Obtaining a Nasopharyngeal Swab

Skill 18-2

Obtaining a Nasopharyngeal Swab

A nasopharyngeal swab provides a sample that can be cultured to aid in the diagnosis of infection and to detect the carrier state for certain organisms. A swab on a flexible wire collects a specimen from the posterior nasopharynx . It can be used to detect viral and bacterial infections, including Bordetella pertussis, respiratory syncytial virus (RSV), Neisseria meningitidis, methicillin-resistant Staphylococcus aureus, influenza, and coronavirus (Higgins et al., 2020; MedlinePlus, 2021b).

Delegation Considerations

Obtaining a nasopharyngeal swab is not delegated to assistive personnel (AP). Depending on the state's nurse practice act and the organization's policies and procedures, this procedure may be delegated to licensed practical/vocational nurses (LPN/LVNs). The decision to delegate must be based on careful analysis of the patient's needs and circumstances as well as the qualifications of the person to whom the task is being delegated. Refer to the Delegation Guidelines in Appendix A.

Equipment

Nasopharyngeal swab (flexible wire)
Penlight
Tongue depressor
Facial tissue
Nonsterile gloves
Additional PPE, as indicated
Biohazard bag
Appropriate label for specimen, based on facility policy and procedure

Assessment

Assess the patient's understanding of the collection procedure, the reason for testing, and their ability to engage in care. Assess the patient's nares and for the presence of nasal symptoms, such as discharge, erythema, or congestion. Inspect the patient's nasopharynx. Assess for conditions that would contraindicate obtaining a nasopharyngeal swab, such as injury to the nares or nose, and surgery of the nose or throat.

Actual or Potential Health Problems and Needs

Many actual or potential health problems or issues may require the use of this skill as part of related interventions. An appropriate health problem or issue may include:

Infection risk
Acute pain
Knowledge deficiency

Outcome Identification and Planning

The expected outcomes to achieve are that an uncontaminated specimen is obtained without injury to the patient and sent to the laboratory promptly. Additional outcomes that may be appropriate include that the patient verbalizes an understanding of the rationale for and the steps of the procedure.

Implementation

Action	Rationale
1. Verify the prescribed intervention for a nasopharyngeal swab in the patient's health record. Gather equipment. Check the expiration date on the swab package.	Verifying the prescribed intervention is crucial for ensuring that the proper procedure is administered to the right patient. Assembling equipment provides for an organized approach to task. The swab package is sterile and should not be used past the expiration date.
2. Perform hand hygiene and put on PPE, if indicated.	Hand hygiene and PPE prevent the transmission of microorganisms. PPE is required based on transmission precautions.
3. Identify the patient.	Identifying the patient ensures the right patient receives the intervention and helps prevent errors.
4. Discuss with the patient the need for a nasopharyngeal swab. Explain the process by which the specimen will be collected. Inform the patient that they may experience discomfort and may gag but should not experience severe pain (Higgins et al., 2020).	Discussion and explanation help to allay some of the patient's anxiety and prepare the patient for what to expect.
5. Check the specimen label with the patient's identification bracelet. The label should include the patient's name and identification number, the time the specimen was collected, the route of collection, identification of person obtaining the sample, and any other information required by facility policy.	Confirmation of patient identification information ensures the specimen is labeled correctly for the right patient.
6. Assemble equipment on the overbed table or other surface within reach.	Arranging items nearby is convenient, saves time, and avoids unnecessary stretching and twisting of muscles on the part of the nurse.
7. Close the curtains around the bed or close the door to the room, if possible.	Closing the door or curtain provides for patient privacy.
8. Put on goggles, a face mask or face shield, and nonsterile gloves.	Goggles, a face mask or face shield, and gloves protect the nurse from exposure to blood or body fluids and prevent the transmission of microorganisms. Irritation to the nose and pharynx during collection with the nasal swab may cause the patient to sneeze or cough.
9. Place the bed at an appropriate and comfortable working height (VHACEOSH, 2016). Ask the patient to blow their nose into facial tissue. Ask the patient to cough into facial tissue, and then to tip back their head. Assist, as necessary.	Having the bed at the proper height prevents back and muscle strain. Blowing the nose clears nasal passages of excess mucus (CDC, 2019b), and coughing clears the nasopharynx of material that may interfere with accurate sampling. Tilting the head allows optimal access to the nares, where the swab will be inserted.
10. Peel open the swab packaging to expose the swab and collection tube. Remove the cap from the collection tube and discard. Remove the swab from packaging by grasping the exposed end. Take care not to contaminate the swab by touching it to any other surface.	The swab must remain sterile to ensure specimen is not contaminated.
11. Ask the patient to open their mouth. Inspect the back of the patient's throat using the tongue depressor.	The swab must make contact with the mucosa to ensure collection of potential pathogens.
12. Continue to observe the nasopharynx and gently insert the swab straight back into the nostril (parallel to the palate, not upward), aiming posteriorly along the floor of the nasal cavity (CDC, 2019e) (Figure 1A). Insert it approximately 9 to 10 cm (adult) (approximately the distance from the nose to the ear) to the posterior wall of the nasopharynx (CDC, 2019e; Higgins et al., 2020) (Figure 1B). Do not insert the swab upward. Do not force the swab. Rotate the swab. Leave the swab in the nasopharynx for several to 30 seconds and remove (CDC, 2019e; MedlinePlus, 2021b). Take care not to touch the swab to the sides of the nostrils.	Observation of the nasopharynx during collection ensures an accurate specimen is collected. The swab must remain uncontaminated to ensure accurate results.
13. Insert the swab fully into the collection tube, taking care not to touch any other surface. The handle end of the swab should fit snugly into the collection tube, and the end of the swab should be in the culture medium at the distal end of the collection tube. Lightly squeeze the bottom of the collection tube as necessary, depending on the type of tube in use in the facility, to break the seal on the culture medium.	The swab must remain uncontaminated to ensure accurate results. Full insertion of the swab ensures it will remain in the collection tube. Placement of the swab end in culture medium and releasing of liquid transport medium is necessary to ensure accurate specimen processing.
14. Dispose of used equipment per facility policy. Remove gloves. Perform hand hygiene.	Proper disposal of equipment reduces the transmission of microorganisms. Removing gloves properly reduces the risk for infection transmission and contamination of other items. Hand hygiene reduces the transmission of microorganisms.
15. Place a label on the collection tube per facility policy. Place the container in a plastic, sealable biohazard bag.	This ensures the specimen is labeled correctly for the right patient as well as proper processing of the specimen. Packaging the specimen in a biohazard bag prevents the person transporting the container from coming in contact with the specimen.
16. Remove other PPE, if used. Perform hand hygiene.	Proper removal of PPE reduces the risk for infection transmission and contamination of other items. Hand hygiene reduces the transmission of microorganisms.
17. Transport the specimen to the laboratory immediately. If immediate transport is not possible, check with laboratory personnel or the policy manual to see whether refrigeration is contraindicated.	Timely transport ensures accurate results.

Evaluation

The expected outcomes have been met when an uncontaminated specimen has been obtained without injury to the patient and sent to the laboratory promptly, and the patient has verbalized an understanding of the rationale for and the steps of the procedure.

Documentation

Guidelines

Record the time the specimen was collected and sent to the laboratory. Document any pertinent assessments of the patient's nares and the presence of nasal symptoms, such as discharge, erythema, or congestion. Record significant assessments of the patient's oral cavity and throat.

Sample Documentation

Developing Clinical Reasoning and Clinical Judgment

Unexpected Situations and Associated Interventions

Patient gags as soon as the tongue depressor is placed in their mouth: Depress the tongue with the tongue depressor by pushing down halfway back on the tongue. Press slightly off center to avoid eliciting the gag reflex (Jarvis & Eckhardt, 2020).

Special Considerations

General Considerations

Warn the patient that the procedure may cause slight discomfort.
Caution the patient that the procedure may cause gagging.
Do not force the swab. Forcing could cause injury. If an obstruction is encountered, try the other nostril (CDC, 2019b).
If the patient has a deviated septum or nasal obstruction, contact the health care team to discuss collection of the specimen (CDC, 2019a). These conditions may prohibit collection.

Infant and Child Considerations

A young child will require restraint so the nurse can depress the tongue and visualize the back of the mouth without injuring the child (Kyle & Carman, 2021).

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Skill 18-2