Policy Manual sample

MDT Home Health Care Agency, Inc. 115 SPUTUM COLLECTION PURPOSE: Instruction regarding the collection of a sputum specimen is given in accordance with the physician's plan of care. Specimen collection by means of suctioning will be performed only upon specific physician order to obtain an acceptable sputum specimen for diagnostic analysis. A copy of the laboratory analysis shall be placed in the medical record and results forwarded to the physician. RESPONSIBLE PERSONNEL: RN, LPN EQUIPMENT: • Sputum Specimen container • Laboratory requisition and transport supplies • If suctioning is used, refer to equipment in suctioning procedure GENERAL CONSIDERATIONS: 1. You will need to explain the difference between saliva and sputum. 2. If special problems exist (i.e., pain, recent surgery) teach appropriate techniques for overcoming these obstacles. For example, hold pillow to abdomen to support abdominal incision. PROCEDURE: 1. Explain procedure to patient. 2. Wash hands, don gloves if likelihood that contact with sputum may occur. 3. Instruct patient to: • Rinse mouth with water and they may also want to remove dentures. • Take several deep breaths and cough deeply and expectorate into container directly. • Be careful not to touch the inside of the container. • Cover the container before and after the specimen is obtained. 4. Clean patient area afterward, disposing of trash and personal protective equipment. 5. Label container with patient name, date and time of collection and place in plastic bag for transport. Complete lab requisition form in it’s entirety. 6. Wash hands. 7. Transport specimen to laboratory or office for lab pickup. DOCUMENTATION: Documentation should include teaching related to the procedure, the date and time the specimen was obtained, patient tolerance to procedure. Document physician notification of results and whether or not additional orders received.