Lab Urinalysis PFN: 18DLAL04. Lab Urinalysis. Lab Urinalysis. Hours: 2.0

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1 Lab Urinalysis PFN: 18DLAL04 Hours: 2.0 Slide 1 Lab Urinalysis OBJECTIVE: Action: Perform a complete Urinalysis on 5 separate specimens Condition: Given the necessary equipment Standard: Within 75% accuracy Slide 2 Lab Urinalysis References used to develop this Lesson: Laboratory subjects book TM Clinical Lab Procedures, Urinalysis Slide 3 1

2 Topics Describe proper urine collection procedures Describe methods of urine preservation Describe normal/abnormal urine output Given the proper equipment describe and perform a macroscopic and microscopic procedure Slide 4 Reason Urinalysis can be an important diagnostic tool providing evidence of the disease process since 25% of the bodies blood flows through the Kidneys each minute Slide 5 Types of Urine Specimen Collection Random most commonly received specimen Purpose Routine screening Inadequate for microbiological exam Container Clean dry container with tight fitting lid Method Void directly into container or bedpan Slide 6 2

3 Types of Urine Specimen Collection First morning void specimen of choice for qualitative analysis Purpose Routine screening Concentrated Container Clean dry container with tight fitting lid Method Collect first specimen immediately upon rising Slide 7 Types of Urine Specimen Collection Midstream clean catch Purpose Most commonly used for bacteriological exam Alternative to catheterized specimens Container Sterile container Method Clean area around urethra and discard initial stream Slide 8 Types of Urine Specimen Collection Catheterized Purpose Bacterial culture Routine urinalysis Collection Container Same as midstream clean catch Method Collected under sterile conditions from catheter Slide 9 3

4 Types of Urine Specimen Collection Slide 10 Types of Urine Specimen Collection Suprapubic aspiration Purpose Bacterial culture Cytological exam Container Same as clean catch Method External introduction of a needle into the bladder Slide 11 Types of Urine Specimen Collection Slide 12 4

5 Types of Urine Specimen Collection Two hour postprandial Purpose Monitoring insulin therapy (diabetes mellitus) Used to compare fasting specimen results Container Clean and dry with tight fitting lid Method Void, Consume meal, collect specimen 2 hours later Slide 13 Types of Urine Specimen Collection Twenty four hour urine Purpose To measure exact amount of urine chemicals Specimen of choice for quantitative chemical testing Container Clean, dark, dry container designed to hold large volume Method Void first morning, collect all other voids to include day 2 first morning void Slide 14 Types of Urine Specimen Collection Slide 15 5

6 Urine Preservative Purpose to prevent changes in urine composition Increased Ph Decreased glucose Decreased ketones Decreased bilirubin Decreased urobilinogen Increased nitrite Increased bacteria Increased turbidity Disintegration cellular elements Color changes Slide 16 Functions of Preservatives Prevent oxygen contact with specimen Maintains acid ph Retard microbial growth Fix organized sediment Slide 17 Types of Urine Preservatives Refrigeration Tolulene Formaline Boric Acid /HCL Slide 18 6

7 Refrigeration Short term preservation of chemical and cellular elements Advantages and disadvantages Easiest and most common No interference Acceptable for urine culture Slide 19 Freezing Used for bilirubin and urobilinogen Advantages and disadvantages Preserves bilirubin and urobilinogen Turbidity occurs upon freezing Slide 20 Formalin Used for sediment preservation Preserves formed elements Disadvantage May cause clumping of sediment Slide 21 7

8 Boric Acid Used for proteins, uric acid and hormones Advantage Acceptable for urine culture Slide 22 Hydrochloric Acid (HCL) Used for calcium, d aminolevulinic acid, and oxalate testing Disadvantages Destroys formed elements Precipitates solutes Slide 23 Boric acid/hcl Test dependent Precautions May interfere with some tests When in doubt look it up When shipping Preserve the specimen as directed by the receiving Laboratory CAUTION: Chemicals may cause burns Slide 24 8

9 Sub Summary Do chemical preservatives interfere with urine dip stix tests? Yes What is the most common urine preservative? Refrigeration Slide 25 Volume Normal excretory output of the kidneys Normal void (600 to 2,000) ml/24 hours Normal average void per 24 hours (1200 to 1500) ml/24hrs Slide 26 Volume Factors affecting normal urine production Temperature Cold (increased) Heat (decreased) Diet Liquid (increased) Less (decreased) Exercise Sweat (decreased) Slide 27 9

10 Abnormal Urine Volume Polyuria Oliguria Anuria Slide 28 Polyuria Increased urine production greater than 2,000 ml/24 hrs Clinical conditions Diabetes insipidus Diabetes mellitus Nervousness and anxiety Increased fluid intake Diuretic medications Diuretic drinks Chronic renal disease Slide 29 Oliguria Decreased urine production less than 500 ml/24 hr Clinical conditions Decrease fluid intake Increase ingestion of salt Excessive perspiration Dehydration Partial renal shutdown Slide 30 10

11 Anuria Cessation of urine flow 100 ml/24 hr Clinical conditions Total renal shutdown Massive fluid loss Heavy metal poisoning Blockage of renal tubules Slide 31 Sub Summary What is increased urine out put? Polyurea What is normal urine output? Normal void 600 to 2,000 ml/24 hours Slide 32 Color Normal color due to varying amounts of pigment called urochrome Straw Yellow Amber normal unless caused by the presence of bilirubin Colorless normal if caused by recent fluid consumption Slide 33 11

12 Abnormal Urine Color Red Fresh blood Orange Medications Brown Hemoglobin Black Malaria Blue green Pseudomonas infections; medications Colorless Due to the absence of urochrome Amber Bilirubin Slide 34 Appearance Clear No turbidity Hazy Slightly turbid Cloudy Excessive turbidity Slide 35 Sub Summary What will cause a normal urine to become cloudy? If it sits for more then an hour the ph changes and amorphous sediment builds up What are normal urine colors? Yellow, straw, amber Slide 36 12

13 Specific Gravity Measure of total solids in urine Density of urine sample compared to the density of distilled water Purpose Measures concentrating and diluting abilities of kidneys Best routine test for total kidney function Slide 37 Clinical significance Specific Gravity Hyposthenuric Low specific gravity <1.010 Glomerulonephritis Pyelonephritis Diabetes insipidus Large intake of fluids Slide 38 Specific Gravity Hypersthenuric High specific gravity >1.010 Hepatic disease Congestive heart failure Excessive loss of water (dehydration) First morning specimen Slide 39 13

14 Specific Gravity Isosthenuric Specific gravity of consistently Severe renal damage Indicates loss of both the concentrating and diluting abilities of the kidneys Slide 40 Specific Gravity Determination Refractometer QC Use one or two drops Hold refractometer Read far left scale Reference range Wipe clean Test sample DI water Slide 41 Specific Gravity Determination Slide 42 14

15 Specific Gravity Determination Slide 43 ph Determines the acidity/alkalinity of urine Urine becomes alkaline upon standing Useful in identification of crystals Used to rule out acidosis/alkalosis Slide 44 ph Clinical significance Acidic Diabetic acidosis Gout Dehydratioin Severe diarrhea High protein diet Certain medicatioin Slide 45 15

16 ph Clinical significance Alkaline Vomiting Renal tubular acidosis Certain medications Urinary tract infection After meals Slide 46 Protein Purpose best routine test to detect renal disease Clinical significance proteinuria (increase protein) Strenuous physical exercise Emotional stress Pregnancy Infections Slide 47 Protein Epithelial cells in urine Severe renal disease Multiple myeloma Leukemia Glomerulonephrites Hematuria Hemoglobinuria WBC in urine Slide 48 16

17 Protein Confirmation Sulfosalicylic acid (SSA) Confirmation of urinary proteins SSA will precipitate protein Rules out false positives Procedure Equal amounts Turbidity Reactions semi quantitated Slide 49 Protein Confirmation Slide 50 Glucose Most common sugar found in urine Presence of detectable amounts known as Glycosuria Occurs when glucose levels exceeds reabsorption capacity Clinical significance Diabetes mellitus Renal tubular dysfunction Pregnancy with possible latent gestational diabetes Slide 51 17

18 Glucose Confirmation Clinitest confirmation for glucose Non specific test Clinitest procedures Add 5 drops of urine and 10 drops of water Add 1 clinitest tablet NOTE: do not touch test tube Shake tube Compare color of liquid Watch for pass through Slide 52 Ketone Bodies Ketonuria Intermediate products of fat metabolism Presence do to altered carbohydrate metabolism Clinical significance Diabetes mellitus Anorexia nervosa Starvation or fad diets Slide 53 Ketone Bodies Confirmation Acetest Confirmation for ketone Procedure Place one drop on tablet Compare color with reaction chart Positive is any purple color Slide 54 18

19 Ketone Bodies Confirmation Slide 55 Blood and Hemoglobin Hematuria presence of intact RBC s in the urine Bleeding in the urinary tract Glomerular damage Trauma Hemoglobinuria presence of free hemoglobin in the urine Slide 56 Blood and Hemoglobin Due to intravascular hemolysis Hemolytic anemia Hemolytic transfusion reactions Malaria Due to lysis of RBC s in urinary tract Traumatic passage of RBC s thru kidney to bladder Exposure of RBC s to dilute urine in the bladder Slide 57 19

20 Bilirubin Bilirubinuria Degrades upon standing while exposed to light Clinical significance Diagnostic sign of liver disease Possible billary obstruction In crease in diseases that causes conjugated bilirubin to be increase in bloodstream Slide 58 Bilirubin Confirmation Ictotest Confirmation test for bilirubin in urine Procedure Place 10 drops of urine on test mat Place one ictotest tablet on mat Place one drop of water on tablet Wait 5 seconds Add one drop of water After 60 seconds observe area around mat Positive reaction (blue or purple color) Slide 59 Bilirubin Confirmation Slide 60 20

21 Urobilinogen Increase in condition with increase bilirubin Hemolytic anemia Malaria Increased in conditions that prevents reabsorption Hepatitis cirrhosis Slide 61 Nitrites Suggests 10⁵ (100,000) or more bacteria per ml of urine Indicative of a infection by nitrate reducing bacteria Slide 62 Leukocyte Esterase White blood cells release esterases in urine Pyuria white blood cells in urine Indication of bacteriuria Indirectly indicates UTI Slide 63 21

22 Leukocyte Esterase Determination False negatives High levels of glucose and proteins High urine specific gravity Slide 64 Slide 65 Sub Summary Which chemical test is indicative of a bacteria infection? Nitrite What is the purpose of specific gravity test? To measure the kidneys ability to concentrate urine Slide 66 22

23 Microscopic Examination Preparation of specimen Pour specimen Spin Pour off supernatant Resuspend button Place one drop on slide Add cover slip Slide 67 Microscopic Examination Stains used in analysis Sterheimer Malbin Protein Peroxidase Differentiates WBC s from renal epithelial cells 3% acetic acid Differentiates RBC s from yeast Sudan III Fat globules will stain orange Iodine Starch globules will stain blue to black Slide 68 Microscopic Examination Examine entire cover slipped area under 10X using subdued light Low power Scan for casts, mucus and even distribution Scan fields under high power 40X High and Dry power objective Identify and enumerate sedimentary elements Slide 69 23

24 Sub Summary How do you differentiate WBC s from renal epithelial cells? Peroxidase How do you differentiate RBC s from yeast? 3% acetic acid Slide 70 White Blood Cell More than 5 WBC/HPF is abnormal Indentifying characteristics Round to oval shape. Segmented or lobulated nucleus (if visible) Granular cytoplasm Report all WBC s as number per high power field (#/HPF) Slide 71 Slide 72 24

25 Slide 73 Red Blood Cell More than 3 RBC/HPF is abnormal Increased in Internal bleeding UTI Traumatic catherterization Some type of trauma Strenuous exercise Menstruation Slide 74 Red Blood Cell Indentifying characteristics Pale, refractive biconcave discs Variation in size In concentrated urine, small and crenated In dilute urine, large and swollen Report all RBC s number per high power field (#/HPF) Slide 75 25

26 Red Blood Cell Slide 76 Red Blood Cell Slide 77 Epithelial Cell Originate from the genitourinary system Three types Squamous Transitional Renal Report all epithelial cells number per high power field (#/HPF) Slide 78 26

27 Epithelial Cell Squamous From distal of urethra Large, flat irregularly shaped Small central nucleus Abundant cytoplasm Slide 79 Slide 80 Slide 81 27

28 Epithelial Cell Transitional From renal pelvis and bladder Round or pear shaped May have tail like projections Large, centrally located nucleus May have two nuclei May be seen in renal disease Slide 82 Slide 83 Slide 84 28

29 Epithelial Cell Renal From renal tubules and nephron Slightly larger than WBC Nucleus usually off center May be flay, cubodial or columnar Suggestive of tubular damage Slide 85 Slide 86 Slide 87 29

30 Sub Summary What would cause RBC s in urine? Bleeding, UTI, or menstrual cycles for women What type of disease would you find transitional cells in? Renal Slide 88 Casts Formation Usually in distal convoluted tubule and collecting duct May also be formed in the ascending loop of henle Slide 89 Casts Cast formation Aggregation of Tamm Horsfall protein Attachment of fibrils Interweaving of fibrils Further protein fibril interweaving Possible attachment Detachment of protein fibrils Excretion of cast Slide 90 30

31 Casts General identifying characteristics Parallel sides Round to blunt ends Slide 91 Types of Casts Hyaline cast White blood cell cast Red blood cell cast Hemoglobin cast Epithelial cell cast Granular cast Waxy cast Fatty cast Slide 92 Types of Casts Hyaline casts consist of Refractive index Normal following strenuous exercise, dehydration, heat exposure and emotional stress Increased in acute glomerulonephritis, pyelonephritis, chronic renal disease, and congestive heart failure Possible basis for all other casts Slide 93 31

32 Slide 94 Slide 95 Slide 96 32

33 Types of Casts White blood cell cast Refractile and granulated Unless disintegration has begun Indicate infection or inflammation Slide 97 Slide 98 Types of Casts Red blood cell cast Refractive, yellow to brown May contain RBC s Primarily associated with glomerulonephrites Other conditions Slide 99 33

34 Slide 100 Slide 101 Types of Casts Hemoglobin cast Homogenous Reddish brown color Associated with same conditions as RBC cast Slide

35 Slide 103 Slide 104 Types of Casts Epithelial cell cast Formed by excessive shedding of epithelial cells Indicative of Glomerulonephritis Pyelonephrites Slide

36 Slide 106 Slide 107 Types of Casts Granular cast Contains homogenous granular material Represent stages of degeneration May occasionally be seen in normal urine May indicate glomerulonephritis or pyelonephritis Slide

37 Slide 109 Slide 110 Types of Casts Waxy cast Result of granular cast degeneration Refractile Brittle appearance Irregularly shaped Indicative of extreme stasis of urine flow Slide

38 Slide 112 Slide 113 Slide

39 Types of Casts Fatty cast Formed by attachment of lipids Highly refractile Contains yellow brown fat droplets Seen in disorders causing lipiduria Slide 115 Slide 116 Slide

40 Report all casts as number per high power field #/LPF Slide 118 Mucous Irregularly shaped Low refractive index Increased amounts Not considered clinically significant Report as occasional, few, or many (OFM) Slide 119 Slide

41 Slide 121 Miscellanious Structures Schistosoma hematobium Common in the Nile valley, Middle East and Mediterranean regions Infection with this parasite occurs from contaminated water The adult worms live in bladder Ovum has terminal spine Rarely seen in united states Report as present Slide 122 Slide

42 Miscellanious Structures Trichomonas Vaginalis Results of contamination In fresh specimen Highly motile Multiple flagella Left out specimens Loss of motility Degeneration Report as Trichomonas spp. present Slide 124 Slide 125 Slide

43 Miscellanious Structures Examples of parasites that can be found in urine as a result of fecal contamination Enterobious vermicularis Ascaris lumbricoides Giardia lamblia Slide 127 Slide 128 Slide

44 Slide 130 Miscellanious Structures Report all parasites as present Slide 131 Miscellanious Structures Bacteria Not normally present in urine May indicate UTI or contamination Presence of WBC s and positive nitrite Report Bacteria as present Slide

45 Slide 133 Slide 134 Slide

46 Miscellanious Structures Yeast Candida albicans most common Smooth, colorless, usually ovoid cells Often confused with RBC s Addition of 3% acetic acid will lyse RBC s May show budding or hyphae Found in UTI s Report as present Slide 136 Slide 137 Slide

47 Slide 139 Miscellanious Structures Spermatozoa Oval bodies with, thin tails Usually found After sexual intercourse Nocturnal emissions Found in female patient due to contact Slide 140 Miscellanious Structures Verbally report spermatozoa as present Slide

48 Slide 142 Artifact Many contaminants can be found in urine Cotton threads Hair Starch granules, powder granules Plant matter Vegetable fibers Glass fragments Must be recognize but not reported Slide 143 Slide

49 Slide 145 Slide 146 Slide

50 Amorphous urates ph <7.0 Normal crystals Acidic urine Yellow brown small granules If present in large amounts, may give urine sediment pink color Slide 148 Slide 149 Slide

51 Uric acid Yellow reddish brown Normal crystal Acidic urine May take on a variety of shapes Rhombic plates Rosettes Wedges Needles Slide 151 Slide 152 Slide

52 Calcium oxalate Normal crystal Acidic urine Colorless squares with a prismatic X inside Dumbbell and oval forms also occur May also be seen in neutral urine Slide 154 Slide 155 Slide

53 Sodium urate Colorless Normal crystal Acidic urine Appears as elongated plates in a Chinese fan arrangement Slide 157 Slide 158 Normal crystal Alkaline urine Amorphous phosphate ph >7.0 Appear as small irregularly shaped granules When present in large amounts, cause a white turbidity in specimen Slide

54 Slide 160 Slide 161 Triple phosphate Three to six sided Normal crystal Alkaline urine Often referred to as coffin lids Slide

55 Slide 163 Slide 164 Ammonium biurate Yellow brown color Normal crystal Alkaline urine Frequently described as thorny apples Slide

56 Slide 166 Slide 167 Calcium carbonate Colorless Normal crystal Alkaline urine Wedge shaped prisms, seen in singles or rosettes Slide

57 Slide 169 Calcium phosphate Colorless thin prisms Normal crystal Alkaline urine May be found in neutral ph Soluble in dilute acetic acid Slide 170 Slide

58 Slide 172 Leucine Abnormal crystal Neutral or Acidic urine Yellow brown spheres with concentric circles with radial striations Seen in liver disease Present in conjunction tyrosine crytsals Slide 173 Slide

59 Tyrosine Abnormal crystal Neutral or Acidic urine Resembles fine silky needles Seen in liver disease Present with leucine Slide 175 Slide 176 Slide

60 Cystine Abnormal crystal Neutral or Acidic urine Appears as colorless hexagonal plates Appear due to inherited inability to reabsorb cysitne Indicates potential for renal calculi formation Slide 178 Slide 179 Slide

61 Cholesterol Abnormal crystal Neutral or Acidic urine Appears as a rectangular plate with notched corners May have a stair step affect Indicative of renal damage Slide 181 Slide 182 Slide

62 Abnormal crystal Neutral or Acidic urine Sulfonamids (sulfa crystals) Presence due to sulfa drug therapy Many different forms Must know patient drug history to rule out Slide 184 Slide 185 Slide

63 Slide 187 Crystals Report all crystals as occasional, few or many (OFM) Slide 188 Sub Summary Leucine is found in what disease? Acute liver disease due to hepatitis What causes cholesterol? Renal damage Slide

64 Summary What is increased urine output? Polyuria How long can you refrigerate a urine specimen? 8 hours How could you get a normal cloudy Urine? If it sits for more then an hour the ph changes and amorphous sediment builds up Slide 190 Summary Which chemical test is indicative of a bacterial infection? Nitrite How do you differentiate WBC s from renal epithelial cells? Peroxidase What would cause RBC s in urine? Bleeding, UTI, or menstrual cycles for women Slide 191 Summary What does 3% acetic acid do? It lyses RBC c to differentiate from yeast How do you report Sperm? Verbally to the Dr Slide

65 Questions? Slide 193 Break Slide