Common Laboratory

procedures:
Nursing Responsibilities and
Implications
 3 Phases of Diagnostic testing

 Pretest
Client preparation

 Intra-test

specimen collection and VS

monitoring
 Post-test

Monitoring and follow-up

nursing care
Related Nursing
Diagnoses
 Anxiety

 Fear

 Impaired physical
mobility
 Deficient knowledge
BLOOD TESTS

 CBC
Hemoglobin, Hematocrit,
WBC, RBC and platelet
 Serum Electrolytes

 Arterial blood gases

 Blood Chemistry

 Drug and Hormone Assay

Complete Blood Count

 Specimen: Venous blood

 Pretest: obtain syringe,
tourniquet, vial with
appropriate anticoagulant
 Intratest: Cubital vein
commonly used for
venipuncture
 Post-test: direct pressure and
observe for bleeding, label vial
Normal values for CBC

 RBC (M) 4.7-6.1/ (F) 4.2-5.4

 Hgb (M) 14-18/ (F) 12-16 mg/dL
 Hct (M) 42-52/ (F) 33-47 %
 WBC 5-10,000 cells/cubic cm
Differential count
 Neutrophils- 55- 70%
 Lymphocytes- 20-40%
 Monocytes- 2-5%
 Eosinophils- 1-4%
 Platelets 150,000-400,000
Table. 11.2
 CBC
Normal WBC count 5-10,000 cell/cm3
Increased WBC More than 10, 000
(Leukocytosis)
Increased ACUTE bacterial
Neutrophils infection
Increased CHRONIC bacterial
Lymphocytes infection
VIRAL infection
Increased PARASITIC infection
Eosinophils
Serum Electrolytes

 Specimen: venous blood

 Pretest/Intratest/Post-test- same

Commonly ordered:
 Sodium- 135-145 mEq/L

 Potassium- 3.5-5.0 mEq/L

 Chloride- 95-105 mEq/L

 Magnesium- 1.3 to 2.1 mEq/L

 Calcium- 8 to 10 mg/dL
Serum Electrolytes

Problems can be
 Hyper if increased

 Hypo if decreased
 Blood Chemistry

 Specimen: Venous blood, serum

 Pretest/Intratrest/Post-test-same
 Examined are enzymes,
hormones, lipid profile BUN ,
Creatinine, etc…
 Place patient on NPO for 8 h
 *Creatinine is produced relatively
constant by muscles, excreted by
the kidneys and is the RELIABLE
Reflection of Renal Status
 Blood Chemistry

Normal values for :

Creatinine: 0.7 to 1.4 mg/dL
BUN: 10-20 mg/dL
Creatinine clearance: 1.67 to 2.5 mL/s
Serum uric acid: 2.5 to 8 mg/dL
Blood osmolality= 250 to 290 mOsm/L
Blood Chemistry
Enzymes/acids Purpose

Uric acid Gout detection

SGOT/SGPT Liver function test

Rheumatoid factor For Rheumatoid

arthritis
Anti-DNA antibody SLE diagnosis

CK-MB, LDH and Identifies Cardiac

Troponin damage or muscle
damage
 Blood Chemistry
Coagulation Purpose
studies
PT Measures the
12-16 seconds effectiveness of
PTT Warfarin
The BEST single
60-70 seconds screening test for
aPTT coagulation
Same as PTT,disorders
30-40 seconds measures
effectiveness of
Bleeding time HEPARIN
Measures Platelet
1-9 minutes (more specific than
function
PTT)
 Blood Chemistry
Others Purpose
ESR (erythrocyte Measures the rate at
sedimentation rate) which the RBCs settle
10-20 mm/hour out of the anti-
coagulated blood
Elevates in
Blood lipids inflammation
To detect auto
immune diseases
Cholesterol= 150-200 hyperlipidemia
mg/dL
Triglycerides= 140-200
mg/dL
 Diabetes Mellitus
DIAGNOSTIC CRITERIA
FBS equal to or greater
than 126 mg/dL
(7.0mmol/L)
(Normal 8 hour FBS-
80-109 mg/dL)
 Diabetes Mellitus
DIAGNOSTIC CRITERIA
OGTT value 1 and 2
hours post-prandial
equal to or greater
than 200 mg/dL
 Normal OGTT 1 and 2
hours post-prandial- is

 Diabetes Mellitus
DIAGNOSTIC CRITERIA
RBS of equal to or
greater than 200
mg/dL PLUS the 3
P’s
 Diabetes Mellitus
DIAGNOSTIC CRITERIA
Glycosylated
hemoglobin
(HbA1c) is a
monitoring test to
assess the adherence
to diabetic
Arterial Blood Gases
 Specimen: arterial blood
 Pretest: obtain syringe with
heparin, rubber stopper,
container with ice
 Intratest: usual site-radial
artery, perform Allen’s test
 Post-test: Apply direct
pressure on site for 5-10
minutes, send specimen with
occluded needle on ice
Normal ABG values

 pH 7.35-7.45
 pCO2 35-45 mmHg
 paO2 80-100 mmHg
 HCO3 22-26 mEq/L
 Base excess -2 to +2
 O2 sat 95-98%
 ABG interpretation
Value Normal Acidosi Alkalosi
s s
pH 7.35-7.45 Below Above
7.35 7.45
paO2 95-100
mmHg
SaO2 95-98%

paCO2 35-45 Respirat Respirat

mmHg ory >45 ory
<35
HCO3 22-26 mEq/L Metaboli Metaboli
c c
<22 >26
Urine Analysis

Specimens
 Clean-voided urine for
routine urinalysis
 Clean-catch or midstream
urine for urine culture
 Suprapubic and
catheterized urine for
urine culture
Routine Urinalysis

 Specimen: Clean voided

 Pretest: give clean vial and
instruct to void directly into the
specimen bottle
 Intratest: Allow a 10 ml collection
 Post-test: prompt delivery to
laboratory
 *First voided urine in a.m. is highly
concentrated, more uniform
concentration and with more
acidic pH
Urine Culture: Normal is <100,000

 Specimen: clean catch,

midstream or catheterized urine
 Pretest: Instruct to wash and dry
genitalia/perineum with soap and
water. (M)- circular motion, (F)-
front to back direction
 Intratest: Midstream urine, 30-60
ml
 Post-test: Cap and label, prompt
delivery and documentation
Special Urine Collection

 Infants
 Special urine bag
 Or cut a hole of the diaper (front
for the boy, middle for the girl)
pulling out through the hole the
special bag
 Children
 May use potty chair or bedpan
 Give another vial to play with,
allow parent to assist
 Elderly
 Assistance may be required
 Timed-urine collection
 Collection of ALL urine voided over
a specified time
 Refrigerated or with preservative
 Pretest: Specimen container with
preservative, receptacle for
collection, a post sign
 Intratest: At the start of collection,
have patient void and discard the
urine
At the end of collection period,
instruct to completely void and save
the urine
 Post test: Documentation
Catheter specimen
Sterile urine
 Insert needle of the syringe through
a drainage port
 Only done with the rubber catheter
not the plastic, silastic or silicone
catheter.
 Intratest: Clamp catheter x 30 mins
if no urine
 Wipe area where needle will be
inserted
 30-45° angle, 3 ml for culture
 Post-test : Unclamp catheter after
collection
Stool Analysis

 Occult Blood GUAIAC test

 Steatorrhea

 Ova/Parasites

 Bacteria

 Viruses
 General Nursing consideration
for stool collection
 Pretest: Determine purpose/s, obtain
gloves, container and tongue blade
 Intratest:
 Instruct to defecate in clean bed
pan
 Void before collection

 Do not discard tissue in bedpan

 Obtain 2.5 (1 inch) formed stool

 15-30 ml of liquid stool

 Post-test: prompt delivery

Occult Blood: Guaiac Test
 Detect the presence of enzyme:
Peroxidase
 (+) blue color positive guaiac
 Restrict intake of red meats, some
medications and Vitamin C for 3-7
days
 FALSE (+): red meat, raw fruits and
vegetables especially radish, turnip,
melon and horseradish; meds like
aspirin, NSAIDS, iron and
anticoagulants
 FALSE (-): Vitamin C, ingested 250
mg per day from any source
Sputum Analysis

 For Culture and sensitivity

 For sputum cytology
 For sputum AFB
 For monitoring of the
effectiveness of therapy
Sputum examination
 Pretest: Morning specimen is
collected
 Intratest:
 Mouthwash with plain water
 Deeply inhale x 2 then cough
 Wear gloves in collecting
specimen
 Expectorate needed- 1-2 Tbsp
or 15-30 ml
 Post-test: oral care and prompt
delivery to lab
VISUALIZATION
PROCEDURES
 Invasive procedures are
direct methods and need
CONSENT
 Non-invasive procedures
are indirect methods and
may need written consent
in some instances
Visualization procedures

They can be:

 Radiographic procedures

 “Scopic” procedures
 GIT Visualization
 Barium Swallow- UGIS
 Pretest: written consent, NPO
the night
 Intratest: administer barium
orally, then followed by X-ray
 Post-test: Laxative for
constipation, increased
fluids, assess for intestinal
obstruction , warn that stool
is light colored!
GIT Visualization
 Barium Enema- LGIS
 Pretest: Informed consent, NPO
the night, Enema the morning
 Intratest: Position on LEFT
side, administer enema, then X-
ray follow
 Post-test: Cleansing enema ,
Laxative for constipation,
assess for intestinal
obstruction
 GIT Visualization

Esophagogastroscopy
 Pretest: Informed consent,
NPO for 8 hours, warn that
gag reflex is abolished
 Intratest: Position on LEFT
side during scope insertion
 Post-test: NPO until gag
returns. Monitor for
complications
 GIT Visualization
 Anoscopy, proctoscopy,
proctosigmoidoscopy,
colonoscopy
 Pretest: Consent, NPO, and
enema administration the
morning
 Intratest: Position on the LEFT
side during scope insertion
 Post-test: Monitor for
complications
Gallbladder

 Oral cholescystogram
 PTC
 ERCP
 Ultrasound
IV Cholecystogram
 X-ray visualization of the
gallbladder after administration of
contrast media intravenously
 Pre-test: Allergy to iodine and sea-
foods
 Intra-test: ensure patent IV line
 Post-test: increase fluid intake to
flush out the dye, Assess for
delayed hypersensitivity reaction
to the dye like chills and N/V
Oral Cholecystogram

 X-ray visualization of the

gallbladder after
administration of contrast
media
 Done 10 hours after ingestion
of contrast tablets
 Done to determine the
patency of biliary duct
Endoscopic retrograde
cholangiopancreatography
 Examination where a flexible
endoscope is inserted into the
mouth and via the common bile
duct and pancreatic duct to
visualize the structures
 Iodinated dye can also be
injected after for the x-ray
procedure
Endoscopic retrograde
cholangiopancreatography
 Pre-test: consent, NPO for 12
hours, Allergy to sea-foods,
Atropine sulfate
 Intra-test: Gag reflex is
abolished, Position on LEFT
side
 Post-test: NPO until gag
reflex returns, Position side
lying and monitor for
perforation and hemorrhage
Percutaneous Transhepatic
Cholangiogram
 Under fluoroscopy, the bile duct
is entered percutaneously and
injected with a dye to observe
filling of hepatic and biliary ducts
Ultrasound of the liver,
gallbladder and pancreas
 Consent MAY be needed
 Place patient on NPO!!!
 Laxative may be given to
decrease the bowel gas
Urinary Visualization
Non-invasive: KUB, IVP,
Ultrasound
 Pretest: Elicit allergy to iodine
and seafood, NPO after
midnight
 Intra-test: IV iodinated Dye is
administered then X-ray is
taken
 Post-test: Increase fluids to
flush the dye. Documentation,
VS monitoring
Urinary Visualization
 Invasive: retrograde
cystourethrogram
 Pretest: Elicit allergy to iodine
and seafood
 Intra-test: catheter is inserted
with dye is administered then
X-ray is taken as patient voids
 Post-test: Increase fluids to
flush the dye. Documentation,
VS monitoring
Pulmonary visualization

 Invasive: Bronchoscopy,
laryngoscopy
 Non-invasive: CXR and Scan
 Bronchoscopy
 Purpose: Diagnostic and
therapeutic
 Pretest: Consent, NPO, client
teaching, anti-anxiety drugs
 Intratest: gag reflex is abolished,
instruct to remain still during
procedure, FOWLER or SUPINE
 Post-test: NPO until gag reflex
returns, monitor patient for
complication like perforation/bleed
Pulmonary function test

 Test to determine lung volumes

and capacities
LUNG VOLUMES

 1. Tidal volume – TV
 2. Inspiratory Reserve Volume-
IRV
 3. Expiratory Reserve Volume-
ERV
 4. Residual volume- RV
LUNG CAPACITIES

Lung volume + another lung volume

 1. Inspiratory Capacity- IC

 2. Functional Residual Capacity-

FRC
 3. Vital capacity- VC

 4. Total Lung capacity- TLC

Pulmonary "Volumes”

1. Tidal Volume:
 -volume of air inspired or
expired with each normal
breath, about 500ml
2. Inspiratory Reserve Volume
 -extra volume of air than can
be inspired over & beyond the
normal tidal volume, about
3000ml
Pulmonary "Volumes”

3. Expiratory Reserve Volume

 -amount of air that can still be
expired by forceful expiration after
the end of a normal tidal
expiration
 -about 1100ml

4. Residual Volume
 -volume of air still remaining in
the lungs after the most forceful
expiration, averages about 1200ml
Pulmonary "Capacities:"

1. Inspiratory Capacity
 -equals TV + IRV, about 3500ml
 -amount of air that a person can
breathe beginning at the normal
expiratory level & distending his
lungs to maximum amount
2. Functional Residual Capacity
 -equals ERV + RV
 -about amount of air remaining in
the lungs at the end of normal
expiration, about 2300ml
 Pulmonary "Capacities:"
3. Vital Capacity
 -equals IRV + TV + ERV or 1C + ERV,
about 4600ml
 -maximum amount of air that a person
can expel from the lungs after filling the
lungs to their maximum extent &
expiring to the maximum extent
4. Total Lung Capacity
 -maximum volume to which the lungs
can be expanded with the greatest
possible effort
 -volume of air in the lungs at this level is
equal to FRC (2300ml) in young adult
Cardiac Visualization

 Invasive:angiography.
Cardiac catheterization
 Non-invasive: ECG,
Echocardiography,
Stress ECG
The Cardiovascular System
LABORATORY PROCEDURES
ECHOCARDIOGRAM
 Non-invasive test that
studies the structural and
functional changes of the
heart with the use of
ultrasound
 No special preparation is
needed
2 D-echocardiogram
Angiography

 Pretest: informed consent,

allergy to dyes, seafood and
iodine
 Intratest: Monitor VS
 Post-test: maintain pressure
dressing over puncture site
 Immobilize for 6 hours
Cardiac Catheterization
 Introduction of catheter into heart
chambers
 Pretest: informed consent, allergy
to dyes, seafood and iodine, NPO
8-12 hours
 Intra-test: Empty bladder, Monitor
VS, explain palpitations
 Post-test: maintain pressure
dressing over puncture site
 Immobilize for 6-8 hours with
extremity straight
Myelography

 Radiographic examination of the

spinal column and sub-
arachnoid space to help
diagnose back pain causes
 Pre-test: Consent, NPO, allergy
to seafoods
 Intra-test: like LT
 Post-test: supine for 12 hours
Arthroscopy
 Insertion of fiber optic scope into
the joint to visualize it, perform
biopsy
 Performed under OR condition
 After care: Dressing over the
puncture site for 24 hours to
prevent bleeding
 Limit activity for several days (7
usually)
Arthrogram

 X-ray visualization of the joint

after introduction of contrast
medium
 Pre-test: consent, allergy to
seafoods
 Post-test: Dressing over
puncture site and limit joint
activity
Electromyelography
 Records the electrical activity in
muscles at rest and during
involuntary and electrical stimulation
 Detects disorders such as MG, MS
and Parkinson’s
 Explain the use of electrode inserted
into the muscles
 Mild discomfort may be experienced
 About 45 minutes for one muscle
CT scan

 Painless, non-invasive, x-
ray procedure
 Mechanism: distinguish
density of tissues
 MRI
 Painless, non-invasive, no radiation
 Creates a magnetic field
 Contraindications:
 (+) pacemaker
 (+) metal prosthesis
 Client teaching:
 Lie still during the procedure for
60-90 minutes
 Earplugs to reduce noise
discomfort
 Claustrophobia
 No radiation
ASPIRATION AND BIOSPY

 Aspiration: withdrawal of
fluid
 Biopsy: removal and exam
of tissue
 Invasive procedure needs
INFORMED CONSENT
Lumbar Puncture
 Withdrawal of CSF from the
arachnoid space
 Purpose: diagnostic and
therapeutic
 To obtain specimen, relieve
pressure and inject
medication
 Pretest: consent, empty
bladder
Lumbar Puncture
 Intra-test: Site used-between
L4/L5
 Position- flexion of the trunk
 Post-test: Flat on bed (8-12
hours)
 Offer fluids to 3 Liters
 Oral analgesic for headache
 Monitor bleeding, swelling
and changes in neurologic
status
Abdominal Paracentesis
 Withdrawal of fluid from the
peritoneal space
 Purpose: diagnostic and
therapeutic
 Pretest: consent, empty
bladder
 Position:sitting
 Site: midway between the
umbilicus and symphysis
Abdominal Paracentesis

 Intratest: 1,500 ml maximum

amount collected at one time,
Monitor VS
 Post-test: monitor VS,
bleeding complication
 Measure abdominal girth and
weight
Thoracentesis

 Removal of fluid from the

pleural space
 Purpose: Diagnostic and
therapeutic
 Pretest: Consent, teach to
avoid coughing
Position: sitting with arms
above head
Thoracentesis

 Intra-test: Support and

observation
 Post-test: Assess VS
 Position Post-procedure: lie
on the UNAFFECTED SIDE
with head elevated 30° x 30
minutes to facilitate
expansion of the affected
lungs
Bone marrow Biopsy
 Removal of specimen of bone
marrow
 Purpose: diagnostic
 Pretest: consent, teach that
procedure is painful
 Site:POSTERIOR SUPERIOR
ILIAC CREST (adult);
PROXIMAL TIBIA (pedia)
 Position: prone or lateral
Bone marrow Biopsy

 Intratest: Monitor, maintain

pressure dressing over
punctured site X 10 mins
 Post-test: Asses for
discomfort, administer
prescribed pain meds
Liver Biopsy
 Liver tissue obtained for
diagnostic purpose
 Pretest: consent,
administer Vitamin K,
monitor bleeding
parameters, NPO 2 hours
before procedure
Position: Supine or
semi-fowlers with upper
right quadrant of
abdomen exposed
Liver Biopsy
 Intra-test: Monitor VS
Take few deep inhalation
and exhalation and hold
final breath in exhalation x
10 seconds as needle is
injected
 Post-test: monitor VS,
bleeding
Position post-procedure:
RIGHT side-lying with
folded towel/pillow under
biopsy site for 4-6 hours
Papanicolau Smear
 Done as screening test for
cervical cancer, for culture
 Pre-test: no coitus for 2-3
days, no menstrual bleeding
 Intra-test: Lithotomy,
speculum with water for
lubrication, specimen
obtained for cervix and
vagina
 Post-test: monitor for
bleeding
The Cardiovascular System
LABORATORY PROCEDURES

ELECTROCARDIOGRAM
(ECG)
 A non-invasive
procedure that evaluates
the electrical activity of
the heart
 Electrodes and wires are
attached to the patient
 What the waves represent?
 P wave= Atrial Depolarization

 QRS= Ventricular Depolarization

 T wave= Ventricular REPOLARIZATION

LABORATORY PROCEDURES
CVP
 The CVP is the pressure
within the SVC
 Reflects the pressure
under which blood is
returned to the SVC and
right atrium
LABORATORY PROCEDURES
CVP
 Normal CVP is 0 to 8
mmHg/ 4-10 cm H2O
 LABORATORY PROCEDURES
Measuring CVP
 1. Position the client supine
with bed elevated at 45 degrees
(CBQ)
 2. Position the zero point of the
CVP line at the level of the right
atrium. Usually this is at the
MAL, 4th ICS
 3. Instruct the client to be
relaxed and avoid coughing
and straining.
Tubes

 Levine
 Salem Sump tube
 Gastrostomy tube
 Jejunostomy tube
Drainage

 Penrose Drain
 Hemovac
 Pleuravac
 Jackson-Pratt
Asked in the local
boards
DRE

Snellen’s chart
Weber’s test

Rinnes’ test
DRE

 Position: Left Lateral or Sim’s

position with upper leg
acutely flexed. Females can
also be examined in lithotomy
 Ask client to BEAR DOWN
To accentuate rectal
fissure, prolapse ,polyps
 To relax the anal sphincter
Snellen’s Chart: test for
visual acuity
 20 ft or 6 m distance
 3 readings: L, R and Both
eyes
 Report: 20/ xxx

Numerator: denotes the

distance from the chart
Snellen’s Chart: test for
visual acuity
Denominator denotes
the distance from which
the normal eye can read
the chart
20/60: the person can
see at 20 feet, what a
normal person can see at
60 feet.
Weber’s test

 Test for lateralization and

bone conduction
 Tuning fork is placed on top
of head
 NORMAL: sound is heard in
BOTH ears, localized at the
center of the head: WEBER
NEGATIVE
Weber’s test

 Sound is heard BETTER in the

affected ear: Bone conductive
hearing loss
 Sound is heard only or better
on the NORMAL ear:
Sensorineural heating loss
 ABNORMAL: WEBER
POSITIVE
Rinne’s Test

 Test for AIR and BONE

conduction
 Tuning fork is initially placed
on the mastoid process until
no vibration is heard
 Tuning fork is now placed in
front of the ear until sound
disappears
Rinne’s Test

 Air
conduction is
LONGER than bone
conduction

 Normal is POSITIVE
Rinne’s
Rinne’s Test

 CONDUCTIVE HEARING
LOSS:
Bone conduction is
GREATER than or equal to
the AIR conduction
Abnormal is NEGATIVE
RINNEs
Rinne’s Test

 SENSORINEURAL
HEARING LOSS:
No bone conduction and
air conduction vibration
can be assessed
NEGATIVE RINNEs
Weber
Rinne’s
Rinne’s
FAILING TO PREPARE
IS
PREPARING TO FAIL…