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Introduction
Registered nurses undertaking patient examination and specimen collection must have successfully completed sexual health competencies and additional education or training as required by local policy and procedures (e.g. phlebotomy). See Delegation of clinical practice.
Patient-collected specimens are commonly used to improve efficiency for asymptomatic patients who do not require an examination. They may also be an alternative in clinical situations where the patient has declined clinician-collected swabs.
Remain client-centred throughout the testing and consider self-collection and noninvasive testing techniques where available and appropriate.
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Outcomes
Clinicians provide all clients, including transgender people, with the appropriate tests.
Procedures may vary due to variation in practice between laboratories.
Standard precautions and infection control principles are adhered to when staff undertake physical examination of patient or collect specimens.
Any client complications arising from specimen collection including venepuncture are appropriately managed and documented.
Relevant information should be included within laboratory request for the benefit of the laboratory technicians including amenorrhoea or use of hormones including testosterone.
Confirmation of patient identity and steps to ensure correct labelling of specimens are completed according to local processes.
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Procedure
Men
Prepare equipment as required prior to beginning examination.
Genital examination
Palpate the inguinal nodes.
- Inspect pubic hair for lice and nits.
- Inspect the penile shaft, glans, meatus (retract foreskin if present) and perianal area for lumps or lesions.
- Roll each testicle between thumb and fingers; the surface of the testicle should feel smooth.
- Palpate the epididymis (the cord-like structure running along the top and back of the testicle)
- Note lumps, pain or swelling.
Pharyngeal swab
Position the client for comfort.
- Palpate lymph nodes of the head and neck, noting size, shape, mobility, consistency and tenderness.
- Gently depress the tongue with a spatula. View tonsillar crypts and posterior pharynx for signs of oedema, exudate, ulceration or tonsillar enlargement.
- Using the appropriate cotton-tipped swab, swab the tonsillar crypts and posterior pharynx.
- Inoculate the culture medium or follow manufacturer’s instruction for nucleic acid amplification test (NAAT) or place in gel transport media.
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Urethral swab
In symptomatic males, urethral meatal swabs are acceptable and effective at detecting gonorrhoea and chlamydia using NAAT.
- Retract the foreskin.
- Depress the urethra from the base of the penis to the glans, or instruct the client to do so.
If microscopy is available on site:
- With the meatus held open, gently insert the inoculation loop or swab 5 mm into the distal urethra, collecting any secretions.
- Wipe the inoculation loop or swab onto a glass slide.
- Inoculate the gonorrhoea culture medium following manufacturer’s instruction for NAAT or place in gel transport media.
If no microscopy on site:
- With the meatus held open, gently insert the transport swab 5 mm into the distal urethra, collecting any secretions.
- Inoculate the gonorrhoea culture medium as per site. Follow manufacturer’s instruction for NAAT or place in gel transport media.
Urethral swab for gonorrhoea:
- Locate the urethral meatus.
- Insert the inoculation loop approximately 5 mm into the urethra.
- Gently rotate the loop.
- Roll or wipe the loop onto the glass slide and inoculate the culture medium or follow manufacturer’s instruction for NAAT.
- Alternatively use an aluminium stem nasal swab and place in gel transport media.
Ulcer or vesicle specimen collection
- Break the vesicle and collect the fluid onto a swab.
- For ulcers only, firmly rub the base of the lesion and place the swab in the transport medium provided.
Urine collection for STI
- Instruct the client to void the first 10–30 mL of urine into a specimen container.
Rectal swab
- Instruct the client to move into a lateral position with knees flexed.
- Ask the client to lift their upper buttock with their hand.
- Inspect the perianal area for lesions, warts, rashes, skin tears or any other abnormalities.
- Lubricate the swabs with normal saline or sterile water.
- Insert each swab 3–4 cm into the anal canal and rotate.
- Using the appropriate cotton-tipped swab, inoculate the culture medium or follow the manufacturer’s instructions for NAAT or place in gel transport media.
Self-collected rectal specimen collection
- Show the swab to the client.
- Label the tubes with the patient’s details to avoid having to handle the tube after the patient returns the specimen.
- Moisten the tip of the swab with saline or sterile water.
- Remove the cap from the tube, put the swab inside and seal the tube.
- Put all equipment in the specimen bag and hand it to the patient.
- Review the collection process with the patient and remind them to put the swab inside the tube, seal the tube and put the sealed tube inside the specimen bag.
Women
Genital examination and specimen collection
Offer the client the opportunity to empty her bladder before the examination in order to optimise comfort (except in those women who have had a hysterectomy or have urethral symptoms).
Prepare equipment prior to undertaking physical examination:
- gonorrhoea culture medium or transport swab
- nucleic acid amplification test (NAAT) collection kit
- 2 cotton-tipped wooden swabs
- large cotton mop
- 2 glass slides
- saline
- cover slip
- speculum
- water-based lubricant
- gloves
- goggles or other personal protective equipment as needed.
For symptomatic patients add:
- Sabouraud culture plate (yeast)
- swab for MC&S if no onsite microscopy
- pH strip
- additional swabs and appropriate transport medium if vesicles or ulcer present.
For cervical screening test:
- Pap test plastic spatula
- endocervical brush (do not use on its own, or if the patient is pregnant)
- cervical sampler broom (if needed see indications for use)
- cervical screening vial (i.e. ThinPrep).
Pharyngeal swab
- Position the client for comfort.
- Palpate the lymph nodes of the head and neck, noting size, shape, mobility, consistency and tenderness; gently depress the tongue with a spatula.
- View tonsillar crypts and posterior pharynx for signs of oedema, exudate, ulceration or tonsillar enlargement.
- Using the appropriate cotton-tipped swab, swab the tonsillar crypts and posterior pharynx.
- Inoculate the culture medium or follow the manufacturer’s instructions for NAAT or place in gel transport media.
External genital exam
- Ask the client to recline in the supine position.
- Palpate the lower abdominal area and inguinal lymph nodes.
- Ask the client to open her legs into the lithotomy position.
- Inspect the pubic hair for lice and nits.
- Inspect the vulva, introitus, perineum and anus for lumps and other lesions.
Speculum examination
- A small amount of water or water-based lubricant (note type) can be used to aid insertion of the speculum.
- Advise the client about how to relax her pelvic muscles before inserting the speculum.
- Separate the labia, ensuring you avoid touching the clitoris.
- Gently insert the closed speculum following the posterior vaginal wall.
- Gently open the blades to locate and visualise the cervix.
- Inspect the vaginal walls and cervix for any sign of abnormality. If a foreign body is noted, refer to Removal of foreign body or retained object from the vagina
- If you have difficulty locating the cervix, remove the speculum. Insert one finger into the vagina to feel for the position of the cervix. Reinsert the speculum in the direction of the located cervix.
- To remove the speculum at completion of the examination, gently pull the speculum back to clear the blades from the cervix and then gently close the blades while removing the speculum.
Endocervical swab collection
The order of endocervical swab collection can vary. Collect the most relevant swab first, based on the clinical assessment of the client.
- Insert a cotton-tipped swab approximately 5–10 mm into the endocervical canal, avoiding contact with the vaginal walls.
- Rotate the swab to allow secretions to be absorbed.
- If performing a Gram stain, roll or wipe the swab onto a glass slide prior to inoculating the culture.
- If not undertaking microscopy on site, place the swab into gel transport media.
- Collect another swab and inoculate the gonorrhoea culture medium or follow manufacturer’s instructions for NAAT. For a pinpoint os, a rayon-tipped aluminium-stemmed swab is recommended.
- Repeat collection process with NAAT collection kit.
- Depending on pathology services, some clinics may use the same swab for both tests.
High vaginal swab collection
- Sample the discharge present at the posterior fornix with a cotton-tipped swab.
- Roll or wipe the swab onto a glass slide for a Gram stain.
- If performing wet film, gently tap the swab into a drop of saline on a separate glass slide.
- Place the cover slip over the drop of saline.
- If the woman has reported a discharge or odour, test pH on an indicator stick.
- If indicated, inoculate a Sabouraud culture plate (for yeast culture).
- If not undertaking local microscopy and culture, place swab in gel transport media.
Cervical screening test (ThinPrep)
Using plastic Pap test spatula or cervical sampler (broom-like device)
- Prepare all equipment before starting the procedure.
- Note expiry date on sample collection vial.
- Remove plastic seal from the lid of the vial and discard.
- Remove lid from the vial before taking the sample.
- Lubricate the speculum with warm water. If more lubrication is needed, a small amount of water-based lubricant may be used, avoiding the tip as it may interfere with pathology tests. (Note type of lubricant—must be water-based.)
- Label the vial as per local regulations. Record the patient information and medical history on the pathology request form.
- Obtain an adequate sample from the ectocervix using a plastic spatula or cervical sampler broom.
– Plastic spatula: Select the contoured end of the plastic spatula and rotate it 360° in a clockwise direction around the entire ectocervix, while maintaining tight contact with the ectocervical surface.
– Cervical sampler (broom-like device): Insert the central bristles of the broom into the endocervical canal deep enough to allow the shorter bristles to fully contact the ectocervix.
- Rinse the plastic spatula immediately into the vial by swirling the spatula vigorously in the vial 10 times. Discard the plastic spatula.
- Tighten the cap so that the torque line on the cap passes the torque line on the vial. Do not overtighten. Place the vial and pathology request form in a specimen bag for transport to the laboratory.
- Certain molecular tests, such as those for human papillomavirus (HPV), chlamydia, gonorrhoea, trichomoniasis and Mycoplasma genitalium, can be performed from the same material collected for the ThinPrep test. Contact your laboratory for more information.
- For transgender patients make clear to the laboratory that the sample being provided is a cervical screening test (especially if listed gender marker is ‘male’) to avoid the sample being run incorrectly as an anal smear test, or discarded.
- The use of testosterone or presence of amenorrhoea should be indicated on the requisition.
The endocervical brush is designed to specifically sample the endocervical canal. It should not be used on its own or in pregnant women. Indications for adding an endocervical brush include:
- postmenopausal women with no visible transformation zone
- previous treatment (e.g. loop or cone biopsy), with no visible transformation zone. See http://www.mps.com.au/media/3380303/collectionguide_cst.mp_k054.pdf
Ulcer or vesicle specimen collection
- If a vesicle is present, break it and collect the fluid onto a swab.
- For ulcers only, firmly rub the base of the lesion and place the swab in the transport medium provided.
Self-collected vaginal swab
See diagram Self-collected vaginal swab.
- Show the swab to the client.
- Label the tubes with the client’s details to avoid having to handle the tube after the client returns the specimen.
- Instruct the client to insert the swab(s) 3–5 cm into the lower vagina and rotate.
- Once the swab has been removed from vagina, ask the client to follow the manufacturer’s instruction for NAAT.
Self-collected rectal specimen collection
See diagram under Self-collected rectal swab.
- Show the swab to the client.
- Label the tubes with the client’s details to avoid having to handle the tube after the client returns the specimen.
- Moisten the tip of the swab with saline or sterile water.
- Remove the cap from the tube, put the swab inside and seal the tube.
- Put all equipment in the specimen bag and hand it to the patient.
- Review the collection process with the client and ask the client to follow the manufacturer’s instructions, putting the collection tube inside the specimen bag.
Self-collected HPV swab
Women eligible for a self-collected swab are 30 years or over and have never had cervical screening or are overdue for screening by two years or longer.
The need to perform a clinician-collected cervical screening test should be assessed by the clinician. Clients performing self-collected tests should understand that in the event that high-risk HPV is detected then further investigation, including examination by a clinician such as a gynaecologist, would be recommended; cervical screening and similar procedures are simply screening tests and are not diagnostic.
Transgender people
For more information on transgender people see http://www.sti.guidelines.org.au/populations-and-situations/transgender.Use of hormones and other medications has no impact on the sensitivity or specificity of the STI tests.
Testosterone may cause dryness of the inner walls of the vagina, creating a higher risk for tearing and bleeding.
Vaginal examinations in transgender women
The anatomy of a neovagina created in a transgender woman differs from a natal vagina in that it is a blind cuff, lacks a cervix or surrounding fornices, and may have a more posterior orientation. Therefore using an anoscope may be a more anatomically appropriate approach for a visual examination. The anoscope can be inserted, the trocar removed, and the vaginal walls visualised collapsing around the end of the anoscope as it is withdrawn.
Cervical screening
Cervical screening is recommended for anyone with a cervix. The recommended screening time frame is the same as for cisgender women, including a self-collected human papillomavirus (HPV) swab.
Vaginal oestrogens are commonly administered in menopausal management for one or two weeks prior to the examination, as this may reduce the vaginal atrophy often seen with testosterone therapy.
It is essential to make clear to the laboratory that the sample being provided is indeed a cervical screening test (especially if the listed gender marker is ‘male’) to avoid the sample being run incorrectly as an anal smear test, or discarded. The use of testosterone or presence of amenorrhoea should be indicated on the requisition.
Venepuncture
Vessel Identification
Blood vessels consist of three types:
- Arteries carry oxygenated blood away from the heart and are not to be used for venepuncture. If by accident an artery is pierced, apply direct pressure for 5–7 minutes. Stay with the client until bleeding ceases. Inform a senior clinician and advise the client to observe the site.
- Veins are less muscular and elastic and have thinner walls than arteries. The common veins used for venepuncture in the cubital fossa are the:
- cephalic vein
- median cubital vein
- basilic vein.
- Capillaries are minute vessels which link into small veins; they are used for finger and heel pricks.
Sites to avoid include limbs with any of the following:
- intravenous therapy
- portacath
- shunt
- on the side of a mastectomy
- graft site
- severe injuries
- infection
- poor circulation e.g. vascular disease
- sclerosed or thrombosed veins
- veins that are to be saved for other treatment (e.g. chemotherapy)
- haematoma.
Methods to assist vein dilation:
- attending to the client’s wellbeing; ensuring they are comfortable, warm and relaxed
- gentle opening and closing of the client’s hand to make a fist
- lowering the client’s limb
- ensuring arm is straight and supported by bed or rolled towel
- gentle massage (do not hit or use excessive rubbing on veins)
- warm towel over the limb
- immersion of hand or foot in warm water.
Equipment
- personal protective equipment as appropriate
- gloves
- kidney dish
- cotton balls
- tourniquet
- alcohol swab
- bandaids
- multi-sample needle, winged infusion set and Luer adaptor
- needle holder
- appropriate Vacuette blood tubes
- sharps container
- biohazard bag
- request form.
Additional equipment information:
The safety winged infusion set (butterfly needle) can be used for:
- multiple collections
- clients with ‘rolling veins’ and with little subcutaneous tissue and poor skin tone
- clients who have small or damaged veins, e.g. people who inject drugs and people with HIV
The safety shield is to be activated as the needle is withdrawn from the vein.
Great care must be taken when using the winged infusion set (butterfly needle). There have been more needlestick injuries reported through use of winged infusion sets than with any other needle. The rubber tubing can recoil, causing a bouncing effect of the needle. Stretching the tubing before use reduces the recoil movement.
Discard the winged infusion set directly into the sharps bin.
Retractable needle devices (safety syringes) have a built-in safety mechanism which can be activated to retract after the blood collection is complete. These are available as a safety winged infusion set (butterfly needle) or needle and syringe device. These devices can minimise the risk of needlestick injury.
The Vacuette is a closed, sterile vacuum-sealed system for blood collection. The tubes are named by additive for easy identification. Additives, draw capacity and expiry date are written on each tube. Stock must be rotated. Note that:
Tubes will not draw when fill line has been reached.
Liquid additives, citrate and acid citrate dextrose do dry out. Check levels before use.
Invert tubes 5 or 6 times after use.
Small tubes (1 mL, 2 mL and 4 mL draw tubes) are available for use when accessing small veins. In large-volume tubes the vacuum is too strong and will collapse the vein(s).
Technique
- Ensure that you have the correct client and gain their consent.
- Identify any previous issues with blood collection.
- Identify all tests to be done.
- Assemble all the required equipment and pathology request forms and explain the procedure to the client, reassuring them before commencing.
- Wash and/or clean hands.
- Transport equipment to the client’s side in a kidney dish.
- Bring the sharps container to the client’s side.
- Assess the client’s anxiety level and reassure if necessary.
- Position client for safety and comfort.
- Support client’s arm.
- Remove any restrictive clothing.
- Apply the tourniquet, placing a finger behind the tourniquet clip to prevent the skin or hairs being pinched. Place the tourniquet approximately 5–15 cm above the puncture site. It should be tight enough to prevent venous return. Do not leave tourniquet on for more than 2 minutes as it can change blood components.
- Wash or clean hands again.
- Inspect and palpate the cubital fossa to determine an appropriate site. Palpate the vein to see if it feels elastic and well anchored and has rebound resilience. When you depress and release an engorged vein, it should spring back to a rounded, filled state. Avoid choosing a vein near an artery.
- Once vein is chosen, loosen tourniquet.
- Choose needle to suit vein; assemble equipment.
- Clean the skin and allow to air dry. Any alcohol left on the skin will be introduced into the skin, causing discomfort.
- Choose equipment to suit vein. Assemble equipment.
- Tighten the tourniquet.
- Wash or clean hands and then put on gloves.
- Position the needle and holder in the direction of the vein, directly over the vein. Do not connect the tube before the needle has pierced the skin. With your free hand, secure the vein by stretching the vein and the skin.
- Inform the client that they may feel a sharp sting prior to piercing the skin. With the bevel of the needle uppermost, pierce the skin directly over the vein, entering at a 10–25° angle and with a smooth quick entry in and along the vein, securing the needle in the vein
- With your nondominant hand, attach the collection tube to the needle connection. The tube will fill automatically.
- If using a needle and holder system, it is important to secure holder and needle as any movement of the needle in the vein can cause rupture of vein wall, causing a haematoma. Loosen the tourniquet if the flow is good and adjust as required.
- Assess client’s wellbeing and continue to assess throughout the procedure.
- Remove tube when filled with the required amount of blood and mix by inverting it top to end 8 to 10 times gently.
- For further collections, attach tubes as before. Tubes may be removed at any time during collection and reapplied after checking amount and mixing.
- Remove the final tube from the holder and loosen the tourniquet.
- Withdraw the needle from the vein in a quick movement. (Always remove the tube from the needle connection before withdrawing the needle from the vein; any remaining vacuum suction may collapse the vein and cause pain and discomfort.)
- Place a clean dry cotton ball over the puncture site and apply direct pressure to the site. Client may apply the pressure. Instruct the client to keep their arm straight.
- Discard the needle and holder at point of collection.
- Place tubes into the kidney dish, label tubes, check correct details on blood tubes with client and then place them in a biohazard bag.
- Check bleeding by gently pressing vein above the puncture site and blotting with cotton ball. Do not wipe as this will dislodge the clot and cause further bleeding.
- Check for allergy, then cover the puncture site with bandage and remove the previously loosened tourniquet from client’s arm. Ask client to remove bandage after a couple of hours.
- Clean the work area and kidney dish.
- Inspect tourniquet and discard if bloodstained.
- Remove gloves and wash your hands.
- Transport specimen according to local requirements.
Variance management
After an unsuccessful attempt at venepuncture consider contacting a clinician with advanced skills in venepuncture for assistance.
If a haematoma occurs, proceed as follows:
- Release tourniquet.
- Remove needle straight away.
- Apply direct pressure to site for 3–4 minutes or until bleeding has ceased.
- Explain to the client what has happened; treat symptoms and reassure.
- Elevate limb.
- Apply ice if the bruise is extensive.
- Dab with a clean cotton ball and inspect for spotting. Do not wipe, as clot covering venepuncture site may be dislodged.
- Apply a crepe or adhesive bandage.
- If the bruise is extensive seek medical attention.
Management of vasovagal syncope:
- Recline chair or lay client down, lower head and elevate feet. If you are unable to get the client to a bed or reclining chair, lay client on floor.
- Do not leave client.
- Call for assistance.
- Maintain clear airway.
- Check pulse and breathing. If absent commence procedure for basic life support.
- Place client on their side; if on their back, tilt head and support chin.
- If pulse present and breathing:
- gently pat cheek and call name
- release restrictive clothing
- if unconscious note the time and duration
- follow incident and accident protocol
Early signs of a vasovagal reaction:
- Blood may suddenly stop flowing.
- Client may become very quiet or restless.
- Client becomes hot and sweaty or cold.
- Client has pale face, white (blanching) around lips.
Management of early signs of vasovagal reaction:
- Recline chair, lower head to lower than heart and elevate feet, or lay client on a bed or the floor. Do not lean client forward. Ask client to take long deep controlled breaths, hold, then release slowly to the count of ten (not frequent short breaths, as this will cause them to hyperventilate).
- Release restrictive clothing.
- Ask client to wriggle their toes.
- Place cold towel on their forehead.
- Give them water to drink (if not fasting).
- Reassure and inform them of what had happened. Advise them to inform their doctor and to mention it to collection staff before having their next blood test.
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Documentation
The complete consultation should be documented in the medical record including:
- presenting issue
- sexual health history
- presence of any symptoms
- tests collected and sites screened
- findings of physical examination:
- throat and tongue: appearance, ulcers, lesions
- inguinal nodes: palpable, tender.
Diagrams to show location of clinical abnormalities are acceptable. Document any reason for decline of physical examination if self-collected swabs were taken.
Record details of male physical examination:
- pubic, penile, perianal, rectal areas: spots, rashes, lumps, lesions, ulcers, redness, swelling
- meatus: discharge, erythema, lesions, ulcers
- testicles: lumps, tenderness or swelling.
Record details of female physical examination:
- pubic, vulval, perianal, rectal area: spots, rashes, lumps, lesions, cuts, redness, swelling, presence of ectoparasites
- vagina: colour, consistency of vaginal secretions, any inflammation of vaginal wall, lesions or lumps, odour, discomfort with speculum examination
- cervix: appearance and size of os, colour and consistency of secretions from the cervix
- bimanual examination: cervical motion tenderness, masses, adnexal tenderness, uterine position
- throat and tongue: appearance, ulcers, lesions
The laboratory request form should include reason for tests being taken, such as asymptomatic screen, contact of a person with a positive diagnosis, symptomatic (describe symptoms and/or signs).
Document any adverse events, any variance management undertaken and client outcome in the medical record.
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References and further reading
- NSW Health. Infection prevention and control policy. Sydney: NSW Health; 2017. Available at: http://www1.health.nsw.gov.au/pds/ActivePDSDocuments/PD2017_013.pdf
- NSW Health. Work health and safety—blood and body substances occupational exposure prevention. Sydney: NSW Health; 2018. Available at: http://www1.health.nsw.gov.au/pds/Pages/doc.aspx?dn=GL2018_013
- South Eastern Area Laboratory Services (SEALS). Information sheets for medical practitioners and staff. Available at: http://www.seals.health.nsw.gov.au/information-sheets/.aspx
- Hand Hygiene Australia. Blood collection hand hygiene practice guidelines. Heidelberg (VIC): Hand Hygiene Australia; 2011. Available at: https://www.hha.org.au/component/jdownloads/send/19-guidance-documents/50-blood-collection
- Pilbeam V, Badrick T, Ridoutt L. Best practice pathology collection. Canberra: Australian Government Department of Health; 2013. Available at: http://www.health.gov.au/internet/main/publishing.nsf/Content/E0178836BF3A78C3CA257EF20018BB97/$File/Best Practice Path Coll Nov 2013.pdf
- Australasian Sexual Health Alliance (ASHA). Australian STI management guidelines. Sydney: ASHM; 2018. Available at: http://www.sti.guidelines.org.au/
- STIs in Gay Men Action Group (STIGMA). Australian sexually transmitted infection & HIV testing guidelines 2014 for asymptomatic men who have sex with men. Sydney: STIPU; 2014. Available at: https://stipu.nsw.gov.au/wp-content/uploads/STIGMA_Testing_Guidelines_Final_v5.pdf
- NSW Health Policy Directive: Infection Control Policy
- NSW Health. Work health and safety—blood and body substances occupational exposure prevention
- Hand Hygiene Australia Blood collection hand hygiene practice guidelines
- Figure 4.4: Self-collection of vaginal swab, Design by Slade Smith, http://members.iinet.net.au/-sladesmith
- Figure 4.5: Self-collection of anal swab, Design by Slade Smith, http://members.iinet.net.au/-sladesmith. Printable copies of the Self-collected specimens charts are available at www.stipu.nsw.gov.au