrier as a result
of infection or renal damage, which may require
further investigation (Nicholls 1997).
Blood The presence of blood in urine is abnormal
and is associated with problems in the urinary
tract, such as cancers, renal damage or stones.
NURSING STANDARD
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Blood in the urine may also be indicative of a
blood clotting problem or a side effect of
anticoagulant drugs. Contamination of the urine
with menstrual blood may also occur. In young
male infants, haematuria may result from the
formation of crystals in the urethra; however, this
should resolve itself in the first few weeks. Any
concerns should be referred to the appropriate
health professional. Patients with dipstick
positive haematuria should be reassessed by
urine microscopy before referral, and
microscopic haematuria should be considered as
a separate entity from macroscopic haematuria
(Khan et al 2002). The presence of visible blood
cells in the urine requires further investigation
(Whitfield 2006).
Glucose The presence of glucose in the urine, or
glycosuria, may be indicative of diabetes mellitus
but can also occur during pregnancy, in cases of
physiological stress and in those taking
corticosteroids. The renal threshold for glucose is
10-11mmol/l and the presence of glucose in the
urine indicates that blood glucose levels are in
excess of 10mmol/l (Higgins 2007). Although
glycosuria is an indication of endocrine
abnormality, it is not diagnostic and a peripheral
fasting blood sample is required to confirm any
suspicions.
Ketones These are acidic chemicals that are
formed during the abnormal excessive
breakdown of fat. This may occur as a result of
prolonged vomiting, fasting, starvation and
poorly controlled diabetes mellitus. Some
medications, for example, captopril, may
produce false positive results (Roche 2007).
Urobilinogen and bilirubin Small amounts of
urobilinogen are usually found in the urine but
elevated levels may indicate liver damage or
abnormal breakdown of red blood cells. Urine
that contains high levels of urobilinogen turns
dark when left to stand. The presence of bilirubin
may indicate liver disease or biliary obstruction.
Leucocytes In urine, leucocytes are associated
with UTI, but may indicate more severe renal
problems. Leucocytes can be present without
bacterial infection and this is termed a sterile
pyuria. Sterile pyuria can occur in tuberculosis
and inflammatory disease of the kidneys
(Higgins 2007).
Nitrite The presence of nitrite in the urine is
associated with infection. Most organisms
responsible for UTI convert nitrate to nitrite,
including Escherichia coli, Klebsiella and
Pseudomonas. However, a negative result does
not mean that infection is not present in the
urine, as some infecting organisms are unable to
convert nitrate to nitrite. For example, Devillé
et al (2004) found that, in around 50% of urine
samples containing bacteria, the urine nitrite test
was negative.
Conclusion
Urinalysis is an effective screening tool that can
be used to detect systemic diseases and
infections. There are a variety of methods of
collecting urine specimens and it is essential to
ensure that contamination is limited to reduce
the potential for inaccurate results. Reagent
strips are a quick and easy method for testing
urine and can provide valuable information
about a patient’s condition NS

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