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Laboratory &
Diagnostic Tests
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FM_i-xx.indd 1 19/11/14 1:04 PM
FM_i-xx.indd 2 19/11/14 1:04 PM
Anne M. Van Leeuwen
Mickey Lynn Bladh
www.fadavis.com
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This book is a reference for nurses, nursing students, and other health-care pro-
fessionals. It is useful as a clinical tool as well as a supportive text to supplement
clinical courses. It guides the nurse in planning what needs to be assessed,
monitored, treated, and taught regarding pretest requirements, intratest proce-
dures, and post-test care. It can be used by nursing students at all levels as a
textbook in theory classes, integrating laboratory and diagnostic data as one
aspect of nursing care; by practicing nurses to update information; and in clinical
settings as a quick reference. Designed for use in academic and clinical settings,
Daviss Comprehensive Handbook of Laboratory and Diagnostic TestsWith
Nursing Implications provides a comprehensive reference that allows easy
access to information about laboratory and diagnostic tests and procedures.
We hear every day from students and instructors that they want a laboratory and
diagnostic test reference that will help them connect-the-dotsthat will show
them how to integrate laboratory and diagnostic test results into safe, compassion-
ate, comprehensive, and effective nursing care. So we have revised the 6th edition
of the Handbook to be not only the comprehensive reference it was originally
designed to be, but it now also presents carefully selected studies that have been
enhanced to reflect aspects of Safe and Effective Nursing Care. The enhanced
studies allow the reader to drill down further into the nursing implications. More
than 80 studies have been expanded and examples include:
Bilirubin
Blood Gases
Blood Groups and Antibodies
Cerebrospinal Fluid Analysis
Chlamydia Group Antibody
Chloride, Sweat
Complete Blood Count, Hemoglobin; Platelet Count; and WBC Count
D-Dimer
Glucose
Glucose Tolerance Tests
Newborn Screening
Prostate Specific Antigen
Prothrombin Time and INR
Rheumatoid Factor
Thyroid Stimulating Hormone
Tuberculosis Testing
Monograph Library
A searchable library of mini-monographs for all the active tests included in
the text. The mini-monograph gives each tests full name, synonyms and
acronyms, specimen type (laboratory tests) or area of application (diagnostic
tests), reference ranges or contrast, and results.
An archive of full monographs of retired tests that are referenced by mini-
monographs in the text.
Alphabetical Order
The tests and procedures are presented in this book in alphabetical order by
their complete name, allowing the user to locate information quickly without
having to first place tests in a specific category or body system. Wherever pos-
sible, information within the Indications, Potential Diagnosis, and Interfering
Factors (drug lists) sections also has been organized alphabetically.
Consistent Format
The following information is provided for each laboratory and diagnostic tests:
Each monograph is titled by the test name and given in its commonly used
designation.
Synonyms and Acronyms for each test are listed where appropriate.
The Common Use section includes a brief description of the purpose for
the study.
The Specimen section includes the type of specimen usually collected and,
where appropriate, the type of collection tube or container commonly rec-
ommended. The amount of specimen collected for blood studies reflects the
amount of serum, plasma, or whole blood required to perform the test and
thus provides a way to project the total number of specimen containers
required because patients usually have multiple laboratory tests requested for
a single draw. Specimen requirements vary by laboratory. The amount of
specimen collected is usually more than what is minimally required so that
additional specimen is available, if needed, for repeat testing (quality-control
failure, dilutions, or confirmation of unexpected results). In the case of diag-
nostic tests, the type of procedure (e.g., nuclear medicine, x-ray) is given.
Normal Findings for each monograph include age-specific, gender-specific,
and ethnicity-specific variations, when indicated. It is important to consider
the normal variation of laboratory values over the life span and across cul-
tures; sometimes what might be considered an abnormal value in one circum-
stance is actually what is expected in another. Normal findings for laboratory
tests are given in conventional and standard international (SI) units.The factor
used to convert conventional to SI units is also given. Because laboratory
values can vary by method, each laboratory reference range is listed along
with the associated methodology.
The Description section includes the studys purpose and insight into how
and why the test results can affect health. Some test descriptions also provide
insight into how test results influence the development of national health
guidelines.
A separate Contraindications section has been created to differentiate cir-
cumstances that might put the patient at risk if the procedure is performed
from interfering factors that may indirectly affect patient care by adversely
affecting the results of the study.
Indications are a list of what the test is used for in terms of assessment,
evaluation, monitoring, screening, identifying, or assisting in the diagnosis of
a clinical condition.
The Potential Diagnosis section presents a list of conditions in which values
may be increased or decreased and, in some cases, an explanation of varia-
tions that may be encountered.
Critical Findings that may be life threatening or for which particular concern
may be indicated are given in conventional and SI units, along with age span
considerations where applicable. This section also includes signs and symp-
toms associated with a critical value as well as possible nursing interventions
and the nurses role in communication of critical findings to the appropriate
health-care provider.
Interfering Factors are substances or circumstances that may influence the
results of the test, rendering the results invalid or unreliable. Knowledge of
interfering factors is an important aspect of quality assurance and includes
pharmaceuticals, foods, natural and additive therapies, timing of test in rela-
tion to other tests or procedures, collection site, handling of specimen, and
underlying patient conditions.
The Pretest section addresses the need to:
Positively identify the patient using at least two unique identifiers before
providing care, treatment, or services.
Provide an explanation to the patient, in the simplest terms possible, of the
purpose of the study.
Obtain pertinent clinical, laboratory, dietary, and therapeutic history of the
patient, especially as it pertains to comparison of previous test results,
preparation for the test, and identification of potentially interfering factors.
Explain the requirements and restrictions related to the procedure as well
as what to expect; provide the education necessary for the patient to be
properly informed.
Anticipate and allay patient and family concerns or anxieties with consider-
ation of social and cultural issues during interactions.
Provide for patient safety.
Some monographs have an additional section for Nursing Problems at the
beginning of the pretest section.The enhanced information presents problems
the nurse might encounter relative to the study topic (e.g., glucose), signs and
symptoms associated with abnormal study findings, and possible interventions.
The additional information provides the reader with the opportunity to drill
further down into the nursing implications. It is provided with the thought that
incorporating laboratory and diagnostic data, on a day-to-day basis, by using the
nursing process can be taught and reinforced using simple examples.
The Intratest section can be used in a quality-control assessment or as a guide
to the nurse who may be called on to participate in specimen collection or
perform preparatory procedures. It provides:
Specific directions for specimen collection and test performance
Nursing Process
Within each phase of the testing procedure, we describe the nurses roles and
responsibilities as defined by the nursing process.
Appendices
These include:
A summary of guidelines for patient preparation with specimen collection
procedures and materials which has been revised to reflect considerations
for special patient populations.
A listing of critical findings for laboratory studies.
A listing of critical findings for diagnostic studies.
Index
Completely updated to reflect the addition of new tests, conditions, and other
key words.
Assumptions
The authors recognize that preferences for the use of specific medical termi-
nology may vary by institution. Much of the terminology used in this
Handbook is sourced from Tabers Cyclopedic Medical Dictionary.
The definition, implementation, and interpretation of national guidelines for
the treatment of various medical conditions changes as new information and
new technology emerge.The publication of updated information may at times
be contentious among the professional institutions that offer either support
or dissent for the proposed changes.This can cause confusion when a patient
asks questions about how their condition will be identified and managed.The
authors believe that the most important discussion about health care occurs
between the patient and their health-care provider(s). While the individual
studies may point out various screening tests used to identify a disease, the
authors often refer the reader to Websites maintained by nationally recog-
nized authorities on a specific topic that reflect the most current information
and recommendations for screening, diagnosis, and treatment.
Most institutions have established policies, protocols, and interdisciplinary
teams that provide for efficient and effective patient care within the appro-
priate scope of practice. While it is not our intention that the actual duties a
nurse may perform be misunderstood by way of misinterpreted inferences in
writing style, the information prepared by the authors considers that s pecific
limitations are understood by the licensed professionals and other team mem-
bers involved in patient care activities and that the desired outcomes are
achieved by order of the appropriate health-care provider.
xv
about pain, understanding the implications of the test results, and describing
post-procedural care. Various related Websites for patient education are includ-
ed throughout the book.
And fourth, laboratory and diagnostic tests do not stand on their ownall
the pieces fit together to form a picture. The section at the end of each mono-
graph integrates both laboratory and diagnostic tests, providing a more com-
plete picture of the studies that may be encountered in a patients health-care
experience. The authors thought it useful for a nurse to know what other tests
might be ordered togetherand all the related tests are listed alphabetically for
ease of use.
Laboratory and diagnostic studies are essential components of a complete
patient assessment. Examined in conjunction with an individuals history and
physical examination, laboratory studies and diagnostic data provide clues
about health status. Nurses are increasingly expected to integrate an under-
standing of laboratory and diagnostic procedures and expected outcomes in
assessment, planning, implementation, and evaluation of nursing care. The data
help develop and support nursing diagnoses, interventions, and outcomes.
Nurses may interface with laboratory and diagnostic testing on several
levels, including:
Interacting with patients and families of patients undergoing diagnostic tests
or procedures, and providing pretest, intratest, and posttest information and
support
Maintaining quality control to prevent or eliminate problems that may
interfere with the accuracy and reliability of test results
Providing education and emotional support at the point of care
Ensuring completion of testing in a timely and accurate manner
Collaborating with other health-care professionals in interpreting findings as
they relate to planning and implementing total patient care
Communicating significant alterations in test outcomes to appropriate health-
care team members
Coordinating interdisciplinary efforts
Whether the nurses role at each level is direct or indirect, the underlying
responsibility to the patient, family, and community remains the same.
The authors hope that the changes and additions made to the book and its
Web-based ancillaries will reward users with an expanded understanding of
and appreciation for the place laboratory and diagnostic testing holds in the
provision of high-quality nursing care and will make it easy for instructors to
integrate this important content in their curricula. The authors would like to
thank all the users of the previous editions for helping us identify what they
like about this book as well as what might improve its value to them. We want
to continue this dialogue. As writers, it is our desire to capture the interest of
our readers, to provide essential information, and to continue to improve the
presentation of the material in the book and ancillary products. We encourage
our readers to provide feedback to the Website and to the publishers sales
professionals. Your feedback helps us modify the materialto change with
your changing needs.
Pamela Ellis, RN, MSHCA, MSN Edward C.Walton, MS, APN-C, NP-C
Nursing Faculty Assistant Professor of Nursing
Mohave Community College Richard Stockton College of
Bullhead City, Arizona New Jersey
Galloway, New Jersey
Stephanie Franks, MSN, RN
Professor of Nursing Jean Ann Wilson, RN, BSN
St. Louis Community CollegeMeramec Coordinator Norton Annex
St. Louis, Missouri Colby Community College
Norton, Kansas
Linda Lott, MSN
AD Nursing Instructor
Itawamba Community College
Fulton, Mississippi
xvii
Dedication v
About This Book vii
Preface xv
Reviewers xvii
Monographs 1
System Tables 1613
APPENDIX A
Patient Preparation and Specimen Collection 1628
APPENDIX B
Laboratory Critical Findings 1644
APPENDIX C
Diagnostic Critical Findings 1654
Index 1656
Available on http://davisplus.fadavis.com:
APPENDIX D: Potential Nursing Diagnoses Associated with Laboratory
Diagnostic Testing
APPENDIX E: Guidelines for Age-Specific Communication
APPENDIX F: Transfusion Reactions: Laboratory Findings and Potential
Nursing Interventions
APPENDIX G: Introduction to CLIA
APPENDIX H: Effects of Natural Products on Laboratory Values
APPENDIX I: Standard and Universal Precautions
Bibliography
xix
Abnormal findings in
Adrenal gland suppression
Adrenal infarction NURSING IMPLICATIONS
Adrenal tumor AND PROCEDURE
Hyperplasia
PRETEST:
Infection
Pheochromocytoma Positively identify the patient using at
least two unique identifiers before pro-
viding care, treatment, or services.
CRITICAL FINDINGS: N/A Patient Teaching: Inform the patient this
procedure can visualize and assess the
function of the adrenal gland, which is
INTERFERING FACTORS located near the kidney.
Factors that may impair Obtain a history of the patients com-
clear imaging plaints or clinical symptoms, including
a list of known allergens, especially
Retained barium from a previous allergies or sensitivities to latex, anes-
radiological procedure. thetics, contrast medium, or sedatives.
Inability of the patient to cooperate Obtain a history of the patients endo-
or remain still during the proce- crine system, symptoms, and results of
dure because of age, significant previously performed laboratory tests
pain, or mental status. and diagnostic and surgical procedures.
Perform all adrenal blood tests before
Other considerations doing this test.
Improper injection of the radionu- Record the date of last menstrual
clide may allow the tracer to seep period and determine the possibility of
deep into the muscle tissue, pro- pregnancy in perimenopausal women.
Obtain a list of the patients current
ducing erroneous hot spots. medications, including herbs, nutri-
Consultation with a health-care pro- tional supplements, and nutraceuticals
vider (HCP) should occur before (see Appendix H online at DavisPlus).
the procedure for radiation safety If iodinated contrast medium is
concerns regarding younger scheduled to be used in patients
patients or patients who are lactat- receiving metformin (Glucophage) for
ing. Pediatric & Geriatric Imaging noninsulin-dependent (type 2) diabe-
Children and geriatric patients are tes, the drug should be discontinued
on the day of the test and continue to
at risk for receiving a higher radia-
be withheld for 48 hr after the test.
tion dose than necessary if settings Iodinated contrast can temporarily
are not adjusted for their small size. impair kidney function, and failure to
Pediatric Imaging Information on withhold metformin may indirectly
the Image Gently Campaign can be result in drug-induced lactic acidosis,
found at the Alliance for Radiation a dangerous and sometimes fatal side
during the 3-day period to prevent 10 days after the injection of the
cessation of milk production. radionuclide. Answer any questions or
Instruct the patient to immediately flush address any concerns voiced by the
the toilet and to meticulously wash patient or family.
A hands with soap and water after each Depending on the results of this pro-
voiding for 48 hrs after the procedure. cedure, additional testing may be
Instruct all caregivers to wear gloves needed to evaluate or monitor pro-
when discarding urine for 48 hrs after gression of the disease process and
the procedure. Wash gloved hands determine the need for a change in
with soap and water before removing therapy. Evaluate test results in rela-
gloves. Then wash ungloved hands tion to the patients symptoms and
after the gloves are removed. other tests performed.
Recognize anxiety related to test
results. Discuss the implications of RELATED MONOGRAPHS:
abnormal test results on the patients Related tests include ACTH and chal-
lifestyle. Provide teaching and informa- lenge tests, aldosterone, angiography
tion regarding the clinical implications adrenal, catecholamines, CT abdomen,
of the test results, as appropriate. cortisol and challenge tests, HVA, MRI
Reinforce information given by the abdomen, metanephrines, potassium,
patients HCP regarding further test- renin, sodium, and VMA.
ing, treatment, or referral to another Refer to the Endocrine System table at
HCP. Advise the patient that SSKI the end of the book for related tests by
(120 mg/day) will be administered for body system.
Adrenocorticotropic Hormone
(and Challenge Tests)
SYNONYM/ACRONYM: Corticotropin, ACTH.
Monograph_A_001-023.indd 11
250 mcg (standard Baseline and 30 min levels are adequate for
pharmacologic protocol) accurate diagnosis using either dosage; low
cosyntropin IM or IV dose protocol sensitivity is most accurate for
30 min level only
Corticotropin- Differential diagnosis between ACTH- IV dose of 1 mcg/kg Eight cortisol and eight ACTH levels: baseline
releasing dependent conditions such as Cushings human CRH collected 15 min before injection, 0 min before
hormone disease (pituitary source) or Cushings injection, and then 5, 15, 30, 60, 120, and
(CRH) syndrome (ectopic source) and ACTH- 180 min after injection
stimulation independent conditions such as Cushings
syndrome (adrenal source)
Dexameth Differential diagnosis between ACTH- Oral dose of 1 mg Collect cortisol at 8 a.m. on the morning after
asone dependent conditions such as Cushings dexamethasone the dexamethasone dose
suppression disease (pituitary source) or Cushings (Decadron) at 11 p.m.
(overnight) syndrome (ectopic source) and ACTH-
independent conditions such as Cushings
syndrome (adrenal source)
Metyrapone Suspect hypothalamic/pituitary disease such Oral dose of 30 mg/kg Collect cortisol, 11-deoxycortisol, and ACTH at
stimulation as adrenal insufficiency, ACTH-dependent metyrapone with snack 8 a.m. on the morning after the metyrapone
(overnight) conditions such as Cushings disease at midnight dose
(pituitary source) or Cushings syndrome
(ectopic source), and ACTH-independent
conditions such as Cushings syndrome
Adrenocorticotropic Hormone (and Challenge Tests)
(adrenal source)
11
17/11/14 12:03 PM
12 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
A ACTH
Values may be unchanged or slightly elevated in healthy older adults. Long-term use of
corticosteroids, to treat arthritis and autoimmune diseases, may suppress secretion of ACTH.
Corticotropin-
Releasing Hormone SI Units (Conventional
Stimulated Conventional Units Units 27.6)
Cortisol peaks at Greater than 552 nmol/L
greater than
20 mcg/dL within
3060 min
SI Units (Conventional
Units 0.22)
ACTH increases Twofold to fourfold increase
twofold to fourfold within 3060 min
within 3060 min
Dexamethasone
Suppressed SI Units (Conventional
Overnight Test Conventional Units Units 27.6)
A
Cortisol less than Less than 49.7 nmol/L
1.8 mcg/dL next day
Metyrapone
Stimulated SI Units (Conventional
Overnight Test Conventional Units Units 27.6)
Cortisol less than Less than 83 nmol/L
3 mcg/dL next day
SI Units (Conventional
Units 0.22)
ACTH greater than 75 pg/mL Greater than 16.5 pmol/L
SI Units (Conventional
Units 28.9)
11-deoxycortisol greater than Greater than 202 nmol/L
7 mcg/dL
Alanine Aminotransferase
SYNONYM/ACRONYM: Serum glutamic pyruvic transaminase (SGPT), ALT.
COMMON USE: To assess liver function related to liver disease and/or damage.
Aldolase
SYNONYM/ACRONYM: ALD.
POTENTIAL DIAGNOSIS
Conventional &
Age SI Units Increased in
ALD is released from any damaged
Newborn30 d 632 units/L
cell in which it is stored, so diseases
1 mo2 yr 3.411.8 units/L
of skeletal muscle, cardiac muscle,
36 yr 2.78.8 units/L
pancreas, red blood cells, and liver
717 yr 3.39.7 units/L
that cause cellular destruction
Adult Less than demonstrate elevated ALD levels.
8.1 units/L
Carcinoma (lung, breast, and genito-
urinary tract and metastasis to liver)
This procedure is Dermatomyositis
contraindicated for: N/A Duchennes muscular dystrophy
Aldosterone
SYNONYM/ACRONYM: N/A.
COMMON USE: To assist in the diagnosis of liver cancer and cirrhosis, or bone
cancer and bone fracture.
Allergen-Specific Immunoglobulin E A
SYNONYM/ACRONYM: Allergen profile, radioallergosorbent test (RAST), ImmunoCAP
Specific IgE.
SPECIMEN: Serum (2 mL per group of six allergens, 0.5 mL for each additional
individual allergen) collected in a gold-, red-, or red/gray-top tube.
Atopic dermatitis
from each side of the nose Echinococcus infection
should be submitted, at room Eczema
temperature, for Hansel staining Hay fever
A and evaluation. Normal findings Hookworm infection
vary by laboratory but generally, Latex allergy
greater than 1015% is consid- Schistosomiasis
ered eosinophilia or increased Visceral larva migrans
presence of eosonophils. Results
may be invalid for patients Decreased in
already taking local or Asthma (endogenous)
systemic corticosteroids. Pregnancy
Radiation therapy
This procedure is CRITICAL FINDINGS: N/A
contraindicated for: N/A
INTERFERING FACTORS
INDICATIONS Recent radioactive scans or radiation
Evaluate patients who refuse to within 1 wk of the test can interfere
submit to skin testing or who have with test results when radioimmuno-
generalized dermatitis or other der- assay is the test method.
matopathic conditions
Monitor response to desensitization
procedures
Test for allergens when skin test- NURSING IMPLICATIONS
ing is inappropriate, such as in AND PROCEDURE
infants
PRETEST:
Test for allergens when there is a
known history of allergic reaction Positively identify the patient using at
least two unique identifiers before pro-
to skin testing
viding care, treatment, or services.
Test for specific allergic sensitivity Patient Teaching: Inform the patient this
before initiating immunotherapy or test can assist in identification of
desensitization shots causal factors related to allergic
Test for specific allergic sensitivity reaction.
when skin testing is unreliable Obtain a history of the patients com-
(patients taking long-acting antihis- plaints, including a list of known aller-
tamines may have false-negative gens, especially allergies or sensitivities
skin test) to latex.
Obtain a history of the patients
immune and respiratory systems,
POTENTIAL DIAGNOSIS symptoms, and results of previously
Different scoring systems are used in performed laboratory tests and diag-
the interpretation of RAST results. nostic and surgical procedures.
Note any recent procedures that can
Increased in interfere with test results.
Related to production of IgE, the Obtain a list of the patients current
antibody that primarily responds medications, including herbs, nutri-
to conditions that stimulate an tional supplements, and nutraceuticals
allergic response (see Appendix H online at DavisPlus).
Review the procedure with the patient.
Allergic rhinitis Inform the patient that specimen col-
Anaphylaxis lection takes approximately 5 to 10 min.
Asthma (exogenous) Address concerns about pain and
A NORMAL FINDINGS: (Method: Selective electrodes that measure Po2 and Pco2)
as arteriovenous fistulas, burns,
Alveolar/ Less than 10 mm Hg tumors, vascular grafts
arterial at rest (room air)
gradient POTENTIAL DIAGNOSIS
2030 mm Hg at
maximum exercise Increased in
activity (room air) Acute respiratory distress syndrome
Arterial/ Greater than 0.75 (ARDS) (related to thickened
alveolar (75%) edematous alveoli)
oxygen Atelectasis (related to mixing
ratio oxygenated and unoxygenated
blood)
Arterial-venous shunts (related to
mixing oxygenated and unoxy-
This procedure is
genated blood)
contraindicated for
Bronchospasm (related to
Arterial puncture in any of the follow-
decrease in the diameter of the
ing circumstances:
airway)
Inadequate circulation as Chronic obstructive pulmonary
evidenced by an abnormal disease (related to decrease in
(negative) Allen test or the the elasticity of lung tissue)
absence of a radial artery pulse Congenital cardiac septal defects
Significant or uncontrolled (related to mixing oxygenated
bleeding disorder as the and unoxygenated blood)
procedure may cause excessive Underventilated alveoli (related to
bleeding; caution should be used mucus plugs)
when performing an arterial Pneumothorax (related to col-
puncture on patients receiving lapsed lung, shunted air, and
anticoagulant therapy or subsequent decrease in arterial
thrombolytic medications oxygen levels)
Infection at the puncture Pulmonary edema (related to
site carries the potential for thickened edematous alveoli)
introducing bacteria from the Pulmonary embolus (related
skin surface into the blood to obstruction of blood flow
stream to alveoli)
Congenital or acquired Pulmonary fibrosis (related to
abnormalities of the skin or thickened edematous alveoli)
blood vessels in the area of the
anticipated puncture site such CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).
INTERFERING FACTORS
for the production of ApoE4 and Some patients with AD may have
development of late-onset AD. normal levels of tau protein
Diagnosis of AD includes a thor-
A ough physical examination, a
because of an insufficient number
of neurofibrillary tangles.
complete medical history, neuro-
logical examination, tests of men-
tal status, blood tests, and brain
imaging procedures.
NURSING IMPLICATIONS
AND PROCEDURE
This procedure is PRETEST:
contraindicated for Positively identify the patient using
Patients with infection present at least two unique identifiers
at the needle insertion site. before providing care, treatment,
Patients with degenerative or services.
joint disease or coagulation Patient Teaching: Inform the patient
defects. this test can assist in diagnosing
Patients who are uncoopera- AD and/or evaluating the
tive during the procedure. effectiveness of medication used
to treat AD.
Patients with increased intracra-
Obtain a history of the patients com-
nial pressure because overly plaints, including a list of known aller-
rapid removal of CSF can result gens, especially allergies or sensitivities
in herniation. to latex or anesthetics.
Obtain a history of the patients neuro-
logical system, symptoms, and results
INDICATIONS of previously performed laboratory
Assist in establishing a diagnosis tests and diagnostic and surgical
of AD procedures.
Obtain a list of the patients current
medications, including herbs, nutri-
POTENTIAL DIAGNOSIS tional supplements, and nutraceuticals
(see Appendix H online at DavisPlus).
Increased in Review the procedure with the
Tau protein is increased in AD. patient. Inform the patient that
Presence of ApoE4 alleles is a genetic the procedure will be performed by a
risk factor for AD. health-care provider (HCP) trained to
Identification of mutations in the perform the procedure and takes
APP, PS-1, and PS-2 genes is associ- approximately 20 min. Address con-
ated with forms of AD. cerns about pain and explain that
there may be some discomfort during
Decreased in the lumbar puncture. Inform the
a-Amyloid-42 is decreased in up to patient that a stinging sensation may
50% of healthy control participants. be felt as the local anesthetic is
injected. Instruct the patient to report
AD (related to accumulation in any pain or other sensations that
the brain with a corresponding may require repositioning of the spi-
decrease in CSF) nal needle.
Creutzfeldt-Jakob disease Inform the patient that the position
required for the lumbar puncture may
be awkward but that someone will
CRITICAL FINDINGS: N/A assist. Stress the importance of
remaining still and breathing normally Record baseline vital signs, and assess
throughout the procedure. neurological status. Protocols may vary
Sensitivity to social and cultural issues, among facilities.
as well as concern for modesty, is To perform a lumbar puncture,
important in providing psychological position the patient in the knee-chest A
support before, during, and after the position at the side of the bed.
procedure. Provide pillows to support the spine
Note that there are no food, fluid, or for the patient to grasp. The
or medication restrictions unless by sitting position is an alternative.
medical direction. In this position, the patient must
Make sure a written and informed bend the neck and chest to the
consent has been signed prior to the knees.
procedure and before administering Prepare the site (usually between
any medications. L3 and L4 or L4 and L5) with
povidone-iodine, and drape the area.
INTRATEST: Inject a local anesthetic. Using sterile
technique, the HCP inserts the spinal
Potential Complications: needle through the spinous pro-
Headache is a common minor com- cesses of the vertebrae and into the
plication experienced after lumbar subarachnoid space. Needle size
puncture and is caused by leakage has been shown to play a significant
of the spinal fluid from around the role in predictable incidence of post-
puncture site. On a rare occasion the puncture headache. However, the
headache may require treatment with smaller the bevel, the more time is
an epidural blood patch in which an required to collect a sufficient volume
anesthesiologist or pain management of fluid; usually a 22g needle is
specialist injects a small amount of used. The stylet is removed. CSF
the patients blood in the epidural drips from the needle if it is properly
space of the puncture site. The placed.
blood patch forms a clot and seals Attach the stopcock and manometer,
the puncture site to prevent further and measure initial CSF pressure.
leakage of CSF and provides relief Normal pressure for an adult in
within 30 minutes. Other complica- the lateral recumbent position is
tions include lower back pain after 60200 mm H2O, and 10100 mm
the procedure, bleeding near the H2O for children less than 8 yr.
puncture site, or brain stem hernia- These values depend on the body
tion, due to increased intracranial position and are different in a
pressure. horizontal or sitting position. CSF
Avoid the use of equipment contain- pressure may be elevated if the
ing latex if the patient has a history patient is anxious, holding his or
of allergic reaction to latex. her breath, tensing muscles, or if
Instruct the patient to cooperate the patients knees are flexed too
fully and to follow directions. firmly against the abdomen. CSF
Direct the patient to breathe pressure may be significantly
normally and to avoid unnecessary elevated in patients with intracranial
movement. tumors or space occupying
Observe standard precautions, and pockets of infection as seen in
follow the general guidelines in meningitis.
Appendix A. Positively identify the If the initial pressure is elevated, the
patient, and label the appropriate HCP may perform Queckenstedts
specimen container with the test. To perform this test, apply
corresponding patient demographics, pressure to the jugular vein for
initials of the person collecting the about 10 sec. CSF pressure usually
specimen, date, and time of rises in response to the occlusion,
collection. then rapidly returns to normal within
10 sec after the pressure is released. Position the patient flat, either on the
Sluggish response may indicate back or abdomen, although some
CSF obstruction. HCPs allow 30 degrees of elevation.
Obtain four (or five) vials of fluid, Maintain this position for 8 hr.
A according to the HCPs request, in Changing position is acceptable as
separate tubes (1 to 3 mL in each), long as the body remains horizontal.
and label them numerically (1 to 4 or Observe/assess the patient for neuro-
5) in the order in which they were logical changes, such as altered level
filled. Take a final pressure reading, of consciousness, change in pupils,
and remove the needle. Clean the reports of tingling or numbness, and
puncture site with an antiseptic irritability.
solution, and apply direct pressure Recognize anxiety related to test
with dry gauze to stop bleeding or results, and be supportive of per-
CSF leakage. Observe/assess ceived loss of independence and
puncture site for bleeding, CSF fear of shortened life expectancy.
leakage, or hematoma formation, Discuss the implications of
and secure gauze with adhesive abnormal test results on the patients
bandage. lifestyle. Provide teaching and
Promptly transport the specimen to information regarding the clinical
the laboratory for processing and implications of the test results, as
analysis. appropriate. Educate the patient
and family members regarding
POST-TEST: access to counseling and other
Inform the patient that a report of the supportive services. Provide
results will be made available to the contact information, if desired,
requesting HCP, who will discuss for the Alzheimers Association
the results with the patient. (www.alz.org).
Monitor vital signs and neurologic Reinforce information given by the
status every 15 min for 1 hr, then patients HCP regarding further testing,
every 2 hr for 4 hr, and as ordered treatment, or referral to another HCP.
after lumbar puncture. Take the tem- Answer any questions or address any
perature every 4 hr for 24 hr. Compare concerns voiced by the patient or
with baseline values. Protocols may family.
vary among facilities. Depending on the results of this
Administer fluids if permitted, especially procedure, additional testing may be
fluids containing caffeine, to replace performed to evaluate or monitor pro-
lost CSF and help prevent or relieve gression of the disease process and
headache, which is a side effect of determine the need for a change in
lumbar puncture. Advise the patient therapy. Evaluate test results in relation
that headache may begin within a few to the patients symptoms and other
hours up to 2 days after the procedure tests performed.
and may be associated with dizziness,
nausea, and vomiting. The length of RELATED MONOGRAPHS:
time for the headache to resolve varies Related tests include CT brain, evoked
considerably. brain potentials, MRI brain, and
Observe/assess the puncture site for FDG-PET scan.
leakage, and frequently monitor body See the Musculoskeletal System table
signs, such as temperature and blood at the end of the book for related tests
pressure. by body system.
c-Aminolevulinic Acid A
SYNONYM/ACRONYM: -ALA.
SPECIMEN: Urine (25 mL) from a timed specimen collected in a dark plastic
container with glacial acetic acid as a preservative.
Note and immediately report to the health-care provider (HCP) abnormal results and associated
symptoms. It is essential that a critical finding be communicated immediately to the requesting
HCP. A listing of these findings varies among facilities. Timely notification of a critical finding for
lab or diagnostic studies is a role expectation of the professional nurse. Notification processes
will vary among facilities. Upon receipt of the critical value the information should be read back
to the caller to verify accuracy. Most policies require immediate notification of the primary HCP,
hospitalist, or on-call HCP. Reported information includes the patient's name, unique identifiers,
critical value, name of the person giving the report, and name of the person receiving the report.
Documentation of notification should be made in the medical record with the name of the HCP
notified, time and date of notification, and any orders received. Any delay in a timely report of a
critical finding may require completion of a notification form with review by Risk Management.
Signs and symptoms of an acute porphyria attack include pain (commonly in the abdomen, arms,
and legs), nausea, vomiting, muscle weakness, rapid pulse, and high blood pressure. Possible
interventions include medication for pain, nausea, and vomiting and, if indicated, respiratory
support. Initial treatment following a moderate to severe attack may include identification and
cessation of harmful drugs the patient may be taking, IV infusion of carbohydrates, and IV heme
therapy (Panhematin) if indicated by markedly elevated urine -ALA and porphyrins.
Ammonia
A
SYNONYM/ACRONYM: NH3.
COMMON USE: To assist in diagnosing liver disease such as hepatitis and cirrho-
sis and evaluating the effectiveness of treatment modalities. Specifically used to
assist in diagnosing infant Reyes syndrome.
SI Units (Conventional
Age Conventional Units Units 0.587)
Newborn 170340 mcg/dL 100200 micromol/L
10 d24 mo 68136 mcg/dL 4080 micromol/L
25 moAdult 1960 mcg/dL 1135 micromol/L
This procedure is
DESCRIPTION: Blood ammonia contraindicated for: N/A
(NH3) comes from two sources:
deamination of amino acids
during protein metabolism and INDICATIONS
degradation of proteins by colon Evaluate advanced liver disease
bacteria. The liver converts or other disorders associated with
ammonia in the portal blood altered serum ammonia levels
to urea, which is excreted by Identify impending hepatic
the kidneys. When liver function encephalopathy with known
is severely compromised, espe- liver disease
cially in situations in which Monitor the effectiveness of treat
decreased hepatocellular func- ment for hepatic encephalopathy,
tion is combined with impaired indicated by declining levels
portal blood flow, ammonia Monitor patients receiving
levels rise. Congenital enzyme hyperalimentation therapy
defects that prevent the break-
down of ammonia or conditions
POTENTIAL DIAGNOSIS
that affect the ability of the kid-
neys to excrete ammonia can Increased in
also result in increased blood Gastrointestinal hemorrhage (related
levels. Ammonia is potentially to decreased blood volume, which
toxic to the central nervous prevents ammonia from reaching
system and may result in enceph- the liver to be metabolized)
alopathy or coma if toxic levels Genitourinary tract infection with
are reached. distention and stasis (related to
Signs &
Problem Symptoms Interventions
Confusion (Related Disorganized Treat the medical condition;
to an alteration in thinking, restless, correlate confusion with the
fluid and electrolytes, irritable, altered need to reverse altered
hepatic disease and concentration and electrolytes; evaluate
encephalopathy; attention span, medications; prevent falls
acute alcohol changeable mental and injury through
consumption; function over the appropriate use of postural
hepatic metabolic day, hallucinations; support, bed alarm, or the
insufficiency) altered attention appropriate use of restraints;
span; unable to consider pharmacological
follow directions; interventions; track accurate
disoriented to intake and output to assess
person, place, fluid status; monitor blood
time, and purpose; ammonia level; determine
inappropriate affect last alcohol use; assess
Signs &
Problem Symptoms Interventions
A for symptoms of hepatic
encephalopathy such as
confusion, sleep
disturbances, incoherence;
protect the patient from
physical harm; administer
lactose as prescribed
Nutrition (Related to Known inadequate Document food intake with
excess alcohol caloric intake; possible calorie count;
intake; insufficient weight loss; assess barriers to eating;
eating habits; muscle wasting in consider using a food diary;
altered liver arms and legs; monitor continued alcohol
function) stool that is pale or use as it is a barrier to
grey colored; skin adequate protein nutrition;
that is flaky with monitor glucose levels;
loss of elasticity monitor daily weight;
perform dietary consult with
assessment of cultural food
selections
Skin (Related to Jaundiced skin and Application of lotion to keep the
jaundice and sclera; dry skin; skin moisturized; avoid
elevated bilirubin itching skin; alkaline soaps; discourage
levels; excessive damage to skin scratching; apply mittens if
scratching) associated with patient is not able to follow
scratching direction to avid scratching;
administer antihistamines as
ordered
Bleeding (Related to Altered level of Increase frequency of vital sign
alerted clotting consciousness; assessment with variances in
factors; portal hypotension; results; monitor for vital sign
hypertension; increased heart trends; administer blood or
esophageal rate; decreased blood products as ordered;
bleeding) HGB and HCT; administer stool softeners as
capillary refill needed; encourage intake of
greater than foods rich in vitamin K; avoid
3 sec; cool foods that may irritate
extremities esophagus
Obtain a list of the patients current who will discuss the results with the
medications, including herbs, nutri- patient.
tional supplements, and nutraceuticals Sensitivity to social and cultural issues,as
(see Appendix H online at DavisPlus). well as concern for modesty, is impor-
Review the procedure with the patient. tant in providing psychological support A
Inform the patient that specimen before, during, and after the proce-
collection takes approximately 5 to dure. Recognize anxiety related to
10 min. Address concerns about pain test results, and carefully observe the
and explain that there may be some cirrhotic patient for the development of
discomfort during the venipuncture. ascites, in which case fluid and elec-
Sensitivity to social and cultural issues, trolyte balance require strict attention.
as well as concern for modesty, is Dietary and fluid restrictions may be
important in providing psychological required; diuretics may be ordered.
support before, during, and after the The patient should be frequently moni-
procedure. tored for weight gain, intake and out-
Note that there are no food, fluid, or put, and abdominal girth. The alcoholic
medication restrictions unless by patient should be encouraged to avoid
medical direction. alcohol and also to seek appropriate
counseling for substance abuse.
INTRATEST: Nutritional Considerations: Increased
Potential Complications: N/A
ammonia levels may be associated with
liver disease. Dietary recommendations
Avoid the use of equipment containing may be indicated, depending on the
latex if the patient has a history of aller- severity of the condition. A low-protein
gic reaction to latex. diet may be in order if the patients liver
Instruct the patient to cooperate fully has lost the ability to process the end
and to follow directions. Direct the products of protein metabolism. A diet
patient to breathe normally and to of soft foods may be required if esoph-
avoid unnecessary movement. ageal varices have developed.
Observe standard precautions, and fol- Ammonia levels may be used to deter-
low the general guidelines in Appendix A. mine whether protein should be added
Positively identify the patient, and label to or reduced from the diet. Patients
the appropriate specimen container with should be encouraged to eat simple
the corresponding patient demograph- carbohydrates and emulsified fats (as in
ics, initials of the person collecting the homogenized milk or eggs) rather than
specimen, date, and time of collection. complex carbohydrates (e.g., starch,
Perform a venipuncture. fiber, and glycogen [animal carbohy-
Remove the needle and apply direct drates]) and complex fats, which would
pressure with dry gauze to stop bleed- require additional bile to emulsify them
ing. Observe/assess the v enipuncture so that they could be used.
site for bleeding or h ematoma forma- Depending on the results of this
tion and secure the gauze with procedure, additional testing may be
adhesive bandage. performed to evaluate or monitor
Promptly transport the specimen to the progression of the disease process
laboratory for processing and analysis. and determine the need for a change
The tightly capped sample should be in therapy. Evaluate test results in
placed in an ice slurry immediately after relation to the patients symptoms and
collection. Information on the specimen other tests performed.
label should be protected from water in
the ice slurry by first placing the speci- Patient Education:
men in a protective plastic bag. Reinforce information given by the
patients HCP regarding further testing,
POST-TEST: treatment, or referral to another HCP.
Inform the patient that a report of the Answer any questions or address
results will be made available to the any concerns voiced by the patient
requesting health-care provider (HCP), or family.
Signs &
Problem Symptoms Interventions
Fear (Related to Verbalization of Evaluate verbal and nonverbal
fetal fear; indicators of fear; assess for the
imperfections restlessness; cause of fear; acknowledge the
secondary to increased patients awareness of fear;
developmental tension; explain all procedures with
abnormality) continuous simple age and culturally
questioning; appropriate language;
increased blood administer proscribed mild
pressure, heart tranquilizer; maintain a confident
rate, respiratory assured professional manner in
rate all patient interactions; address
concerns regarding care of
disabled child; recommend
support group and provide
contact information
Spirituality Anger; stated Obtain a history of the patients
(Related to feelings of lack of religious affiliation; identify the
anxiety peace or serenity; patients willingness to meet
associated stated feelings of with spiritual leader; encourage
with feral alienation from verbalization of concerns,
developmental others; stated feelings of fear and loneliness;
abnormality; feelings of acknowledge and support
unexpected life hopelessness; religious practices;
changes) request to meet accommodate a display of
with spiritual religious objects; facilitate
leader communication between the
patient, family, and religious
leader
Signs &
Problem Symptoms Interventions
A Knowledge Lack of interest or Identify the primary learners and
(Related to questions; provide specific information that
insufficient multiple is culturally appropriate and to
information questions; the correct literacy level; assess
associated anxiety in for the willingness and ability to
with relation to learn; identify the patients
diagnosed disease process priority for learning; identify and
developmental and dispel any misconceptions
abnormality; management; associated with the
lack of stating developmental disability; identify
familiarity or inaccurate the patients learning style;
understanding information; provide a quiet atmosphere for
with disease frustration; learning; allow the parents to be
and treatment) confusion self-directed in their learning;
provide sufficient time for
questions and follow up; refer to
a support group and social
services as appropriate
Amylase
SYNONYM/ACRONYM: N/A.
Review the procedure with the patient. patients with gastrointestinal disorders.
Inform the patient that specimen Consideration should be given to
collection takes approximately 5 to dietary alterations in the case of
10 min. Address concerns about pain gastrointestinal disorders. Usually after
A and explain that there may be some acute symptoms subside and bowel
discomfort during the venipuncture. sounds return, patients are given a
Sensitivity to social and cultural issues, clear liquid diet, progressing to a
as well as concern for modesty, is low-fat, high-carbohydrate diet. Vitamin
important in providing psychological B12 may be ordered for parenteral
support before, during, and after the administration to patients with
procedure. decreased levels, especially if their
Note that there are no food, fluid, disease prevents adequate absorption
or medication restrictions unless by of the vitamin. The alcoholic patient
medical direction. should be encouraged to avoid alcohol
and to seek appropriate c ounseling for
INTRATEST: substance abuse.
Depending on the results of this
Potential Complications: procedure, additional testing may be
Avoid the use of equipment containing performed to evaluate or monitor pro-
latex if the patient has a history of gression of the disease process and
allergic reaction to latex. determine the need for a change in
Instruct the patient to cooperate fully therapy. Evaluate test results in relation
and to follow directions. Direct the to the patients symptoms and other
patient to breathe normally and to tests performed.
avoid unnecessary movement.
Patient Education:
Observe standard precautions, and
follow the general guidelines in Teach the patient to use the incentive
Appendix A. Positively identify the spirometer with deep cough to help
patient, and label the appropriate maintain open airways and move
specimen container with the corre- secretions that interfere with adequate
sponding patient demographics, initials oxygenation
of the person collecting the specimen, Teach the patient the symptoms of
date, and time of collection. Perform fluid overload and deficit with an
a venipuncture. explanation of proper hydration.
Remove the needle and apply direct Reinforce information given by the
pressure with dry gauze to stop patients HCP regarding further testing,
bleeding. Observe/assess venipuncture treatment, or referral to another HCP.
site for bleeding or hematoma Recognize anxiety related to test
formation and secure gauze with results, and answer any questions or
adhesive bandage. address any concerns voiced by the
Promptly transport the specimen to patient or family.
the laboratory for processing and
analysis. Expected Patient Outcomes:
Knowledge
POST-TEST: Demonstrates understanding of the
link between alcohol use and disease
Inform the patient that a report of the process
results will be made available to the Describes symptoms that indicate
requesting health-care provider (HCP), being respiratory compromised and
who will discuss the results with the should be reported to the physician
patient.
Nutritional Considerations: Increased Skills
amylase levels may be associated with Accurately self-administers oxygen
gastrointestinal disease or alcoholism. Proficiently monitors intake and output
Small, frequent meals work best for and records results accurately
COMMON USE: To assist in monitoring therapeutic drug levels and detect toxic
levels of acetaminophen and salicylate in suspected overdose and drug abuse.
Monograph_A_047-079.indd 70
Therapeutic
Range
Conventional Conversion to Volume of Protein
Drug Units SI units SI Units Half-Life Distribution Binding Excretion
Acetaminophen 520 mcg/mL SI units = 33132 13 hr 0.95 L/kg 20%50% 85%95% hepatic;
Conventional micromol/L metabolites, renal
Units 6.62
Salicylate 1030 mg/dL SI units = 0.72.2 23 hr 0.10.3 L/kg 90%95% 1 hepatic; metabolites,
Conventional mmol/L renal
Units 0.073
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
17/11/14 12:04 PM
Analgesic, Anti-inflammatory, and Antipyretic Drugs 71
Angiography, Abdomen
SYNONYM/ACRONYM: Abdominal angiogram, abdominal arteriography.
Angiography, Adrenal
A
SYNONYM/ACRONYM: Adrenal angiogram, adrenal arteriography.
COMMON USE: To visualize and assess the adrenal gland for cancer or other
tumors or masses.
that barium studies were performed Instruct the patient to remove jewelry
more than 4 days before angiography. and other metallic objects from the
Record the date of the last menstrual area to be examined.
period and determine the possibility of Instruct the patient to fast and restrict
pregnancy in perimenopausal women. fluids for 2 to 4 hr prior to the procedure. A
Obtain a list of the patients current med- Protocols may vary among facilities.
ications, including anticoagulants, aspirin This procedure may be terminated if
and other salicylates, herbs, nutritional chest pain, severe cardiac arrhythmias, or
supplements, and nutraceuticals, espe- signs of a cerebrovascular accident occur.
cially those known to affect coagulation Make sure a written and informed
(see Appendix H online at DavisPlus). consent has been signed prior to the
Such products should be discontinued procedure and before administering
by medical direction for the appropriate any medications.
number of days prior to a surgical proce-
dure. Note the last time and dose of INTRATEST:
medication taken.
If iodinated contrast medium is sched- Potential Complications:
uled to be used in patients receiving Establishing an IV site and injection of
metformin (Glucophage) for non- contrast medium by catheter are invasive
insulin-dependent (type 2) diabetes, procedures. Complications are rare but
the drug should be discontinued on do include risk for allergic reaction
the day of the test and continue to be (related to contrast reaction); bleeding
withheld for 48 hr after the test. from the puncture site (related to a
Iodinated contrast can temporarily bleeding disorder, or the effects of nat-
impair kidney function, and failure to ural products and medications known
withhold metformin may indirectly to act as blood thinners; postproce-
result in drug-induced lactic acidosis, a dural bleeding from the site is rare
dangerous and sometimes fatal side because at the conclusion of the proce-
effect of metformin (related to renal dure a resorbable device, composed of
impairment that does not support non-latex-containing arterial anchor,
sufficient excretion of metformin). collagen plug, and suture, is deployed
Review the procedure with the patient. to seal the puncture site); blood clot for-
Address concerns about pain and mation (related to thrombus formation
explain that there may be moments of on the tip of the catheter sheath sur-
discomfort and some pain experienced face or in the lumen of the catheter, but
during the test. Inform the patient that the use of a heparinized saline flush
the procedure is usually performed in a during the procedure decreases the
radiology or vascular suite by an HCP risk of emboli); hematoma (related to
and takes approximately 30 to 60 min. blood leakage into the tissue following
Sensitivity to social and cultural issues,as needle insertion); infection (which might
well as concern for modesty, is impor- occur if bacteria from the skin surface
tant in providing psychological support is introduced at the puncture site); tis-
before, during, and after the procedure. sue damage (related to extravasation of
Explain that an IV line may be inserted to the contrast during injection); or nerve
allow infusion of IV fluids such as normal injury or damage to a nearby organ
saline, anesthetics, sedatives, or emer- (which might occur if the catheter
gency medications. Explain that the strikes a nerve or perforates an organ).
contrast medium will be injected, by cath- Avoid the use of equipment containing
eter, at a separate site from the IV line. latex if the patient has a history of
Inform the patient that a burning and allergic reaction to latex.
flushing sensation may be felt through- Observe standard precautions, and
out the body during injection of the follow the general guidelines in Appendix
contrast medium. After injection of the A. Positively identify the patient.
contrast medium, the patient may Ensure the patient has complied with
experience an urge to cough, flushing, dietary, fluid, and medication restric-
nausea, or a salty or metallic taste. tions and pretesting preparations.
Ensure the patient has removed all x-ray images are taken, and then to
external metallic objects from the area exhale after the images are taken.
to be examined. Instruct the patient to take slow, deep
Administer ordered prophylactic ste- breaths if nausea occurs during the
A roids or antihistamines before the pro- procedure.
cedure. Use nonionic contrast medium Monitor the patient for complications
for the procedure if the patient has a related to the procedure (e.g., allergic
history of allergic reactions to any reaction, anaphylaxis, bronchospasm).
substance or drug. The needle or catheter is removed,
Have emergency equipment readily and a pressure dressing is applied over
available. the puncture site.
Instruct the patient to void prior to the Observe/assess the needle/catheter
procedure and to change into the gown, insertion site for bleeding, inflamma-
robe, and foot coverings provided. tion, or hematoma formation.
Instruct the patient to cooperate fully
and to follow directions. Instruct the POST-TEST:
patient to remain still throughout the Inform the patient that a report of the
procedure because movement results will be made available to the
produces unreliable results. requesting HCP, who will discuss the
Record baseline vital signs, and continue results with the patient.
to monitor throughout the procedure. Instruct the patient to resume usual diet,
Protocols may vary among facilities. fluids, medications, or activity, as directed
Establish an IV fluid line for the injec- by the HCP. Renal function should be
tion of saline, sedatives, or emergency assessed before metformin is resumed.
medications. Monitor vital signs and neurological sta-
Administer an antianxiety agent, as tus every 15 min for 1 hr, then every
ordered, if the patient has claustropho- 2 hr for 4 hr, and as ordered. Take
bia. Administer a sedative to a child or temperature every 4 hr for 24 hr.
to an uncooperative adult, as ordered. Monitor intake and output at least every
Place electrocardiographic electrodes 8 hr. Compare with baseline values.
on the patient for cardiac monitoring. Protocols may vary among facilities.
Establish a baseline rhythm; deter- Observe for delayed allergic reactions,
mine if the patient has ventricular such as rash, urticaria, tachycardia,
arrhythmias. hyperpnea, hypertension, palpitations,
Using a pen, mark the site of the nausea, or vomiting.
patients peripheral pulses before angi- Instruct the patient to immediately
ography; this allows for quicker and report symptoms such as fast heart
more consistent assessment of the rate, difficulty breathing, skin rash,
pulses after the procedure. itching, chest pain, persistent right
Place the patient in the supine posi- shoulder pain, or abdominal pain.
tion on an examination table. Cleanse Immediately report symptoms to the
the selected area, and cover with a appropriate HCP.
sterile drape. Assess extremities for signs of isch-
A local anesthetic is injected at the emia or absence of distal pulse caused
site, and a small incision is made by a catheter-induced thrombus.
or a needle inserted under Observe/assess the needle/catheter
fluoroscopy. insertion site for bleeding, inflamma-
The contrast medium is injected, and a tion, or hematoma formation.
rapid series of images is taken during Instruct the patient in the care and
and after the filling of the vessels to be assessment of the site.
examined. Delayed images may be Instruct the patient to apply cold com-
taken to examine the vessels after a presses to the puncture site as needed,
time and to monitor the venous phase to reduce discomfort or edema.
of the procedure. Instruct the patient to maintain bed
Instruct the patient to inhale deeply rest for 4 to 6 hr after the procedure or
and hold his or her breath while the as ordered.
Angiography, Carotid
SYNONYM/ACRONYM: Carotid angiogram, carotid arteriography.
COMMON USE: To visualize and assess the carotid arteries and surrounding tis-
sues for abscess, tumors, aneurysm, and evaluate for atherosclerotic disease
related to stroke risk.
level is also needed before contrast Inform the patient that a burning and
medium is to be used. flushing sensation may be felt through-
Note any recent procedures that can out the body during injection of the
interfere with test results, including contrast medium. After injection of the
A examinations using iodine-based con- contrast medium, the patient may
trast medium or barium. Ensure that experience an urge to cough, flushing,
barium studies were performed more nausea, or a salty or metallic taste.
than 4 days before angiography. Instruct the patient to remove jewelry
Record the date of the last menstrual and other metallic objects from the
period and determine the possibility of area to be examined.
pregnancy in perimenopausal women. Instruct the patient to fast and restrict
Obtain a list of the patients current fluids for 2 to 4 hr prior to the
medications, including anticoagulants, procedure. Protocols may vary among
aspirin and other salicylates, herbs, facilities.
nutritional supplements, and nutraceu- This procedure may be terminated if
ticals, especially those known to affect chest pain, severe cardiac arrhythmias,
coagulation (see Appendix H online at or signs of a cerebrovascular
DavisPlus). Such products should be accident occur.
discontinued by medical direction for Make sure a written and informed
the appropriate number of days prior consent has been signed prior to the
to a surgical procedure. Note the last procedure and before administering
time and dose of medication taken. any medications.
If iodinated contrast medium is sched-
uled to be used in patients receiving INTRATEST:
metformin (Glucophage) for non-insu- Potential Complications:
lin-dependent (type 2) diabetes, the Establishing an IV site and injection of
drug should be discontinued on the contrast medium by catheter are inva-
day of the test and continue to be sive procedures. Complications are
withheld for 48 hr after the test. rare but do include risk for: allergic
Iodinated contrast can temporarily reaction (related to contrast reac-
impair kidney function, and failure to tion); bleeding from the puncture site
withhold metformin may indirectly (related to a bleeding disorder, or
result in drug-induced lactic acidosis, a the effects of natural products and
dangerous and sometimes fatal side medications known to act as blood
effect of metformin (related to renal thinnerspostprocedural bleeding
impairment that does not support
from the site is rare because at the
etformin).
sufficient excretion of m
conclusion of the procedure a
Review the procedure with the patient. resorbable device, composed of
Address concerns about pain and non-latex-containing arterial anchor,
explain that there may be moments of collagen plug, and suture, is
discomfort and some pain experienced deployed to seal the puncture site);
during the test. Inform the patient that blood clot formation (related to
the procedure is usually performed in a thrombus formation on the tip of the
radiology or vascular suite by an HCP catheter sheath surface or in the
and takes approximately 30 to 60 min. lumen of the catheterthe use of a
Sensitivity to social and cultural issues,as heparinized saline flush during the
well as concern for modesty, is impor- procedure decreases the risk of
tant in providing psychological support emboli); hematoma (related to blood
before, during, and after the procedure. leakage into the tissue following
Explain that an IV line may be inserted needle insertion); infection (that
to allow infusion of IV fluids such as might occur if bacteria from the skin
normal saline, anesthetics, sedatives, surface is introduced at the punc-
or emergency medications. Explain ture site); tissue damage (related to
that the contrast medium will be extravasation of the contrast during
injected, by catheter, at a separate site injection); or nerve injury or damage
from the IV line. to a nearby organ (which might occur
Angiography, Coronary
SYNONYM/ACRONYM: Angiography of heart, angiocardiography, cardiac angiogra-
phy, cardiac catheterization, cineangiocardiography, coronary angiography,
coronary arteriography.
COMMON USE: To visualize and assess the heart and surrounding structure for
abnormalities, defects, aneurysm, and tumors.
with the name of the HCP notified, working in the examination area
time and date of notification, and any should wear badges to record their
orders received. Any delay in a timely level of radiation exposure.
report of a critical finding may require Failure to follow dietary restrictions A
completion of a notification form and other pretesting preparations
with review by Risk Management. may cause the procedure to be can-
celed or repeated.
INTERFERING FACTORS
Factors that may impair clear
imaging NURSING IMPLICATIONS
Gas or feces in the gastrointestinal AND PROCEDURE
tract resulting from inadequate
cleansing or failure to restrict food PRETEST:
intake before the study. Positively identify the patient using
Retained barium from a previous at least two unique identifiers
radiological procedure. before providing care, treatment,
Metallic objects within the exami- or services.
nation field (e.g., jewelry, body Patient Teaching: Inform the patient this
procedure can assist with assessment
rings), which may inhibit organ of cardiac function and check for heart
visualization and can produce disease.
unclear images. Obtain a history of the patients
Inability of the patient to cooperate complaints or clinical symptoms,
or remain still during the proce- including a list of known allergens,
dure because of age, significant especially allergies or sensitivities to
pain, or mental status. latex, anesthetics, contrast medium, or
sedatives.
Other considerations Obtain a history of results of the
patients cardiovascular system, symp-
Consultation with an HCP should toms, and results of previously per-
occur before the procedure for formed laboratory tests and diagnostic
radiation safety concerns regarding and surgical procedures. Ensure
younger patients or patients who results of coagulation testing are
are lactating. Pediatric & Geriatric obtained and recorded prior to the
Imaging Children and geriatric procedure; a creatinine level is also
patients are at risk for receiving a needed before contrast medium is to
higher radiation dose than neces- be used.
sary if settings are not adjusted for Note any recent procedures that can
interfere with test results, including
their small size. Pediatric Imaging examinations using iodine-based con-
Information on the Image Gently trast medium or barium. Ensure that
Campaign can be found at the barium studies were performed more
Alliance for Radiation Safety in than 4 days before angiography.
Pediatric Imaging (www.pedrad Record the date of last menstrual
.org/associations/5364/ig/). period and determine the possibility
Risks associated with radiation of pregnancy in perimenopausal
overexposure can result from women.
frequent x-ray procedures. Obtain a list of the patients current
medications, including anticoagulants,
Personnel in the room with the aspirin and other salicylates, herbs,
patient should wear a protective nutritional supplements, and nutraceu-
lead apron, stand behind a shield, ticals, especially those known to affect
or leave the area while the exami- coagulation (see Appendix H online at
nation is being done. Personnel DavisPlus). Such products should be
Angiography, Pulmonary A
SYNONYM/ACRONYM: Pulmonary angiography, pulmonary arteriography.
COMMON USE: To visualize and assess the lungs and surrounding structure for
abscess, tumor, cancer, defects, tuberculosis, and pulmonary embolism.
Angiography, Renal
A
SYNONYM/ACRONYM: Renal angiogram, renal arteriography.
COMMON USE: To visualize and assess the kidneys and surrounding structure for
tumor, cancer, absent kidney, and level of renal disease.
Metallic objects within the exami- kidney function and check for
nation field (e.g., jewelry, body disease.
rings), which may inhibit organ Obtain a history of the patients com-
plaints or clinical symptoms, including
A visualization and can produce
a list of known allergens, especially
unclear images. allergies or sensitivities to latex, anes-
Inability of the patient to cooperate thetics, contrast medium, or sedatives.
or remain still during the proce- Obtain a history of the patients genito-
dure because of age, significant urinary system, symptoms, and results
pain, or mental status. of previously performed laboratory
tests and diagnostic and surgical pro-
Other considerations cedures. Ensure results of coagulation
Consultation with a health-care pro- testing are obtained and recorded prior
vider (HCP) should occur before the to the procedure; a creatinine level is
also needed before contrast medium is
procedure for radiation safety con- to be used.
cerns regarding younger patients or Note any recent procedures that can
patients who are lactating. Pediatric interfere with test results, including
& Geriatric Imaging Children and examinations using iodine-based con-
geriatric patients are at risk for trast medium or barium. Ensure that
receiving a higher radiation dose barium studies were performed more
than necessary if settings are not than 4 days before angiography.
adjusted for their small size. Record the date of the last menstrual
Pediatric Imaging Information on period and determine the possibility of
pregnancy in perimenopausal women.
the Image Gently Campaign can be Obtain a list of the patients current
found at the Alliance for Radiation medications, including anticoagulants,
Safety in Pediatric Imaging (www aspirin and other salicylates, herbs,
.pedrad.org/associations/5364/ig/). nutritional supplements, and nutraceu-
Risks associated with radiation over- ticals (see Appendix H online at
exposure can result from frequent DavisPlus). Such products should be
x-ray procedures. Personnel in the discontinued by medical direction for
room with the patient should wear a the appropriate number of days prior
protective lead apron, stand behind a to a surgical procedure. Note the last
time and dose of medication taken.
shield, or leave the area while the If iodinated contrast medium is sched-
examination is being done. Personnel uled to be used in patients receiving
working in the examination area metformin (Glucophage) for non-insulin-
should wear badges to record their dependent (type 2) diabetes, the drug
level of radiation exposure. should be discontinued on the day of
Failure to follow dietary restrictions the test and continue to be withheld for
and other pretesting preparations 48 hr after the test. Iodinated contrast
may cause the procedure to be can- can temporarily impair kidney function,
celed or repeated. and failure to withhold metformin may
indirectly result in drug-induced lactic
acidosis, a dangerous and sometimes
fatal side effect of metformin (related
NURSING IMPLICATIONS to renal impairment that does not
AND PROCEDURE support sufficient excretion of
metformin).
PRETEST: Review the procedure with the patient.
Positively identify the patient using at Address concerns about pain and
least two unique identifiers before pro- explain that there may be moments of
viding care, treatment, or services. discomfort and some pain experienced
Patient Teaching: Inform the patient this during the test. Inform the patient that
procedure can assist in assessment of the procedure is usually performed in a
Angiotensin-Converting Enzyme A
SYNONYM/ACRONYM: Angiotensin Iconverting enzyme (ACE).
Anion Gap
A
SYNONYM/ACRONYM: Agap.
Route of
Drug Administration Recommended Collection Time
Amiodarone Oral Trough: immediately before next dose
Digoxin Oral Trough: 1224 hr after dose
Never draw peak samples
Disopyramide Oral Trough: immediately before next dose
Peak: 25 hr after dose
Flecainide Oral Trough: immediately before next dose
Peak: 3 hr after dose
Lidocaine IV 15 min, 1 hr, then every 24 hr
Procainamide IV 15 min; 2, 6, 12 hr; then every 24 hr
Procainamide Oral Trough: immediately before next dose
Peak: 75 min after dose
Quinidine sulfate Oral Trough: immediately before next dose
Peak: 1 hr after dose
Quinidine gluconate Oral Trough: immediately before next dose
Peak: 5 hr after dose
Quinidine Oral Trough: immediately before next dose
polygalacturonate Peak: 2 hr after dose
Monograph_A_111-131.indd 112
Units 1.55
Digoxin 0.52 ng/mL SI units = 0.62.6 2060 7 2030 1 renal
Conventional nmol/L
Units 1.28
Disopyramide 2.87 mcg/mL SI units = 8.320.6 410 0.70.9 2060 1 renal
Conventional micromol/L
Units 2.95
Flecainide 0.21 mcg/mL SI units = 0.52.4 719 513 4050 1 renal
Conventional micromol/L
Units 2.41
Lidocaine 1.55 mcg/mL SI units = 6.421.4 1.52 11.5 6080 1 hepatic
Conventional micromol/L
Units 4.27
Procainamide 410 mcg/mL SI units = 1742 26 24 1020 1 renal
Conventional micromol/L
Units 4.25
N-acetyl 1020 mcg/mL SI units = 4285 8 1 renal
procainamide Conventional micromol/L
Units 4.25
Quinidine 25 mcg/mL SI units = 615 68 23 7090 Renal and
Conventional micromol/L hepatic
Units 3.08
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
17/11/14 12:04 PM
Antiarrhythmic Drugs 113
POTENTIAL DIAGNOSIS
Level Response
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amiodarone Hepatic impairment, older results
Digoxin Renal impairment, CHF,* older adults
Disopyramide Renal impairment
Flecainide Renal impairment, CHF
Lidocaine Hepatic impairment, CHF
Procainamide Renal impairment
Quinidine Renal and hepatic impairment, CHF, older adults
Review the procedure with the patient. Reinforce information given by the
Inform the patient that specimen patients HCP regarding further test-
collection takes approximately 5 to ing, treatment, or referral to another
10 min. Address concerns about HCP. Explain to the patient the
pain and explain that there may importance of following the medica- A
be some discomfort during the tion regimen and instructions regard-
venipuncture. ing drug interactions. Instruct the
Sensitivity to social and cultural issues, patient to immediately report any
as well as concern for modesty, is unusual sensations (e.g., dizziness,
important in providing psychological changes in vision, loss of appetite,
support before, during, and after the nausea, vomiting, diarrhea, weak-
procedure. ness, or irregular heartbeat) to his or
Note that there are no food, fluid, or her HCP. Instruct the patient not to
medication restrictions unless by take medicine within 1 hr of food
medical direction. high in fiber (as the fiber may
decrease absorption by binding
INTRATEST: some of the medication, reducing
Potential Complications: N/A its bioavailability). Answer any ques-
tions or address any concerns voiced
Avoid the use of equipment containing
by the patient or family.
latex if the patient has a history of aller-
Instruct the patient to be prepared to
gic reaction to latex.
provide the pharmacist with a list of
Instruct the patient to cooperate fully
other medications he or she is already
and to follow directions. Direct the
taking in the event that the requesting
patient to breathe normally and to
HCP prescribes a medication.
avoid unnecessary movement.
Depending on the results of this
Observe standard precautions, and
procedure, additional testing may be
follow the general guidelines in
performed to evaluate or monitor
Appendix A. Consider recommended
progression of the disease process
collection time in relation to the dos-
and determine the need for a change
ing schedule. Positively identify the
in therapy. Testing for aspirin respon-
patient, and label the appropriate
siveness/resistance may be a consid-
specimen container with the corre-
eration for patients, especially women,
sponding patient demographics, ini-
on low-dose aspirin therapy. Evaluate
tials of the person collecting the spec-
test results in relation to the patients
imen, date, and time of collection,
symptoms and other tests performed.
noting the last dose of medication
taken. Perform a venipuncture.
Remove the needle and apply direct RELATED MONOGRAPHS:
pressure with dry gauze to stop bleed- Related tests include ALT; albumin;
ing. Observe/assess venipuncture site ALP; apolipoproteins A, B, and E;
for bleeding or hematoma formation AST; atrial natriuretic peptide; BNP;
and secure gauze with adhesive blood gases; BUN; CRP; calcium;
bandage. calcium ionized; chest x-ray; choles-
Promptly transport the specimen to the terol (total, HDL, and LDL); CBC
laboratory for processing and analysis. platelet count; CK and isoenzymes;
creatinine; ECG; glucose; glycated
POST-TEST: hemoglobin; homocysteine; ketones;
Inform the patient that a report of the LDH and isoenzymes; magnesium;
results will be made available to the myoglobin; potassium; triglycerides;
requesting HCP, who will discuss the and troponin.
results with the patient. See the Cardiovascular System table
Nutritional Considerations: Include avoid- at the end of the book for related tests
ance of alcohol consumption. by body system.
Antibodies, Anti-Glomerular
Basement Membrane
SYNONYM/ACRONYM: Goodpastures antibody, anti-GBM.
This procedure is
the absence of drugs known to contraindicated for: N/A
cause it), positive ANA in the
absence of a drug known to INDICATIONS
A induce lupus, or immunological Assist in the diagnosis and evalua-
disorder (evidenced by positive tion of SLE
anti-ds DNA, positive anti-Sm, Assist in the diagnosis and
positive antiphospholipid such as evaluation of suspected immune
anticardiolipin antibody, positive disorders, such as rheumatoid
lupus anticoagulant test, or a false- arthritis, systemic sclerosis, polymy-
positive serological syphilis test, ositis, Raynauds syndrome, sclero-
known to be positive for at least derma, Sjgrens syndrome, and
6 months and confirmed to be mixed connective tissue disease
falsely positive by a negative Assist in the diagnosis and evalua-
Treponema pallidum immobiliza- tion of idiopathic inflammatory
tion or FTA-ABS). myopathies
POTENTIAL DIAGNOSIS
*ANA patterns are helpful in that certain conditions are frequently associated with specific
patterns. RNP = ribonucleoprotein.
Remove the needle and apply direct child; pregnancies should be carefully
pressure with dry gauze to stop b
leeding. planned.
Observe/assess venipuncture site for Patients with lupus are at increased risk
bleeding or hematoma formation and for infection and should discuss the
secure gauze with adhesive b andage. need for vaccinations with their HCP. A
Promptly transport the specimen to the Recommendations may include receiv-
laboratory for processing and analysis. ing vaccines during periods of remission.
Depending on the results of this
POST-TEST: procedure, additional testing may be
performed to evaluate or monitor
Inform the patient that a report of the progression of the disease process
results will be made available to the and determine the need for a change
requesting health-care provider (HCP), in therapy. Evaluate test results in
who will discuss the results with the relation to the patients symptoms and
patient. other tests performed.
Recognize anxiety related to test
results, and be supportive of perceived Patient Education:
loss of independence and fear of short-
Educate the patient regarding access
ened life expectancy. Collagen and
to counseling services.
connective tissue diseases are chronic
Educate the patient, as appropriate,
and, as such, they must be addressed
regarding the importance of preventing
on a continuous basis. Discuss the
infection, which is a significant cause of
implications of abnormal test results on
death in immunosuppressed individuals.
the patients lifestyle. Stress the impor-
Reinforce information given by the
tance of compliance to the treatment
patients HCP regarding further testing,
regimen. Instruct the patient with SLE
treatment, or referral to another HCP.
to contact the HCP immediately if new
Answer any questions or address any
symptoms present, including vague or
concerns voiced by the patient or family.
common symptoms such as fever.
Provide teaching and information
Educate the patient regarding lifestyle
regarding the clinical implications of the
changes that must be implemented to
test results, as appropriate.
protect them from increased risk of
Provide contact information, if desired,
infection and development of cardio-
for the American College of
vascular disease. Patients with lupus
Rheumatology (www.rheumatology.
should be advised to avoid direct expo-
org), the Lupus Foundation of America
sure to sunlight or other sources of UV
(www.lupus.org), or the Arthritis
light, like tanning beds (related to
Foundation (www.arthritis.org).
hypersensitivity of skin cells in people
Provide education on caring for open
with lupus to UV light. The exact
sores to prevent infection.
mechanism for this is not clearly
Discuss the importance of adequate
understood, but it is believed that in
nutrients in supporting the immune
people with lupus, damaged or dead
system and preventing infection.
skin cells are not sloughed as effi-
ciently as occurs in normal individu- Expected Patient Outcomes:
als. It is also believed that cell con-
Knowledge
tents released from damaged or dead
Describes the relationship between sun
skin cells may instigate an immune
exposure and triggering an acute lupus
response leading to development of a
episode
skin rash. Sun exposure is known to
Explains that wearing loose, long-leg
damage skin; therefore, avoiding
and long-sleeve clothing can enhance
direct exposure reduces the amount
sun protection
of damage incurred.).
Patients wishing to become pregnant Skills
should discuss the possibility with their Routinely demonstrates good hand
HCP. The stress of pregnancy and hygiene skills
medication regimen may present Demonstrates proficiency in the correct
significant risks to both mother and application of sunscreen
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Antibodies, Antisperm
SYNONYM/ACRONYM: Infertility screen.
Antibodies, Antistreptolysin O
A
SYNONYM/ACRONYM: Streptozyme, ASO.
Antibodies, Antithyroglobulin,
and Antithyroid Peroxidase
SYNONYM/ACRONYM: Thyroid antibodies, antithyroid peroxidase antibodies
(thyroid peroxidase [TPO] antibodies were previously called thyroid anti
microsomal antibodies).
Conventional Units
IgA and IgG Gliadin Antibody Less than 20 units
Tissue transglutaminase antibody Less than 20 units
Endomysial antibodies Negative
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Monograph_A_132-152.indd 141
Drug Units to SI units Range SI Units (hr) (L/kg) (%) Excretion
Carbamazepine 412 mcg/mL SI units = Conventional 1751 1540 0.81.8 6080 Hepatic
Units 4.23 micromol/L
Ethosuximide 40100 mcg/mL SI units = Conventional 283708 2570 0.7 05 Renal
Units 7.08 micromol/L
Lamotrigine 14 mcg/mL SI units = Conventional 416 2533 0.91.3 505 Hepatic
Units 3.9 micromol/L
Phenobarbital Adult: 1540 SI units = Conventional Adult: 65172 Adult: 0.51 4050 80% Hepatic
mcg/mL Units 4.31 micromol/L 50140 and 20%
Renal
Child: 1530 SI units = Conventional Child: 65129 Child: 80%
mcg/mL Units 4.31 micromol/L 4070 Hepatic and
20% Renal
Phenytoin 1020 mcg/mL SI units = Conventional 4079 2040 0.60.7 8595 Hepatic
Units 3.96 micromol/L
Primidone Adult: 512 SI units = Conventional Adult: 2355 412 0.51 020 Hepatic
mcg/mL Units 4.58 micromol/L
Child: 710 SI units = Conventional Child: 3246
mcg/mL Units 4.58 micromol/L
Valproic acid 50125 mcg/mL SI units = Conventional 347866 815 0.10.5 8595 Hepatic
Units 6.93 micromol/L
Anticonvulsant Drugs
141
17/11/14 12:02 PM
142 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
Antideoxyribonuclease-B, Streptococcal
SYNONYM/ACRONYM: ADNase-B, AntiDNase-B titer, antistreptococcal DNase-B
titer, streptodornase.
COMMON USE: To assist in assessing the cause of recent infection, such as strep-
tococcal exposure, by identification of antibodies.
Route of
Drug Administration Recommended Collection Time
Amitriptyline Oral Trough: immediately before next dose
(at steady state)
Nortriptyline Oral Trough: immediately before next dose
(at steady state)
Protriptyline Oral Trough: immediately before next dose
(at steady state)
Doxepin Oral Trough: immediately before next dose
(at steady state)
Imipramine Oral Trough: immediately before next dose
(at steady state)
Monograph_A_132-152.indd 149
Range Therapeutic Volume of Protein
Conventional Conversion Range Half-Life Distribution Binding
Drug Units to SI units SI Units (h) (L/kg) (%) Excretion
Amitriptyline 125250 ng/mL SI units = 450900 nmol/L 2040 1036 8595 Hepatic
Conventional
Units 3.6
Nortriptyline 50150 ng/mL SI units = 190570 nmol/L 2060 1523 9095 Hepatic
Conventional
Units 3.8
Protriptyline 70250 ng/mL SI units = 266950 nmol/L 6090 1531 9193 Hepatic
Conventional
Units 3.8
Doxepin 110250 ng/mL SI units = 394895 nmol/L 1025 1030 7585 Hepatic
Conventional
Units 3.58
Imipramine 180240 ng/mL SI units = 643857 nmol/L 618 923 6095 Hepatic
Conventional
Units 3.57
Antidepressant Drugs (Cyclic)
149
17/11/14 12:03 PM
150 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
Antidiuretic Hormone
A
SYNONYM/ACRONYM: Vasopressin, arginine vasopressin hormone, ADH.
SI Units
Antidiuretic (Conventional Units
Age Hormone* 0.923)
Neonates Less than 1.5 pg/mL Less than 1.4 pmol/L
1 day18 yr 0.51.7 pg/mL Less than 0.51.6 pmol/L
(normally hydrated)
Adult (normally 05 pg/mL 04.6 pmol/L
hydrated)
*Conventional units.
Recommendation
This test should be ordered and interpreted with results of a serum osmolality.
SI Units (Conventional
Serum Osmolality* Antidiuretic Hormone Units 0.923)
270280 mOsm/kg Less than 1.5 pg/mL Less than 1.4 pmol/L
280285 mOsm/kg Less than 2.5 pg/mL Less than 2.3 pmol/L
285290 mOsm/kg 15 pg/mL 0.94.6 pmol/L
290295 mOsm/kg 27 pg/mL 1.86.5 pmol/L
295300 mOsm/kg 412 pg/mL 3.711.1 pmol/L
*Conventional units.
release from damaged cells in an
This procedure is
adjacent affected area)
contraindicated for: N/A
Disorders involving the central ner-
POTENTIAL DIAGNOSIS vous system, thyroid gland, and adre-
nal gland (numerous conditions
Increased in influence the release of ADH)
Acute intermittent porphyria Ectopic production (related to
(speculated to be related to the ADH production from a systemic
release of ADH from damaged neoplasm)
cells in the hypothalamus and Guillain-Barr; syndrome (relation-
effect of hypovolemia; the mecha- ship to syndrome of inappropri-
nisms are unclear) ate ADH [SIADH] is unclear)
Brain tumor (related to ADH Hypovolemia (potent instigator of
production from the tumor or ADH release)
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Antimicrobial DrugsAminoglycosides:
Amikacin, Gentamicin, Tobramycin; Tricyclic
Glycopeptide: Vancomycin
SYNONYM/ACRONYM: Amikacin (Amikin); gentamicin (Garamycin, Genoptic,
Gentacidin, Gentafair, Gentak, Gentamar, Gentrasul, G-myticin, Oco-Mycin,
Spectro-Genta); tobramycin (Nebcin, Tobrex); vancomycin (Lyphocin,
Vancocin, Vancoled).
Route of
Drug Administration Recommended Collection Time*
Amikacin IV, IM Trough: immediately before next dose A
Peak: 30 min after the end of a 30-min
IV infusion
Gentamicin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-min
IV infusion
Tobramycin IV, IM Trough: immediately before next dose
Peak: 30 min after the end of a 30-min
IV infusion
Tricyclic IV, PO Trough: immediately before next dose
glycopeptide and Peak: 3060 min after the end of a
vancomycin 60-min IV infusion
*Usually after fifth dose if given every 8 hr or third dose if given every 12 hr. IM = intramuscular;
IV = intravenous; PO = by mouth.
Monograph_A_153-190.indd 156
Conventional micromol/L
Units 1.71
Trough 48 mcg/mL SI units = 714 1 renal
Conventional micromol/L
Units 1.71
Gentamicin (Standard dosing)
Peak 510 mcg/mL SI units = 1021 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09
Trough Less than 2 mcg/mL SI units = Less than 4 1 renal
Conventional micromol/L
Units 2.09
Tobramycin (Standard dosing)
Peak 48 mcg/mL SI units = 8.416.7 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09
Trough Less than 1 mcg/mL SI units = Less than 2.1 1 renal
Conventional micromol/L
Units 2.09
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
17/11/14 12:03 PM
Monograph_A_153-190.indd 157
Volume of
Therapeutic Range Conversion to Half-Life Distribution Binding
Drug Conventional Units SI units SI Units (hr) (L/kg) (%) Excretion
Tobramycin (Once daily dosing)
Peak 812 mcg/mL SI units = 16.725.1 48 0.41.3 50 1 renal
Conventional micromol/L
Units 2.09
17/11/14 12:03 PM
158 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
POTENTIAL DIAGNOSIS
Level Response
A
Normal levels Therapeutic effect
Subtherapeutic levels Adjust dose as indicated
Toxic levels Adjust dose as indicated
Amikacin Renal, hearing impairment
Gentamicin Renal, hearing impairment
Tobramycin Renal, hearing impairment
Vancomycin Renal, hearing impairment
Toxic Levels
Drug Name Conventional Units Toxic Levels SI Units
Amikacin Greater than 10 mcg/mL Greater than 17.1 micromol/L
Gentamicin Peak greater than Peak greater than 25.1 micromol/L,
12 mcg/mL, trough trough greater than 4.2
greater than 2 mcg/mL micromol/L
Tobramycin Peak greater than Peak greater than 25.1 micromol/L,
12 mcg/mL, trough trough greater than
greater than 2 mcg/mL 4.2 micromol/L
Vancomycin Trough greater than Trough greater than
30 mcg/mL 20.7 micromol/L
Positively identify the patient using Avoid the use of equipment containing
at least two unique identifiers before latex if the patient has a history of aller
providing care, treatment, or services. gic reaction to latex.
Patient Teaching: Inform the patient this Instruct the patient to cooperate fully
test can assist in monitoring for sub and to follow directions. Direct the
therapeutic, therapeutic, or toxic drug patient to breathe normally and to
levels used in treatment of infection. avoid unnecessary movement.
Obtain a history of the patients com Observe standard precautions, and fol
plaints, including a list of known aller low the general guidelines in Appendix A.
gens, especially allergies or sensitivities Consider recommended collection time
to latex. in relation to the dosing schedule.
Obtain a history of the patients immune Positively identify the patient, and label
system, symptoms, and results of pre the appropriate specimen container
viously performed laboratory tests and with the corresponding patient demo
diagnostic and surgical procedures. graphics, initials of the person collect
Nephrotoxicity is a risk associated with ing the specimen, date, and time of
administration of aminoglycosides. collection, noting the last dose of med
Obtain a history of the patients genito ication taken. Perform a venipuncture.
urinary system, symptoms, and results Remove the needle and apply direct
of previously performed laboratory pressure with dry gauze to stop
tests and diagnostic and surgical bleeding. Observe/assess venipunc
procedures. ture site for bleeding or hematoma
Ototoxicity is a risk associated with formation and secure gauze with
administration of aminoglycosides. adhesive bandage.
Obtain a history of the patients known Promptly transport the specimen to the
or suspected hearing loss, including laboratory for processing and analysis.
type and cause; ear conditions with
treatment regimens; ear surgery; and POST-TEST:
other tests and procedures to assess Inform the patient that a report of the
and diagnose auditory deficit. results will be made available to the
Obtain a list of the patients current requesting HCP, who will discuss the
medications, including herbs, nutri results with the patient.
tional supplements, and nutraceuticals Instruct the patient receiving aminoglyco
(see Appendix H online at DavisPlus). sides to immediately report any unusual
Note the last time and dose of medica symptoms (e.g., hearing loss, decreased
tion taken. urinary output) to his or her HCP.
Monograph_A_153-190.indd 162
Volume of Protein
Therapeutic Range Therapeutic Half-Life Distribution Binding
Drug Conventional Units Conversion to SI Units Range SI Units (hr) (L/kg) (%) Excretion
Haloperidol 624 ng/mL SI units = Conventional 1664 nmol/L 1540 1830 90 Hepatic
Units 2.66
Lithium 0.61.2 mEq/L SI units = Conventional 0.61.2 mmol/L 1824 0.71 0 Renal
(chronic) Units 1
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
17/11/14 12:03 PM
Antipsychotic Drugs and Antimanic Drugs: Haloperidol, Lithium 163
Antithrombin III
SYNONYM/ACRONYM: Heparin cofactor assay, ATIII.
SPECIMEN: Serum (1 mL) for a1-AT and serum (2 mL) for a1-AT phenotyping
collected in a gold-, red-, or red/gray-top tube. Whole blood from one full laven-
der-top (EDTA) is also acceptable.
`1-Antitrypsin
Apolipoproteins: A, B, and E
SYNONYM/ACRONYM: Apo A (Apo A1), Apo B (Apo B100), and Apo E.
NORMAL FINDINGS: (Method: Immunonephelometry for Apo A and Apo B; PCR with
restriction length enzyme digestion and polyacrylamide gel electrophoresis for
Apo E)
Apolipoprotein A
Apolipoprotein B
POTENTIAL DIAGNOSIS
Apolipoprotein E is found in Apolipoproteins are the protein por-
most lipoproteins, except LDL, tion of lipoproteins. Their function is
and is synthesized in a variety of
A cell types including liver, brain
to transport and to assist in cell sur-
face receptor recognition and cellu-
astrocytes, spleen, lungs, adre- lar absorption of lipoproteins to be
nals, ovaries, kidneys, muscle used as energy. While studies of the
cells, and in macrophages. The exact role of apolipoproteins in
largest amount is produced by health and disease continue, there
the liver; the next significant is a very strong association between
amount is produced by the brain. Apo A and HDL good cholesterol
There are three forms of Apo E: and Apo B and LDL bad cholesterol.
apo-E 2, apo-E 3, and apo-E 4, and
six possible combinations; of Apolipoprotein A
these, Apo-E 3 (e3/3e) is the fully
functioning form. The varied Increased in
roles of Apo E include removal Familial hyper--lipoproteinemia
of chylomicrons and very-low- Pregnancy
density lipoprotein (VLDL) from Weight reduction
the circulation by binding to Decreased in
LDL. The Apo E2 isoform demon- Abetalipoproteinemia
strates significantly less LDL Cholestasis
receptor binding, which results Chronic renal failure
in impaired clearance of chylo- Coronary artery disease
microns, VLDL, and triglyceride Diabetes (uncontrolled)
remnants. The presence of Apo E Diet high in carbohydrates or poly-
isoforms E2 and E4 is associated unsaturated fats
with high cholesterol levels, high Familial deficiencies of related
triglyceride levels, and the pre- enzymes and lipoproteins (e.g.,
mature development of athero- Tangiers disease)
sclerosis. The presence of the E2 Hemodialysis
isoform is associated with type Hepatocellular disorders
III hyperlipidemia, a familial dys- Hypertriglyceridemia
lipidemia, which is important to Nephrotic syndrome
distinguish from other causes of Premature coronary heart disease
hyperlipidemia to determine the Smoking
correct treatment regimen. Apo
E4 is being used in association Apolipoprotein B
with studies of predisposing fac-
tors in the development of Increased in
Alzheimers disease. Detailed Anorexia nervosa
information is found in the study Biliary obstruction
titled Alzheimers Disease Coronary artery disease
Markers. Cushings syndrome
Diabetes
Dysglobulinemia
This procedure is Emotional stress
contraindicated for: N/A Hemodialysis
Hepatic disease
INDICATIONS Hepatic obstruction
Evaluation for risk of CAD Hyperlipoproteinemias
treatment, or referral to another HCP. AST, ANP, BNP, blood gases, CRP,
Answer any questions or address any calcium and ionized calcium, choles
concerns voiced by the patient or family. terol (total, HDL, and LDL), CK and
Depending on the results of this isoenzymes, CT scoring, echocardiog
procedure, additional testing may be raphy, glucose, glycated hemoglobin, A
performed to evaluate or monitor Holter monitor, homocysteine, ketones,
progression of the disease process LDH and isoenzymes, lipoprotein
and determine the need for a change electrophoresis, magnesium, MRI
in therapy. Evaluate test results in chest, myocardial infarct scan,
relation to the patients symptoms and myocardial perfusion heart scan,
other tests performed. myoglobin, PET heart, potassium,
triglycerides, and troponin.
RELATED MONOGRAPHS: See the Cardiovascular System table
Related tests include Alzheimers at the end of the book for related tests
disease markers, antiarrhythmic drugs, by body system.
Arthrogram
SYNONYM/ACRONYM: Joint study.
COMMON USE: To assess and identify the cause of persistent joint pain and
monitor the progression of joint disease.
CONTRAST: Iodinated or gadolinium contrast; air may also be used with or with-
out liquid contrast.
Arthroscopy
SYNONYM/ACRONYM: N/A.
CONTRAST: None.
Gout or pseudogout
a biopsy, and surgical repairs to Joint tumors
the joint. Meniscus removal, spur Loose bodies
removal, and ligamentous repair Meniscal disease
A are some of the surgical proce- Osteoarthritis
dures that may be performed. Osteochondritis
Rheumatoid arthritis
Subluxation, fracture, or dislocation
This procedure is contraindicated
Synovitis
for
Torn cartilage
Patients with bleeding disor-
Torn ligament
ders undergoing arthroscopy,
Torn rotator cuff
because the insertion site may
Trapped synovium
not stop bleeding.
Patients with infection in the CRITICAL FINDINGS: N/A
joint of interest or on the
skin surrounding the area of the INTERFERING FACTORS
insertion site because the infec-
tion can be introduced into the Factors that may impair clear
joint by the contaminated imaging
arthroscope. Inability of the patient to cooperate
Patients with active or remain still during the proce-
arthritis. dure because of age, significant
Patients who have had an pain, or mental status.
arthrogram within the last Fibrous ankylosis of the joint prevent-
14 days related to residual ing effective use of the arthroscope.
inflammation from the contrast. Joints with flexion of less than 50.
Other considerations
INDICATIONS Failure to follow dietary restrictions
Detect torn ligament or tendon before the procedure may cause
Evaluate joint pain and damaged the procedure to be canceled or
cartilage repeated.
Evaluate meniscal, patellar, condylar,
extrasynovial, and synovial injuries
or diseases of the knee
Evaluate the extent of arthritis
NURSING IMPLICATIONS
Evaluate the presence of gout
AND PROCEDURE
Monitor effectiveness of therapy PRETEST:
Remove loose objects Positively identify the patient using
at least two unique identifiers
POTENTIAL DIAGNOSIS before providing care, treatment,
or services.
Normal findings in Patient Teaching: Inform the patient this
Normal muscle, ligament, cartilage, procedure can assist in assessing the
synovial, and tendon structures of joint being examined.
the joint Obtain a history of the patients
Abnormal findings in complaints, including a list of known
allergens, especially allergies or
Arthritis sensitivities to latex and anesthetics.
Chondromalacia Obtain a history of the patients musculo
Cysts skeletal system, symptoms, and results
Degenerative joint changes of previously performed laboratory tests
Ganglion or Bakers cyst and diagnostic and surgical procedures.
Record the date of the last menstrual Make sure a written and informed
period and determine the possibility of consent has been signed prior to the
pregnancy in perimenopausal women. procedure and before administering
Obtain a list of the patients current any medications.
medications including anticoagulants, A
aspirin and other salicylates, herbs, INTRATEST:
nutritional supplements, and nutraceu
ticals (see Appendix H online at Potential Complications:
DavisPlus). Such products should be Possible complications include
discontinued by medical direction for infection, phlebitis, hemarthrosis,
the appropriate number of days prior hematoma, swelling, formation of
to a surgical procedure. Note the last blood clots, and synovial sac rupture.
time and dose of medication taken. Avoid the use of equipment containing
Review the procedure with the patient. latex if the patient has a history of aller
Address concerns about pain, and gic reaction to latex.
explain that some discomfort and pain Observe standard precautions, and fol
may be experienced during the test. low the general guidelines in Appendix A.
Inform the patient that the procedure is Positively identify the patient.
performed by a health-care provider Ensure the patient has complied with
(HCP), usually in the surgery department, food and fluid restrictions for at least
and takes approximately 30 to 60 min. 6 to 8 hr prior to the procedure.
Explain that a preprocedure sedative Resuscitation equipment and patient
may be administered to promote monitoring equipment must be available.
relaxation, as ordered. Instruct the patient to void prior to the
Crutch walking should be taught procedure and to change into the gown,
before the procedure if it is anticipated robe, and foot coverings provided.
postoperatively. The extremity is scrubbed, elevated,
Hair around the joint area and areas 5 and wrapped with an elastic bandage
to 6 in. above and below the joint are from the distal portion of the extremity
clipped and prepared for the to the proximal portion to drain as
procedure. much blood from the limb as possible.
Sensitivity to social and cultural issues,as A pneumatic tourniquet placed around
well as concern for modesty, is impor the proximal portion of the limb is inflated,
tant in providing psychological support and the elastic bandage is removed.
before, during, and after the procedure. As an alternative to a tourniquet, a mix
Explain that an IV line may be inserted ture of lidocaine with epinephrine and
to allow infusion of IV fluids such as sterile normal saline may be instilled
normal saline, anesthetics, sedatives, into the joint to help reduce bleeding.
or emergency medications. The joint is placed in a 45 angle, and
Instruct the patient that to reduce the a local anesthetic is administered.
risk of nausea and vomiting, solid food A small incision is made in the skin in
and milk or milk products have been the lateral or medial aspect of the joint.
restricted for at least 8 hr, and clear The arthroscope is inserted into the joint
liquids have been restricted for at spaces. The joint is manipulated as it is
least 2 hr prior to general anesthesia, visualized. Added puncture sites may be
regional anesthesia, or sedation/ needed to provide a full view of the joint.
analgesia (monitored anesthesia). The Biopsy or treatment can be performed
American Society of Anesthesiologists at this time, and photographs should
has fasting guidelines for risk levels be taken for future reference.
according to patient status. More infor After inspection, specimens may be
mation can be located at www.asahq obtained for cytological and microbiologi
.org. Patients on beta blockers before cal study. All specimens are placed in
the surgical procedure should be appropriate containers, labeled with the
instructed to take their medication as corresponding patient demographics,
ordered during the perioperative period. date and time of collection, site location,
Protocols may vary among facilities. and promptly sent to the laboratory.
The joint is irrigated, and the arthro Recognize anxiety related to test
scope is removed. Manual pressure is results, and be supportive of impaired
applied to the joint to remove remain activity related to anticipated chronic
ing irrigation solution. pain resulting from joint inflammation,
A The incision sites are sutured, and a impairment in mobility, musculoskeletal
pressure dressing is applied. deformity, and loss of independence.
Sterile gloves and gowns are worn Discuss the implications of abnormal
throughout the procedure. test results on the patients lifestyle.
Provide teaching and information
POST-TEST: regarding the clinical implications of the
Inform the patient that a report of the test results, as appropriate. Educate
results will be made available to the patient regarding access to coun
the requesting HCP, who will discuss seling services, as appropriate. Provide
the results with the patient. contact information, if desired, for the
Advise the patient to avoid strenuous American College of Rheumatology
activity involving the joint until approved (www.rheumatology.org) or for the
by the HCP. Driving may be restricted for Arthritis Foundation (www.arthritis.org).
a period of time, as ordered by the HCP. Reinforce information given by the
Instruct the patient to resume normal patients HCP regarding further testing,
diet and medications, as directed by the treatment, or referral to another HCP.
HCP. The patient may be given specific Answer any questions or address any
activity restrictions and may also need concerns voiced by the patient or family.
to be taught to use crutches. Depending on the results of this proce
Monitor the patients circulation and dure, additional testing may be needed
sensations in the joint area. to evaluate or monitor progression of
Instruct the patient to immediately report the disease process and determine the
symptoms such as fever, excessive need for a change in therapy. Evaluate
bleeding, difficulty breathing, incision site test results in relation to the patients
redness, swelling, and tenderness. symptoms and other tests performed.
Instruct the patient to elevate the joint
when sitting and to avoid overbending RELATED MONOGRAPHS:
of the joint to reduce swelling and Related tests include anti-cyclic citrulli
formation of blood clots. nated peptide, ANA, arthrogram, BMD,
Instruct the patient to take an analge bone scan, CBC, CRP, ESR, MRI
sic for joint discomfort after the musculoskeletal, radiography of the
procedure; ice bags may be used to bone, RF, synovial fluid analysis, and
reduce postprocedure swelling. uric acid.
Inform the patient to shower after 48 hr Refer to the Musculoskeletal System
but to avoid a tub bath until after his or table at the end of the book for related
her appointment with the HCP. tests by body system.
Aspartate Aminotransferase
SYNONYM/ACRONYM: Serum glutamic-oxaloacetic transaminase, AST, SGOT.
SI Units (Conventional
Age Conventional Units Units 0.017)
Newborn 2575 units/L 0.431.28 micro kat/L A
10 days23 mo 1560 units/L 0.261.02 micro kat/L
23 yr 1056 units/L 0.170.95 micro kat/L
46 yr 2039 units/L 0.340.66 micro kat/L
719 yr 1232 units/L 0.20.54 micro kat/L
2049 yr
Male 2040 units/L 0.340.68 micro kat/L
Female 1530 units/L 0.260.51 micro kat/L
Greater than 50 yr (older adult)
Male 1035 units/L 0.170.6 micro kat/L
Greater than 45 yr (older adult)
Female 1035 units/L 0.170.6 micro kat/L
Values may be slightly elevated in older adults due to the effects of medications and the
presence of multiple chronic or acute diseases with or without muted symptoms.
may be in order if the patients liver can lean poultry. A similar dietary pattern
no longer process the end products of known as the DASH diet makes addi
protein metabolism. A diet of soft tional recommendations for the reduc
foods may be required if esophageal tion of dietary sodium. Both dietary
A varices have developed. Ammonia lev styles emphasize a reduction in con
els may be used to determine whether sumption of red meats, which are high
protein should be added to or reduced in saturated fats and cholesterol, and
from the diet. Patients should be other foods containing sugar, saturated
encouraged to eat simple carbohy fats, trans fats, and sodium.
drates and emulsified fats (as in Social and Cultural Considerations:
homogenized milk or eggs) rather than Numerous studies point to the preva
complex carbohydrates (e.g., starch, lence of excess body weight in
fiber, and glycogen [animal carbohy American children and adolescents.
drates]) and complex fats, which Experts estimate that obesity is pres
require additional bile to emulsify them ent in 25% of the population ages 6 to
so that they can be used. The cirrhotic 11. The medical, social, and emotional
patient should be observed carefully consequences of excess body weight
for the development of ascites, in are significant. Special attention should
which case fluid and electrolyte bal be given to instructing the child and
ance requires strict attention. caregiver regarding health risks and
Nutritional Considerations: Increased AST weight-control education.
levels may be associated with coronary Recognize anxiety related to test
artery disease (CAD). Nutritional ther results, and be supportive of fear of
apy is recommended for the patient shortened life expectancy. Discuss the
identified to be at risk for developing implications of abnormal test results on
CAD or for individuals who have the patients lifestyle. Provide teaching
specific risk factors and/or existing and information regarding the clinical
medical conditions (e.g., elevated LDL implications of the test results, as
cholesterol levels, other lipid disorders, appropriate. Educate the patient
insulin-dependent diabetes, insulin regarding access to counseling ser
resistance, or metabolic syndrome). vices. Provide contact information, if
Other changeable risk factors warrant desired, for the American Heart
ing patient education include strategies Association (www.americanheart.org)
to encourage patients, especially those or the NHLBI (www.nhlbi.nih.gov).
who are overweight and with high Instruct the patient to immediately
blood pressure, to safely decrease report chest pain and changes in
sodium intake, achieve a normal breathing pattern to the HCP.
weight, ensure regular participation in Reinforce information given by the
moderate aerobic physical activity patients HCP regarding further testing,
three to four times per week, eliminate treatment, or referral to another HCP.
tobacco use, and adhere to a heart- Answer any questions or address any
healthy diet. If triglycerides also are concerns voiced by the patient or family.
elevated, the patient should be advised Depending on the results of this
to eliminate or reduce alcohol. The procedure, additional testing may be
2013 Guideline on Lifestyle performed to evaluate or monitor pro
Management to Reduce gression of the disease process and
Cardiovascular Risk published by the determine the need for a change in
ACC and AHA in conjunction with the therapy. Evaluate test results in relation
NHLBI recommends a to the patients symptoms and other
Mediterranean-style diet rather than a tests performed.
low-fat diet. The new guideline empha
sizes inclusion of vegetables, whole RELATED MONOGRAPHS:
grains, fruits, low-fat dairy, nuts, Related tests include acetaminophen,
legumes, and nontropical vegetable ALT, albumin, ALP, ammonia, AMA/
oils (e.g., olive, canola, peanut, sun ASMA, a1-antitrypsin/phenotyping,
flower, flaxseed) along with fish and bilirubin and fractions, biopsy liver,
COMMON USE: To evaluate hearing loss in school-age children but can be used
for all ages.
CONTRAST: N/A.
This procedure is
Conventional & contraindicated for: N/A
Sample SI Units
Serum INDICATIONS
Newborn1 mo 1.64.8 mg/L Detect aminoglycoside toxicity
26 mo 13.8 mg/L Detect chronic lymphocytic
711 mo 0.93.1 mg/L leukemia, multiple myeloma,
16 yr 0.62.4 mg/L lung cancer, hepatoma, or
718 yr 0.72 mg/L breast cancer
Adult 0.62.4 mg/L Detect HIV infection (Note: levels
Urine 0300 mcg/L do not correlate with stages of
infection)
Evaluate renal disease to
DESCRIPTION: 2-Microglobulin differentiate glomerular from
(BMG) is a protein component of tubular dysfunction
human leukocyte antigen (HLA) Evaluate renal transplant viability
complexes. BMG is on the surface and predict rejection
of most cells and is therefore a Monitor antiretroviral therapy
useful indicator of cell death or
unusually high levels of cell produc- POTENTIAL DIAGNOSIS
tion. BMG is a small protein and is
readily reabsorbed by kidneys with Increased in
normal function. BMG increases in AIDS (related to increased
inflammatory conditions and when lymphocyte turnover)
lymphocyte turnover increases, Aminoglycoside toxicity (related to
such as in lymphocytic leukemia or renal damage; urine BMG becomes
when T-lymphocyte helper (OKT4) elevated before creatinine)
cells are attacked by HIV. Serum Amyloidosis (related to chronic
BMG becomes elevated with mal- inflammatory conditions
functioning glomeruli but decreases associated with increased
with malfunctioning tubules BMG and other acute-phase
because it is metabolized by the reactant proteins; also related to
renal tubules. Conversely, urine deposition of amyloid in joints
BMG decreases with malfunction- and tissues of patients receiving
ing glomeruli but becomes elevated long-term hemodialysis)
with malfunctioning tubules. Autoimmune disorders (related to
increased lymphocyte turnover)
191
Monograph_B_191-221.indd 193
Potential Nursing Problems:
17/11/14 12:13 PM
B
194
Monograph_B_191-221.indd 194
associated with sputum culture positive for antibiotics and medications for fever reduction; administer cooling
chemotherapy and infection; increased heart rate measures; be vigilant with hand hygiene; educate patient and family
radiation therapy; and respiratory rate; chills; regarding good hand hygiene; infuse ordered IV fluids to support
opportunistic change in mental status; adequate hydration; ensure implementation of infection prevention
hosts) fatigue; malaise; weakness; measures with consideration of age and culture such as adequate
anorexia; headache; nausea; nutrition; perform aseptic wound care; ensure skin care; ensure oral care;
elevated blood glucose; ensure adequate rest; avoid exposure to opportunistic hosts; send
hypotension; diminished oxygen cultures to the laboratory as ordered; correlate culture findings with
saturation; elevated WBC; selected antibiotics; avoid mouthwashes with high alcohol content; notify
elevated C-reactive protein health-care provider (HCP) of temperature spikes or flu-like symptoms;
discuss implementation of protective isolation for neutrophil count less
than 500 to 1,000 103/microL
Bleeding (Related to Decreased platelet count; altered Administer prescribed platelets or blood as ordered; monitor and trend
altered bone level of consciousness; platelet count; increase frequency of vital sign assessment with variances
marrow function hypotension; increased heart in results; monitor for vital sign trends; administer stool softeners as
secondary to rate; decreased HGB and HCT; needed; monitor stool for blood; encourage intake of foods rich in vitamin
radiation therapy capillary refill greater than three K; monitor and trend HGB/HCT; assess skin for petechiae, purpura,
and chemotherapy) seconds; cool extremities hematoma; monitor for blood in emesis or sputum; institute bleeding
precautions (prevent unnecessary venipuncture; avoid IM injections;
prevent trauma; be gentle with oral care, suctioning; avoid use of a sharp
razor); coordinate lab draws to decrease number of sticks; review
transfusion reaction symptoms
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
17/11/14 12:13 PM
a2-Microglobulin, Blood and Urine 195
the urine into a larger container period- Depending on the results of this
ically during the collection period; mon- procedure, additional testing may
itor to ensure continued drainage, and be performed to evaluate or
conclude the test the next morning at monitor progression of the disease
the same hour the collection started. process and determine the need
Compare the quantity of urine with the for a change in therapy. Evaluate
B urinary output record for the collection test results in relation to the
at the conclusion of the test. If the patients symptoms and other
specimen contains less than what was tests performed.
recorded as output, some urine may
have been discarded, thus invalidating Patient Education:
the test. Educate the patient regarding the risk
Blood or Urine of infection related to immunosup-
Promptly transport the specimen to the pressed inflammatory response and
laboratory for processing and analysis. fatigue related to decreased energy
Include on the urine specimen label the production.
amount of urine and ingestion of any Educate the patient regarding access
medications that can affect test results. to counseling services.
Provide a nonjudgmental, nonthreaten-
POST-TEST: ing atmosphere for a discussion during
which risks of sexually transmitted
Inform the patient that a report of the diseases are explained.
results will be made available to the Discuss emotional problems the
requesting HCP, who will discuss the patient may experience (e.g., guilt,
results with the patient. depression, anger).
Nutritional Considerations: Stress the Reinforce information given by the
importance of good nutrition, and patients HCP regarding further
suggest that the patient meet with testing, treatment, or referral to another
a nutritional specialist. Also, stress the HCP.
importance of following the care plan Inform the patient that retesting may
for medications and follow-up visits. be necessary.
Social and Cultural Considerations: Answer any questions or address
Recognize anxiety related to test any concerns voiced by the patient
results, and be supportive of impaired or family.
activity related to weakness, perceived
loss of independence, and fear of Expected Patient Outcomes:
shortened life expectancy. Discuss the Knowledge
implications of abnormal test results on States understanding of the normal
the patients lifestyle. Provide teaching range of a platelet count
and information regarding the clinical States understanding of the rationale
implications of the test results, as for bleeding precautions to overall
appropriate. Educate the patient health
regarding access to counseling ser-
vices. Provide contact information, if Skills
desired, for AIDS information provided Demonstrates proficient use of nasal
by the National Institutes of Health spray and lip lubricant to decrease
(www.aidsinfo.nih.gov). cracking and bleeding
Social and Cultural Considerations: Demonstrates proficiency in protecting
Counsel the patient, as appropriate, self from injury and trauma with
regarding risk of transmission and associated bleeding risk
proper prophylaxis, and reinforce the Attitude
importance of strict adherence to the Complies with the request for type
treatment regimen. and cross match for possible platelet
Social and Cultural Considerations: Offer transfusion
support, as appropriate, to patients Complies with recommendation to
who may be the victims of rape or attend support groups to assist with
sexual assault. managing end-of-life concerns
Barium Enema
SYNONYM/ACRONYM: Air-contrast barium enema, double-contrast barium enema,
lower GI series, BE.
COMMON USE: To assist in diagnosing bowel disease in the colon such as tumors
and polyps.
impair kidney function, and failure to best time to talk about the test is right
withhold metformin may indirectly result before the procedure. The child should
in drug-induced lactic acidosis, be assured that he or she will be
a dangerous and sometimes fatal side allowed to bring a favorite comfort item
effect of metformin (related to renal into the examination room, and if appro-
impairment that does not support priate, that a parent will be with them
B etformin).
sufficient excretion of m during the procedure. Explain that there
Review the procedure with the patient. will be monitors in the room and they
Address concerns about pain and will be able to watch their procedure
explain that there may be moments of along with their health-care team.
discomfort and some pain experienced Sensitivity to social and cultural issues,as
during the test. Inform the patient that well as concern for modesty, is important
the procedure is performed in a radiol- in providing psychological support
ogy department, by an HCP specializ- before, during, and after the procedure.
ing in this procedure, with support staff, Instruct the patient to eat a low-residue
and takes approximately 30 min. diet for several days before the proce-
Pediatric Considerations Preparing dure and to consume only clear liquids
children for a barium enema depends the evening before the test. The patient
on the age of the child. Encourage par- should fast and restrict fluids for 8 hr
ents to be truthful about unpleasant prior to the procedure. Protocols may
sensations (cramping, pressure, full- vary among facilities. Inform the patient
ness) the child may experience during that a laxative and cleansing enema
the procedure and to use words that may be needed the day before the
they know their child will understand. procedure, with cleansing enemas
Toddlers and preschool-age children on the morning of the procedure,
have a very short attention span, so the depending on the institutions policy.
Pediatric Preps
Barium Swallow
SYNONYM/ACRONYM: Esophagram, video swallow, esophagus x-ray, swallowing
function, esophagraphy.
study. Swallowing the additional bar- normal color, the patient should notify
ium evaluates the passage of barium the requesting HCP.
from the esophagus into the stomach. Recognize anxiety related to test
results. Discuss the implications of
POST-TEST: abnormal test results on the patients
Inform the patient that a report of the lifestyle. Provide teaching and informa-
B results will be made available to the tion regarding the clinical implications
requesting HCP, who will discuss the of the test results, as appropriate.
results with the patient. Reinforce information given by the
Instruct the patient to resume usual patients HCP regarding further testing,
diet, fluids, medications, and activity, treatment, or referral to another HCP.
as directed by the HCP. Answer any questions or address any
Carefully monitor the patient for fatigue concerns voiced by the patient or family.
and fluid and electrolyte imbalance. Depending on the results of this
Instruct the patient to take a mild laxative procedure, additional testing may be
and increase fluid intake (four 8-oz performed to evaluate or monitor pro-
glasses) to aid in elimination of barium, gression of the disease process and
unless contraindicated. Pediatric determine the need for a change in
Considerations Instruct the parents of therapy. Evaluate test results in relation
pediatric patients to hydrate children with to the patients symptoms and other
electrolyte fluids post barium swallow. tests performed.
Geriatric Considerations Chronic
dehydration can also result in frequent RELATED MONOGRAPHS:
bouts of constipation. Therefore, after Related tests include capsule
the procedure, elderly patients should be endoscopy, chest x-ray, CT thoracic,
encouraged to use a mild laxative daily endoscopy, esophageal manometry,
until the stool is back to normal color. gastroesophageal reflux scan, MRI
Instruct the patient that stools will be chest, and thyroid scan.
white or light in color for 2 to 3 days. Refer to the Gastrointestinal System
If the patient is unable to eliminate the table at the end of the book for related
barium, or if stools do not return to tests by body system.
COMMON USE: A multipurpose lab test that acts as an indicator for various dis-
eases of the liver or for disease that affects the liver.
SI Units (Conventional
Age Conventional Units Units 17.1)
Total bilirubin
Newborn1 day Less than 5.8 mg/dL Less than 99 micromol/L
12 days Less than 8.2 mg/dL Less than 140 micromol/L
35 days Less than 11.7 mg/dL Less than 200 micromol/L
B
67 days Less than 8.4 mg/dL Less than 144 micromol/L
89 days Less than 6.5 mg/dL Less than 111 micromol/L
1011 days Less than 4.6 mg/dL Less than 79 micromol/L
1213 days Less than 2.7 mg/dL Less than 46 micromol/L
1430 days Less than 0.8 mg/dL Less than 14 micromol/L
1 moolder adult Less than 1.2 mg/dL Less than 21 micromol/L
Unconjugated bilirubin Less than 1.1 mg/dL Less than 19 micromol/L
Conjugated bilirubin
Neonate Less than 0.6 mg/dL Less than 10 micromol/L
29 daysolder adult Less than 0.3 mg/dL Less than 5 micromol/L
Delta bilirubin Less than 0.2 mg/dL Less than 3 micromol/L
lipase, liver and spleen scan, protein See the Hepatobiliary System table at
total and fractions, PT/INR, US abdo- the end of the book for related tests by
men, US liver, and UA. body system.
Biopsy, Bladder
SYNONYM/ACRONYM: N/A.
Biopsy, Bone
SYNONYM/ACRONYM: N/A.
SPECIMEN: Bone marrow aspirate, bone core biopsy, marrow and peripheral smears.
diagnosis of bone marrow and immune and milk or milk products have been
system disease. restricted for at least 8 hr, and clear
Obtain a history of the patients liquids have been restricted for at least
complaints, including a list of known 2 hr prior to general anesthesia, regional
allergens, especially allergies or anesthesia, or sedation/analgesia
sensitivities to latex or anesthetics. (monitored anesthesia). The American
Obtain a history of the patients hema- Society of Anesthesiologists has fasting B
topoietic and immune systems, espe- guidelines for risk levels according to
cially any bleeding disorders and other patient status. More information can be
symptoms, and results of previously located at www.asahq.org. Protocols
performed laboratory tests and may vary among facilities.
diagnostic and surgical procedures. Make sure a written and informed
Record the date of the last menstrual consent has been signed prior to the
period and determine the possibility of procedure and before administering
pregnancy in perimenopausal women. any medications.
Note any recent procedures that can
interfere with test results. INTRATEST:
Obtain a list of the patients current
medications, including anticoagulants, Potential Complications:
aspirin and other salicylates, herbs, Bleeding (related to a bleeding disor-
nutritional supplements, and nutraceu- der, or the effects of natural products
ticals (see Appendix H online at and medications known to act as
DavisPlus). Such products should be blood thinners)
discontinued by medical direction for Ensure that the patient has complied
the appropriate number of days prior with dietary restrictions.
to a surgical procedure. Ensure that anticoagulant therapy has
Review the procedure with the patient. been withheld for the appropriate num-
Inform the patient that it may be neces- ber of days prior to the procedure.
sary to remove hair from the site before Number of days to withhold medica-
the procedure. Address concerns about tion is dependent on the type of anti-
pain and explain that a sedative and/or coagulant. Notify the HCP if patient
analgesia will be administered to pro- anticoagulant therapy has not been
mote relaxation and reduce discomfort withheld.
prior to the percutaneous biopsy. Explain Avoid the use of equipment containing
to the patient that any discomfort with latex if the patient has a history of aller-
the needle biopsy will be minimized with gic reaction to latex.
local anesthetics and systemic analge- Have emergency equipment readily
sics. Explain that the patient may feel available.
some pain when the lidocaine is injected Have the patient void before the
and some discomfort at the stage in the procedure.
procedure when the specimen is aspi- Observe standard precautions, and fol-
rated. Inform the patient that the biopsy low the general guidelines in Appendix
is performed under sterile conditions by A. Positively identify the patient, and
an HCP specializing in this procedure. label the appropriate specimen con-
A needle biopsy usually takes about tainers with the corresponding patient
20 min to complete. demographics, initials of the person
Sensitivity to social and cultural issues, collecting the specimen, date and time
as well as concern for modesty, is of collection, and site location.
important in providing psychological Assist the patient to the desired posi-
support before, during, and after the tion depending on the test site to be
procedure. used. In young children, the most fre-
Explain that an IV line may be inserted quently chosen site is the proximal
to allow infusion of IV fluids, anesthetics, tibia. Vertebral bodies T10 through L4
or sedatives. are preferred in older children. In
Instruct the patient that to reduce the adults, the sternum or iliac crests are
risk of nausea and vomiting, solid food the preferred sites. Place the patient in
Biopsy, Breast
SYNONYM/ACRONYM: N/A.
biopsy. Explain to the patient that no Ensure that anticoagulant therapy has
pain will be experienced during the test been withheld for the appropriate num-
when general anesthesia is used but ber of days prior to the procedure.
that any discomfort with a needle Number of days to withhold medica-
biopsy will be minimized with local tion is dependent on the type of anti-
anesthetics and systemic analgesics. coagulant. Notify the HCP if patient
B Inform the patient that the biopsy is anticoagulant therapy has not been
performed under sterile conditions by withheld. Ensure that patients on beta-
an HCP specializing in this procedure. blocker therapy have continued their
The surgical procedure usually takes medication regimen as ordered.
about 20 to 30 min to complete, and Avoid the use of equipment containing
sutures may be necessary to close the latex if the patient has a history of aller-
site. A needle biopsy usually takes gic reaction to latex.
about 15 min to complete. Have emergency equipment readily
Sensitivity to social and cultural issues, available.
as well as concern for modesty, is Have the patient void before the
important in providing psychological procedure.
support before, during, and after the Observe standard precautions, and
procedure. follow the general guidelines in
Explain that an IV line may be inserted Appendix A. Positively identify the
to allow infusion of IV fluids, anesthet- patient, and label the appropriate
ics, analgesics, or IV sedation. specimen containers with the corre-
Instruct the patient that to reduce the sponding patient demographics,
risk of nausea and vomiting, solid food initials of the person collecting the
and milk or milk products have been specimen, date and time of collection,
restricted for at least 8 hr, and clear and site location, especially right or
liquids have been restricted for at least left breast.
2 hr prior to general anesthesia, Assist the patient to the desired posi-
regional anesthesia, or sedation/ tion depending on the test site to be
analgesia (monitored anesthesia). The used, and direct the patient to breathe
American Society of Anesthesiologists normally during the beginning of the
has fasting guidelines for risk levels general anesthetic. Instruct the patient
according to patient status. More infor- to cooperate fully and to follow direc-
mation can be located at www.asahq tions. For the patient undergoing local
.org. Patients on beta blockers before anesthesia, direct him or her to
the surgical procedure should be breathe normally and to avoid
instructed to take their medication as unnecessary movement during the
ordered during the perioperative period. procedure.
Protocols may vary among facilities. Open Biopsy
Make sure a written and informed Adhere to Surgical Care Improvement
consent has been signed prior to the Project (SCIP) quality measures.
procedure and before administering Administer ordered prophylactic antibi-
any medications. otics 1 hr before incision, use antibiot-
ics that are consistent with current
INTRATEST: guidelines specific to the procedure,
and use clippers to remove hair from
Potential Complications: the surgical site if appropriate.
Bleeding (related to a bleeding After administration of general anesthe-
disorder, or the effects of natural sia and surgical preparation are com-
products and medications known to pleted, an incision is made, suspicious
act as blood thinners) or seeding of area(s) are located, and tissue samples
the biopsy tract with tumor cells. are collected.
Ensure that the patient has complied Record baseline vital signs, and
with dietary restrictions. Ensure that the continue to monitor throughout
patient has not received antiestrogen the procedure. Protocols may vary
therapy within 2 mo of the test. among facilities.
Biopsy, Cervical
SYNONYM/ACRONYM: Cone biopsy, LEEP.
concerns about pain and explain that a Ensure that the patient has complied
sedative and/or analgesia will be with dietary restrictions.
administered to promote relaxation and Ensure that anticoagulant therapy has
reduce discomfort prior to the percuta- been withheld for the appropriate number
neous biopsy; general anesthesia will of days prior to the procedure. Number
be administered prior to the open of days to withhold medication is depen-
B biopsy. Explain that no pain will be dent on the type of a nticoagulant. Notify
experienced during the test when gen- HCP if patient anticoagulant therapy has
eral anesthesia is used but that any not been withheld. Ensure that patients
discomfort with a needle biopsy will be on beta-blocker therapy have continued
minimized with local anesthetics and their medication regimen as ordered.
systemic analgesics. Inform the patient Avoid the use of equipment containing
the biopsy is performed under sterile latex if the patient has a history of
conditions by an HCP specializing in allergic reaction to latex.
this procedure. The biopsy can be per- Have emergency equipment readily
formed in the HCPs office and takes available.
approximately 5 to 10 min to complete. Have the patient void before the
The open biopsy is performed in a sur- procedure.
gical suite, usually takes about 20 to Observe standard precautions, and
30 min to complete, and sutures may follow the general guidelines in
be necessary to close the site. Appendix A. Positively identify the
Sensitivity to social and cultural issues,as patient, and label the appropriate speci-
well as concern for modesty, is impor- men containers with the corresponding
tant in providing psychological support patient demographics, initials of the
before, during, and after the p rocedure. person collecting the specimen, date
Explain that an IV line may be inserted and time of collection, and site location.
to allow infusion of IV fluids, anesthet- Have the patient remove clothes below
ics, analgesics, or IV sedation. the waist. Assist the patient into a
Instruct the patient that to reduce the lithotomy position on a gynecological
risk of nausea and vomiting, solid food examination table (with feet in stirrups).
and milk or milk products have been Drape the patients legs. Instruct the
restricted for at least 8 hr, and clear patient to cooperate fully and to follow
liquids have been restricted for at least directions. Direct the patient to breathe
2 hr prior to general anesthesia, normally and to avoid unnecessary
regional anesthesia, or sedation/ movement during the local or general
analgesia (monitored anesthesia). The anesthetic and the procedure.
American Society of Anesthesiologists
has fasting guidelines for risk levels Punch Biopsy
according to patient status. More infor- Iodine solution is used to cleanse the
mation can be located at www.asahq. cervix and distinguish normal from
org. Patients on beta blockers before abnormal tissue. Local anesthesia,
the surgical procedure should be analgesics, or both, are administered
instructed to take their medication as to minimize discomfort.
ordered during the perioperative period. A small, round punch is rotated into
Protocols may vary among facilities. the skin to the desired depth. The
Make sure a written and informed cylinder of skin is pulled upward with
consent has been signed prior to the forceps and separated at its base
procedure and before administering with a scalpel or scissors.
any medications. LEEP in the HCPs Office
INTRATEST: A speculum is inserted into the vagina
and is opened to gently spread
Potential Complications: apart the vagina for inspection
Bleeding (related to a bleeding disor- of the cervix.
der, or the effects of natural products Iodine solution is used to cleanse the
and medications known to act as cervix and distinguish normal from
blood thinners) abnormal tissue. Local anesthesia,
Biopsy, Intestinal
SYNONYM/ACRONYM: N/A.
B
COMMON USE: To assist in confirming a diagnosis of intestinal cancer or disease.
CRITICAL FINDINGS
DESCRIPTION: Intestinal biopsy is
the excision of a tissue sample Assessment of clear margins after
from the small intestine for micro- tissue excision
scopic analysis to determine cell Classification or grading of tumor
morphology and the presence of Identification of malignancy
tissue abnormalities.This test assists It is essential that critical findings be
in confirming the diagnosis of can- communicated immediately to the
cer or intestinal disorders. Biopsy requesting health-care provider (HCP).
specimen is usually obtained A listing of these findings varies
during endoscopic examination. among facilities.
Timely notification of a critical
This procedure is finding for lab or diagnostic studies is
contraindicated for a role expectation of the professional
Patients with bleeding disor- nurse. The notification processes will
ders (related to the potential vary among facilities. Upon receipt of
for prolonged bleeding from the the critical finding the information
biopsy site) or aortic arch aneurysm. should be read back to the caller to
verify accuracy. Most policies require
INDICATIONS immediate notification of the primary
Assist in the diagnosis of various HCP, hospitalist, or on-call HCP.
intestinal disorders, such as lactose Reported information includes the
and other enzyme deficiencies, celi- patients name, unique identifiers,
ac disease, and parasitic infections critical finding, name of the person
Confirm suspected intestinal giving the report, and name of the
malignancy person receiving the report.
Confirm suspicious findings during Documentation of notification should
endoscopic visualization of the be made in the medical record with
intestinal wall the name of the HCP notified, time
and date of notification, and any
POTENTIAL DIAGNOSIS orders received. Any delay in a timely
report of a critical finding may require
Abnormal findings in completion of a notification form
Cancer with review by Risk Management.
Celiac disease
Lactose deficiency INTERFERING FACTORS
Parasitic infestation Barium swallow within 48 hr of
Tropical sprue small intestine biopsy affects results.
Biopsy, Kidney
SYNONYM/ACRONYM: Renal biopsy.
B
COMMON USE: To assist in diagnosing cancer and other renal disorders.
accuracy. Most policies require immedi- and other salicylates, herbs, nutritional
ate notification of the primary HCP, supplements, and nutraceuticals (see
hospitalist, or on-call HCP. Reported Appendix H online at DavisPlus). Such
information includes the patients products should be discontinued by
medical direction for the appropriate num-
name, unique identifiers, critical find- ber of days prior to a surgical procedure.
ing, name of the person giving the Review the procedure with the patient.
B report, and name of the person receiv- Inform the patient that it may be neces-
ing the report. Documentation of noti- sary to remove hair from the site before
fication should be made in the medical the procedure. Instruct the patient that
record with the name of the HCP noti- prophylactic antibiotics may be adminis-
fied, time and date of notification, and tered before the procedure. Address
any orders received. Any delay in a concerns about pain and explain that a
timely report of a critical finding may sedative and/or analgesia will be admin-
istered before the percutaneous biopsy
require completion of a notification to promote relaxation and reduce dis-
form with review by Risk Management. comfort; general anesthesia will be
administered before the open biopsy.
INTERFERING FACTORS Explain to the patient that no pain will
Obesity and severe spinal deformity be experienced during the test when
can make percutaneous biopsy general anesthesia is used but that any
impossible. discomfort with a needle biopsy will be
Failure to follow dietary restrictions minimized with local anesthetics and
before the procedure may cause systemic analgesics. Inform the patient
that the biopsy is performed under ster-
the procedure to be canceled or ile conditions by an HCP specializing in
repeated. this procedure. The surgical procedure
usually takes about 60 min to complete,
and sutures may be necessary to close
NURSING IMPLICATIONS the site. A needle biopsy usually takes
AND PROCEDURE about 40 min to complete.
Sensitivity to social and cultural issues,
PRETEST: as well as concern for modesty, is
Positively identify the patient using at important in providing psychological
least two unique identifiers before pro- support before, during, and after the
viding care, treatment, or services. procedure.
Patient Teaching: Inform the patient this Explain that an IV line will be inserted
procedure can assist in establishing a to allow infusion of IV fluids, antibiotics,
diagnosis of kidney disease. anesthetics, analgesics, or IV sedation.
Obtain a history of the patients com- Instruct the patient that to reduce the
plaints, including a list of known aller- risk of nausea and vomiting, solid food
gens, especially allergies or sensitivities and milk or milk products have been
to latex or anesthetics. restricted for at least 8 hr, and clear liq-
Obtain a history of the patients genito- uids have been restricted for at least
urinary and immune systems, especially 2 hr prior to general anesthesia, regional
any bleeding disorders or other symp- anesthesia, or sedation/analgesia
toms, and results of previously per- (monitored anesthesia). The American
formed laboratory tests and diagnostic Society of Anesthesiologists has fasting
and surgical procedures. guidelines for risk levels according to
Record the date of the last menstrual patient status. More information can be
period and determine the possibility of located at www.asahq.org. Patients on
pregnancy in perimenopausal women. beta blockers before the surgical pro-
Note any recent procedures that can cedure should be instructed to take
interfere with test results. their medication as ordered during the
Obtain a list of the patients current medi- perioperative period. Protocols may
cations, including anticoagulants, aspirin vary among facilities.
intake and output at least every 8 hr. course of antibiotic therapy, even if
Compare with baseline values. Notify signs and symptoms disappear before
the HCP if temperature is elevated. completion of therapy.
Discontinue prophylactic antibiotics Recognize anxiety related to test
within 24 hr after the conclusion of the results. Discuss the implications of
procedure. Protocols may vary among abnormal test results on the patients
B facilities. lifestyle. Provide teaching and informa-
Observe/assess for delayed allergic tion regarding the clinical implications
reactions, such as rash, urticaria, of the test results, as appropriate.
tachycardia, hyperpnea, hypertension, Educate the patient regarding access
palpitations, nausea, or vomiting. to counseling services.
Instruct the patient to immediately report Reinforce information given by the
symptoms such as fast heart rate, patients HCP regarding further testing,
difficulty breathing, skin rash, itching, treatment, or referral to another HCP.
chest pain, persistent right shoulder pain, Inform the patient of a follow-up
or abdominal pain. Immediately report appointment for removal of sutures, if
symptoms to the appropriate HCP. indicated. Answer any questions or
Observe/assess the biopsy site for address any concerns voiced by the
bleeding, inflammation, or hematoma patient or family.
formation. Instruct the patient in the use of any
Instruct the patient in the care and ordered medications. Explain the
assessment of the site. importance of adhering to the ther-
Instruct the patient to report any red- apy regimen. As appropriate, instruct
ness, edema, bleeding, or pain at the the patient in significant side effects
biopsy site. Instruct the patient to and systemic reactions associated
immediately report chills or fever. with the prescribed medication.
Observe/assess the biopsy site for Encourage him or her to review cor-
bleeding, inflammation, or hematoma responding literature provided by a
formation. pharmacist.
Inform the patient that blood may be Depending on the results of this pro-
seen in the urine after the first or sec- cedure, additional testing may be
ond postprocedural voiding. performed to evaluate or monitor
Monitor fluid intake and output for progression of the disease process
24 hr. Instruct the patient on intake and determine the need for a change
and output recording and provide in therapy. Evaluate test results in
appropriate measuring containers. relation to the patients symptoms
Instruct the patient to report any and other tests performed.
changes in urinary pattern or volume
or any unusual appearance of the RELATED MONOGRAPHS:
urine. If urinary volume is less than Related tests include albumin,
200 mL in the first 8 hr, encourage aldosterone, angiography renal,
the patient to increase fluid intake antibodies antiglomerular basement
unless contraindicated by another membrane, 2-microglobulin, BUN,
medical condition. CT renal, creatinine, creatinine clear-
Assess for nausea and pain. ance, cytology urine, cystoscopy, IVP,
Administer antiemetic and analgesic KUB studies, osmolality, PTH,
medications as needed and as potassium, protein, renin, renogram,
directed by the HCP. sodium, US kidney, and UA.
Administer antibiotic therapy if Refer to the Genitourinary and Immune
ordered. Remind the patient of the systems tables at the end of the book
importance of completing the entire for related tests by body system.
Biopsy, Liver
SYNONYM/ACRONYM: N/A.
B
COMMON USE: To assist in diagnosing liver cancer, and other liver disorders such
as cirrhosis and hepatitis.
report, and name of the person receiv- necessary to remove hair from the site
ing the report. Documentation of noti- before the procedure. Instruct the
fication should be made in the medical patient that prophylactic antibiotics may
record with the name of the HCP noti- be administered before the procedure.
Address concerns about pain and
fied, time and date of notification, and explain that a sedative and/or analgesia
any orders received. Any delay in a will be administered before the percuta-
B timely report of a critical finding may neous biopsy to promote relaxation and
require completion of a notification reduce discomfort; general anesthesia
form with review by Risk Management. will be administered before the open
biopsy. Explain to the patient that no
INTERFERING FACTORS pain will be experienced during the test
Failure to follow dietary restrictions when general anesthesia is used but
before the procedure may cause that any discomfort with a needle biopsy
will be minimized with local anesthetics
the procedure to be canceled or and systemic analgesics. Inform the
repeated. patient that the biopsy is performed
under sterile conditions by an HCP spe-
cializing in this procedure. The surgical
NURSING IMPLICATIONS procedure usually takes about 90 min to
AND PROCEDURE complete, and sutures may be neces-
sary to close the site. A needle biopsy
PRETEST: usually takes about 15 min to complete.
Positively identify the patient using at Sensitivity to social and cultural issues,
least two unique identifiers before as well as concern for modesty, is impor-
providing care, treatment, or services. tant in providing psychological support
Patient Teaching: Inform the patient this before, during, and after the p rocedure.
procedure can assist in establishing a Explain that an IV line will be inserted
diagnosis of liver disease. to allow infusion of IV fluids, antibiotics,
Obtain a history of the patients com- anesthetics, analgesics, or IV sedation.
plaints, especially fatigue and pain Instruct the patient that to reduce the risk
related to inflammation and swelling of of nausea and vomiting, solid food and
the liver. Include a list of known aller- milk or milk products have been restricted
gens, especially allergies or sensitivities for at least 8 hr, and clear liquids have
to latex or anesthetics. been restricted for at least 2 hr prior to
Obtain a history of the patients hepa- general anesthesia, regional anesthesia,
tobiliary and immune systems, espe- or sedation/analgesia (monitored anes-
cially any bleeding disorders and other thesia). The American Society of
symptoms, and results of previously Anesthesiologists has fasting guidelines
performed laboratory tests and diag- for risk levels according to patient status.
nostic and surgical procedures. More information can be located at
Record the date of the last menstrual www.asahq.org. Patients on beta block-
period and determine the possibility of ers before the surgical procedure should
pregnancy in perimenopausal women. be instructed to take their medication as
Note any recent procedures that can ordered during the perioperative period.
interfere with test results. Protocols may vary among facilities.
Obtain a list of the patients current med- Make sure a written and informed
ications including anticoagulants, aspirin consent has been signed prior to the
and other salicylates, herbs, nutritional procedure and before administering
supplements, and nutraceuticals (see any medications.
Appendix H online at DavisPlus). Such
products should be discontinued by INTRATEST:
medical direction for the appropriate num-
ber of days prior to a surgical procedure. Potential Complications:
Review the procedure with the patient. Bleeding (related to a bleeding disor-
Inform the patient that it may be der, bleeding initiated by surgical
Biopsy, Lung
SYNONYM/ACRONYM: Transbronchial lung biopsy, open lung biopsy.
COMMON USE: To assist in diagnosing lung cancer and other lung tissue disease.
Biopsy, Muscle
SYNONYM/ACRONYM: N/A.
B
COMMON USE: To assist in diagnosing muscular disease such as Duchennes
muscular dystrophy as well as other neuropathies and parasitic infections.
Fungal infection
DESCRIPTION: Muscle biopsy is the Myasthenia gravis
excision of a muscle tissue sam Myotonia congenita
ple for microscopic analysis to Parasitic infestation
determine cell morphology and Polymyalgia rheumatica
the presence of tissue abnormali Polymyositis
ties. This test is used to confirm a
diagnosis of neuropathy or myo CRITICAL FINDINGS
pathy and to diagnose parasitic
infestation. A biopsy specimen is Assessment of clear margins after
usually obtained from the deltoid tissue excision
or gastrocnemius muscle after Classification or grading of tumor
a surgical incision. Identification of malignancy
It is essential that critical findings be
communicated immediately to the
This procedure is
requesting health-care provider (HCP).
contraindicated for
A listing of these findings varies among
Patients with bleeding disor
facilities.
ders (related to the potential
Timely notification of a critical find
for prolonged bleeding from the
ing for lab or diagnostic studies is a role
biopsy site)
expectation of the professional nurse.
The notification processes will vary
INDICATIONS
among facilities. Upon receipt of the
Assist in confirming suspected fun
critical finding the information should
gal infection or parasitic infestation
be read back to the caller to verify
of the muscle
accuracy. Most policies require immedi
Assist in diagnosing the cause of
ate notification of the primary HCP,
neuropathy or myopathy
hospitalist, or on-call HCP. Reported
Assist in the diagnosis of
information includes the patients
Duchennes muscular dystrophy
name, unique identifiers, critical find
ing, name of the person giving the
POTENTIAL DIAGNOSIS
report, and name of the person receiv
Abnormal findings in ing the report. Documentation of noti
Alcoholic myopathy fication should be made in the medical
Amyotrophic lateral sclerosis record with the name of the HCP noti
Duchennes muscular dystrophy fied, time and date of notification, and
any orders received. Any delay in a concerns about pain and explain that a
timely report of a critical finding may sedative and/or analgesia will be admin-
require completion of a notification istered before the percutaneous biopsy
form with review by Risk Management. to promote relaxation and reduce dis-
comfort; general anesthesia will be
administered before the open biopsy.
INTERFERING FACTORS Explain to the patient that no pain will
If electromyography is performed B
be experienced during the test when
before muscle biopsy, residual general anesthesia is used but that any
inflammation may lead to false- discomfort with a needle biopsy will be
positive biopsy results. minimized with local anesthetics and
Failure to follow dietary restrictions systemic analgesics. Inform the patient
before the procedure may cause the that the biopsy is performed under ster-
procedure to be canceled or repeated. ile conditions by an HCP specializing in
this procedure. The surgical procedure
usually takes about 20 min to complete,
and sutures may be necessary to close
NURSING IMPLICATIONS the site. A needle biopsy usually takes
AND PROCEDURE about 15 min to complete.
Sensitivity to social and cultural issues,as
PRETEST: well as concern for modesty, is impor-
Positively identify the patient using at tant in providing psychological support
least two unique identifiers before pro- before, during, and after the p rocedure.
viding care, treatment, or services. Explain that an IV line may be inserted
Patient Teaching: Inform the patient this to allow infusion of IV fluids, antibiotics,
procedure can assist in establishing a anesthetics, or sedatives.
diagnosis of musculoskeletal disease. Instruct the patient that to reduce the
Obtain a history of the patients com- risk of nausea and vomiting, solid food
plaints, including a list of known aller- and milk or milk products have been
gens, especially allergies or sensitivities restricted for at least 8 hr, and clear
to latex or anesthetics. liquids have been restricted for at least
Obtain a history of the patients 2 hr prior to general anesthesia,
immune and musculoskeletal systems, regional anesthesia, or sedation/anal-
any bleeding disorders or other symp- gesia (monitored anesthesia). The
toms, and results of previously per- American Society of Anesthesiologists
formed laboratory tests and diagnostic has fasting guidelines for risk levels
and surgical procedures. according to patient status. More infor-
Record the date of the last menstrual mation can be located at www.asahq
period and determine the possibility of .org. Patients on beta blockers before
pregnancy in perimenopausal women. the surgical procedure should be
Note any recent procedures that can instructed to take their medication as
interfere with test results. ordered during the perioperative period.
Obtain a list of the patients current med- Protocols may vary among facilities.
ications including anticoagulants, aspirin Make sure a written and informed
and other salicylates, herbs, nutritional consent has been signed prior to the
supplements, and nutraceuticals (see procedure and before administering
Appendix H online at DavisPlus). Such any medications.
products should be discontinued by INTRATEST:
medical direction for the appropriate num-
ber of days prior to a surgical procedure. Potential Complications:
Review the procedure with the patient. Bleeding (related to a bleeding disor-
Inform the patient that it may be neces- der, or the effects of natural products
sary to remove hair from the site before and medications known to act as
the procedure. Instruct the patient that blood thinners)
prophylactic antibiotics may be adminis- Ensure that the patient has complied
tered before the procedure. Address with dietary restrictions.
Ensure that anticoagulant therapy has After infiltration of the site with local
been withheld for the appropriate num- anesthetic, a cutting biopsy needle is
ber of days prior to the procedure. introduced through a small skin inci-
Number of days to withhold medica- sion and bored into the muscle. A core
tion is dependent on the type of anti- needle is introduced through the cut-
coagulant. Notify the HCP if patient ting needle, and a plug of muscle is
B anticoagulant therapy has not been removed. The needles are withdrawn,
withheld. Ensure that patients on and the specimen is placed in a pre-
beta-blocker therapy have continued servative solution. Pressure is applied
their medication regimen as ordered. to the site for 3 to 5 min, and then a
Avoid the use of equipment containing pressure dressing is applied.
latex if the patient has a history of aller- General
gic reaction to latex. Monitor the patient for complications
Have emergency equipment readily related to the procedure (e.g., allergic
available. reaction, anaphylaxis).
Have the patient void before the Place tissue samples in properly
procedure. labeled specimen container containing
Observe standard precautions, and formalin solution, and promptly trans-
follow the general guidelines in port the specimen to the laboratory for
Appendix A. Positively identify the processing and analysis.
patient, and label the appropriate spec-
imen containers with the corresponding POST-TEST:
patient demographics, initials of the
person collecting the specimen, date Inform the patient that a report of
and time of collection, and site location. the results will be made available
Assist the patient to a comfortable posi- to the requesting HCP, who will dis-
tion: a supine position (for deltoid biopsy) cuss the results with the patient.
or prone position (for gastrocnemius Instruct the patient to resume preoper-
biopsy). Instruct the patient to cooperate ative diet, as directed by the HCP.
fully and to follow directions. Direct the Monitor vital signs and neurological
patient to breathe normally and to avoid status every 15 min for 1 hr, then every
unnecessary movement during the local 2 hr for 4 hr, and then as ordered by
anesthetic and the procedure. the HCP. Monitor temperature every
Record baseline vital signs, and continue 4 hr for 24 hr. Compare with baseline
to monitor throughout the procedure. values. Notify the HCP if temperature
Protocols may vary among facilities. is elevated. Discontinue prophylactic
After the administration of general or local antibiotics within 24 hr after the con-
anesthesia, use clippers to remove hair clusion of the procedure. Protocols
from the surgical site if appropriate, may vary among facilities.
cleanse the site with an antiseptic solution, Observe/assess for delayed allergic
and drape the area with sterile towels. reactions, such as rash, urticaria,
tachycardia, hyperpnea, hypertension,
Open Biopsy palpitations, nausea, or vomiting.
Adhere to Surgical Care Improvement Observe/assess the biopsy site for
Project (SCIP) quality measures. bleeding, inflammation, or hematoma
Administer ordered prophylactic antibi- formation.
otics 1 hr before incision, and use anti- Instruct the patient in the care and
biotics that are consistent with current assessment of the site.
guidelines specific to the procedure. Instruct the patient to report any red-
After administration of general anesthesia ness, edema, bleeding, or pain at the
and surgical preparation are completed, biopsy site.
an incision is made, suspicious areas are Assess for nausea and pain.
located, and tissue samples are collected. Administer antiemetic and analgesic
Needle Biopsy medications as needed and as
Instruct the patient to take slow deep directed by the HCP.
breaths when the local anesthetic is Administer antibiotic therapy if ordered.
injected. Protect the site with sterile Remind the patient of the importance of
drapes. completing the entire course of antibiotic
therapy, even if signs and symptoms patient in significant side effects and
disappear before completion of therapy. systemic reactions associated with the
Recognize anxiety related to test prescribed medication. Encourage him
results. Discuss the implications of or her to review c orresponding
abnormal test results on the patients literature provided by a pharmacist.
lifestyle. Provide teaching and informa- Depending on the results of this proce-
tion regarding the clinical implications dure, additional testing may be performed B
of the test results, as appropriate. to evaluate or monitor progression of the
Educate the patient regarding access disease process and determine the need
to counseling services. for a change in therapy. Evaluate test
Reinforce information given by the results in relation to the patients symp-
patients HCP regarding further testing, toms and other tests performed.
treatment, or referral to another HCP.
Inform the patient of a follow-up appoint- RELATED MONOGRAPHS:
ment for removal of sutures, if indicated. Related tests include AChR, aldolase,
Answer any questions or address any ANA, antibody Jo-1, antithyroglobulin
concerns voiced by the patient or family. antibodies, CK and isoenzymes, EMG,
Instruct the patient in the use of any ENG, myoglobin, and RF.
ordered medications. Explain the Refer to the Immune and Musculo
importance of adhering to the therapy skeletal systems tables at the end of the
regimen. As appropriate, instruct the book for related tests by body system.
Biopsy, Prostate
SYNONYM/ACRONYM: N/A.
Gleason Grading
1 Simple round glands, closely packed rounded masses with well-defined
edges. Closely resemble normal prostate tissue.
2 Simple round glands, loosely packed in vague, rounded masses with
loosely packed edges. Closely resemble normal prostate tissue.
3 Discrete glands of varying size and shape interposed among
nonneoplastic cells.
4 Small, medium, or large ill-defined glands fused into cords, chains,
or ragged infiltrating masses; glands may be perforated or have a
hypernephromatoid pattern.
5 No glandular differentiation, solid sheets, cords, single cells with central
necrosis.
Gleasons score is the sum of two where the cancer is the most promi
grades assigned by the pathologist nent. The second number is the sec
during microscopic examination of ondary grade (1 to 5), which indicates
the biopsy samples. The score ranges where the cancer is next most promi
from 1 to 10 with 10 being the worst. nent. It is important to have the
The first number assigned is the pri breakdown in grading as well as the
mary grade (1 to 5), which indicates total score. For example, Patient As
breathe normally during the beginning Apply digital pressure to the biopsy
of the general anesthesia. site. If there is no bleeding after the
Cleanse the biopsy site with an anti- perineal approach, place a sterile
septic solution, use clippers to remove dressing on the biopsy site.
hair from the surgical site if appropriate, Immediately notify the HCP if there is
and drape the area with sterile towels. significant bleeding.
Record baseline vital signs, and continue Place tissue samples for standard B
to monitor throughout the procedure. biopsy examination in properly labeled
Protocols may vary among facilities. specimen containers containing for-
Transurethral Approach malin solution, place tissue samples
After administration of general anesthe- for molecular diagnostic studies in
sia, position the patient on a urological properly labeled specimen containers,
examination table with the feet in and promptly transport the specimen
stirrups. The endoscope is inserted to the laboratory for processing and
into the urethra. The tissue is excised analysis.
with a cutting loop and is placed in
formalin solution. POST-TEST:
Biopsy, Skin
SYNONYM/ACRONYM: N/A.
B
COMMON USE: To assist in diagnosing skin cancer.
The notification processes will vary aspirin and other salicylates, herbs,
among facilities. Upon receipt of the nutritional supplements, and nutraceu-
critical finding the information should ticals (see Appendix H online at
be read back to the caller to verify DavisPlus). Such products should be
discontinued by medical direction for
accuracy. Most policies require immedi the appropriate number of days prior
ate notification of the primary HCP, to a surgical procedure.
B hospitalist, or on-call HCP. Reported Review the procedure with the patient.
information includes the patients Inform the patient that it may be nec-
name, unique identifiers, critical find essary to remove hair from the site
ing, name of the person giving the before the procedure. Instruct that
report, and name of the person receiv prophylactic antibiotics may be admin-
ing the report. Documentation of noti istered before the procedure. Address
fication should be made in the medical concerns about pain and explain that
a sedative and/or analgesia will be
record with the name of the HCP noti administered before the punch biopsy
fied, time and date of notification, and to promote relaxation and reduce dis-
any orders received. Any delay in a comfort. Explain that any discomfort
timely report of a critical finding may will be minimized with local anesthetics
require completion of a notification and systemic analgesics. Inform the
form with review by Risk Management. patient the biopsy is performed under
sterile conditions by an HCP, with sup-
INTERFERING FACTORS port staff, specializing in this proce-
Failure to follow dietary restrictions dure. The procedure usually takes
about 20 min to complete, and sutures
before the procedure may cause the may be necessary to close the site.
procedure to be canceled or repeated. Sensitivity to social and cultural issues,as
well as concern for modesty, is impor-
tant in providing psychological support
NURSING IMPLICATIONS before, during, and after the p rocedure.
AND PROCEDURE Explain that an IV line may be inserted
to allow infusion of IV fluids, anesthet-
PRETEST: ics, or sedatives, depending on the
Positively identify the patient using at type of biopsy.
least two unique identifiers before Note that there are no food, fluid, or
providing care, treatment, or services. medication restrictions unless by
Patient Teaching: Inform the patient this medical direction.
procedure can assist in establishing Make sure a written and informed
a diagnosis of skin disease. consent has been signed prior to the
Obtain a history of the patients procedure and before administering
complaints, including a list of known any medications.
allergens, especially allergies or
sensitivities to latex or anesthetics. INTRATEST:
Obtain a history of the patients
immune and musculoskeletal systems, Potential Complications:
any bleeding disorders or other Bleeding (related to a bleeding disor-
symptoms, and results of previously der, or the effects of natural products
performed laboratory tests and and medications known to act as
diagnostic and surgical procedures. blood thinners) or seeding of the
Record the date of the last menstrual biopsy tract with tumor cells
period and determine the possibility of Ensure that the patient has complied with
pregnancy in perimenopausal women. dietary restrictions if ordered by the HCP.
Note any recent procedures that can Ensure that anticoagulant therapy
interfere with test results. has been withheld for the appropriate
Obtain a list of the patients current number of days prior to the
medications including anticoagulants, procedure. Number of days to
Biopsy, Thyroid
SYNONYM/ACRONYM: N/A.
This procedure is
DESCRIPTION: Thyroid biopsy is the contraindicated for
excision of a tissue sample for micro Patients with bleeding disor
scopic analysis to determine cell ders (related to the potential
morphology and the presence of for prolonged bleeding from the
tissue abnormalities. This test assists biopsy site)
in confirming a diagnosis of cancer
or determining the cause of persis INDICATIONS
tent thyroid symptoms. A biopsy Assist in the diagnosis of
specimen can be obtained by needle thyroid cancer or benign cysts
aspiration or by surgical excision. or tumors
the breath while the biopsy needle is Administer antibiotic therapy if ordered.
inserted and rotated to obtain a core of Remind the patient of the importance of
thyroid tissue. Once the needle is completing the entire course of antibiotic
removed, the patient may breathe. therapy, even if signs and symptoms
Pressure is applied to the site for 3 to disappear before completion of therapy.
5 min, then a sterile pressure dressing Recognize anxiety related to test. Discuss
is applied. the implications of the abnormal test B
results on the patients lifestyle. Provide
General teaching and information regarding the
Monitor the patient for complications clinical implications of the test results, as
related to the procedure (e.g., allergic appropriate. Educate the patient regard-
reaction, anaphylaxis). ing access to counseling services.
Place tissue samples in properly Reinforce information given by the
labeled specimen container containing patients HCP regarding further testing,
formalin solution, and promptly trans- treatment, or referral to another HCP.
port the specimen to the laboratory for Inform the patient of a follow-up appoint-
processing and analysis. ment for removal of sutures, if indicated.
Answer any questions or address any
POST-TEST: concerns voiced by the patient or family.
Inform the patient that a report of the Instruct the patient in the use of any
results will be made available to the ordered medications. Explain the
requesting HCP, who will discuss the importance of adhering to the therapy
results with the patient. regimen. As appropriate, instruct the
Instruct the patient to resume preoper- patient in significant side effects and
ative diet, as directed by the HCP. systemic reactions associated with the
Assess the patients ability to swallow prescribed medication. Encourage him
before allowing the patient to attempt or her to review corresponding litera-
liquids or solid foods. ture provided by a pharmacist.
Monitor vital signs and neurological Depending on the results of this
status every 15 min for 1 hr, then every procedure, additional testing may be
2 hr for 4 hr, and then as ordered by performed to evaluate or monitor pro-
the HCP. Monitor temperature every gression of the disease process and
4 hr for 24 hr. Monitor intake and determine the need for a change in
output at least every 8 hr. Compare therapy. Genetic testing may be con-
with baseline values. Notify the HCP ducted to search for mutations in
if temperature is elevated. Discontinue various genes associated with types
prophylactic antibiotics within 24 hr of thyroid cancer. Markers associated
after the conclusion of the procedure. with a significant incidence of thyroid
Protocols may vary among facilities. cancers include BRAF (associated with
Observe/assess for delayed allergic papillary thyroid cancer), RAS (associ-
reactions, such as rash, urticaria, ated with follicular and papillary thyroid
tachycardia, hyperpnea, hypertension, cancers), RET/PTC (associated with an
palpitations, nausea, or vomiting. increased risk of developing inherited
Observe/assess the biopsy site for medullary thyroid cancer, also known
bleeding, inflammation, or hematoma as multiple endocrine neoplasia or
formation. MEN), and PAX8/PPAR (associated
Instruct the patient in the care and with congenital hypothyroidism and
assessment of the site. thyroid dysgenesis). Evaluate test
Instruct the patient to report any red- results in relation to the patients
ness, edema, bleeding, or pain at the symptoms and other tests performed.
biopsy site.
Assess for nausea and pain. RELATED MONOGRAPHS:
Administer antiemetic and analgesic Related tests include antibodies,
medications as needed and as antithyroglobulin, calcitonin and
directed by the HCP. stimulation tests, parathyroid scan,
NORMAL FINDINGS: (Method: Disease specific) Negative findings for the organ
ism or toxin of interest; negative serology; negative PCR.
Monograph_B_260-288.indd 277
anthracis is a naturally in soil and between 1 and 7 days and may vary for testing include
gram-positive, causes disease in according to the site of entry with inhalation blood, stool, skin
aerobic, rod- humans when spores anthrax having the most rapid progression of lesions, sputum,
shaped, spore- from the bacteria are symptoms. Symptoms may also vary throat culture, body
forming ingested into the GI according to the site of entry. General fluids (sputum,
bacteria; system in contaminated symptoms include fever, malaise, and ascites, cerebrospinal
spores are a water, undercooked vomiting. Papules escalating to skin fluid (CSF), pleural
dormant form meat, or cutaneously by ulceration and eschar formation are fluid), tissue biopsy,
of the bacteria. handling meat, wool, or associated with cutaneous anthrax; bloody and contaminated
The hides from infected diarrhea is associated with gastrointestinal food (in the original
composition of animals (usually hoofed (GI) anthrax; severe respiratory distress, container if possible).
the spore animals in close contact pulmonary edema, and development of Test methods include
confers with humans); by pleural effusions are associated with culture and gram
resistance to inhalation of spores or inhalation anthrax, advancing to shock, coma, stain; polymerase
unfavorable introduction of spores nd possible death within 13 days after chain reaction (PCR);
conditions for through breaks in the inhalation. Treatment for all forms of anthrax immunochemical
growth until a skin from contaminated with antibiotics (penicillin, doxycycline, and techniques (tissue
suitable animal products; or by ciprofloxacin) is usually successful, especially samples); serology;
environment is an intentional and if administered early in the course of the enzyme-linked
attained. targeted release of disease. Untreated anthrax of any type or late immunosorbent
spores in a bioterrorist stage inhaled anthrax may be fatal. assays (ELISA).
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B
278
Infectious
Organism/ Mode of Transmission Incubation Period, Signs, Symptoms, Specimen Required
Toxin Disease and Site of Entry and Treatment and Test Method
individuals are not immunization of livestock, where appropriate. culture handling
contagious; the disease A cell free culture filtrate vaccine prepared should be performed
Monograph_B_260-288.indd 278
is not transmitted directly from a non-encapsulated strain of Bacillus in a Biosafety Level
from person to person. anthracis is available to individuals in high risk (BSL) 2 environment.
groups (military personnel and other
individuals with high exposure risk due to the
nature of their jobs). The vaccine is given in a
series of five doses over 18 months (three
primary doses and two boosters), the
effectiveness is not well established, and
there is a possibility of significant side effects.
Clostridium Botulism Clostridium botulinum is The most common type of botulism is food Specimens considered
botulinum is a found naturally in soil borne, and the incubation period is a few for testing include
gram-positive, and other types of hours to 3 days. Incubation periods for other blood, stool, vomitus,
anaerobic, environments, including types of botulism may vary according to the and contaminated
rod-shaped, the human intestine. site of entry and can extend up to 1 wk for food (in the original
spore-forming There are four forms of exposure by wound. Neuromuscular container if possible).
bacteria that botulism. The food-borne symptoms are the hallmark of how the toxin Test methods include
produces a disease occurs when the achieves its effect on the body and include mouse neutralization
potent bacteria, toxin, or spores blurred vision, difficulty swallowing, and test (to detect the
neurotoxin; are ingested into the GI muscle weakness that progresses to toxin), culture.
spores are a system in undercooked, paralysis. Irreversible binding of the toxin Specimen handling,
dormant form contaminated meat, fish, to sites where neuromuscular activity is testing, and culture
of the bacteria. vegetables, sauces, and normally initiated prevent the release of handling should be
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Infectious
Organism/ Mode of Transmission Incubation Period, Signs, Symptoms, Specimen Required
Toxin Disease and Site of Entry and Treatment and Test Method
of the spore cooking. Infants under Respiratory symptoms may also occur with
confers 1 year of age are inhalation botulism. Additional symptoms of
Monograph_B_260-288.indd 279
resistance to susceptible to a type of infant botulism include other indications of
unfavorable botulism linked to altered neuromuscular function such as poor
conditions for ingestion of spores in feeding (due to loss of muscle function
growth until a honey. Wound botulism related to sucking), constipation (due to loss
suitable occurs when the bacteria, of muscle function related to elimination),
environment is toxin, or spores are pooled oral secretions (due to loss of muscle
attained introduced through breaks function related to swallowing), and loss of
in the skin. Botulism can head control related to loss of neck muscle
also occur by inhalation of strength and function. There is no prescribed
spores from a treatment for botulism other than palliative
contaminated source or care. As the paralysis advances and organ
by an intentional and function diminishes, mechanical support is
targeted release of spores required for breathing and nutrition. A
in a bioterrorist attack. heptavalent vaccine is available for
Infected individuals are individuals identified as high risk and is
not contagious; the effective for clostridial toxin strains A through
disease is not transmitted G. An IV botulism immune globulin is
directly from person to available for infant botulism and is approved
person. There are seven for the treatment of botulism types A and B.
distinct botulism More information can be obtained from
neurotoxin types known to http://www.infantbotulism.org/.
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Infectious
280
Monograph_B_260-288.indd 280
gram-negative, of different ways: depending on the site of entry. Symptoms serum, blood, sputum/
aerobic, ingestion of the bacteria may also vary according to the site of entry; throat swab,
coccobacillus. into the GI system from the general symptoms of which include fever, bronchial/tracheal
contaminated water or chills, headache, diarrhea, weakness, muscle wash, and stool. Test
plants; cutaneously aches, and joint pain. Ingestion of the methods include
through a break in the bacteria can cause symptoms that affect the serology, gram stain,
skin when handling entire alimentary canal including mouth and culture. Specimen
infected animal products ulcers, sore throat, swollen and painful lymph handling and testing
or from the bite of an glands, intestinal pain, vomiting, and should be performed
infected insect, such as diarrhea. Inhalation of the bacteria can cause in a BSL2
a tick or deerfly; or symptoms that resemble influenza or environment; culture
breathing the bacteria pneumonia, such as chest pain from difficulty handling should be
into the lungs. Infected breathing or bloody sputum. When the performed in a BSL3
individuals are not infection is introduced cutaneously, skin environment.
contagious; the disease ulcers and swelling of the associated lymph
is not transmitted directly nodes are evident. The disease can be fatal if
from person to person. it is not treated in a timely manner. Treatment
for infection is a 2-wk course of the antibiotic
doxycycline or ciprofloxacin. Currently there
is no vaccine available in the United States;
there is ongoing research to identify an
effective vaccine.
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
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Infectious
Organism/ Mode of Transmission Incubation Period, Signs, Symptoms, Specimen Required
Toxin Disease and Site of Entry and Treatment and Test Method
Variola major is a Smallpox The smallpox virus is The incubation period for smallpox averages Specimens considered
severe and transmitted by an 12 to 14 days after which general symptoms for testing include
Monograph_B_260-288.indd 281
potentially infected human through develop to include fever, headache, and body culture, vesicular fluid,
lethal strain of the respiratory system in aches followed by the development of a rash skin scraping, and
the variola droplets that become in the mouth and on the skin; the most biopsy specimens.
DNA virus. aerosolized and are infectious period is during the first 7 to 10 Test methods include
inhaled by another days following development of the rash. In viral culture or
person in very close the next stage of the infection the rash identification from a
proximity. The smallpox becomes pustular. Eventually the pustules sample using electron
virus can also be dry up and scab formation occurs. Viable viral microscopy. Specimen
transmitted by direct particles are present in the scabs; therefore, handling, testing, and
contact with a person is considered contagious until after culture handling
contaminated fomites or the last scab has fallen off. There is no should be performed
direct contact with body specified treatment for smallpox, and the only in a BSL4
fluids from an infected prevention is by vaccination. Routine environment.
person (secretions from vaccination in the United States ended in
rashes, pustules, or 1972 after the disease was eradicated.
scabs), or by an
intentional and targeted
bioterrorist attack. The
disease can be directly
transmitted from person
to person.
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Infectious
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Monograph_B_260-288.indd 282
Marburg), by different RNA viruses. fever, headache, body aches, fatigue, serum, blood, sputum,
arenaviruses The viruses are jaundice, and vomiting; some cases progress and tissue. Test
(e.g., Lassa, transmitted to humans with bleeding, shock, and multiorgan failure. methods include viral
Machupo), cutaneously by way of a There is no prescribed treatment for VHFs, isolation, PCR, ELISA,
flaviviruses bite from an infected and patients are given supportive treatment immunohistochemistry
(including the reservoir host (e.g., for their symptoms. Care should be taken in of tissue, and
virus that rodent) or infected the selection of medications to reduce fever serology. Specimen
causes yellow arthropod vector (e.g., and pain, avoiding those medications known handling, testing, and
fever), and mosquito or tick that has to increase the risk of bleeding (e.g., culture handling for
bunyaviridae bitten an infected host). salicylates and NSAIDs). Yellow fever is the yellow fever should be
(e.g., Haantan). Some viruses (e.g., only VHF for which an effective vaccine is performed in a BSL3;
The viruses Ebola, Marburg, Lassa) available. Additional preventive measures for for dengue should be
responsible for can be directly yellow fever include avoidance of further performed in a BSL2;
viral transmitted from person exposure to mosquitos by staying indoors for others should be
hemorrhagic to person by way of during hours when they are most active and performed in a BSL4
fevers (VHFs) contact with using repellents and mosquito netting. environment.
are RNA contaminated blood or Preventive measures decrease the
viruses. body fluids. The infection opportunity for uninfected mosquitoes to feed
is significant; it can result on infected blood, which in turn decreases
in multisystem failure the spread of the disease.
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Infectious
Organism/ Mode of Transmission Incubation Period, Signs, Symptoms, Specimen Required
Toxin Disease and Site of Entry and Treatment and Test Method
and death. Because
some viruses have the
Monograph_B_260-288.indd 283
potential to cause
massive numbers of
deaths through
contagious infection they
are considered possible
weapons for use in an
intentional and targeted
bioterrorist attack.
Yersinia pestis is Plague There are three forms of The average incubation period for plague is Specimens considered
a gram- plague. The first and 1 to 6 days depending on the site of entry; for testing include
negative, probably best known is generally pneumonic plague has a shorter serum, blood, sputum/
facultatively bubonic plague. The incubation period. General symptoms include throat swab,
anaerobic, reservoir host (usually a fever, chills, enlarged lymph nodes, malaise, bronchial/tracheal
obligate rodent) carries infected septicemia, hemorrhagic skin changes, wash, and lymph
intracellular fleas; the fleas spread pneumonia (pneumonic plague), shock, and node aspirate. Test
coccobacillus. the disease cutaneously death. Early identification and administration methods include
to humans through a of antibiotics (tetracycline or fluoroquinolone) serology, gram stain,
bite. The bacteria for 7 days, with supportive care is the most and culture. Specimen
multiply in the lymph effective treatment for plague. Currently there and culture handling
node closest to the site is no FDA-approved vaccine available. should be performed
of the flea bite. in a BSL2
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Monograph_B_260-288.indd 284
or by the bite of an
infected animal.
Pneumonic plague is the
most lethal form of
plague. It occurs when
the infection from either
untreated bubonic or
septicemic plague
spreads to the lungs.
Pneumonic is the only
form of plague that can
be transmitted person
to person from inhalation
of aerosolized droplets
of contaminated fluid,
direct contact with
contaminated fomites
(for short periods of
time), or by an intentional
and targeted bioterrorist
attack.
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
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Infectious
Organism/ Mode of Transmission Incubation Period, Signs, Symptoms, Specimen Required
Toxin Disease and Site of Entry and Treatment and Test Method
Category B
Brucella abortus, Brucellosis Infection occurs after The average incubation period for brucellosis Specimens considered
Monograph_B_260-288.indd 285
B. suis, B. ingestion into the GI infection is 1 to 2 mo. General symptoms for testing include
melitensis, or system from infected include fever, chills, headache, night sweats, serum, blood, bone
B. canis; the meats and contaminated back pain, joint pain, and malaise. The marrow, spleen or
species are milk products (especially disease is systemic, affecting multiple organs liver tissue, sputum,
gram-negative, goats milk), direct and body systems. Brucellosis can be and food. Test
aerobic, puncture of the skin (by effectively treated with antibiotics (e.g., methods include
coccobacilli butchers and farmers), or doxycycline, tetracycline, streptomycin, serology, gram stain,
by inhalation. It is not a bactrim, rifampin, ciprofloxicin, or gentamicin). culture, and
contagious disease that Currently there is no vaccine available for use immunofluorescence.
is transmitted from in humans. Specimen handling
person to person. should be performed
in a BSL2
environment; culture
handling should be
performed in a BSL3
environment.
Ricinus Ricin poisoning. Ricin poisoning occurs by Symptoms of ricin poisoning vary based on the Environmental samples
communis is The toxin is ingestion into the GI site of entry and concentration of the dose. If can be tested for the
the name for released after system or by inhalation the toxin is ingested, GI symptoms such as presence of ricin by
the castor oil ingestion of into the respiratory nausea, pain, and vomiting appear in 6 to time-resolved
plant. The castor beans. system. It is not a 12 hr; if the toxin is inhaled, respiratory fluorescence
Bioterrorism and Public Health Safety Concerns
plants seeds It can also be contagious disease that symptoms such as difficulty breathing, immunoassay and
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Monograph_B_260-288.indd 286
mostly of the waste product the likelihood of rapidly escalate toward organ failure. Ricin performed in a BSL2
lipid ricinolein generated in accidental poisoning affects the body at the cellular level by or BSL3 environment
and smaller the normal is very low. The preventing the production of proteins, an depending on the
amounts of production of manufactured toxin can essential process for every living cell, tissue, possibility of
ricin, a castor oil. The be released as a powder and organ. Presently there are no methods aerosolization and
powerful toxin. manufactured into the air or dissolved available for the detection of ricin in biological concentration of toxin
toxin can then in water supplies. Very fluids. Diagnosis of ricin poisoning is made submitted for testing.
be used in an small amounts could using general laboratory tests for evidence of
intentional sicken and kill large the effects of the toxin on the body and is
and targeted numbers of people and arrived at within the context of high suspicion
bioterrorist for this reason it is of exposure. Lab results of interest might
attack. considered as a potential include elevated liver function results,
weapon for use in an elevated renal function results, abnormal
intentional and targeted urinalysis findings such as blood in the urine,
bioterrorist attack. and moderate to very increased WBC count
(two to five times normal levels).
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Bioterrorism and Public Health Safety Concerns 287
NORMAL FINDINGS: (Method: Enzyme immunoassay for NMP22 and bladder tumor
antigen [BTA], fluorescence in situ hybridization [FISH] for cytogenic marker)
NMP22: Negative: Less than 6 units/mL, borderline: 6 to 10 units/mL, positive:
Greater than 10 units/mL
BTA: Negative
Cytogenic Marker: Negative
Timely notification of a critical find- Patient Teaching: Inform the patient this
ing for lab or diagnostic studies is a role procedure can assist in establishing a
expectation of the professional nurse. diagnosis of bladder disease.
The notification processes will vary Obtain a history of the patients
complaints, including a list of known
among facilities. Upon receipt of the allergens.
critical finding the information should Obtain a history of the patients genito-
B be read back to the caller to verify accu- urinary system, symptoms, and results
racy. Most policies require immediate of previously performed laboratory
notification of the primary HCP, hospi- tests and diagnostic and surgical
talist, or on-call HCP. Reported informa- procedures.
tion includes the patients name, unique Note any recent procedures that can
identifiers, critical finding, name of the interfere with test results.
person giving the report, and name of Obtain a list of the patients current
medications including herbs, nutritional
the person receiving the report. supplements, and nutraceuticals
Documentation of notification should (see Appendix H online at DavisPlus).
be made in the medical record with the Review the procedure with the patient.
name of the HCP notified, time and date Address concerns about pain and
of notification, and any orders received. explain that there should be no dis-
Any delay in a timely report of a critical comfort during the procedure. Inform
finding may require completion of a the patient that specimen collection
notification form with review by Risk takes approximately 5 min, depending
Management. on the cooperation and ability of the
patient.
Sensitivity to social and cultural issues,
INTERFERING FACTORS as well as concern for modesty, is
NMP22: Any condition that results important in providing psychological
in inflammation of the bladder or support before, during, and after the
urinary tract may cause falsely ele- procedure.
vated values. Note that there are no food, fluid, or
BTA: Recent surgery, biopsy, or medication restrictions unless by
other trauma to the bladder or uri- medical direction.
nary tract may cause falsely elevat- INTRATEST:
ed values. Bacterial overgrowth
Potential Complications: N/A
from active urinary tract infection,
renal or bladder calculi, gross con- Instruct the patient to cooperate fully
tamination from blood, and positive and to follow directions.
Observe standard precautions, and
leukocyte dipstick may also cause follow the general guidelines in
false-positive results. Appendix A. Positively identify the
Cytogenic marker: Incorrect fixa- patient, and label the appropriate
tive, gross contamination from blood, specimen containers with the corre-
bacterial overgrowth from active uri- sponding patient demographics, initials
nary tract infection, inadequate num- of the person collecting the specimen,
ber of bladder cells in specimen. date and time of collection.
Obtain urine specimen in a clean plas-
tic collection container. Promptly trans-
port the specimen to the laboratory for
NURSING IMPLICATIONS processing and analysis.
AND PROCEDURE
POST-TEST:
PRETEST: Inform the patient that a report of the
Positively identify the patient using at results will be made available to the
least two unique identifiers before pro- requesting HCP, who will discuss the
viding care, treatment, or services. results with the patient.
Bleeding Time
SYNONYM/ACRONYM: Mielke bleeding time, Simplate bleeding time, template
bleeding time, Surgicutt bleeding time, Ivy bleeding time.
Blood Gases
SYNONYM/ACRONYM: Arterial blood gases (ABGs), venous blood gases, capillary
blood gases, cord blood gases. B
SPECIMEN: Whole blood. Specimen volume and collection container may vary
with collection method. See Intratest section for specific collection instruc-
tions. Specimen should be tightly capped and transported in an ice slurry.
NORMAL FINDINGS: (Method: Selective electrodes for pH, Pco2 and Po2)
Monograph_B_289-307.indd 294
SI Units SI Units SI Units
(Conventional (Conventional (Conventional
Pco2 Arterial Units 0.133) Venous Units 0.133) Capillary Units 0.133)
Scalp 4050 mm Hg 5.36.6 kPa
Birth, cord, full term 3266 mm Hg 4.38.8 kPa 2749 mm Hg 3.66.5 kPa
Newbornadult 3545 mm Hg 4.76 kPa 4151 mm Hg 5.46.8 kPa 2641 mm Hg 3.55.4 kPa
17/11/14 12:14 PM
Blood Gases 295
Arterial Blood
Gas Parameter Less Than Greater Than
Adult/child pH 7.2 7.6
Adult/child HCO3 10 mmol/L 40 mmol/L
L Adult/child Pco2 20 mm Hg (SI: 2.7 kPa) 67 mm Hg (SI: 8.9 kPa)
Adult/child Po2 45 mm Hg (SI: 6 kPa)
Newborns Po2 37 mm Hg (SI: 4.9 kPa) 92 mm Hg (SI: 12.2 kPa)
Note that there are no food, fluid, specimen in a protective plastic bag.
or medication restrictions unless by Promptly transport the specimen to
medical direction. the laboratory for p
rocessing and
Prepare an ice slurry in a cup or plas- analysis.
tic bag to have ready for immediate
transport of the specimen to the Venous
laboratory. Central venous blood is collected in a
heparinized syringe. B
Venous blood is collected percutane-
INTRATEST:
ously by venipuncture in a 5-mL
Potential Complications: N/A green-top (heparin) tube (for adult
Bleeding, pain, hematoma patients) or a heparinized Microtainer
Avoid the use of equipment containing (for pediatric patients). The vacuum
latex if the patient has a history of collection tube must be removed from
allergic reaction to latex. the needle before the needle is
Instruct the patient to cooperate fully removed from the patients arm. Apply
and to follow directions. Direct the a pressure dressing over the puncture
patient to breathe normally and to site. Samples should be mixed by
avoid unnecessary movement. gently rolling the syringe to ensure
Observe standard precautions, and proper mixing of the heparin with the
follow the general guidelines in sample, which prevents the formation
Appendix A. Positively identify the of small clots leading to rejection of
patient, and label the appropriate the sample. The tightly capped sample
specimen container with the corre- should be placed in an ice slurry
sponding patient demographics, initials immediately after collection.
of the person collecting the specimen, Information on the specimen label
date, and time of collection. Perform should be protected from water in
an arterial puncture. the ice slurry by first placing the
specimen in a protective plastic bag.
Arterial Promptly transport the specimen to
Perform an arterial puncture and the laboratory for processing and
collect the specimen in an air-free analysis.
heparinized syringe. There is no
demonstrable difference in results Capillary
between samples collected in plastic Perform a capillary puncture and
syringes and samples collected in collect the specimen in two 250-L
glass syringes. It is very important heparinized capillaries (scalp or heel
that no room air be introduced into for neonatal patients) or a heparinized
the collection container because the Microtainer (for pediatric patients).
gases in the room and in the sample Observe standard precautions and
will begin equilibrating immediately. follow the general guidelines in
The end of the syringe must be Appendix A. The capillary tubes
stoppered immediately after the should be filled as much as possible
needle is withdrawn and removed. and capped on both ends. Some
Apply a pressure dressing over the hospitals recommend that metal
puncture site. Samples should be fleas be added to the capillary tube
mixed by gently rolling the syringe to before the ends are capped. During
ensure proper mixing of the heparin transport, a magnet can be moved up
with the sample, which prevents the and down the outside of the capillary
formation of small clots leading to tube to facilitate mixing and prevent
rejection of the sample. The tightly the formation of clots, which would
capped sample should be placed in cause rejection of the sample. It is
an ice slurry immediately after collec- important to inform the laboratory or
tion. Information on the specimen respiratory therapy staff of the number
label should be protected from water of fleas used so the fleas can be
in the ice slurry by first placing the accounted for and removed before
COMMON USE: To identify ABO blood group and Rh type, typically for transfu-
sion purposes.
Determine cardiomyopathy
MUGA scan can evaluate the Determine drug cardiotoxicity to
effectiveness of the drug on ven- stop therapy before development
tricular function. Heart shunt of congestive heart failure
imaging is done in conjunction Determine ischemic coronary
with a resting MUGA scan to artery disease
B obtain ejection fraction and assess Differentiate between chronic
regional wall motion. First-pass obstructive pulmonary disease and
cardiac flow study is done to left ventricular failure
study heart chamber disorders, Evaluate ventricular size, function,
including left-to-right and right-to- and wall motion after an acute epi-
left shunts, determine both right sode or in chronic heart disease
and left ventricular ejection frac- Quantitate cardiac output by calcu-
tions, and assess blood flow lating global or regional ejection
through the great vessels. The fraction
study uses a jugular or antecubital
vein injection of the radionuclide. POTENTIAL DIAGNOSIS
Normal findings in
This procedure is Normal wall motion, ejection frac-
contraindicated for tion (55% to 65%), coronary blood
Patients who are pregnant or flow, ventricular size and function,
suspected of being pregnant, and symmetry in contractions of
unless the potential benefits of a the left ventricle
procedure using radiation far out-
Abnormal findings in
weigh the risk of radiation expo-
Abnormal wall motion (akinesia or
sure to the fetus and mother.
dyskinesia)
Patients with anginal pain at
L Cardiac hypertrophy
rest or in patients with severe
Cardiac ischemia
atherosclerotic coronary vessels;
Enlarged left ventricle
dipyridamole testing is not per-
Infarcted areas are akinetic
formed in these circumstances.
Ischemic areas are hypokinetic
Chemical stress with vasodila-
Myocardial infarction
tors in patients having asthma
(because bronchospasm can CRITICAL FINDINGS
occur).
Myocardial infarction
INDICATIONS It is essential that critical findings be
Aid in the diagnosis of myocardial communicated immediately to the
infarction requesting health-care provider
Aid in the diagnosis of true or false (HCP). A listing of these findings var-
ventricular aneurysms ies among facilities.
Aid in the diagnosis of valvular Timely notification of a critical
heart disease and determining the finding for lab or diagnostic studies is
optimal time for valve replacement a role expectation of the professional
surgery nurse. The notification processes will
Detect left-to-right shunts and vary among facilities. Upon receipt of
determine pulmonary-to-systemic the critical finding the information
blood flow ratios, especially in should be read back to the caller to
children verify accuracy. Most policies require
immediate notification of the primary sary if settings are not adjusted for
HCP, hospitalist, or on-call HCP. their small size. Pediatric Imaging
Reported information includes the Information on the Image Gently
patients name, unique identifiers, Campaign can be found at the
critical finding, name of the person Alliance for Radiation Safety in
giving the report, and name of the Pediatric Imaging (www.pedrad
person receiving the report. .org/associations/5364/ig/). B
Documentation of notification should Risks associated with radiation over-
be made in the medical record with exposure can result from frequent
the name of the HCP notified, time x-ray or radionuclide procedures.
and date of notification, and any Personnel working in the examina-
orders received. Any delay in a timely tion area should wear badges to
report of a critical finding may require record their level of radiation.
completion of a notification form
with review by Risk Management.
INTERFERING FACTORS: N/A
NURSING IMPLICATIONS
Factors that may impair clear AND PROCEDURE
imaging
Inability of the patient to cooperate PRETEST:
or remain still during the proce- Positively identify the patient using at
dure because of age, significant least two unique identifiers before pro-
pain, or mental status. viding care, treatment, or services.
Metallic objects within the exami- Patient Teaching: Inform the patient this
procedure can assist in assessing the
nation field (e.g., jewelry, body
pumping action of the heart.
rings), which may inhibit organ Obtain a history of the patients com-
visualization and can produce plaints or clinical symptoms, including
unclear images. a list of known allergens, especially
Other considerations allergies or sensitivities to latex, anes-
thetics, sedatives, radionuclides, or
Conditions such as chest wall trau-
medications used in the procedure.
ma, cardiac trauma, angina that is Obtain a history of the patients cardio-
difficult to control, significant cardi- vascular system, symptoms, and
ac arrhythmias, or a recent cardio- results of previously performed labora-
version procedure may affect test tory tests and diagnostic and surgical
results. procedures.
Atrial fibrillation and extrasystoles Note any recent procedures that can
invalidate the procedure. interfere with test results, including
Suboptimal cardiac stress or patient examinations using iodine-based
contrast medium.
exhaustion, preventing maximum
Record the date of the last menstrual
heart rate testing, will affect results period and determine the possibility of
when the procedure is done in pregnancy in perimenopausal women.
conjunction with exercise testing. Obtain a list of the patients current
Consultation with an HCP should medications including herbs, nutritional
occur before the procedure for supplements, and nutraceuticals
radiation safety concerns regarding (see Appendix H online at DavisPlus).
younger patients or patients who Review the procedure with the patient.
are lactating. Pediatric & Geriatric Address concerns about pain related
to the procedure and explain that
Imaging Children and geriatric
some pain may be experienced during
patients are at risk for receiving a the test, or there may be moments of
higher radiation dose than neces-
discomfort. Reassure the patient that into the tissue following needle
the radionuclide poses no radioactive insertion), infection (that might occur
hazard and rarely produces side if bacteria from the skin surface is
effects. Inform the patient that the introduced at the puncture site), or
procedure is performed in a nuclear nerve injury (that might occur if the
medicine department by an HCP needle strikes a nerve).
B specializing in this procedure and takes Observe standard precautions, and fol-
approximately 60 min. low the general guidelines in Appendix
Sensitivity to social and cultural issues, A. Positively identify the patient.
as well as concern for modesty, is Ensure that the patient has complied
important in providing psychological with dietary and medication restrictions.
support before, during, and after the Ensure that the patient has removed
procedure. external metallic objects from the area
Explain that an IV line may be inserted to be examined prior to the procedure.
to allow infusion of IV fluids such as Administer ordered prophylactic ste-
normal saline, anesthetics, sedatives, roids or antihistamines before the pro-
radionuclides, medications used in the cedure if the patient has a history of
procedure, or emergency medications. allergic reactions to any substance or
Instruct the patient to wear walking drug.
shoes for the treadmill or bicycle exer- Avoid the use of equipment containing
cise. Emphasize to the patient the latex if the patient has a history of
importance of reporting fatigue, pain, allergic reaction to latex.
or shortness of breath. Have emergency equipment readily
Instruct the patient to remove external available.
metallic objects from the area to be Record baseline vital signs and assess
examined prior to the procedure. neurological status. Protocols may vary
Instruct the patient to fast and restrict among facilities.
fluids for 4 hr prior to the procedure. Establish an IV fluid line for the injec-
Instruct the patient to withhold medica- tion of saline, anesthetics, sedatives,
tions for 24 hr before the test as radionuclides, or emergency
ordered by the HCP. Protocols may medications.
L Instruct the patient to cooperate fully
vary among facilities.
Make sure a written and informed and to follow directions. Instruct the
consent has been signed prior to the patient to remain still throughout the
procedure and before administering procedure because movement
any medications. produces unreliable results.
The patient is placed at rest in the
INTRATEST: supine position on the scanning table.
Expose the chest and attach the ECG
Potential Complications:
leads. Record baseline readings.
Although it is rare, there is the possibil- IV radionuclide is administered and the
ity of allergic reaction to the radionu- heart is scanned with images taken
clide. Have emergency equipment and in various positions over the entire
medications readily available. If the cardiac cycle.
patient has a history of allergic reac- When the scan is to be done under
tions to any substance or drug, admin- exercise conditions, the patient is
ister ordered prophylactic steroids or assisted onto the treadmill or bicycle
antihistamines before the procedure. ergometer and is exercised to a calcu-
Establishing an IV site and injection of lated 80% to 85% of the maximum
radionuclides is an invasive procedure. heart rate as determined by the proto-
Complications are rare but do include col selected. Images are done at each
bleeding from the puncture site (related exercise level and begun immediately
to a bleeding disorder, or the effects after injection of the radionuclide.
of natural products and medications If nitroglycerin is given, an HCP
known to act as blood thinners), assessing the baseline MUGA scan
hematoma (related to blood leakage injects the medication. Additional
scans are repeated until blood Instruct the patient in the care and
pressure reaches the desired level. assessment of the injection site.
Patients who cannot exercise are given If a woman who is breastfeeding must
dipyridamole before the radionuclide is have a nuclear scan, she should not
injected. breastfeed the infant until the radionu-
Monitor the patient for complications clide has been eliminated. This could
related to the procedure (e.g., allergic take as long as 3 days. She should B
reaction, anaphylaxis, bronchospasm). be instructed to express the milk and
Remove the needle or catheter and discard it during the 3-day period to
apply a pressure dressing over the prevent cessation of milk production.
puncture site. Instruct the patient to immediately flush
Observe/assess the needle/catheter the toilet and to meticulously wash
site for bleeding, hematoma formation, hands with soap and water after each
or inflammation. voiding for 24 hr after the procedure.
Instruct all caregivers to wear gloves
POST-TEST: when discarding urine for 24 hr after
Inform the patient that a report of the the procedure. Wash gloved hands
results will be made available to the with soap and water before removing
requesting HCP, who will discuss the gloves. Then wash hands after the
results with the patient. gloves are removed.
Unless contraindicated, advise patient Nutritional Considerations: Abnormal
to drink increased amounts of fluids for findings may be associated with cardio-
24 to 48 hr to eliminate the radionu- vascular disease. Nutritional therapy is
clide from the body. Inform the patient recommended for the patient identified
that radionuclide is eliminated from the to be at risk for developing CAD or for
body within 6 to 24 hr. individuals who have specific risk fac-
No other radionuclide tests should be tors and/or existing medical conditions
scheduled for 24 to 48 hr after this (e.g., elevated low-density lipoprotein
procedure. [LDL] cholesterol levels, other lipid dis-
Evaluate the patients vital signs. orders, insulin-dependent diabetes,
Monitor vital signs and neurological insulin resistance, or metabolic syn-
status every 15 min for 1 hr, then every drome). Other changeable risk factors
2 hr for 4 hr, and then as ordered by warranting patient education include
HCP. Monitor intake and output at strategies to encourage patients, espe-
least every 8 hr. Compare with baseline cially those who are overweight and
values. Protocols may vary among with high blood pressure, to safely
facilities. decrease sodium intake, achieve a nor-
Instruct the patient to resume usual mal weight, ensure regular participation
dietary, medication, and activity, as in moderate aerobic physical activity
directed by the HCP. three to four times per week, eliminate
Observe for delayed allergic reactions, tobacco use, and adhere to a heart-
such as rash, urticaria, tachycardia, healthy diet. If triglycerides are also ele-
hyperpnea, hypertension, palpitations, vated, the patient should be advised to
nausea, or vomiting. eliminate or reduce alcohol. The 2013
Instruct the patient to immediately Guideline on Lifestyle Management to
report symptoms such as fast heart Reduce Cardiovascular Risk published
rate, difficulty breathing, skin rash, by the American College of Cardiology
itching, chest pain, persistent right (ACC) and American Heart Association
shoulder pain, or abdominal pain. (AHA) in conjunction with the National
Immediately report symptoms to the Heart, Lung, and Blood Institute
appropriate HCP. (NHLBI) recommends a
Monitor ECG tracings and compare Mediterranean-style diet rather than a
with baseline readings until stable. low-fat diet. The new guideline empha-
Observe/assess the needle/catheter sizes inclusion of vegetables, whole
site for bleeding, hematoma formation, grains, fruits, low-fat dairy, nuts,
or inflammation. legumes, and nontropical vegetable oils
compared to a known standard. This test is the most expensive and involves
the highest radiation dose of all techniques.
Radiographic absorptiometry (RA): A standard x-ray of the hand. Results
are compared to a known standard.
Ultrasound densitometry: Studies bone mineral content in peripheral den-
sitometry sites such as the heel or wrist. It is not as precise as x-ray techniques
but is less expensive than other techniques. B
CONTRAST: None.
risk for receiving a higher radia- Patient Teaching: Inform the patient this
tion dose than necessary if procedure can assist in assessing
settings are not adjusted for their bone density.
small size. Pediatric Imaging Obtain a history of the patients com-
plaints, including a list of known aller-
Information on the Image Gently gens, especially allergies or sensitivities
Campaign can be found at the to latex, iodine, seafood, contrast
Alliance for Radiation Safety in B
medium, anesthetics, or dyes.
Pediatric Imaging (www.pedrad.org/ Obtain a history of the patients mus-
associations/5364/ig/). culoskeletal system, symptoms, and
Risks associated with radiation over- results of previously performed labora-
exposure can result from frequent tory tests and diagnostic and surgical
x-ray or radionuclide procedures. procedures
Personnel in the room with the Note any recent procedures that can
interfere with test results, including
patient should stand behind a shield, examinations using iodine-based
or leave the area while the examina- contrast medium.
tion is being done. Personnel work- Record the date of the last menstrual
ing in the examination area should period and determine the possibility of
wear badges to record their radia- pregnancy in perimenopausal women.
tion exposure level. Obtain a list of the patients current
medications, including herbs, nutri-
tional supplements, and nutraceuticals
Other considerations as a result (see Appendix H online at DavisPlus).
of altered BMD, not the BMD Review the procedure with the patient.
testing process Address concerns about pain related
Vertebral fractures may cause com- to the procedure and explain that
plications including back pain, some pain may be experienced during
height loss, and kyphosis. the test, or there may be moments of
Limited activity, including difficulty discomfort. Inform the patient that the
bending and reaching, may result. procedure is usually performed in a
radiology department by a HCP, and
Patient may have poor self-esteem staff, specializing in this procedure and
resulting from the cosmetic effects takes approximately 60 min.
of kyphosis. Instruct the patient to remove jewelry
Potential restricted lung function and other metallic objects from the
may result from fractures. area to be examined.
Fractures may alter abdominal anat- Note that there are no food, fluid, or
omy, resulting in constipation, pain, medication restrictions unless by
distention, and diminished appetite. medical direction.
Potential for a restricted lifestyle Sensitivity to social and cultural issues,
as well as concern for modesty, is
may result in depression and other important in providing psychological
psychological symptoms. support before, during, and after the
Possible increased dependency on procedure.
family for basic care may occur.
INTRATEST:
Potential Complications: N/A
NURSING IMPLICATIONS Observe standard precautions, and fol-
AND PROCEDURE low the general guidelines in Appendix
A. Positively identify the patient.
PRETEST: Ensure that the patient has removed
Positively identify the patient using at all external metallic objects from the
least two unique identifiers before area to be examined prior to the
providing care, treatment, or services. procedure.
Instruct the patient to void prior to the Provide contact information, if desired,
procedure and to change into the for the National Osteoporosis
gown, robe, and foot coverings pro- Foundation (www.nof.org).
vided. Patients clothing may not need Reinforce information given by the
to be removed unless it contains metal patients HCP regarding further test-
that would interfere with the test. ing, treatment, or referral to another
B Avoid the use of equipment containing HCP. Answer any questions or
latex if the patient has a history of aller- address any concerns voiced by the
gic reaction to latex. patient or family.
Instruct the patient to cooperate fully Depending on the results of this proce-
and to follow directions. Instruct the dure, additional testing may be needed
patient to remain still throughout the to evaluate or monitor progression of
procedure because movement the disease process and determine the
produces unreliable results. need for a change in therapy. Evaluate
Place the patient in a supine position test results in relation to the patients
on a flat table with foam wedges, symptoms, previous BMD values, and
which help maintain position and other tests performed.
immobilization.
RELATED MONOGRAPHS:
POST-TEST: Related tests include ALP, antibod-
Inform the patient that a report of the ies anticyclic citrullinated peptide,
results will be made available to the ANA, arthrogram, arthroscopy,
requesting HCP, who will discuss the biopsy bone, bone scan, calcium,
results with the patient. CRP, collagen cross-linked telopep-
Recognize anxiety related to test tides, CT pelvis, CT spine, ESR, MRI
results, and be supportive of perceived musculoskeletal, MRI pelvis, osteo-
loss of independent function. Discuss calcin, PTH, phosphorus, radiogra-
the implications of abnormal test phy bone, RF, synovial fluid analysis,
results on the patients lifestyle. and vitamin D.
Provide teaching and information Refer to the Musculoskeletal System
L regarding the clinical implications of table at the end of the book for related
the test results, as appropriate. tests by body system.
Bone Scan
SYNONYM/ACRONYM: Bone imaging, radionuclide bone scan, bone scintigraphy,
whole-body bone scan.
Record the date of the last menstrual Make sure a written and informed
period and determine the possibility of consent has been signed prior to the
pregnancy in perimenopausal women. procedure and before administering
Obtain a list of the patients current any medications.
medications, including herbs, nutri-
tional supplements, and nutraceuticals INTRATEST:
(see Appendix H online at DavisPlus).
Potential Complications:
B
Review the procedure with the patient.
Address concerns about pain related Although it is rare, there is the possibil-
to the procedure and explain to the ity of allergic reaction to the radionu-
patient that some pain may be experi- clide. Have emergency equipment and
enced during the test, or there may be medications readily available. If the
moments of discomfort. Reassure the patient has a history of allergic reac-
patient that the radionuclide poses no tions to any substance or drug, admin-
radioactive hazard and rarely produces ister ordered prophylactic steroids or
side effects. Inform the patient the antihistamines before the procedure.
procedure is performed in a nuclear Establishing an IV site and injection of
medicine department by an HCP spe- radionuclides is an invasive procedure.
cializing in this procedure, and takes Complications are rare but do include
approximately 30 to 60 min. Pediatric bleeding from the puncture site
Considerations Preparing children for (related to a bleeding disorder, or the
a bone scan depends on the age of effects of natural products and
the child. Encourage parents to be medications known to act as blood
truthful about what the child may expe- thinners), hematoma (related to blood
rience during the procedure (e.g., there leakage into the tissue following
may be a pinch or minor discomfort needle insertion), infection (that might
when the IV needle is inserted) and to occur if bacteria from the skin
use words that they know their child surface is introduced at the puncture
will understand. Toddlers and pre- site), or nerve injury (that might occur
school-age children have a very short if the needle strikes a nerve).
attention span, so the best time to talk Observe standard precautions, and fol-
about the test is right before the pro- low the general guidelines in Appendix A.
cedure. The child should be assured Positively identify the patient.
that he or she will be allowed to bring Ensure that the patient has removed all
a favorite comfort item into the exami- external metallic objects from the area
nation room, and if appropriate, that a to be examined prior to the procedure.
parent will be with the child during the Administer ordered prophylactic steroids
procedure. Explain the importance of or antihistamines before the procedure if
remaining still while the images are the patient has a history of allergic reac-
taken. tions to any substance or drug.
Sensitivity to social and cultural issues, Avoid the use of equipment containing
as well as concern for modesty, is latex if the patient has a history of aller-
important in providing psychological gic reaction to latex.
support before, during, and after the Have emergency equipment readily
procedure. available.
Explain that an IV line may be inserted Instruct the patient to void prior to the
to allow infusion of IV fluids such as procedure as a full bladder may
normal saline, anesthetics, sedatives, obscure pelvic bones, and to change
radionuclides, medications used in the into the gown, robe, and foot cover-
procedure, or emergency medications. ings provided.
Note that there are no food, fluid, or Record baseline vital signs and assess
medication restrictions unless by neurological status. Protocols may vary
medical direction. among facilities.
Instruct the patient to remove jewelry Establish an IV fluid line for the injection
and other metallic objects in the area of saline, anesthetics, sedatives, radio-
to be examined. nuclides, or emergency medications.
Instruct the patient to cooperate fully breastfeed the infant until the
and to follow directions. Instruct the radionuclide has been eliminated. This
patient to remain still throughout the could take as long as 3 days. She
procedure because movement should be instructed to express the
produces unreliable results. milk and discard it during the 3-day
Administer sedative to a child or to an period to prevent cessation of milk
B uncooperative adult, as ordered. production.
Place the patient in a supine Instruct the patient to immediately
position on a flat table with foam flush the toilet and to meticulously
wedges to help maintain position and wash hands with soap and water after
immobilization. each voiding for 24 hr after the
IV radionuclide is administered and procedure.
images are taken immediately to Instruct all caregivers to wear gloves
assess blood flow to the bones. when discarding urine for 24 hr after
After a delay of 2 to 3 hr to allow the the procedure. Wash gloved hands
radionuclide to be taken up by the with soap and water before removing
bones, multiple images are obtained gloves. Then wash ungloved hands
over the complete skeleton. Delayed after the gloves are removed.
views may be taken up to 24 hr after Recognize anxiety related to test
the injection. results, and be supportive of per-
The needle or catheter is removed, ceived loss of independent function.
and a pressure dressing is applied over Discuss the implications of abnormal
the puncture site. test results on the patients lifestyle.
Observe/assess the needle/catheter Provide teaching and information
insertion site for bleeding, inflamma- regarding the clinical implications of
tion, or hematoma formation. the test results, as appropriate.
The patient may be imaged by Provide contact information, if
single-photon emission computed desired, for the American College
tomography (SPECT) techniques to of Rheumatology (www.rheumatology
further clarify areas of suspicious .org) or for the Arthritis Foundation
L radionuclide localization. (www.arthritis.org).
Reinforce information given by the
POST-TEST: patients HCP regarding further testing,
Inform the patient that a report of the treatment, or referral to another HCP.
results will be made available to the Answer any questions or address any
requesting HCP, who will discuss the concerns voiced by the patient or family.
results with the patient. Depending on the results of this proce-
Unless contraindicated, advise patient dure, additional testing may be needed
to drink increased amounts of fluids for to evaluate or monitor progression of
24 to 48 hr to eliminate the radionu- the disease process and determine the
clide from the body. Inform the patient need for a change in therapy. Evaluate
that radionuclide is eliminated from the test results in relation to the patients
body within 6 to 24 hr. symptoms and other tests performed.
No other radionuclide tests should be
scheduled for 24 to 48 hr after this RELATED MONOGRAPHS:
procedure. Related tests include antibodies, anti-
Instruct the patient to resume medica- cyclic citrullinated peptide, ANA,
tion and activity as directed by the arthroscopy, BMD, calcium, CRP, colla-
HCP. gen cross-linked telopeptide, CT pelvis,
Observe/assess the needle/catheter CT spine, culture blood, ESR, MRI
insertion site for bleeding, inflamma- musculoskeletal, MRI pelvis, osteocal-
tion, or hematoma formation. cin, radiography bone, RF, synovial fluid
Instruct the patient in the care and analysis, and white blood cell scan.
assessment of the injection site. Refer to the Musculoskeletal System
If a woman who is breastfeeding must table at the end of the book for related
have a nuclear scan, she should not tests by body system.
Bronchoscopy
SYNONYM/ACRONYM: Flexible bronchoscopy.
B
COMMON USE: To visualize and assess bronchial structure for disease such as
cancer and infection.
CONTRAST: None.
Obtain a list of the patients current guidelines for risk levels according to
medications including anticoagulants, patient status. More information can be
aspirin and other salicylates, herbs, located at www.asahq.org. Patients on
nutritional supplements, and nutraceu- beta blockers before the surgical pro-
ticals (see Appendix H online at cedure should be instructed to take
DavisPlus). Such products should be their medication as ordered during the
discontinued by medical direction for perioperative period. Protocols may B
the appropriate number of days prior vary among facilities.
to a surgical procedure. Note the last Instruct the patient to avoid taking anti-
time and dose of medication taken. coagulant medication or to reduce
Review the procedure with the patient. dosage as ordered prior to the proce-
Instruct that prophylactic antibiotics dure. Number of days to withhold
may be administered prior to the pro- medication is dependent on the type of
cedure. Address concerns about pain anticoagulant. Protocols may vary
related to the procedure and explain among facilities.
that some pain may be experienced Make sure a written and informed
during the test, and there may be consent has been signed prior to the
moments of discomfort. Explain that a procedure and before administering
sedative and/or analgesia may be any medications.
administered to promote relaxation and
reduce discomfort prior to the bron- INTRATEST:
choscopy. Atropine is usually given
before bronchoscopy examinations to Potential Complications:
reduce bronchial secretions and pre- Complications from the procedure are
vent vagally induced bradycardia. rare but may include infection (related to
Meperidine (Demerol) or morphine may the use of an endoscope), hypoxemia,
be given as a sedative. Lidocaine is pneumothorax, or bleeding, (related to a
sprayed in the patients throat to bleeding disorder, or the effects of nat-
reduce discomfort caused by the pres- ural products and medications known
ence of the tube. Inform the patient to act as blood thinners).
that the procedure is performed in a Establishing an IV site is an invasive
gastrointestinal laboratory or radiology procedure. Complications are rare but
department, under sterile conditions, do include risk for bleeding from the
by a health-care provider (HCP) spe- puncture site (related to a bleeding
cializing in this procedure. The proce- disorder, or the effects of natural
dure usually takes about 30 to 60 min products and medications known to
to complete. act as blood thinners), hematoma
Sensitivity to social and cultural issues, (related to blood leakage into the tis-
as well as concern for modesty, is sue following needle insertion), infec-
important in providing psychological tion (that might occur if bacteria from
support before, during, and after the the skin surface is introduced at the
procedure. puncture site), or nerve injury (that
Explain that an IV line may be inserted might occur if the needle strikes a
to allow infusion of IV fluids such as nerve).
normal saline, antibiotics, anesthetics, Ensure that the patient has complied
analgesics, sedatives, or emergency with food, fluid, and medication restric-
medications. tions for 8 hr prior to the procedure.
Instruct the patient that to reduce the Ensure that the patient has removed
risk of nausea and vomiting, solid food dentures, jewelry, and external metallic
and milk or milk products have been objects in the area to be examined
restricted for at least 8 hr, and clear liq- prior to the procedure.
uids have been restricted for at least Avoid the use of equipment containing
2 hr prior to general anesthesia, regional latex if the patient has a history of
anesthesia, or sedation/analgesia allergic reaction to latex.
(monitored anesthesia). The American Have emergency equipment readily
Society of Anesthesiologists has fasting available.
Instruct the patient to void prior to the a side-lying position with the head
procedure and change into the gown, slightly elevated to promote recovery.
robe, and foot coverings provided. Fiberoptic Bronchoscopy
Avoid using morphine sulfate in those Provide mouth care to reduce oral
with asthma or other pulmonary dis- bacterial flora.
ease. This drug can further exacerbate The patient is placed in a sitting position
B bronchospasms and respiratory while the tongue and oropharynx are
impairment. sprayed or swabbed with local anes-
Observe standard precautions, and thetic. Provide an emesis basin for the
follow the general guidelines in increased saliva and encourage the
Appendix A. Positively identify the patient to spit out the saliva because the
patient, and label the appropriate gag reflex may be impaired. When loss
specimen container with the corre- of sensation is adequate, the patient is
sponding patient demographics, ini- placed in a supine or side-lying position.
tials of the person collecting the The fiberoptic scope can be introduced
specimen, date and time of collection, through the nose, the mouth, an endo-
and site location, especially right or tracheal tube, a tracheostomy tube, or a
left lung. rigid bronchoscope. Most common
Assist the patient to a comfortable insertion is through the nose. Patients
position, and direct the patient to with copious secretions or massive
breathe normally during the beginning hemoptysis, or in whom airway compli-
of the general anesthesia. Instruct the cations are more likely, may be intubated
patient to cooperate fully and to follow before the bronchoscopy. Additional
directions. Direct the patient to breathe local anesthetic is applied through the
normally and to avoid unnecessary scope as it approaches the vocal cords
movement during the local anesthetic and the carina, eliminating reflexes in
and the procedure. these sensitive areas. The fiberoptic
Record baseline vital signs and approach allows visualization of airway
continue to monitor throughout the segments without having to move the
procedure. Protocols may vary among patients head through various p ositions.
L facilities. After visual inspection of the lungs, tis-
Establish an IV fluid line for the injec- sue samples are collected from suspi-
tion of saline, antibiotics, anesthetics, cious sites by bronchial brush or
analgesics, sedatives, or emergency biopsy forceps to be used for cytologi-
medications. cal and microbiological studies.
Rigid Bronchoscopy After the procedure, the bronchoscope
The patient is placed in the supine is removed. Patients who had local
position and a general anesthetic is anesthesia are placed in a semi-
administered. The patients neck is Fowlers position to recover.
hyperextended, and the lightly lubri-
cated bronchoscope is inserted orally General
and passed through the glottis. The Monitor the patient for complications
patients head is turned or repositioned related to the procedure (e.g., allergic
to aid visualization of various s egments. reaction, anaphylaxis).
After inspection, the bronchial brush, Place tissue samples in properly
suction catheter, biopsy forceps, laser, labeled specimen containers contain-
and electrocautery devices are intro- ing formalin solution, and promptly
duced to obtain specimens for cyto- transport the specimen to the labora-
logical or microbiological study or for tory for processing and analysis.
therapeutic procedures.
If a bronchial washing is performed, POST-TEST:
small amounts of solution are instilled Inform the patient that a report of the
into the airways and removed. results will be made available to the
After the procedure, the bronchoscope requesting HCP, who will discuss the
is removed and the patient is placed in results with the patient.
SI Units
BNP Conventional Units (Conventional Units 1)
Male & Female Less than 100 pg/mL Less than 100 ng/L
proBNP (N-terminal)
074 yr Less than 125 pg/mL Less than 125 ng/mL
Greater than 75 yr Less than 449 pg/mL Less than 449 ng/mL
BNP levels are increased in elderly adults.
This procedure is
DESCRIPTION:The peptides B-type contraindicated for
natriuretic peptide (BNP) and atrial Patients receiving Nesiritide.
L natriuretic peptide (ANP) are Nesiritide (Natrecor) is a recom-
antagonists of the renin-angioten- binant form of BNP that may be given
sin-aldosterone system, which assist therapeutically by IV to patients in
in the regulation of electrolytes, acutely decompensated heart failure;
fluid balance, and blood pressure. with some assays, BNP levels may be
BNP, proBNP, and ANP are useful transiently and significantly elevated
markers in the diagnosis of conges- at the time of administration and
tive heart failure (CHF). BNP or must be interpreted with caution.The
brain natriuretic peptide, first iso- testing laboratory should be consult-
lated in the brain of pigs, is a neu- ed to verify whether test measure-
rohormone synthesized primarily ments are affected by Natrecor.
in the ventricles of the human
heart in response to increases in
ventricular pressure and volume. INDICATIONS
Circulating levels of BNP and proB- Assist in determining the prognosis
NP increase in proportion to the and therapy of patients with heart
severity of heart failure. A rapid failure
BNP point-of-care immunoassay Assist in the diagnosis of heart failure
may be performed, in which a Assist in differentiating heart failure
venous blood sample is collected, from pulmonary disease
placed on a strip, and inserted into Cost-effective screen for left ventric-
a device that measures BNP. Results ular dysfunction; positive findings
are completed in 10 to 15 min. would point to the need for echocar-
diography and further assessment
COMMON USE: To diagnose and monitor the effectiveness of treatment for med-
ullary thyroid cancer.
Recommended Collection
Procedure Medication Administered Times
Calcium and Calcium, 2 mg/kg IV 4 calcitonin levelsbaseline
pentagastrin for 1 min, followed by immediately before bolus;
stimulation pentagastrin 0.5 mcg/kg and 1 min, 2 min, and
5 min postbolus
Calcium Calcium, 2 mg/kg IV 4 calcitonin levelsbaseline
stimulation for 1 min or 2.4 mg/kg immediately before bolus;
IV push and 1 min, 2 min, and
5 min postbolus
Pentagastrin Pentagastrin 0.5 mcg/kg 4 calcitonin levelsbaseline
stimulation immediately before bolus;
and 1 min, 2 min, and
5 min postbolus
IV = intravenous.
SI Units (Conventional
Conventional Units Units 1)
Calcitonin Baseline
Male Less than 10 pg/mL Less than 10 ng/L
Female Less than 5 pg/mL Less than 5 ng/L
Maximum Response
5 min after calcium and
pentagastrin stimulation
Male 8343 pg/mL 8343 ng/L
Female Less than 39 pg/mL Less than 39 ng/L
5 min after calcium
stimulation
Male Less than 190 pg/mL Less than 190 ng/L
Female Less than 130 pg/mL Less than 130 ng/L
5 min after pentagastrin
stimulation
Male Less than 110 pg/mL Less than 110 ng/L
Female Less than 30 pg/mL Less than 30 ng/L
339
Calcium, Blood
SYNONYM/ACRONYM: Total calcium, Ca.
SI Units (Conventional
Age Conventional Units Units 0.25)
Cord 8.211.2 mg/dL 2.12.8 mmol/L
010 days 7.610.4 mg/dL 1.92.6 mmol/L
11 days2 yr 911 mg/dL 2.22.8 mmol/L
312 yr 8.810.8 mg/dL 2.22.7 mmol/L
1318 yr 8.410.2 mg/dL 2.12.6 mmol/L
Adult 8.210.2 mg/dL 2.12.6 mmol/L C
Adult older than 90 yr 8.29.6 mg/dL 2.12.4 mmol/L
PRETEST: INTRATEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before pro-
viding care, treatment, or services. Avoid the use of equipment containing
Patient Teaching: Inform the patient this latex if the patient has a history of aller-
test can assist as a general indicator in gic reaction to latex.
diagnosing health concerns. Instruct the patient to cooperate fully
Obtain a history of the patients com- and to follow directions. Direct the
plaints, including a list of known aller- patient to breathe normally and to
gens, especially allergies or sensitivities avoid unnecessary movement.
to latex. Observe standard precautions, and fol-
Obtain a history of the patients cardio- low the general guidelines in Appendix
vascular, gastrointestinal, genitourinary, A. Positively identify the patient, and
hematopoietic, hepatobiliary, and mus- label the appropriate specimen con-
culoskeletal systems, as well as results tainer with the corresponding patient
of previously performed laboratory demographics, initials of the person
tests and diagnostic and surgical collecting the specimen, date,
procedures. and time of collection. Perform a
Note any recent procedures that can venipuncture.
interfere with test results. Remove the needle and apply direct
Obtain a list of the patients current pressure with dry gauze to stop bleed-
medications, including herbs, nutri- ing. Observe/assess venipuncture site
tional supplements, and nutraceuticals for bleeding or hematoma
(see Appendix H online at DavisPlus). formation and secure gauze with
Review the procedure with the patient. adhesive bandage.
Inform the patient that specimen Promptly transport the specimen to the
collection takes approximately 5 to laboratory for processing and analysis.
10 min. Address concerns about
pain and explain that there may be POST-TEST:
some discomfort during the Inform the patient that a report of the
venipuncture. results will be made available to the
Sensitivity to social and cultural issues, requesting HCP, who will discuss the
as well as concern for modesty, is results with the patient.
important in providing psychological Recognize anxiety related to test
support before, during, and after results, and assess the patient for
the procedure. signs and symptoms of calcium imbal-
Note that there are no food, fluid, or ance. Teach the patient the signs and
medication restrictions unless by medi- symptoms associated with a calcium
cal direction. imbalance. Assess associated studies
such as ECG, phosphorus, and albu- Educate the patient regarding access
min so the correct therapeutic to nutritional counseling services.
measures can be taken. Provide contact information, if desired,
Hypoalbuminemia may initiate for the Institute of Medicine of the
symptoms of hypocalcemia in the National Academies (www.iom.edu).
presence of near-normal calcium levels. Teach the patient and family the impor-
Nutritional Considerations: Patients with tance of adequate dietary calcium
abnormal calcium values should be intake to maintain health.
informed that daily intake of calcium is Teach the patient that good oral
important even though body stores in hygiene prior to eating can improve the C
the bones can be called on to supple- food's flavor.
ment circulating levels. Dietary calcium
can be obtained from animal or plant Expected Patient Outcomes:
sources. Milk and milk products, sar- Knowledge
dines, clams, oysters, salmon, rhubarb, Validates that eating in a pleasant envi-
spinach, beet greens, broccoli, kale, ronment with companionship can
tofu, legumes, and fortified orange juice enhance the appetite
are high in calcium. Milk and milk prod- States that parenteral or enteral
ucts also contain vitamin D and lac- nutrition may be used if oral intake is
tose, which assist calcium absorption. insufficient to support caloric needs
Cooked vegetables yield more absorb-
able calcium than raw vegetables. Skills
Patients should be informed of the sub- Performs an accurate daily self-weight
stances that can inhibit calcium and records the results correctly
absorption by irreversibly binding to Accurately self-administers prescribed
some of the calcium, making it unavail- dietary supplements
able for absorption, such as oxalates, Attitude
which naturally occur in some vegeta- Complies with the request to take
bles (e.g., beet greens, collards, leeks, prescribed calcium replacement
okra, parsley, quinoa, spinach, Swiss therapy
chard) and are found in tea; phytic Arranges consultation with the speech
acid, found in some cereals (e.g., therapist to evaluate swallowing
wheat bran, wheat germ); phosphoric ability
acid, found in dark cola; and insoluble
dietary fiber (in excessive amounts). RELATED MONOGRAPHS:
Excessive protein intake can also nega- Related tests include ACTH, albumin,
tively affect calcium absorption, espe- aldosterone, ALP, biopsy bone marrow,
cially if it is combined with foods high in BMD, bone scan, calcitonin, calcium
phosphorus and in the presence of a ionized, urine calcium, calculus kidney
reduced dietary calcium intake. stone analysis, catecholamines,
Depending on the results of this chloride, collagen cross-linked
procedure, additional testing may be telopeptides, CBC, CT pelvis, CT
performed to evaluate or monitor pro- spine, cortisol, CK and isoenzymes,
gression of the disease process and DHEA, fecal fat, glucose, HVA, magne-
determine the need for a change in sium, metanephrines, osteocalcin,
therapy. Evaluate test results in relation PTH, phosphorus, potassium, protein
to the patients symptoms and other total, radiography bone, renin, sodium,
tests performed. thyroid scan, thyroxine, US abdomen,
US thyroid and parathyroid, UA, and
Patient Education: vitamin D.
Reinforce information given by the Refer to the Cardiovascular,
patients HCP regarding further testing, Gastrointestinal, Genitourinary,
treatment, or referral to another HCP. Hematopoietic, Hepatobiliary, and
Answer any questions or address Musculoskeletal systems tables at the
any concerns voiced by the patient end of the book for related tests by
or family. body system.
Calcium, Ionized
SYNONYM/ACRONYM: Free calcium, unbound calcium, Ca++, Ca2+.
with the name of the HCP notified, venipuncture can falsely elevate
time and date of notification, and any calcium levels.
orders received. Any delay in a timely Patients on ethylenediaminetet-
report of a critical finding may require raacetic acid (EDTA) therapy (che-
completion of a notification form lation) may show falsely decreased
with review by Risk Management. calcium values.
Observe the patient for symptoms Specimens should never be collect-
of critically decreased or elevated cal- ed above an IV line because of the
C cium levels. Hypocalcemia is evi- potential for dilution when the
denced by convulsions, arrhythmias, specimen and the IV solution com-
changes in electrocardiogram (ECG) in bine in the collection container,
the form of prolonged ST segment and falsely decreasing the result. There
Q-T interval, facial spasms (positive is also the potential of contaminat-
Chvosteks sign), tetany, lethargy, mus- ing the sample with the substance
cle cramps, numbness in extremities, of interest if it is present in the
tingling, and muscle twitching (posi- IV solution, falsely increasing
tive Trousseaus sign). Possible inter- the result.
ventions include seizure precautions,
increased frequency of ECG monitor-
ing, and administration of calcium or NURSING IMPLICATIONS
magnesium. AND PROCEDURE
Severe hypercalcemia is manifest-
ed by excessive thirst, polyuria, con- PRETEST:
stipation, changes in ECG ( shortened Positively identify the patient using at
QT interval due to shortening of the least two unique identifiers before pro-
ST segment and prolonged PR inter- viding care, treatment, or services.
val), lethargy, confusion, muscle Patient Teaching: Inform the patient this
test can assist in evaluating the level of
weakness, joint aches, apathy, anorex- blood calcium.
ia, headache, nausea, vomiting, and Obtain a history of the patients com-
ultimately may result in coma. plaints, including a list of known aller-
Possible interventions include the gens, especially allergies or sensitivities
administration of normal saline and to latex.
diuretics to speed up excretion or Obtain a history of the patients cardio-
administration of calcitonin or ste- vascular, gastrointestinal, genitourinary,
roids to force the circulating calcium hematopoietic, hepatobiliary, and mus-
into the cells. culoskeletal systems, as well as results
of previously performed laboratory
tests and diagnostic and surgical pro-
INTERFERING FACTORS cedures.
Drugs that may increase calcium Note any recent procedures that could
levels include antacids (some), cal- interfere with test results.
citriol, and lithium. Obtain a list of the patients current
Drugs that may decrease calcium medications, including herbs, nutri-
levels include calcitonin, citrates, tional supplements, and nutraceuticals
foscarnet, and pamidronate (see Appendix H online at DavisPlus).
(initially). Review the procedure with the patient.
Calcium exhibits diurnal variation; Inform the patient that specimen collec-
tion takes approximately 5 to 10 min.
serial samples should be Address concerns about pain and
collected at the same time of day explain that there may be some dis-
for comparison. comfort during the venipuncture.
Venous hemostasis caused by pro- Sensitivity to social and cultural issues,
longed use of a tourniquet during as well as concern for modesty, is
Calcium, Urine
SYNONYM/ACRONYM: N/A.
SI Units (Conventional
Age Conventional Units* Units 0.025)*
Infant and child Up to 6 mg/kg per 24 hr Up to 0.15 mmol/kg per 24 hr
Adult on average 100300 mg/24 hr 2.57.5 mmol/24 hr
diet
Signs &
Problem Symptoms Interventions
Pain (Related to Report of pain, Administer prescribed medication
obstruction of restlessness, for pain; assesses effectiveness
urinary flow by grimace, moan, of pain medication and trend
stone, presence sleeplessness, outcome; assess characteristics
of stone, diaphoretic, of pain (location, duration);
movement of nausea, vomiting; consider nonpharmacological
stone) elevated blood pain interventions that have
pressure worked for the patient in the past
(table continues on page 356)
Access additional resources at davisplus.fadavis.com
Signs &
Problem Symptoms Interventions
Infection (Related Temperature; Monitor urinary output; assess
to stasis; elevated white urine color, odor, presence of
interrupted blood cell (WBC) blood; monitor and trend
urinary flow; count; cloudy temperature and WBC count;
gravel; urinary urine; sediment in obtain urine for culture and
C tract urine; blood in sensitivity as required;
instrumentation) urine encourage fluid intake in
excess of 3,000 mL/day;
administer prescribed
antibiotics
Knowledge Lack of interest or Assess understanding of renal
(Related to questions; stone formation; assess for a
unfamiliarity of multiple family history of renal stones;
factors related to questions; anxiety assess patients understanding
the development in relation to of the relationship between
of kidney disease process fluid intake and stone
stones; and formation; strain urine; limit
unfamiliarity management; protein intake to decrease risk
with disease renal stone of stone formation; add
management; reoccurrence cranberry juice to dietary
methods of intake; administer prescribed
disease medications to decrease stone
prevention) formation (cholestyramine,
thiazide, allopurinol)
Elevated Elevated Assess the patients temperature
temperature temperature; frequently; encourage the use
(Related to flushed; warm of light bedding and lightweight
infection skin; diaphoresis clothing to prevent overheating;
secondary to increase fluid intake to offset
stone formation) insensible fluid loss; encourage
bathing with tepid water for
comfort and promotion of
cooling; administer prescribed
medication for elevated
temperature
Review the procedure with the patient. to develop stones), race (whites are
Address concerns about pain and three to four times more likely than
explain that there may be some African Americans to develop stones),
discomfort during the procedure. and climate.
Sensitivity to social and cultural issues, Nutritional Considerations: Nutritional
as well as concern for modesty, is therapy is indicated for individuals
important in providing psychological identified as being at high risk for
support before, during, and after the developing kidney stones. Educate the
procedure. patient that diets rich in protein, salt,
Note that there are no food, fluid, or and oxalates increase the risk of stone C
medication restrictions unless by formation. Adequate fluid intake should
medical direction. be encouraged.
Recognize anxiety related to test
INTRATEST: results.
Follow-up testing of urine may be
Potential Complications: N/A requested, but usually not for 1 mo
Instruct the patient to cooperate fully after the stones have passed or been
and to follow directions. removed. Answer any questions or
Observe standard precautions, and address any concerns voiced by the
follow the general guidelines in patient or family.
Appendix A. Positively identify the Depending on the results of this
patient, and label the appropriate procedure, additional testing may
specimen container with the corre- be performed to evaluate or monitor
sponding patient demographics, progression of the disease process
initials of the person collecting the and determine the need for a change
specimen, date, and time of in therapy. Evaluate test results in rela-
collection. tion to the patients symptoms and
The patient presenting with symptoms other tests performed.
indicating the presence of kidney stones
may be provided with a device to strain Patient Education:
the urine. The patient should be Discuss the implications of abnormal
informed to transfer any particulate mat- test results on the patients lifestyle.
ter remaining in the strainer into the Provide teaching and information
specimen collection container p rovided. regarding the clinical implications of the
Stones removed by the health-care test results, as appropriate.
provider (HCP) should be placed in the Reinforce information given by
appropriate collection container. the patients HCP regarding further
Promptly transport the specimen to testing, treatment, or referral to
the laboratory for processing and another HCP.
analysis. Teach patient to report worsening
symptoms of infection such as fever,
POST-TEST: chills, and pain.
Inform the patient that a report of
the results will be made available Expected Patient Outcomes:
to the requesting HCP, who will
Knowledge
discuss the results with the patient.
States the process and importance of
Inform the patient with kidney stones
straining all urine
that the likelihood of recurrence is high.
States the importance of increasing
Educate the patient regarding risk fac-
fluid intake and adding cranberry juice
tors that contribute to the likelihood of
to their diet
kidney stone formation, including family
history, osteoporosis, urinary tract Skills
infections, gout, magnesium defi- Accurately self-administers prescribed
ciency, Crohns disease with prior medication
resection, age, gender (males are two Demonstrates proficiency in straining
to three times more likely than females urine to check for stones
COMMON USE: To identify the presence of various cancers, such as breast and
ovarian, as well as to evaluate the effectiveness of cancer treatment.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Care must be taken to use
the same assay method if serial measurements are to be taken.
Smoking
Status Conventional Units SI Units (Conventional Units 1)
CEA
Smoker Less than 5.0 ng/mL Less than 5.0 mcg/L
Nonsmoker Less than 2.5 ng/mL Less than 2.5 mcg/L
Decreased in INTRATEST:
Effective therapy or removal of
Potential Complications: N/A
the tumor
Avoid the use of equipment containing
latex if the patient has a history of aller-
CRITICAL FINDINGS: N/A gic reaction to latex.
Instruct the patient to cooperate fully
INTERFERING FACTORS: N/A and to follow directions. Direct the
patient to breathe normally and to and older as long as they are in good
avoid unnecessary movement. health. The ACS also recommends
Observe standard precautions, and annual MRI testing for women at high
follow the general guidelines in risk of developing breast cancer.
Appendix A. Positively identify the Genetic testing for inherited mutations
patient, and label the appropriate (BRCA1 and BRCA2) associated with
specimen container with the corre- increased risk of developing breast
sponding patient demographics, initials cancer may be ordered for women at
of the person collecting the specimen, risk. The test is performed on a
date, and time of collection. Perform a blood specimen. The most current C
venipuncture. guidelines for breast cancer
Remove the needle and apply direct screening of the general population
pressure with dry gauze to stop bleed- as well as of individuals with
ing. Observe/assess venipuncture increased risk are available from
site for bleeding or hematoma the American Cancer Society (www
formation and secure gauze with .cancer.org), the American College of
adhesive bandage. Obstetricians and Gynecologists
Promptly transport the specimen to the (ACOG) (www.acog.org), and the
laboratory for processing and analysis. American College of Radiology
(www.acr.org). Answer any questions
POST-TEST: or address any concerns voiced by
Inform the patient that a report of the the patient or family.
results will be made available to the Decisions regarding the need for and
requesting health-care provider (HCP), frequency of occult blood testing,
who will discuss the results with the colonoscopy, or other cancer screen-
patient. ing procedures should be made after
Recognize anxiety related to test consultation between the patient and
results, and be supportive of per- HCP. The American Cancer Society
ceived loss of independence and fear recommends regular screening for
of shortened life expectancy. Discuss colon cancer, beginning at age 50 yr
the implications of abnormal test for individuals without identified risk
results on the patients lifestyle. factors. Their recommendations for
Provide teaching and information frequency of screening: annual for
regarding the clinical implications of occult blood testing (fecal occult
the test results, as appropriate. blood testing [FOBT] and fecal immu-
Educate the patient regarding access nochemical testing [FIT]); every 5 yr
to counseling services. Provide con- for flexible sigmoidoscopy, double
tact information, if desired, for the contrast barium enema, and CT colo-
American Cancer Association (www nography; and every 10 yr for colo-
.cancer.org). noscopy. There are both advantages
Reinforce information given by the and disadvantages to the screening
patients HCP regarding further test- tests that are available today.
ing, treatment, or referral to another Methods to use DNA testing of stool
HCP. Decisions regarding the need are being investigated and awaiting
for and frequency of breast self- FDA approval. The DNA test is
examination, mammography, MRI designed to identify abnormal
breast, or other cancer screening changes in DNA from the cells in the
procedures should be made after lining of the colon that are normally
consultation between the patient and shed and excreted in stool. The DNA
HCP. The American Cancer Society tests under development would use
(ACS) recommends breast examina- multiple markers to identify colon can-
tions be performed every 3 yr for cers with various, abnormal DNA
women between the ages of 20 and changes and would be able to detect
39 yr and annually for women over precancerous polyps. The most cur-
40 yr of age; annual mammograms rent guidelines for colon cancer
should be performed on women 40 yr screening of the general population as
Capsule Endoscopy
SYNONYM/ACRONYM: Pill GI endoscopy.
CONTRAST: None.
Carbon Dioxide
SYNONYM/ACRONYM: CO2 combining power, CO2, Tco2.
COMMON USE: To assess the effect of total carbon dioxide levels on respiratory
and metabolic acid-base balance.
Carboxyhemoglobin
SYNONYM/ACRONYM: Carbon monoxide, CO, COHb, COH.
COMMON USE: To identify the amount of carbon monoxide in the blood related
C to poisoning, toxicity from smoke inhalation, or exhaust from cars.
% Saturation of Hemoglobin
Newborns 1012%
Nonsmokers Up to 2%
Smokers Up to 10%
Note and immediately report to the Women and children may suffer
health-care provider (HCP) any criti- more severe symptoms of carbon
cally increased or decreased values monoxide poisoning at lower levels
and related symptoms. of carbon monoxide than men
It is essential that a critical finding because women and children usually
be communicated immediately to the have lower red blood cell counts.
requesting health-care provider A possible intervention in moder-
(HCP). A listing of these findings var- ate CO poisoning is the administra-
ies among facilities. tion of supplemental oxygen given at
Timely notification of a critical atmospheric pressure. In severe CO
finding for lab or diagnostic studies is poisoning, hyperbaric oxygen treat-
a role expectation of the professional ments may be used.
nurse. Notification processes will vary
among facilities. Upon receipt of the INTERFERING FACTORS
critical value the information should Specimen should be collected before
be read back to the caller to verify administration of oxygen therapy.
accuracy. Most policies require imme-
diate notification of the primary HCP,
Hospitalist, or on-call HCP. Reported NURSING IMPLICATIONS
information includes the patients AND PROCEDURE
name, unique identifiers, critical value,
name of the person giving the report, PRETEST:
and name of the person receiving the Positively identify the patient using
report. Documentation of notification at least two unique identifiers
should be made in the medical record before providing care, treatment,
with the name of the HCP notified, or services.
Patient Teaching: Inform the patient
time and date of notification, and any this test can assist in evaluating the
orders received. Any delay in a timely extent of carbon monoxide poisoning
report of a critical finding may require or toxicity.
completion of a notification form with Obtain a history of the patients
review by Risk Management. complaints, including a list of known
SPECIMEN: Plasma (2 mL) collected in green-top (heparin) tube. Urine (25 mL)
from a timed specimen collected in a clean, plastic, amber collection container
with 6N hydrochloric acid as a preservative.
CD4/CD8 Enumeration
SYNONYM/ACRONYM: T-cell profile.
Mature Suppressor
T cells Helper T T cells
(CD3) cells (CD4) (CD8)
Absolute Absolute Absolute
Age (cells/microL) % (cells/microL) % (cells/microL) %
03 mo 2,5005,500 5384 1,6004,000 3564 5601,700 1228
36 mo 2,5005,600 5177 1,8004,000 3556 5901,600 1223
612 mo 1,9005,900 4976 1,4004,300 3156 5001,700 1224
1224 mo 2,1006,200 5375 1,3003,400 3251 6202,000 1430
256 yr 1,4003,700 5675 7002,200 2847 4901,300 1630
612 yr 1,2002,600 6076 6501,500 3147 3701100 1835
1218 yr 1,0002,200 5684 5301,300 3152 330920 1835
Adult 5272,846 4981 3321,642 2851 170811 1238
Pediatric values adapted with permission by Elsevier from Shearer, W., et. al. (November,
2003). Lymphocyte subsets in healthy children from birth through 18 years of age: The pediatric
AIDS clinical trials group P1009 study. Journal of Allergy and Clinical Immunology. 112(5):
973980.
be elevated if the patients knees are signs, such as temperature and blood
flexed too firmly against the abdomen. pressure. Position the patient flat, either
CSF pressure may be significantly ele- on the back or abdomen following the
vated in patients with intracranial tumors HCPs instructions; some HCPs allow
or space occupying pockets of infection 30 degrees of elevation. Maintain this
as seen in meningitis. If the initial pres- position for 8 hr. Changing position is
sure is elevated, the HCP may perform acceptable as long as the body remains
Queckenstedts test. To perform this horizontal. Observe/assess the patient
test, pressure is applied to the jugular for neurological changes, such as
C vein for about 10 sec. CSF pressure altered level of consciousness, change
usually rises rapidly in response to the in pupils, reports of tingling or numb-
occlusion and then returns to the pre- ness, and irritability.
test level within 10 sec after the pres- Recognize anxiety related to test results.
sure is released. Sluggish response may Discuss the implications of abnormal
indicate CSF obstruction. test results on the patients lifestyle.
Obtain four (or five) vials of fluid, Provide teaching and information
according to the HCPs request, in regarding the clinical implications of the
separate tubes (1 to 3 mL in each), test results, as appropriate.
and label them numerically (1 to 4 or 5) Reinforce information given by the
in the order they were filled. patients HCP regarding further testing,
A final pressure reading is taken, and treatment, or referral to another HCP.
the needle is removed. Clean the punc- Provide information regarding vaccine-
ture site with an antiseptic solution and preventable diseases when indicated
apply direct pressure with dry gauze to (encephalitis, influenza, meningococcal
stop bleeding or CSF leakage. Observe/ diseases). Answer any questions or
assess puncture site for bleeding, CSF address any concerns voiced by the
leakage, or hematoma formation and patient or family.
secure gauze with adhesive bandage. Instruct the patient in the use of any
Promptly transport the specimen to the ordered medications. Explain the
laboratory for processing and analysis. importance of adhering to the therapy
regimen. As appropriate, instruct the
POST-TEST: patient in significant side effects and
Inform the patient that a report of the systemic reactions associated with the
results will be made available to the prescribed medication. Encourage him
requesting HCP, who will discuss the or her to review corresponding litera-
results with the patient. ture provided by a pharmacist.
Monitor vital signs and neurological Depending on the results of this
status and for headache every 15 min procedure, additional testing may be
for 1 hr, then every 2 hr for 4 hr, and performed to evaluate or monitor pro-
then as ordered by the HCP. Monitor gression of the disease process and
temperature every 4 hr for 24 hr. determine the need for a change in
Compare with baseline values. Notify therapy. Evaluate test results in relation
the HCP if temperature is elevated. to the patients symptoms and other
Protocols may vary among facilities. tests performed.
Administer fluids if permitted, especially
fluids containing caffeine, to replace lost RELATED MONOGRAPHS:
CSF and help prevent or relieve head- Related tests include CBC, CT brain,
ache, which is a side effect of lumbar culture for appropriate organisms
puncture. Advise the patient that head- (blood, fungal, mycobacteria, sputum,
ache may begin within a few hours up throat, viral, wound), EMG, evoked
to 2 days after the procedure and may brain potentials, Gram stain, MRI
be associated with dizziness, nausea, brain, PET brain, and syphilis serology.
and vomiting. The length of time for the Refer to the Immune and
headache to resolve varies considerably. Musculoskeletal systems tables at the
Observe/assess the puncture site for end of the book for related tests by
leakage, and frequently monitor body body system.
Ceruloplasmin
SYNONYM/ACRONYM: Copper oxidase, Cp.
SI Units (Conventional
Age Conventional Units Units 10)
Newborn3 mo 518 mg/dL 50180 mg/L
612 mo 3343 mg/dL 330430 mg/L
13 yr 2655 mg/dL 260550 mg/L
45 yr 2756 mg/dL 270560 mg/L
67 yr 2448 mg/dL 240480 mg/L
8 yrolder adult 2054 mg/dL 200540 mg/L
Chest X-Ray
SYNONYM/ACRONYM: Chest radiography, CXR, lung radiography.
CONTRAST: None.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Place separated serum into
a standard transport tube within 2 hr of collection.
Chloride, Blood
SYNONYM/ACRONYM: Cl.
Chloride, Sweat
SYNONYM/ACRONYM: Sweat test, pilocarpine iontophoresis sweat test, sweat
chloride.
Addisons disease
The sweat test is a noninva- Alcoholic pancreatitis (dysfunction
sive study done to assist in the of CF gene is linked to pancreatic
diagnosis of CF when considered disease susceptibility)
with other test results and physi- CF
cal assessments. This test is usually Chronic pulmonary infections
performed on children, although (related to undiagnosed CF)
adults may also be tested; it is not Congenital adrenal hyperplasia
C usually ordered on adults because Diabetes insipidus
results can be highly variable and Familial cholestasis
should be interpreted with Familial hypoparathyroidism
caution. Sweat for specimen col- Fucosidosis
lection is induced by a small Glucose-6-phosphate dehydroge-
electrical current carrying the nase deficiency
drug pilocarpine. The test mea- Hypothyroidism
sures the concentration of chlo- Mucopolysaccharidosis
ride produced by the sweat glands Nephrogenic diabetes insipidus
of the skin. A high concentration Renal failure
of chloride in the specimen indi-
cates the presence of CF. The Decreased in
sweat test is used less commonly Conditions that affect electrolyte dis-
to measure the concentration of tribution and retention may produce
sodium ions for the same purpose. false-negative sweat test results.
Edema
This procedure is contraindicated Hypoaldosteronism
for Hypoproteinemia
Patients with skin disorders Sodium depletion
(e.g., rash, erythema, eczema).
CRITICAL FINDINGS
INDICATIONS
20 yr or younger: greater than
Assist in the diagnosis of CF
60 mEq/L or mmol/L (SI greater
Screen for CF in individuals with a
than 60 mEq/L) considered diag-
family history of the disease
nostic of CF
Screen for suspected CF in children
Older than 20 years: greater than
with recurring respiratory infections
70 mEq/L or mmol/L (SI greater
Screen for suspected CF in infants
than 70 mEq/L) considered diag-
with failure to thrive and infants
nostic of CF
who pass meconium late
Screen for suspected CF in individ- Note and immediately report to the
uals with malabsorption health-care provider (HCP) any critical-
syndrome ly increased values and related symp-
toms. Values should be interpreted
with consideration of family history
POTENTIAL DIAGNOSIS
and clinical signs and symptoms.
Increased in It is essential that a critical finding
Conditions that affect electrolyte be communicated immediately to the
distribution and excretion may requesting health-care provider (HCP).
produce false-positive sweat test A listing of these findings varies among
results. facilities.
estimated that the daily caloric intake long-term implications. Recognize that
needed for children with CF between anticipatory anxiety and grief related to
4 and 7 yr may be 2,000 to 2,800 and potential lifestyle changes may be
for teens 3,000 to 5,000. Tube feeding expressed when someone is faced with
may be necessary to supplement a chronic disorder. Provide information
regular high-calorie meals. To prevent regarding genetic counseling and pos-
pulmonary infection and decrease the sible screening of other family members
extent of lung tissue damage, ade- if appropriate. Provide contact informa-
quate intake of vitamins A and C is tion, if desired, for the Cystic Fibrosis
also important. Excessive loss of Foundation (www.cff.org). C
sodium chloride through the sweat Reinforce information given by the
glands of a patient with CF may patients HCP regarding further testing,
necessitate increased salt intake, treatment, or referral to another HCP.
especially in environments where Explain that a positive sweat test alone
increased sweating is induced. The is not diagnostic of CF; repetition of
importance of following the prescribed borderline and positive tests is gener-
diet should be stressed to the patient ally recommended. Answer any ques-
and caregiver. tions or address any concerns voiced
If appropriate, instruct the patient and by the patient or family.
caregiver that ineffective airway clear- Depending on the results of this
ance related to excessive production procedure, additional testing may be
of mucus and decreased ciliary action performed to evaluate or monitor pro-
may result. Chest physical therapy and gression of the disease process and
the use of aerosolized antibiotics and determine the need for a change in
mucus-thinning drugs are an important therapy. Evaluate test results in relation
part of the daily treatment regimen. to the patients symptoms and other
Recognize anxiety related to test tests performed.
results, and be supportive of impaired
activity related to perceived loss of RELATED MONOGRAPHS:
independence and fear of shortened Related tests include 1-antitrypsin/
life expectancy. Discuss the implica- phenotype, amylase, anion gap, biopsy
tions of abnormal test results on the chorionic villus, blood gases, fecal
patients lifestyle. Provide teaching and analysis, fecal fat, newborn screening,
information regarding the clinical impli- osmolality, phosphorus, potassium,
cations of the test results, as appropri- and sodium.
ate. Educate the patient regarding Refer to the Endocrine and Respiratory
access to counseling services. Help systems tables at the end of the book
the patient and caregiver to cope with for related tests by body system.
COMMON USE: To visualize and assess biliary ducts for causes of obstruction and
jaundice, such as cancer or stones.
Cholangiography, Postoperative
SYNONYM/ACRONYM: T-tube cholangiography.
not adjusted for their small size. If iodinated contrast medium is sched-
Pediatric Considerations uled to be used in patients receiving
Information on the Image Gently metformin (Glucophage) for noninsu-
Campaign can be found at the lin-dependent (type 2) diabetes, the
drug should be discontinued on the
Alliance for Radiation Safety in day of the test and continue to be
Pediatric Imaging (www.pedrad withheld for 48 hr after the test.
.org/associations/5364/ig/). Iodinated contrast can temporarily
Risks associated with radiation impair kidney function, and failure to
C overexposure can result from withhold metformin may indirectly
frequent x-ray procedures. result in drug-induced lactic acidosis,
Personnel in the examination a dangerous and sometimes fatal side
room with the patient should effect of metformin related to renal
wear a protective lead apron, impairment that does not support
sufficient excretion of metformin.
stand behind a shield, or leave Review the procedure with the patient.
the area while the examination is Address concerns about pain and
being done. Personnel working in explain that there may be moments of
the examination area should discomfort and some pain experi-
wear badges to record their enced during the test. Inform the
radiation level. patient that the procedure is usually
performed in the radiology department
by an HCP and takes approximately
30 to 60 min.
NURSING IMPLICATIONS Sensitivity to social and cultural issues,
AND PROCEDURE as well as concern for modesty, is
important in providing psychological
PRETEST: support before, during, and after the
Positively identify the patient using at procedure.
least two unique identifiers before pro- Explain that an IV line may be inserted
viding care, treatment, or services. to allow infusion of IV fluids such as
Patient Teaching: Inform the patient this normal saline, anesthetics, sedatives, or
procedure can assist in assessing the emergency medications. Explain that
bile ducts of the gallbladder and the contrast medium will be injected
pancreas. through the t-tube that was left in place.
Obtain a history of the patients com- Instruct the patient to remove jewelry
plaints or clinical symptoms, including and other metallic objects in the area
a list of known allergens, especially to be examined.
allergies or sensitivities to latex, anes- Note that there are no food or fluid
thetics, contrast medium, or sedatives. restrictions for a post-surgical study
Obtain a history of results of the but the patient should follow the stan-
patients gastrointestinal and dard pre-operative restrictions on food
hepatobiliary systems, symptoms, and fluids for 8 hr prior to an operative
and previously performed laboratory cholangiogram. Protocols may vary
tests and diagnostic and surgical among facilities.
procedures. Make sure a written and informed
Ensure that this procedure is per- consent has been signed prior to the
formed before an upper GI study or procedure and before administering
barium swallow. any medications.
Record the date of the last menstrual INTRATEST:
period and determine the possibility of
pregnancy in perimenopausal women. Potential Complications:
Obtain a list of the patients current Cholangiography and establishing an
medications, including herbs, nutri- IV site are invasive procedures and
tional supplements, and nutraceuticals have potential risks that include allergic
(see Appendix H online at DavisPlus). reaction related to contrast reaction,
Cholangiopancreatography,
Endoscopic Retrograde
SYNONYM/ACRONYM: ERCP.
COMMON USE: To visualize and assess the pancreas and common bile ducts for
occlusion or stricture.
on the day of the test and continue to demographics, initials of the person
be withheld for 48 hr after the test. collecting the specimen, date, and
Iodinated contrast can temporarily time of collection.
impair kidney function, and failure to Ensure the patient has complied with
withhold metformin may indirectly dietary, fluid, and medication restric-
result in drug-induced lactic acidosis, tions for 8 hr prior to the procedure.
a dangerous and sometimes fatal side Ensure the patient has removed all
effect of metformin related to renal external metallic objects from the area
impairment that does not support to be examined.
sufficient excretion of metformin. Assess for completion of bowel prepa- C
Review the procedure with the patient. ration according to the institutions
Address concerns about pain and procedure.
explain that some pain may be experi- Administer ordered prophylactic ste-
enced during the test, and there may roids or antihistamines before the pro-
be moments of discomfort. Inform the cedure if the patient has a history of
patient that the procedure is performed allergic reactions to any relevant sub-
in a GI lab or radiology department, stance or drug. Use nonionic contrast
usually by an HCP, with support staff, medium for the procedure.
and takes approximately 30 to 60 min. Avoid the use of equipment containing
Sensitivity to social and cultural issues,as latex if the patient has a history of aller-
well as concern for modesty, is impor- gic reaction to latex.
tant in providing psychological support Have emergency equipment readily
before, during, and after the procedure. available.
Explain that an IV line may be inserted Instruct the patient to void prior to the
to allow infusion of IV fluids such as procedure and to change into the gown,
normal saline, anesthetics, sedatives, robe, and foot coverings provided.
or emergency medications. Explain that Instruct the patient to cooperate fully
the contrast medium will be injected at and to follow directions. Instruct the
a separate site from the IV line. patient to remain still throughout the
Instruct the patient to remove jewelry procedure because movement pro-
and other metallic objects from the duces unreliable results.
area to be examined. Record baseline vital signs, and con-
Instruct the patient to fast and restrict tinue to monitor throughout the proce-
fluids for 8 hr prior to the procedure dure. Protocols may vary among
and to avoid taking anticoagulant med- facilities.
ication or to reduce dosage as ordered Establish an IV fluid line for the injec-
prior to the procedure. Protocols may tion of saline, sedatives, or emergency
vary among facilities. medications.
Make sure a written and informed Administer ordered sedation.
consent has been signed prior to the An x-ray of the abdomen is obtained
procedure and before administering to determine if any residual contrast
any medications. medium is present from previous
studies.
INTRATEST: The oropharynx is sprayed or swabbed
with a topical local anesthetic.
Potential Complications: The patient is placed on an examina-
Cholangiography is an invasive proce- tion table in the left lateral position with
dure and has potential risks that the left arm behind the back and right
include allergic reaction related to hand at the side with the neck slightly
contrast reaction, bleeding, septicemia, flexed. A protective guard is inserted
pancreatitis, and bowel perforation. into the mouth to cover the teeth.
Observe standard precautions, and fol- A bite block can also be inserted to
low the general guidelines in Appendix A. maintain adequate opening of the
Positively identify the patient, and label mouth.
the appropriate specimen container The endoscope is passed through the
with the corresponding patient mouth with a dental suction device in
COMMON USE: To assess risk and monitor for coronary artery disease. C
SI Units (Conventional
HDLC Conventional Units Units 0.0259)
Birth 656 mg/dL 0.161.45 mmol/L
Children, adults, and
older adults
Desirable Greater than 60 mg/dL Greater than 1.55 mmol/L
Acceptable 4060 mg/dL 11.55 mmol/L
Low Less than 40 mg/dL Less than 1 mmol/L
SI Units (Conventional
LDLC Conventional Units Units 0.0259)
Optimal Less than 100 mg/dL Less than 2.59 mmol/L
Near optimal 100129 mg/dL 2.593.34 mmol/L
Borderline high 130159 mg/dL 3.374.11 mmol/L
High 160189 mg/dL 4.144.9 mmol/L
Very high Greater than 190 mg/dL Greater than 4.92 mmol/L
restricted for at least 12 hr prior to the vated, the patient should be advised to
procedure. eliminate or reduce alcohol. The 2013
Avoid the use of equipment containing Guideline on Lifestyle Management to
latex if the patient has a history of Reduce Cardiovascular Risk published
allergic reaction to latex. by the ACC and AHA in conjunction
Instruct the patient to cooperate fully with the NHLBI recommends a
and to follow directions. Direct the Mediterranean-style diet rather
patient to breathe normally and to than a low-fat diet. The new guideline
avoid unnecessary movement. emphasizes inclusion of vegetables,
Observe standard precautions, and fol- whole grains, fruits, low-fat dairy, C
low the general guidelines in Appendix nuts, legumes, and nontropical vegeta-
A. Positively identify the patient, and ble oils (e.g., olive, canola, peanut,
label the appropriate specimen con- sunflower, flaxseed), along with fish
tainer with the corresponding patient and lean poultry. A similar dietary pat-
demographics, initials of the person tern known as the DASH diet makes
collecting the specimen, date, and time additional recommendations for the
of collection. Perform a venipuncture. reduction of dietary sodium. Both
Remove the needle and apply direct dietary styles emphasize a reduction in
pressure with dry gauze to stop consumption of red meats, which are
bleeding. Observe/assess venipuncture high in saturated fats and cholesterol,
site for bleeding or hematoma forma- and other foods containing sugar, satu-
tion and secure gauze with adhesive rated fats, trans fats, and sodium.
bandage. Social and Cultural Considerations:
Promptly transport the specimen to the Numerous studies point to the preva-
laboratory for processing and analysis. lence of excess body weight in
American children and adolescents.
POST-TEST: Experts estimate that obesity is pres-
Inform the patient that a report of the ent in 25% of the population ages 6 to
results will be made available to the 11 yr. The medical, social, and emo-
requesting HCP, who will discuss the tional consequences of excess body
results with the patient. weight are significant. Special attention
Instruct the patient to resume usual should be given to instructing the child
diet, fluids, and medications, as and caregiver regarding health risks
directed by the HCP. and weight-control education.
Nutritional Considerations: Decreased Recognize anxiety related to test
HDLC level and increased LDLC level results, and be supportive of fear of
may be associated with CAD. shortened life expectancy. Discuss the
Nutritional therapy is recommended for implications of abnormal test results on
the patient identified to be at risk for the patients lifestyle. Provide teaching
developing CAD or for individuals who and information regarding the clinical
have specific risk factors and/or exist- implications of the test results, as
ing medical conditions (e.g., elevated appropriate. Educate the patient
LDL cholesterol levels, other lipid disor- regarding access to counseling ser-
ders, insulin-dependent diabetes, insu- vices. Provide contact information, if
lin resistance, or metabolic syndrome). desired, for the American Heart
Other changeable risk factors warrant- Association (www.americanheart.org)
ing patient education include strategies or the NHLBI (www.nhlbi.nih.gov).
to encourage patients, especially those Reinforce information given by the
who are overweight and with high patients HCP regarding further test-
blood pressure, to safely decrease ing, treatment, or referral to another
sodium intake, achieve a normal HCP. Answer any questions or
weight, ensure regular participation in address any concerns voiced by the
moderate aerobic physical activity three patient or family.
to four times per week, eliminate Depending on the results of this
tobacco use, and adhere to a heart- procedure, additional testing may be
healthy diet. If triglycerides also are ele- performed to evaluate or monitor
Cholesterol, Total
SYNONYM/ACRONYM: N/A.
COMMON USE: To assess and monitor risk for coronary artery disease.
SI Units (Conventional
Risk Conventional Units Units 0.0259)
Children and
adolescents (less than
20 yr)
Desirable Less than 170 mg/dL Less than 4.4 mmol/L
Borderline 170199 mg/dL 4.45.2 mmol/L
High Greater than 200 mg/dL Greater than 5.2 mmol/L
Adults and older adults
Desirable Less than 200 mg/dL Less than 5.2 mmol/L
Borderline 200239 mg/dL 5.26.2 mmol/L
High Greater than 240 mg/dL Greater than 6.2 mmol/L
week, eliminate tobacco use, and Educate the patient regarding access
adhere to a heart-healthy diet. If triglycer- to counseling services.
ides also are elevated, the patient should Provide contact information, if desired,
be advised to eliminate or reduce alco- for the AHA (www.americanheart.org)
hol. The 2013 Guideline on Lifestyle or the NHLBI (www.nhlbi.nih.gov).
Management to Reduce Cardiovascular Reinforce information given by the
Risk published by the American College patients HCP regarding further testing,
of Cardiology (ACC) and the American treatment, or referral to another HCP.
Heart Association (AHA) in conjunction Answer any questions or address any
C with the National Heart, Lung, and Blood concerns voiced by the patient or
Institute (NHLBI) recommends a family.
Mediterranean-style diet rather than a Explain to the patient and the family
low-fat diet. The new guideline empha- the anatomy and pathophysiology of
sizes inclusion of vegetables, whole the heart and coronary arteries.
grains, fruits, low-fat dairy, nuts, Explain to the patient and the family the
legumes, and nontropical vegetable oils risk factors for coronary artery disease.
(e.g., olive, canola, peanut, sunflower,
flaxseed) along with fish and lean poultry. Expected Patient Outcomes:
A similar dietary pattern known as the Knowledge
Dietary Approaches to Stop Differentiates between the signs and
Hypertension (DASH) diet makes addi- symptoms of myocardial infarction and
tional recommendations for the reduction angina
of dietary sodium. Both dietary styles Describes the signs and symptoms of
emphasize a reduction in consumption heart attack
of red meats, which are high in saturated Skills
fats and cholesterol, and other foods Demonstrates readiness to learn and
containing sugar, saturated fats, trans identified their learning preferences
fats, and sodium. Demonstrates making food selections
Social and Cultural Considerations: that are low in saturated fats and high
Numerous studies point to the in polyunsaturated fats
prevalence of excess body weight in
American children and adolescents. Attitude
Experts estimate that obesity is present Displays an emotional response to the
in 25% of the population ages 6 to cardiac event that is appropriate to the
11 yr. The medical, social, and emo- circumstances
tional consequences of excess body Complies with recommended lifestyle
weight are significant. Special attention alterations and involvement in cardiac
should be given to instructing the child rehabilitation
and caregiver regarding health risks
RELATED MONOGRAPHS:
and weight-control education.
Recognize anxiety related to test Related tests include antiarrhythmic
results, and be supportive of fear of drugs, apolipoprotein A and B, AST,
shortened life expectancy. ANP, blood gases, BNP, calcium, cho-
Depending on the results of this proce- lesterol (HDL and LDL), CT cardiac
dure, additional testing may be performed scoring, CRP, CK and isoenzymes,
to evaluate or monitor progression of the echocardiography, glucose, glycated
disease process and determine the need hemoglobin, Holter monitor, homocys-
for a change in therapy. Evaluate test teine, ketones, LDH and isoenzymes,
results in relation to the patients symp- lipoprotein electrophoresis, MRI chest,
toms and other tests performed. magnesium, MI scan, myocardial per-
fusion heart scan, myoglobin, PET
Patient Education: heart, potassium, triglycerides, and
Discuss the implications of abnormal troponin.
test results on the patients lifestyle. Refer to the Cardiovascular,
Provide teaching and information Gastrointestinal, and Hepatobiliary sys-
regarding the clinical implications of the tems tables at the end of the book for
test results, as appropriate. related tests by body system.
COMMON USE: To test for suspected chromosomal disorders that result in birth
defects such as Downs syndrome. C
SPECIMEN: Whole blood (2 mL) collected in a green-top (sodium heparin) tube.
C
Autosomal
Syndrome Chromosome Defect Features
Angleman Deletion 15q11q13 Developmental delays (physical
growth, communication, and motor
skills); hyperactive behavior;
overall happy demeanor with
frequent laughter and hand-
flapping actions; fascination with
water
Beckwith- Duplication 11p15 Macroglossia, omphalocele, earlobe
Wiedemann creases
Bloom Mutations of BLM, 15 Birth weight and length are below
normal and stature remains below
normal to adulthood; skin changes
in response to sun exposure;
increased risk of cancers which
develop early in life; high-pitched
voice; disctinctive facial features
(long, narrow face with a small jaw;
large nose and ears)
Canavan Mutations of ASPA, Developmental delays that become
17p13.3 obvious at 3 to 5 months of age;
hypotonia that contributes to
inability to roll over, sit upright,
or swallow; macrocephaly; and
intellectual disability
Cats eye Trisomy 2q11 Anal atresia, coloboma
Cri du chat Deletion 5p Catlike cry, microcephaly,
hypertelorism, intellectual disability,
retrognathia
Cystic fibrosis Mutations of CFTR, 7 Impaired transport of chloride affects
the movement of water in and out
of the cells lining the lungs and
pancreas. The result is production
of thick mucus that obstructs
airways and prevents normal
function of the affected organs;
life threatening, permanent lung
damage
Autosomal
Syndrome Chromosome Defect Features
DiGeorge Deletion 22q11.2 There is a wide variety in the type
and severity of problems
associated with this syndrome of
impaired development of body
systems, most commonly included:
cardiac abnormalities or defects, C
poor immune system function
(hypothymic or absent thymus),
cleft palate, hypoparathyroidism
(low calcium); behavioral disorders;
distinctive facial features (long face
with downturned mouth,
asymmetric face when crying,
microcephaly, hooded eye lids,
malformed ears)
Down Trisomy 21 Epicanthal folds, simian crease of
palm, flat nasal bridge, mental
retardation, congenital heart
disease
Edwards Trisomy 18 Micrognathia, clenched third/fourth
fingers with the fifth finger
overlapping, rocker-bottom feet,
mental retardation, congenital
heart disease
Gauchers Mutations of GBA, 1 Hepatomegaly and splenomegaly
related to accumulation of lipids;
anemia; thrombocytopenia; bone
disease (bone pain, fractures, and
arthritis).
Maple Syrup Mutations of Developmental delays; poor feeding;
BCKDHA, BCKDHB, lethargy; distinctive maple syrup
DBT, and DLD, 19 odor in urine
Miller-Dieker Deletion 17 Lissencephaly (incomplete or absent
development of the folds of the
cerebrum); microcephaly;
developmental delays, especially in
growth; intellectual disability with
seizures; difficulty feeding and
failure to thrive; cardiac
malformations
Niemann-Pick Chromosome 14q24.3 Both types demonstrate symptoms
(type C2), 18q11.2 that reflect abnormalities in liver
(type C1), 11p15.4 and lung function; blood tests show
p15.1 (types A & B) hyperlipidemia (cholesterol and
other fats) and thrombocytopenia
Autosomal
Syndrome Chromosome Defect Features
Pallister- Trisomy 12p Psychomotor delay, sparse anterior
Killian scalp hair, micrognathia, hypotonia
Patau Trisomy 13 Microcephaly, cleft palate or lip,
polydactyly, mental retardation,
congenital heart disease
C Prader-Willi Deletion 15q11q13 Delayed development; distinctive facial
features (narrow forehead, almond-
shaped eyes, triangular-shaped
mouth, diminished stature with small
hands and feet); hypotonia;
childhood development of an
insatiable appetite, hyperphagia, and
obesity; mild to moderate intellectual
disability; behavioral problems
(outbursts of anger and compulsive
behavior such as picking at the skin)
Smith- Deletion 17p11.2 The major features of this condition
Magenis include mild to moderate intellectual
disability, delayed speech and
language skills, distinctive facial
features, sleep disturbances, and
behavioral problems
Tay-Sachs Mutations of HEXA, Normal development until age 3 to
15q24.1 6 mo when development slows and
hypotonia affects motor skills such
as ability to turn over, sit upright, and
crawl; exaggerated startle reaction to
loud noises; seizures; eventual loss
of vision (cherry red spot upon eye
exam is characteristic) and hearing;
intellectual disability
Warkam Mosaic trisomy 8 Malformed ears, bulbous nose, deep
palm creases, absent or
hypoplastic patellae
Wolf- Deletion 4p16.3 Microcephaly, growth retardation,
Hirschhorn mental retardation, carp mouth
Sex-Chromosome
Syndrome Defect Features
Fragile X Xq27.3 Intellectual disability; autism and
autism spectrum disorders
XYY 47,XYY Tall, increased risk of behavior
problems
Klinefelter 47,XXY Hypogonadism, infertility,
underdeveloped secondary sex
characteristics, learning disabilities
Sex-Chromosome
Syndrome Defect Features
Rett Mutations of, Xq28 Severe and progressive
developmental problems related to
brain functions such as speech,
motor and intelligence begin after
6 to 18 mo of normal growth; brain
disorder almost exclusively affecting C
females; slower than normal
physical growth; microcephaly;
meaningful use of hands is lost in
early childhood and replaced by
repetitive random hand motions
such as clapping or wringing.
Triple X 47,XXX Increased risk of infertility and
learning disabilities
Ullrich-Turner 45,X Short, gonadal dysgenesis, webbed
neck, low posterior hairline, renal
and cardiovascular abnormalities
Clot Retraction
SYNONYM/ACRONYM: N/A.
Coagulation Factors
SYNONYM/ACRONYM: See table.
Responses in the
Presence of
Preferred Name Synonym Role in Modern Coagulation Cascade Model Factor Deficiency
Factor I Fibrinogen Assists in the formation of the fibrin clot PT prolonged,
Monograph_C_435-466.indd 442
aPTT prolonged
Factor II Prothrombin Prethrombin Assists factor Xa in formation of trace thrombin PT prolonged,
in the initiation phase and assists factors aPTT prolonged
VIIIa, IXa, Xa, and Va to form thrombin in the
propagation phase of hemostasis
Tissue factor Tissue factor Tissue thromboplastin Assists factor VII and Ca2+ in the activation of PT prolonged,
(formerly known factors IX and X during the initiation phase aPTT prolonged
as factor III) of hemostasis
Calcium (formerly Calcium Ca2+ Essential to the activation of multiple clotting N/A
known as factors
factor IV)
Factor V Proaccelerin Labile factor, Assists factors VIIIa, IXa, Xa, and II in the PT prolonged,
accelerator globulin formation of thrombin during the amplification aPTT prolonged
(AcG) and propagation phases of hemostasis
Factor VII Proconvertin Stabile factor, serum Assists tissue factor and Ca2+ in the activation PT prolonged,
prothrombin of factors IX and X aPTT normal
conversion accelerator,
autoprothrombin I
Factor VIII Antihemophilic Antihemophilic globulin Activated by trace thrombin during the initiation PT normal, aPTT
factor (AHF) (AHG), antihemophilic phase of hemostasis to amplify formation of prolonged
factor A, platelet additional thrombin
cofactor 1
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
29/10/14 6:39 PM
Coagulation Test
Responses in the
Presence of
Preferred Name Synonym Role in Modern Coagulation Cascade Model Factor Deficiency
Factor IX Plasma Christmas factor, Assists factors Va and VIIIa in the amplification PT normal, aPTT
Monograph_C_435-466.indd 443
thromboplastin antihemophilic factor phase and factors VIIIa, Xa, Va, and II to form prolonged
component B, platelet cofactor 2 thrombin in the propagation phase
(PTC)
Factor X Stuart-Prower Autoprothrombin III, Assists with formation of trace thrombin in the PT prolonged,
factor thrombokinase initiation phase and acts with factors VIIIa, aPTT prolonged
IXa, Va, and II to form thrombin in the
propagation phase
Factor XI Plasma Antihemophilic factor C Activated by thrombin produced in the extrinsic PT normal, aPTT
thromboplastin path-way to enhance production of additional prolonged
antecedent thrombin inside the fibrin clot via the intrinsic
(PTA) path-way; this factor also participates in
slowing down the process of fibrinolysis
Factor XII Hageman factor Glass factor, contact Contact activator of the kinin system (e.g., PT normal, aPTT
factor prekallikrein, and high-molecular-weight prolonged
kininogen)
Factor XIII Fibrin-stabilizing Laki-Lorand factor Activated by thrombin and assists in formation PT normal, aPTT
factor (FSF) (LLF), fibrinase, of bonds between fibrin strands to complete normal
plasma secondary hemostasis
transglutaminase
von Willebrand von Willebrand vWF Assists in platelet adhesion and thrombus Ristocetin cofactor
factor factor formation decreased
Coagulation Factors
443
29/10/14 6:39 PM
444 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
Coagulation Process
Tissue factor Contact activation
pathway pathway
(former extrinsic (former intrinsic
pathway) pathway)
XII
Initiation Phase Trauma
(Tissue factor bearing
C cells interact with
XIIa
Factor VII)
VII
XI
X TF-VIIa-Ca++ IX XIa
Xa VIII V
Amplification Prothrombin Trace
Phase (Factor II) thrombin
(Platelets become
activated by thrombin)
VIIIa Va IXa
Xa & Va
Common
pathway
Prothrombin Thrombin
(Factor II) (Factor IIa)
Fibrinogen Fibrin
(Factor I) (Factor IIa)
XIIIa XIII
value the information should be read Drugs that may decrease factor V
back to the caller to verify accuracy. levels include streptokinase.
Most policies require immediate notifi- Drugs that may decrease factor VII
cation of the primary HCP, Hospitalist, levels include acetylsalicylic acid,
or on-call HCP. Reported information asparaginase, cefamandole, ceftriax-
includes the patients name, unique one, dextran, dicumarol, gemfibrozil,
identifiers, critical value, name of the oral contraceptives, and warfarin.
person giving the report, and name of Drugs that may increase factor VIII
the person receiving the report. levels include chlormadinone. C
Documentation of notification should Drugs that may decrease factor VIII
be made in the medical record with levels include asparaginase.
the name of the HCP notified, time and Drugs that may increase factor IX
date of notification, and any orders levels include chlormadinone and
received. Any delay in a timely report oral contraceptives.
of a critical finding may require com- Drugs that may decrease factor IX
pletion of a notification form with levels include asparaginase and
review by Risk Management. warfarin.
Signs and symptoms of microvas- Drugs that may decrease factor X
cular thrombosis include cyanosis, levels include chlormadinone,
ischemic tissue necrosis, hemorrhag- dicumarol, oral contraceptives, and
ic necrosis, tachypnea, dyspnea, pul- warfarin.
monary emboli, venous distention, Drugs that may decrease factor XI
abdominal pain, and oliguria. Possible levels include asparaginase and
interventions include identification captopril.
and treatment of the underlying Drugs that may decrease factor XII
cause, support through administra- levels include captopril.
tion of required blood products Test results of patients on anticoag-
(cryoprecipitate or fresh frozen plas- ulant therapy are unreliable.
ma), and administration of heparin. Placement of tourniquet for longer
Cryoprecipitate may be a more effec- than 1 min can result in venous
tive product than fresh frozen plasma stasis and changes in the concen-
in cases where the fibrinogen level is tration of plasma proteins to be
less than 100 mg/dL, the minimum measured. Platelet activation may
level required for adequate hemosta- also occur under these conditions,
sis, because it delivers a concentrated causing erroneous results.
amount of fibrinogen without as Vascular injury during phlebotomy
much plasma volume. can activate platelets and coagulation
factors, causing erroneous results.
INTERFERING FACTORS Hemolyzed specimens must be
Drugs that may increase factor II rejected because hemolysis is an
levels include fluoxymesterone, indication of platelet and coagula-
methandrostenolone, nandrolone, tion factor activation.
and oxymetholone. Icteric or lipemic specimens inter-
Drugs that may decrease factor II fere with optical testing methods,
levels include warfarin. producing erroneous results.
Drugs that may increase factor V, Incompletely filled collection tubes,
VII, and X levels include anabolic specimens contaminated with hep-
steroids, fluoxymesterone, arin, clotted specimens, or unpro-
methandrostenolone, nandrolone, cessed specimens not delivered to
oral contraceptives, and the laboratory within 1 to 2 hr of
oxymetholone. collection should be rejected.
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COMMON USE: To identify and confirm the presence of viral infections such as
found in atypical pneumonia. C
SPECIMEN: Serum (2 mL) collected in a red-top tube. The tube must be placed
in a water bath or heat block at 37C for 1 hr and allowed to clot before the
serum is separated from the red blood cells (RBCs).
PRETEST: POST-TEST:
Positively identify the patient using at Inform the patient that a report of the
least two unique identifiers before pro- results will be made available to the
viding care, treatment, or services. requesting health-care provider (HCP),
Patient Teaching: Inform the patient this who will discuss the results with the
test can assist in diagnosing osteopo- patient.
rosis and evaluating the effectiveness Nutritional Considerations: Increased NTx
of therapy. levels may be associated with osteopo-
Obtain a history of the patients rosis. Nutritional therapy may be indi-
complaints, including a list of known cated for patients identified as being at
C
allergens. high risk for developing osteoporosis.
Obtain a history of the patients Educate the patient about the National
musculoskeletal system and results Osteoporosis Foundations guidelines
of previously performed laboratory regarding a regular regimen of weight-
tests and diagnostic and surgical bearing exercises, limited alcohol intake,
procedures. avoidance of tobacco products, and
Obtain a list of the patients current adequate dietary intake of vitamin D
medications, including herbs, nutri- and calcium. Dietary calcium can be
tional supplements, and nutraceuticals obtained in animal or plant sources.
(see Appendix H online at DavisPlus). Milk and milk products, sardines, clams,
Review the procedure with the patient. oysters, salmon, rhubarb, spinach, beet
Inform the patient that specimen greens, broccoli, kale, tofu, legumes,
collection takes approximately 5 to and fortified orange juice are high in
10 min. Address concerns about pain calcium. Milk and milk products also
and explain that there should be no contain vitamin D and lactose to assist
discomfort during the procedure. in absorption. Cooked vegetables yield
Sensitivity to social and cultural issues, more absorbable calcium than raw
as well as concern for modesty, is vegetables. Patients should also be
important in providing psychological informed of the substances that can
support before, during, and after the inhibit calcium absorption by irreversibly
procedure. binding to some of the calcium and
Note that there are no food, fluid, making it unavailable for absorption,
or medication restrictions unless by such as oxalates, which naturally occur
medical direction. in some vegetables (e.g., beet greens,
collards, leeks, okra, parsley, quinoa,
INTRATEST: spinach, Swiss chard) and are found in
tea; phytic acid, found in some cereals
Potential Complications: N/A (e.g., wheat bran, wheat germ); phos-
Instruct the patient to cooperate fully phoric acid, found in dark cola; and
and to follow directions. excessive intake of insoluble dietary
Observe standard precautions, and fol- fiber (in excessive amounts). Excessive
low the general guidelines in Appendix protein intake also can affect calcium
A. Positively identify the patient, and absorption negatively, especially if it is
label the appropriate specimen con- combined with foods high in phospho-
tainer with the corresponding patient rus. Vitamin D is synthesized by the
demographics, initials of the person skin and is available in fortified dairy
collecting the specimen, date, and foods and cod liver oil.
time of collection. Recognize anxiety related to test
Instruct the patient to collect a second- results, and be supportive of impaired
void morning specimen as follows: activity related to lack of muscular con-
(1) void and then drink a glass of trol, perceived loss of independence,
water; (2) wait 30 min, and then try and fear of shortened life expectancy.
to void again. Depending on the results of this
Promptly transport the specimen procedure, additional testing may be
to the laboratory for processing performed to evaluate or monitor
and analysis. progression of the disease process
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Colonoscopy
SYNONYM/ACRONYM: Full colonoscopy, lower endoscopy, lower panendoscopy.
COMMON USE: To visualize and assess the lower colon for tumor, cancer, and
infection.
CONTRAST: Air.
CONTRAST: N/A.
Abnormal findings in
Color perception tests are per- Identification of some but not
formed to determine the acuity of all colors
color discrimination. The most
common test uses pseudoisochro- CRITICAL FINDINGS: N/A
mic plates with numbers or let-
ters buried in a maze of dots. INTERFERING FACTORS
Misreading the numbers or letters Inability of the patient to cooperate
C indicates a color perception defi- or remain still during the proce-
ciency and may indicate color dure because of age, significant
blindness, a genetic dysfunction, pain, or mental status.
or retinal pathology. Inability of the patient to read.
Color perception is important Poor visual acuity or poor lighting.
in some occupations and testing Failure of the patient to wear
for color perception may be a corrective lenses (glasses or
requirement for employment, contact lenses).
especially for health-care workers Damaged or discolored test plates.
whose responsibilities include
assessment and monitoring of
symptoms or changes in patients
conditions. Some common exam- NURSING IMPLICATIONS
ples of color based assessments in AND PROCEDURE
a health-care environment include
interpreting the results of color PRETEST:
pads on blood or urine test strips, Positively identify the patient using at
identifying changes in body color least two unique identifiers before pro-
(e.g. pallor, cyanosis, jaundice), viding care, treatment, or services.
determining the presence of Patient Teaching: Inform the patient or
blood or bile in body fluids and parent/child this procedure can assist
feces, or evaluating pH test strips in detection of color vision impairment.
to verify correct placement of a Obtain a history of the patients
complaints, including a list of known
nasopharyngeal tube.
allergens.
Obtain a history of the patients known
or suspected vision loss; changes in
This procedure is visual acuity, including type and cause;
contraindicated for: N/A use of glasses or contact lenses; eye
conditions with treatment regimens;
INDICATIONS eye surgery; and other tests and
Detect deficiencies in color procedures to assess and diagnose
perception visual deficit.
Evaluate because of family history Obtain a history of symptoms and
results of previously performed labora-
of color visual defects tory tests and diagnostic and surgical
Investigate suspected retinal pathol- procedures.
ogy affecting the cones Obtain a list of the patients current
medications, including herbs, nutri-
POTENTIAL DIAGNOSIS tional supplements, and nutraceuticals
(see Appendix H online at DavisPlus).
Normal findings in Review the procedure with the patient.
Normal visual color discrimination; Ask the patient if he or she wears cor-
no difficulty in identification of rective lenses; also inquire about the
color combinations importance of color discrimination in
his or her work, as applicable. Address requesting HCP, who will discuss the
concerns about pain and explain that results with the patient.
no discomfort will be experienced dur- Recognize anxiety related to test
ing the test. Inform the patient that a results and be supportive of impaired
health-care provider (HCP) performs activity related to color vision loss.
the test in a quiet, darkened room, and Discuss the implications of abnormal
that to evaluate both eyes, the test can test results on the patients lifestyle.
take 5 to 15 or up to 30 min, depend- Provide teaching and information
ing on the complexity of testing regarding the clinical implications of the
required. test results, as appropriate. Provide C
Sensitivity to social and cultural issues,as contact information regarding vision
well as concern for modesty, is impor- aids for people with impaired color per-
tant in providing psychological support ception, if desired: ABLEDATA (spon-
before, during, and after the procedure. sored by the National Institute on
Note that there are no food, fluid, or Disability and Rehabilitation Research
medication restrictions unless by medi- [NIDRR], available at www.abledata
cal direction. .com).
Reinforce information given by the
INTRATEST: patients HCP regarding further testing,
Potential Complications: N/A treatment, or referral to another HCP.
Answer any questions or address
Observe standard precautions, and fol- any concerns voiced by the patient or
low the general guidelines in Appendix family.
A. Positively identify the patient. Depending on the results of this
Instruct the patient to cooperate fully procedure, additional testing may be
and to follow directions. performed to evaluate or monitor pro-
Seat the patient comfortably. Occlude gression of the disease process and
one eye and hold test booklet 12 to 14 determine the need for a change in
in. in front of the exposed eye. therapy. Evaluate test results in relation
Ask the patient to identify the numbers to the patients symptoms and other
or letters buried in the maze of dots or tests performed.
to trace the objects with a handheld
pointed object. RELATED MONOGRAPHS:
Repeat on the other eye. Related tests include refraction and
slit-lamp biomicroscopy.
POST-TEST: Refer to the Ocular System table at the
Inform the patient that a report of the end of the book for related tests by
results will be made available to the body system.
Colposcopy
SYNONYM/ACRONYM: Cervical biopsy, endometrial biopsy.
COMMON USE: To visualize and assess the cervix and vagina related to suspected
cancer or other disease.
CONTRAST: None.
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C3
C4
Diabetes
the complement system, but cells Myocardial infarction
in other tissues can also produce Pneumococcal pneumonia
C3. C3 is an essential activating Pregnancy
protein in the classic and alter- Rheumatic disease
nate complement cascades. It is Thyroiditis
decreased in patients with immu- Viral hepatitis
nological diseases, in whom it is C4
C consumed at an increased rate. C4 Certain malignancies
is produced primarily in the liver
Decreased in
but can also be produced by
Related to overconsumption during
monocytes, fibroblasts, and macro-
immune response
phages. C4 participates in the
classic complement pathway. C3 and C4
Hereditary deficiency (insufficient
production)
This procedure is Liver disease (insufficient production
contraindicated for: N/A related to damaged liver cells)
SLE
INDICATIONS C3
Detect genetic deficiencies Chronic infection (bacterial, parasitic,
Evaluate immunological diseases viral)
Postmembranoproliferative
POTENTIAL DIAGNOSIS glomerulonephritis
Poststreptococcal infection
Normal Acute Rheumatic arthritis
C4 and glomerulonephritis, C4
decreased membranous Angioedema (hereditary and acquired)
C3 glomerulonephritis, Autoimmune hemolytic anemia
immune complex Autoimmune thyroiditis
Cryoglobulinemia
diseases, SLE, C3
Glomerulonephritis
deficiency
Juvenile dermatomyositis
Decreased Immune complex
Meningitis (bacterial, viral)
C4 and diseases, Pneumonia
normal C3 cryoglobulinemia, Streptococcal or staphylococcal sepsis
C4 deficiency,
hereditary
CRITICAL FINDINGS: N/A
angioedema
Decreased Immune complex
C4 and diseases INTERFERING FACTORS
decreased Drugs that may increase C3 levels
C3 include cimetidine and cyclophos-
phamide.
Drugs that may decrease
Increased in C3 levels include danazol
Response to sudden increased and phenytoin.
demand Drugs that may increase C4 levels
C3 and C4 include cimetidine, cyclophospha-
Acute-phase reactions mide, and danazol.
C3 Drugs that may decrease
Amyloidosis C4 levels include dextran
Cancer and penicillamine.
Complement, Total
SYNONYM/ACRONYM: Total hemolytic complement, CH50, CH100.
C
This procedure is Infections (bacterial, parasitic,
contraindicated for: N/A viral; related to increased con-
sumption during immune
POTENTIAL DIAGNOSIS response)
Liver disease (related to decreased
Increased in
production by damaged liver cells)
Acute-phase immune response
Malignancy (related to consump-
(related to sudden response to
tion during cellular immune
increased demand)
response)
Decreased in Membranous glomerulonephritis
Autoimmune diseases (related to (related to consumption during
continuous demand) cellular immune response)
Autoimmune hemolytic anemia Rheumatoid arthritis (related to
(related to consumption during consumption during immune
hemolytic process) response)
Burns (related to increased SLE (related to consumption dur-
consumption from initiation of ing immune response)
complement cascade) Trauma (related to consumption
Cryoglobulinemia (related to during immune response)
increased consumption) Vasculitis (related to consumption
Hereditary deficiency (related to during cellular immune response)
insufficient
production) CRITICAL FINDINGS: N/A
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).
COMMON USE: To evaluate numerous conditions involving red blood cells, white
blood cells, and platelets. This test is also used to indicate inflammation, infec-
tion, and response to chemotherapy.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube or Microtainer.
Whole blood from a green-top (lithium or sodium heparin) tube may be sub-
mitted, but the following automated values may not be reported: white blood
cell (WBC) count, WBC differential, platelet count, immature platelet fraction
(IPF), and mean platelet volume.
Hemoglobin
Hematocrit
Note: See Complete Blood Count, Hematocrit monograph for more detailed information.
Conventional
Units WBC
Age 103/microL Neutrophils Lymphocytes Monocytes Eosinophils Basophils
Monograph_C_467-494.indd 472
Total Bands Segments (Absolute) and (Absolute) (Absolute) (Absolute)
Neutrophils (Absolute) (Absolute) % and % and % and %
(Absolute) and % and %
and %
Birth 9.130.1 (5.518.3) (0.82.7) (4.715.6) (2.89.3) (0.51.7) (0.020.7) (0.10.2)
61% 9.1% 52% 31% 5.8% 2.2% 0.6%
123 mo 6.117.5 (1.95.4) (0.20.5) (1.74.9) (3.710.7) (0.30.8) (0.20.5) (00.1)
31% 3.1% 28% 61% 4.8% 2.6% 0.5%
210 yr 4.513.5 (2.47.3) (0.10.4) (2.36.9) (1.75.1) (0.20.6) (0.10.3) (00.1)
54% 3% 51% 38% 4.3% 2.4% 0.5%
11 yrolder 4.511.1 (2.76.5) (0.10.3) (2.56.2) (1.53.7) (0.20.4) (0.050.5) (00.1)
adult 59% 3% 56% 34% 4.0% 2.7% 0.5%
Age Immature Granulocytes (Absolute) (103/microL) Immature Granulocyte Fraction (IGF) (%)
Birth9 yr 00.03 00.4%
10 yrolder adult 00.09 00.9%
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
29/10/14 6:41 PM
Complete Blood Count 473
Note: See Complete Blood Count, RBC Count monograph for more detailed information.
MCH MCHC
Age MCV (fl) (pg/cell) (g/dL) RDW RDWSD
Cord blood 107119 3539 3135 14.918.7 5166
01 wk 104116 2945 2436 14.918.7 5166
23 wk 95117 2638 2634 14.918.7 5166
12 mo 81125 2537 2634 14.918.7 4455
311 mo 78110 2234 2634 14.918.7 3546
15 yr 7494 2432 3034 11.614.8 3542
68 yr 7393 2432 3236 11.614.8 3542
914 yr 7494 2533 3236 11.614.8 3744
15 yradult
Male 7797 2634 3236 11.614.8 3848
Female 7898 2634 3236 11.614.8 3848
Older adult
Male 79103 2735 3236 11.614.8 3848
Female 78102 2735 3236 11.614.8 3848
Monograph_C_467-494.indd 474
Macrocytes 05 510 1020 2050 Greater than 50
Microcytes 05 510 1020 2050 Greater than 50
Shape
Poikilocytes 02 310 1020 2050 Greater than 50
Burr cells 02 310 1020 2050 Greater than 50
Acanthocytes Less than 1 25 510 1020 Greater than 20
Schistocytes Less than 1 25 510 1020 Greater than 20
Dacryocytes (teardrop cells) 02 25 510 1020 Greater than 20
Codocytes (target cells) 02 210 1020 2050 Greater than 50
Spherocytes 02 210 1020 2050 Greater than 50
Ovalocytes 02 210 1020 2050 Greater than 50
Stomatocytes 02 210 1020 2050 Greater than 50
Drepanocytes (sickle cells) Absent Reported as present or absent
Helmet cells Absent Reported as present or absent
Agglutination Absent Reported as present or absent
Rouleaux Absent Reported as present or absent
Hemoglobin Content
Hypochromia 02 310 1050 5075 Greater than 75
Polychromasia
Adult Less than 1 25 510 1020 Greater than 20
Newborn 16 715 1520 2050 Greater than 50
Note: See Complete Blood Count, RBC Morphology and Inclusions monograph for more detailed information.
Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
29/10/14 6:41 PM
Complete Blood Count 475
Within
Normal
Inclusions Limits 1+ 2+ 3+ 4+
Cabots rings Absent Reported as
present or absent
Basophilic 01 15 510 1020 Greater C
stippling than 20
Howell-Jolly Absent 12 35 510 Greater
bodies than 10
Heinz bodies Absent Reported as
present or absent
Hemoglobin C Absent Reported as
crystals present or absent
Pappenheimer Absent Reported as
bodies present or absent
Intracellular Absent Reported as
parasites (e.g., present or absent
Plasmodium,
Babesia,
trypanosomes)
Note: See Complete Blood Count, RBC Morphology and Inclusions monograph for more
detailed information.
Platelet Count
Note: See Complete Blood Count, Platelet Count monograph for more detailed information.
Platelet counts may decrease slightly with age.
value, name of the person giving the Patient Teaching: Inform the patient this
report, and name of the person receiving test can assist in evaluating general
the report. Documentation of notifica- health and the bodys response to illness.
tion should be made in the medical Obtain a history of the patients com-
plaints, including a list of known aller-
record with the name of the HCP noti- gens, especially allergies or sensitivities
fied, time and date of notification, and to latex.
any orders received.Any delay in a timely Obtain a history of the patients gastro-
report of a critical finding may require intestinal, hematopoietic, immune, and
C completion of a notification form with respiratory systems as well as results of
review by Risk Management. previously performed laboratory tests
The presence of abnormal cells, and diagnostic and surgical p rocedures.
other morphological characteristics, or Obtain a list of the patients current
cellular inclusions may signify a poten- medications, including herbs, nutri-
tional supplements, and nutraceuticals
tially life-threatening or serious health (see Appendix H online at DavisPlus).
condition and should be investigated. Review the procedure with the patient.
Examples are the presence of sickle Inform the patient that specimen collec-
cells, moderate numbers of spherocytes, tion takes approximately 5 to 10 min.
marked schistocytosis, oval macrocytes, Address concerns about pain and
basophilic stippling, eosinophil count explain that there may be some discom-
greater than 10%, monocytosis greater fort during the venipuncture.
than 15%, nucleated RBCs (if patient is Sensitivity to social and cultural issues,as
not an infant), malarial organisms, hyper- well as concern for modesty, is impor-
tant in providing psychological support
segmented neutrophils, agranular neu- before, during, and after the procedure.
trophils, blasts or other immature cells, Note that there are no food, fluid, or
Auer rods, Dhle bodies, marked toxic medication restrictions unless by
granulation, or plasma cells. medical direction.
analyzed within 24 hr, two blood smears Reinforce information given by the
should be made immediately after the patients HCP regarding further testing,
venipuncture and submitted with the treatment, or referral to another HCP.
blood sample. Smears made from spec- Answer any questions or address any
imens older than 24 hr may contain an concerns voiced by the patient or family.
unacceptable number of misleading arti- Depending on the results of this
factual abnormalities of the RBCs, such procedure, additional testing may be
as echinocytes and spherocytes, as well performed to evaluate or monitor pro-
as necrobiotic white blood cells. gression of the disease process and
Remove the needle and apply direct determine the need for a change in C
pressure with dry gauze to stop therapy. Evaluate test results in relation
bleeding. Observe/assess venipunc- to the patients symptoms and other
ture site for bleeding or hematoma tests performed.
formation and secure gauze with
adhesive bandage. RELATED MONOGRAPHS:
Promptly transport the specimen to the Related tests include alveolar arterial
laboratory for processing and analysis. ratio, biopsy bone marrow, blood
gases, blood groups and antibodies,
POST-TEST: erythropoietin, ferritin, CBC hematocrit,
Inform the patient that a report of the CBC hemoglobin, CBC platelet count,
results will be made available to the CBC RBC count, CBC RBC indices,
requesting HCP, who will discuss the CBC RBC morphology, CBC WBC
results with the patient. count and cell differential, iron/TIBC,
Nutritional Considerations: Instruct lead, pulse oximetry, reticulocyte
patients to consume a variety of foods count, and US abdomen.
within the basic food groups, maintain Refer to the Gastrointestinal,
a healthy weight, be physically active, Hematopoietic, Immune, and Respiratory
limit salt intake, limit alcohol intake, systems tables at the end of the book
and avoid use of tobacco. for related tests by body system.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube, Microtainer, or
capillary. Whole blood from a green-top (lithium or sodium heparin) tube may
also be submitted.
SI Units (Conventional
Age Conventional Units (%) Units 0.01)
Cord blood 4262 0.420.62
01 wk 4668 0.460.68
SI Units (Conventional
Age Conventional Units (%) Units 0.01)
23 wk 4056 0.410.56
12 mo 3254 0.320.54
3 mo5 yr 3143 0.310.43
68 yr 3341 0.330.41
914 yr 3345 0.330.45
C 15 yradult
Male 3851 0.380.51
Female 3345 0.330.45
Older adult
Male 3652 0.360.52
Female 3446 0.340.46
POTENTIAL DIAGNOSIS
should be within 3 times the Hgb
if the RBC population is normal in Increased in
size and shape. The Hct plus 6 Burns (related to dehydration;
should approximate the first two total blood volume is decreased,
figures of the RBC count within 3 but RBC count remains the same)
(e.g., Hct is 40%; therefore 40 + 6 = Congestive heart failure (when the
46, and the RBC count should be underlying cause is anemia, the
4.6 or in the range of 4.3 to 4.9). body responds by increasing pro- C
There are some cultural variations duction of RBCs with a corre-
in Hgb and Hct (H&H) values. sponding increase in Hct)
After the first decade of life, the Chronic obstructive pulmonary dis-
mean Hgb in African Americans is ease (related to chronic hypoxia
0.5 to 1 g lower than in whites. that stimulates production of
Mexican Americans and Asian RBC and a corresponding
Americans have higher H&H increase in Hct)
values than whites. Dehydration (total blood volume
is decreased, but RBC count
remains the same)
This procedure is Erythrocytosis (total blood volume
contraindicated for: N/A remains the same, but RBC count
is increased)
INDICATIONS Hemoconcentration (same effect
Detect hematological disorder, neo- as seen in dehydration)
plasm, or immunological abnormality High altitudes (related to
Determine the presence of heredi- hypoxia that stimulates produc-
tary hematological abnormality tion of RBC and therefore
Evaluate known or suspected increases Hct)
anemia and related treatment, in Polycythemia (abnormal bone
combination with Hgb marrow response resulting in
Monitor blood loss and response to overproduction of RBC)
blood replacement, in combination Shock
with Hgb
Monitor the effects of physical or Decreased in
emotional stress on the patient Anemia (overall decrease in
Monitor fluid imbalances or their RBC and corresponding decrease
treatment in Hct)
Monitor hematological status during Blood loss (acute and chronic)
pregnancy, in combination with Hgb (overall decrease in RBC
Monitor the progression of and corresponding decrease
nonhematological disorders such in Hct)
as chronic obstructive pulmonary Bone marrow hyperplasia (bone
disease, malabsorption syndromes, marrow failure that results in
cancer, and renal disease decreased RBC production)
Monitor response to drugs or che- Carcinoma (anemia is often
motherapy, and evaluate undesired associated with chronic
reactions to drugs that may cause disease)
blood dyscrasias Cirrhosis (related to accumula-
Provide screening as part of a CBC tion of fluid)
in a general physical examination, Chronic disease (anemia is
especially upon admission to a often associated with chronic
health-care facility or before surgery disease)
Access additional resources at davisplus.fadavis.com
Fluid retention (dilutional effect Greater than 60% (SI: Greater than
of increased blood volume while 0.6 L/L)
RBC count remains stable)
Newborns
Hemoglobinopathies (reduced
Less than 28.5% (SI: Less than
RBC survival with corresponding
0.28 L/L)
decrease in Hgb)
Greater than 66.9% (SI: Greater
Hemolytic disorders (e.g., hemolyt-
than 0.67 L/L)
ic anemias, prosthetic valves)
C (reduced RBC survival with cor- Consideration may be given to verify-
responding decrease in Hct) ing the critical findings before action is
Hemorrhage (acute and chronic) taken. Policies vary among facilities
(related to loss of RBC that and may include requesting immediate
exceeds rate of production) recollection and retesting by the labo-
Hodgkins disease (bone marrow ratory or retesting using a rapid Point
failure that results in decreased of Care instrument at the bedside.
RBC production) Note and immediately report to
Incompatible blood transfusion the health-care provider (HCP) any
(reduced RBC survival with cor- critically increased or decreased val-
responding decrease in Hgb) ues and related symptoms.
Intravenous overload (dilutional It is essential that a critical finding
effect) be communicated immediately to the
Fluid retention (dilutional effect requesting health-care provider (HCP).
of increased blood volume while A listing of these findings varies among
RBC count remains stable) facilities.
Leukemia (bone marrow failure Timely notification of a critical
that results in decreased RBC finding for lab or diagnostic studies is
production) a role expectation of the professional
Lymphomas (bone marrow failure nurse. Notification processes will vary
that results in decreased RBC among facilities. Upon receipt of the
production) critical value the information should
Nutritional deficit (anemia related be read back to the caller to verify
to dietary deficiency in iron, vita- accuracy. Most policies require imme-
mins, folate needed to produce diate notification of the primary HCP,
sufficient RBC; decreased RBC Hospitalist, or on-call HCP. Reported
count with corresponding information includes the patients
decrease in Hct) name, unique identifiers, critical value,
Pregnancy (related to anemia) name of the person giving the report,
Renal disease (related to and name of the person receiving the
decreased levels of erythropoie- report. Documentation of notification
tin, which stimulates production should be made in the medical record
of RBCs) with the name of the HCP notified,
Splenomegaly (total blood volume time and date of notification, and any
remains the same, but spleen orders received. Any delay in a timely
retains RBCs and Hct reflects report of a critical finding may require
decreased RBC count) completion of a notification form with
review by Risk Management.
Low Hct leads to anemia. Anemia
CRITICAL FINDINGS
can be caused by blood loss, decreased
Adults & children blood cell production, increased blood
Less than 19.8% (SI: Less than 0.2 L/L) cell destruction, and hemodilution.
COMMON USE: To assist in diagnosing and evaluating treatment for blood disor-
ders such as thrombocytosis and thrombocytopenia and to evaluate preproce- C
dure or preoperative coagulation status.
SI Units
(Conventional
Age Platelet Count* Units 1) MPV (fL) IPF (%)
Newborn
Male 150350 103/microL 150350 109/L 7.110.2 1.17.1
Female 235345 103/microL 235345 109/L 7.310.2 1.17.1
12 mo
Male 275565 103/microL 275565 109/L 7.111.3 1.17.1
Female 295615 103/microL 295615 109/L 7.49.7 1.17.1
36 mo
Male 275565 103/microL 275565 109/L 6.89.1 1.17.1
Female 288598 103/microL 288598 109/L 7.28.9 1.17.1
723 mo
Male 220450 103/microL 220450 109/L 7.19.3 1.17.1
Female 230465 103/microL 230465 109/L 7.19.3 1.17.1
26 yr
Male & 205405 103/microL 205405 109/L 7.19.3 1.17.1
Female
712 yr
Male 195365 103/microL 195365 109/L 7.29.4 1.17.1
Female 185370 103/microL 185370 109/L 7.19.2 1.17.1
1218 yr
Male 165332 103/microL 165332 109/L 7.39.7 1.17.1
Female 185335 103/microL 185335 109/L 7.59.3 1.17.1
Adult/
Older
adult
Male & 150450 103/microL 150450 109/L 7.110.2 1.17.1
Female
COMMON USE: To evaluate the number of circulating red cells in the blood
toward diagnosing disease and monitoring therapeutic treatment. Variations in
the number of cells is most often seen in anemias, cancer, and hemorrhage.
deficiency is the most common eggs, meats, fish, and green leafy
nutrient deficiency in the United vegetables. Vitamin E is fairly stable
States. Patients at risk (e.g., chil- at most cooking temperatures
dren, pregnant women and women (except frying) and when exposed to
of childbearing age, low-income acidic foods. Supplemental vitamin E
populations) should be instructed may also be taken, but the danger
to include foods that are high in of toxicity should be explained to the
iron in their diet, such as meats patient. Very large supplemental
(especially liver), eggs, grains, green doses, in excess of 600 mg of vita-
leafy vegetables, and multivitamins min E over a period of 1 yr, may C
with iron. Iron absorption is affected result in excess bleeding. Vitamin E
by numerous factors (see mono- is heat stable but is very negatively
graph titled Iron). affected by light.
Nutritional Considerations: Patients at Reinforce information given by the
risk for vitamin B12 or folate deficiency patients HCP regarding further test-
include those with the following condi- ing, treatment, or referral to another
tions: malnourishment (inadequate HCP. Answer any questions or
intake), pregnancy (increased need), address any concerns voiced by the
infancy, malabsorption syndromes patient or family. Educate the patient
(inadequate absorption/increased regarding access to nutritional coun-
metabolic rate), infections, cancer, seling services. Provide contact infor-
hyperthyroidism, serious burns, mation, if desired, for the Institute of
excessive blood loss, and gastrointes- Medicine of the National Academies
tinal damage. Instruct the patient with (www.iom.edu).
vitamin B12 deficiency, as appropriate, Depending on the results of this
in the use of vitamin supplements. procedure, additional testing may be
Inform the patient, as appropriate, performed to evaluate or monitor
that the best dietary sources of vita- progression of the disease process
min B12 are meats, milk, cheese, and determine the need for a change
eggs, and fortified soy milk products. in therapy. Evaluate test results in
Instruct the folate-deficient patient relation to the patients symptoms
(especially pregnant women), as and other tests performed.
appropriate, to eat foods rich in folate,
such as meats (especially liver), RELATED MONOGRAPHS:
salmon, eggs, beets, asparagus, Related tests include biopsy bone
green leafy vegetables such as spin- marrow, biopsy kidney, blood groups
ach, cabbage, oranges, broccoli, and antibodies, CBC, CBC hematocrit,
sweet potatoes, kidney beans, and CBC hemoglobin, CBC RBC morphol-
whole wheat. ogy and inclusions, Coombs antiglob-
Nutritional Considerations: A diet ulin, erythropoietin, fecal analysis, ferri-
deficient in vitamin E puts the tin, folate, gallium scan, haptoglobin,
patient at risk for increased RBC iron/TIBC, lymphangiogram, Meckels
destruction, which could lead to diverticulum scan, reticulocyte count,
anemia. Nutritional therapy may be and vitamin B12.
indicated for these patients. Educate Refer to the Cardiovascular,
the patient with a vitamin E defi- Gastrointestinal, Genitourinary,
ciency, if appropriate, that the main Hematopoietic, Hepatobiliary, Immune,
dietary sources of vitamin E are veg- and Respiratory systems tables at the
etable oils including olive oil), whole end of the book for related tests by
grains, wheat germ, nuts, milk, body system.
MCV = mean corpuscular volume; MCH = mean corpuscular hemoglobin; MCHC = mean
corpuscular hemoglobin concentration; RDWCV = coefficient of variation in red blood cell
distribution width; RDWSD = standard deviation in RBC distribution width index.
COMMON USE: To make a visual evaluation of the red cell shape and/or size as a
confirmation in assisting to diagnose and monitor disease progression.
SPECIMEN: Whole blood from one full lavender-top (EDTA) tube or Wrights-
stained, thin-film peripheral blood smear. The laboratory should be consulted
as to the necessity of thick-film smears for the evaluation of malarial inclusions.
Chemotherapy
DESCRIPTION:The decision to Chronic hemolytic anemia
manually review a peripheral Grossly elevated glucose
blood smear for abnormalities in (hyperosmotic)
red blood cell (RBC) shape or Hemolytic disease of the newborn
size is made on the basis of cri- Hypothyroidism
teria established by the report- Leukemia
ing laboratory. Cues in the Lymphoma
C results of the complete blood Metastatic carcinoma
count (CBC) will point to specif- Myelofibrosis
ic abnormalities that can be con- Myeloma
firmed visually by microscopic Refractory anemia
review of the sample on a Sideroblastic anemia
stained blood smear. Vitamin B12/folate deficiency
(related to impaired DNA
This procedure is synthesis and delayed cell divi-
contraindicated for: N/A sion, which permits the cells to
grow for a longer period than
INDICATIONS normal)
Assist in the diagnosis of anemia
Decreased in
Detect a hematological disorder,
neoplasm, or immunological Cell Size
abnormality Hemoglobin C disease
Determine the presence of Hemolytic anemias
a hereditary hematological Hereditary spherocytosis
abnormality Inflammation
Monitor the effects of physical or Iron-deficiency anemia
emotional stress on the patient Thalassemias
Monitor the progression of non-
hematological disorders, such as Red Blood Cell Shape
chronic obstructive pulmonary Variations in cell shape are the
disease, malabsorption syndromes, result of hereditary conditions such
cancer, and renal disease as elliptocytosis, sickle cell anemia,
Monitor the response to drugs spherocytosis, thalassemias, or
or chemotherapy, and evaluate hemoglobinopathies (e.g., hemoglo-
undesired reactions to drugs that bin C disease). Irregularities in cell
may cause blood dyscrasias shape can also result from acquired
Provide screening as part of a CBC conditions, such as physical/
in a general physical examination, mechanical cellular trauma, expo-
especially upon admission to a sure to chemicals, or reactions to
health-care facility or before surgery medications.
Acquired spherocytosis can result
POTENTIAL DIAGNOSIS from Heinz body hemolytic anemia,
microangiopathic hemolytic ane-
Red Blood Cell Size
mia, secondary isoimmunohemolyt-
Increased in ic anemia, and transfusion of old
banked blood.
Cell Size Acanthocytes are associated with
Alcoholism acquired conditions such as alco-
Aplastic anemia holic cirrhosis with hemolytic
COMMON USE: To evaluate viral and bacterial infections and to assist in diagnos-
ing and monitoring leukemic disorders.
Conventional
Units WBC
Age 103/microL Neutrophils Lymphocytes Monocytes Eosinophils Basophils
(Absolute) and % (Absolute) and % (Absolute) and % (Absolute) and % (Absolute) and %
Birth 9.130.1 (5.518.3) 2458% (2.89.3) 2656% (0.51.7) 713% (0.020.7) 08% (0.10.2) 02.5%
123 mo 6.117.5 (1.95.4) 2167% (3.710.7) 2064% (0.30.8) 411% (0.20.5) 03.3% (00.1) 01%
210 yr 4.513.5 (2.47.3) 3077% (1.75.1) 1450% (0.20.6) 49% (0.10.3) 05.8% (00.1) 01%
11 yrolder 4.511.1 (2.76.5) 4075% (1.53.7) 1244% (0.20.4) 49% (0.050.5) 05.5% (00.1) 01%
adult
29/10/14 7:11 PM
522 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
C
DESCRIPTION: White blood cells blood cell inclusions and may not
(WBCs) constitute the bodys pri- be identified in the interpretation
mary defense system against for- of an automated blood count.The
eign organisms, tissues, and other decision to report a manual or
substances.The life span of a nor- automated differential is based on
mal WBC is 13 to 20 days. Old specific criteria established by the
WBCs are destroyed by the lym- laboratory.The criteria are
phatic system and excreted in the designed to identify findings that
feces. Reference values for WBC warrant further investigation or
counts vary significantly with age. confirmation by manual review. An
WBC counts vary diurnally, with increased WBC count is termed
counts being lowest in the morn- leukocytosis, and a decreased WBC
ing and highest in the late after- count is termed leukopenia. A total
noon. Other variables such as stress WBC count indicates the degree of
and high levels of activity or physi- response to a pathological process,
cal exercise can trigger transient but a more complete evaluation for
increases of 25 103/ microL.The specific diagnoses for any one
main WBC types are neutrophils disorder is provided by the differ-
(band and segmented neutrophils), ential count.The WBCs in the
eosinophils, basophils, monocytes, count and differential are reported
and lymphocytes. WBCs are pro- as an absolute value and as a per-
duced in the bone marrow. B-cell centage.The relative percentages
lymphocytes remain in the bone of cell types are arrived at by bas-
marrow to mature.T-cell lympho- ing the enumeration of each cell
cytes migrate to and mature in the type on a 100-cell count.The abso-
thymus.The WBC count can be lute value is obtained by multiply-
performed alone with the differen- ing the relative percentage
tial cell count or as part of the value of each cell type by the total
complete blood count (CBC).The WBC count. For example, on a
WBC differential can be performed CBC report, with a total WBC of
by an automated instrument or 9 103/microL and WBC differen-
manually on a slide prepared from tial with 92% segmented neutro-
a stained peripheral blood sample. phils, 1% band neutrophils, 5%
Automated instruments provide lymphocytes, and 1% monocytes
excellent, reliable information, but the absolute values are calculated
the accuracy of the WBC count can as follows: 92/100 9 = 8.3 segs,
be affected by the presence of cir- 1/100 9 = 0.1 bands, 5/100 9
culating nucleated red blood cells = 0.45 lymphs, 1/100 9 = 0.1
(RBCs), clumped platelets, fibrin monos for a total of 9.0 WBC
strands, cold agglutinins, cryoglobu- count.The absolute neutrophil
lins, intracellular parasitic count (ANC) for this patient would
organisms, or other significant be 9 (.92+.1) = 8.4.
The absolute neutrophil count are called bands and can repre-
(ANC) reflects the number of seg- sent 35% of total circulating neu-
mented and band type neutrophils trophils in healthy individuals.
in the total WBC count. It is used Bandemia is defined by the pres-
as an indicator of immune status ence of greater than 610% band
because it reflects the type and neutrophils in the total neutrophil
number of WBC available to rapid- cell population.These changes in
ly respond to an infection. the white cell population are most C
Neutropenia is a decrease below commonly associated with an
normal in the number of neutro- infectious process, usually bacterial,
phils. ANC = Total WBC but they can occur in healthy indi-
((Segs/100) + (Bands/100)) or total viduals who are under stress (in
WBC (% Segs + % Bands). The response to epinephrine produc-
normal value varies with age but tion), such as women in childbirth
in general mild neutropenia is less and very young infants.The WBC
than 1.5, moderate neutropenia is count and differential of a woman
between 0.5 and 1, and severe in labor or of an actively crying
neutropenia is less than 0.5. The infant may show an overall increase
ANC is helpful when managing in WBCs with a shift to the left.
patients receiving chemotherapy. Before initiating any kind of inter-
It can drive decisions to place a vention, it is important to deter-
hospitalized patient in isolation in mine whether an increased WBC
order to protect them from expo- count is the result of a normal
sure to infectious agents. When the condition involving physiological
patient is aware of their ANC they stress or a pathological process.
can also make informed decisions The use of multiple specimen
in taking actions to avoid exposure types may confuse the interpreta-
to crowds, avoid touching things tion of results in infants. Multiple
in public places that may carry samples from the same collection
germs, or avoiding friends and fam- site (i.e., capillary versus venous)
ily who may be sick. may be necessary to obtain an
Acute leukocytosis is initially accurate assessment of the WBC
accompanied by changes in the picture in these young patients.
WBC count population, followed Neutrophils are normally
by changes within the individual found as the predominant WBC
WBCs. Leukocytosis usually occurs type in the circulating blood. Also
by way of increase in a single WBC called polymorphonuclear cells,
family rather than a proportional they are the bodys first line of
increase in all cell types.Toxic gran- defense through the process of
ulation and vacuolation are com- phagocytosis. They also contain
monly seen in leukocytosis accom- enzymes and pyogenes, which
panied by a shift to the left, or combat foreign invaders.
increase in the percentage of imma- Lymphocytes are agranular,
ture neutrophils to mature seg- mononuclear blood cells that are
mented neutrophils. An increased smaller than granulocytes. They
number or percentage of immature are found in the next highest
granulocytes, reflected by a shift to percentage in normal circulation.
the left, represents production of Lymphocytes are classified as
WBCs and is useful as an indicator B cells and T cells. Both types are
of infection. Immature neutrophils formed in the bone marrow, but
This procedure is
B cells mature in the bone mar- contraindicated for: N/A
row and T cells mature in the
thymus. Lymphocytes play a major
INDICATIONS
role in the bodys natural defense
Assist in confirming suspected
system. B cells differentiate into
bone marrow depression
immunoglobulin-synthesizing plas-
Assist in determining the cause of
ma cells. T cells function as cellu-
an elevated WBC count (e.g., infec-
C lar mediators of immunity and
tion, inflammatory process)
comprise helper/inducer (CD4)
Detect hematological disorder,
lymphocytes, delayed hypersensi-
neoplasm, or immunological
tivity lymphocytes, cytotoxic
abnormality
(CD8 or CD4) lymphocytes, and
Determine the presence of a
suppressor (CD8) lymphocytes.
hereditary hematological
Monocytes are mononuclear
abnormality
cells similar to lymphocytes, but
Monitor the effects of physical or
they are related more closely to
emotional stress
granulocytes in terms of their func-
Monitor the progression of nonhe-
tion.They are formed in the bone
matological disorders, such as
marrow from the same cells as
chronic obstructive pulmonary
those that produce neutrophils.The
disease, malabsorption syndromes,
major function of monocytes is
cancer, and renal disease
phagocytosis. Monocytes stay in the
Monitor the response to drugs or
peripheral blood for about 70 hr,
chemotherapy and evaluate unde-
after which they migrate into the
sired reactions to drugs that may
tissues and become macrophages.
cause blood dyscrasias
The function of eosinophils is
Provide screening as part of a
phagocytosis of antigen-antibody
CBC in a general physical
complexes.They become active in
examination, especially on admis-
the later stages of inflammation.
sion to a health-care facility or
Eosinophils respond to allergic and
before surgery
parasitic diseases:They have gran-
ules that contain histamine used to
kill foreign cells in the body and POTENTIAL DIAGNOSIS
proteolytic enzymes that damage Increased in
parasitic worms (see monograph
titled Eosinophil Count). Leukocytosis
Basophils are found in small Normal physiological and environ-
numbers in the circulating blood. mental conditions:
They have a phagocytic function Early infancy (increases are believed to
and, similar to eosinophils, contain be related to the physiological stress
numerous specific granules. of birth and metabolic demands of
Basophilic granules contain hepa- rapid development)
rin, histamines, and serotonin. Emotional stress (related to secretion of
Basophils may also be found in tis- epinephrine)
sue and as such are classified as Exposure to extreme heat or cold
mast cells. Basophilia is noted in (related to physiological stress)
conditions such as leukemia, Pregnancy and labor (WBC counts may
Hodgkins disease, polycythemia be modestly elevated due to increased
neutrophils into the third trimester and
vera, ulcerative colitis, nephrosis,
during labor, returning to normal within
and chronic hypersensitivity states.
a week postpartum)
requesting HCP, who will discuss the whole grains, coffee, cocoa, or tea)
results with the patient. bind zinc and prevent it from being
Nutritional Considerations: Infection, fever, absorbed. Decreases in zinc also can
sepsis, and trauma can result in an be induced by increased intake of iron,
impaired nutritional status. Malnutrition copper, or manganese. Vitamin and
can occur for many reasons, including mineral supplements with a greater
fatigue, lack of appetite, and gastroin- than 3:1 iron/zinc ratio inhibit zinc
testinal distress. absorption.
Nutritional Considerations: Adequate Recognize anxiety related to test
intake of vitamins A and C, and zinc results, and be supportive of fear of C
are also important for regenerating shortened life expectancy.
body stores depleted by the effort Depending on the results of this
exerted in fighting infections. procedure, additional testing may be
Educate the patient or caregiver performed to evaluate or monitor pro-
regarding the importance of following gression of the disease process and
the prescribed diet. determine the need for a change in
Nutritional Considerations: Educate therapy. Evaluate test results in relation
the patient with vitamin A deficiency, to the patients symptoms and other
as appropriate, that the main dietary tests performed.
source of vitamin A comes from caro-
tene, a yellow pigment noticeable in Patient Education:
most fruits and vegetables, especially Discuss the implications of
carrots, sweet potatoes, squash, apri- abnormal test results on the patients
cots, and cantaloupe. It is also pres- lifestyle.
ent in spinach, collards, broccoli, and Provide teaching and information
cabbage. This vitamin is fairly stable regarding the clinical implications of the
at most cooking temperatures, but it test results, as appropriate.
is destroyed easily by light and Educate the patient regarding access
oxidation. to counseling services.
Provide contact information, if desired,
Vitamin C for the National Cancer Institute
Nutritional Considerations: Educate the (www.nci.nih.org) and for the Institute
patient with vitamin C deficiency, as of Medicine of the National Academies
appropriate, that citrus fruits are (www.iom.edu).
excellent dietary sources of vitamin C. Reinforce information given by the
Other good sources are green and patients HCP regarding further
red peppers, tomatoes, white pota- testing, treatment, or referral to
toes, cabbage, broccoli, chard, kale, another HCP.
turnip greens, asparagus, berries, Answer any questions or address
melons, pineapple, and guava. any concerns voiced by the patient or
Vitamin C is destroyed by exposure to family.
air, light, heat, or alkalis. Boiling water Expected Patient Outcomes:
before cooking eliminates dissolved
oxygen that destroys vitamin C in the Knowledge
process of boiling. Vegetables should States understanding of the signs and
be crisp and cooked as quickly as symptoms of infection
possible. States understanding of the impor-
Nutritional Considerations: Topical or oral tance of compliance with follow-up
supplementation may be ordered for laboratory tests to manage disease
patients with zinc deficiency. Dietary process
sources high in zinc include shellfish, Skills
red meat, wheat germ, nuts, and pro- Demonstrates proficiency in taking
cessed foods such as canned pork prescribed antibiotics
and beans and canned chili. Patients Demonstrates proficiency in taking and
should be informed that phytates (from recording temperature
COMMON USE: To visualize and assess abdominal structures and to assist in diag-
nosing tumors, bleeding, and abscess. Used as an evaluation tool for surgical,
radiation, and medical therapeutic interventions.
discomfort and some pain experienced infection that might occur if bacteria
during the test. Inform the patient from the skin surface is introduced at
that the procedure is performed in a the IV needle insertion site.
radiology suite, usually by an HCP, Observe standard precautions, and
and takes approximately 30 to follow the general guidelines in
60 min. Appendix A. Positively identify the
Sensitivity to social and cultural issues, patient.
as well as concern for modesty, is Ensure the patient has complied
important in providing psychological with dietary, fluids, and medication
C support before, during, and after the restrictions for 8 hr prior to the
procedure. procedure.
Explain that an IV line may be inserted Ensure the patient has removed all
to allow infusion of IV fluids (e.g., nor- external metallic objects from the area
mal saline), anesthetics, contrast to be examined.
medium, or sedatives. Administer ordered prophylactic
Inform the patient that he or she may steroids or antihistamines before the
experience nausea, a feeling of procedure if the patient has a history
warmth, a salty or metallic taste, or a of allergic reactions to any substance
transient headache after injection of or drug. Use nonionic contrast medium
contrast medium, if given. for the procedure.
The patient may be requested to drink Avoid the use of equipment containing
approximately 450 mL of a dilute bar- latex if the patient has a history of aller-
ium solution (approximately 1% barium) gic reaction to latex.
or a water-soluble oral contrast Have emergency equipment readily
beginning 1 hr before the examination. available.
This is administered to distinguish GI Instruct the patient to void prior to
organs from the other abdominal the procedure and to change into the
organs. gown, robe, and foot coverings
Instruct the patient to remove jewelry provided.
and other metallic objects from the Instruct the patient to cooperate fully
area to be examined. and to follow directions. Instruct the
Instruct the patient to fast and restrict patient to remain still throughout the
fluids for 8 hr prior to the procedure procedure because movement pro-
and to avoid taking anticoagulant duces unreliable results.
medication or to reduce dosage as Record baseline vital signs, and con-
ordered prior to the procedure. tinue to monitor throughout the proce-
Protocols may vary among facilities. dure. Protocols may vary among
Make sure a written and informed facilities.
consent has been signed prior to the Establish an IV fluid line for the injec-
procedure and before administering tion of contrast, emergency drugs, and
any medications. sedatives.
Administer an antianxiety agent, as
INTRATEST: ordered, if the patient has claustropho-
bia. Administer a sedative to a child
Potential Complications: or to an uncooperative adult, as
Injection of the contrast through IV tub- ordered.
ing into a blood vessel is an invasive Place the patient in the supine position
procedure. Complications are rare but on an examination table.
do include risk for allergic reaction If IV contrast media is used, during and
related to contrast reaction, cardiac after injection a rapid series of images
arrhythmias, hematoma related to is taken.
blood leakage into the tissue follow- Instruct the patient to inhale deeply
ing insertion of the IV needle, or and hold his or her breath while
the x-ray images are taken, and then Instruct the patient in the care and
to exhale after the images are taken. assessment of the site.
Instruct the patient to take slow, deep Instruct the patient to apply cold
breaths if nausea occurs during the compresses to the insertion site as
procedure. needed, to reduce discomfort or
Monitor the patient for complications edema.
related to the procedure (e.g., allergic Instruct the patient to increase fluid
reaction, anaphylaxis, bronchospasm) intake to help eliminate the contrast
if contrast is used. medium, if used.
The needle is removed, and a Inform the patient that diarrhea may C
pressure dressing is applied over the occur after ingestion of oral contrast
puncture site. medium.
Observe/assess the needle site for Recognize anxiety related to test
bleeding, inflammation, or hematoma results. Discuss the implications of
formation. abnormal test results on the patients
lifestyle. Provide teaching and
POST-TEST: information regarding the clinical impli-
Inform the patient that a report of the cations of the test results, as
results will be made available to the appropriate.
requesting HCP, who will discuss the Reinforce information given by the
results with the patient. patients HCP regarding further testing,
Instruct the patient to resume usual treatment, or referral to another HCP.
diet, fluids, medications, and activity, Answer any questions or address
as directed by the HCP. Renal any concerns voiced by the patient
function should be assessed before or family.
metformin is resumed, if contrast Depending on the results of this
was used. procedure, additional testing may be
Monitor vital signs and neurological needed to evaluate or monitor progres-
status every 15 min for 1 hr, then sion of the disease process and deter-
every 2 hr for 4 hr, and then as ordered mine the need for a change in therapy.
by the HCP. Monitor temperature Evaluate test results in relation to the
every 4 hr for 24 hr. Monitor intake and patients symptoms and other tests
output at least every 8 hr. Compare performed.
with baseline values. Notify the HCP if
temperature is elevated. Protocols may
vary from facility to facility. RELATED MONOGRAPHS:
If contrast was used, observe for Related tests include ACTH and
delayed allergic reactions, such as challenge tests, amylase, angiography
rash, urticaria, tachycardia, hyperpnea, abdomen, biopsy intestinal, BUN,
hypertension, palpitations, nausea, calculus kidney stone panel, CBC,
or vomiting. CBC hematocrit, CBC hemoglobin,
Instruct the patient to immediately cortisol and challenge tests,
report symptoms such as fast heart creatinine, cystoscopy, hepatobiliary
rate, difficulty breathing, skin rash, scan, IVP, KUB studies, MRI
itching, chest pain, persistent right abdomen, peritoneal fluid analysis,
shoulder pain, or abdominal pain. PT/INR, renogram, US abdomen, and
Immediately report symptoms to the US pelvis.
appropriate HCP. Refer to the Gastrointestinal and
Observe/assess the needle insertion Hepatobiliary systems tables at the
site for bleeding, inflammation, or end of the book for related tests by
hematoma formation. body system.
COMMON USE: To visualize and assess the vascular structure to assist in the
C diagnosis of aneurysm, embolism, or stenosis.
AREA OF APPLICATION: Vessels.
drug. Use nonionic contrast medium Instruct the patient to resume pretest-
for the procedure. ing diet, as directed by the HCP.
Avoid the use of equipment containing Assess the patients ability to swallow
latex if the patient has a history of aller- before allowing the patient to attempt
gic reaction to latex. liquids or solid foods. Renal function
Have emergency equipment readily should be assessed before metformin
available. is resumed.
Instruct the patient to void prior to the Monitor vital signs and neurological
procedure and to change into the status every 15 min for 1 hr, then every
C gown, robe, and foot coverings 2 hr for 4 hr, and then as ordered by
provided. the HCP. Monitor temperature every
Instruct the patient to cooperate fully 4 hr for 24 hr. Monitor intake and out-
and to follow directions. Instruct the put at least every 8 hr. Compare with
patient to remain still throughout the baseline values. Notify the HCP if tem-
procedure because movement perature is elevated. Protocols may
produces unreliable results. vary among facilities.
Establish an IV fluid line for the injec- If contrast was used, observe for
tion of contrast, emergency drugs, and delayed allergic reactions, such as
sedatives. rash, urticaria, tachycardia, hyperpnea,
Administer an antianxiety agent, as hypertension, palpitations, nausea, or
ordered, if the patient has claustropho- vomiting.
bia. Administer a sedative to a child or Instruct the patient to immediately
to an uncooperative adult, as ordered. report symptoms such as fast heart
Place the patient in the supine position rate, difficulty breathing, skin rash,
on an examination table. itching, chest pain, persistent right
The contrast medium is injected, and a shoulder pain, or abdominal pain.
rapid series of images is taken during Immediately report symptoms to the
and after the filling of the vessels to be appropriate HCP.
examined. Delayed images may be Assess extremities for signs of isch-
taken to examine the vessels after a emia or absence of distal pulse caused
time and to monitor the venous phase by a catheter-induced thrombus.
of the procedure. Observe/assess the needle insertion
Ask the patient to inhale deeply and site for bleeding, inflammation, or
hold his or her breath while the x-ray hematoma formation.
images are taken, and then to exhale Instruct the patient to apply cold com-
after the images are taken. presses to the insertion site as needed,
Instruct the patient to take slow, deep to reduce discomfort or edema.
breaths if nausea occurs during the Instruct the patient to increase fluid
procedure. Monitor and administer an intake to help eliminate the contrast
antiemetic agent if ordered. Ready an medium, if used.
emesis basin for use. Inform the patient that diarrhea may
Monitor the patient for complications occur after ingestion of oral contrast
related to the procedure (e.g., allergic medium.
reaction, anaphylaxis, bronchospasm). Instruct the patient to maintain bed
Observe that the needle is removed rest for 4 to 6 hr after the procedure.
and a pressure dressing is applied over Nutritional Considerations: Abnormal find-
the puncture site. ings may be associated with cardiovas-
Observe/assess the needle site for cular disease. Nutritional therapy is
bleeding, inflammation, or hematoma recommended for the patient identified
formation. to be at risk for developing CAD or for
individuals who have specific risk fac-
POST-TEST: tors and/or existing medical conditions
Inform the patient that a report of the (e.g., elevated LDL cholesterol levels,
results will be made available to the other lipid disorders, insulin-dependent
requesting HCP, who will discuss the diabetes, insulin resistance, or meta-
results with the patient. bolic syndrome). Other changeable risk
C COMMON USE: To visualize and assess the structure of the liver and biliary tract
toward the diagnosis of tumor, obstruction, bleeding, and infection. Used as an
evaluation tool for surgical, radiation, and medical therapeutic interventions.
COMMON USE: To visualize and assess the brain to assist in diagnosing tumor, C
bleeding, infarct, infection, structural changes, and edema. Also valuable in
evaluation of medical, radiation, and surgical interventions.
are lactating. Pediatric & Geriatric barium studies were performed more
Imaging Children and geriatric than 4 days before the CT scan.
patients are at risk for receiving a Record the date of the last menstrual
higher radiation dose than neces- period and determine the possibility of
pregnancy in perimenopausal women.
sary if settings are not adjusted for Obtain a list of the patients current medi-
their small size. Pediatric Imaging cations including anticoagulants, aspirin
Information on the Image Gently and other salicylates, herbs, nutritional
Campaign can be found at the supplements, and nutraceuticals (see
C Alliance for Radiation Safety in Appendix H online at DavisPlus). Note the
Pediatric Imaging (www.pedrad last time and dose of medication taken.
.org/associations/5364/ig/). Note that if iodinated contrast medium
Risks associated with radiation over- is scheduled to be used in patients
exposure can result from frequent receiving metformin (Glucophage) for
non-insulin-dependent (type 2) diabetes,
x-ray procedures. Personnel in the the drug should be discontinued on the
room with the patient should wear a day of the test and continue to be with-
protective lead apron, stand behind a held for 48 hr after the test. Iodinated
shield, or leave the area while the contrast can temporarily impair kidney
examination is being done. Personnel function, and failure to withhold metfor-
working in the examination area min may indirectly result in drug-induced
should wear badges to record their lactic acidosis, a dangerous and some-
level of radiation exposure. times fatal side effect of metformin
related to renal impairment that does
not support sufficient excretion of
metformin.
Review the procedure with the patient.
NURSING IMPLICATIONS Address concerns about pain and
AND PROCEDURE explain that there may be moments of
discomfort and some pain experienced
PRETEST: during the test. Inform the patient the
Positively identify the patient using at procedure is usually performed in a
least two unique identifiers before pro- radiology suite by an HCP specializing
viding care, treatment, or services. in this procedure, with support staff,
Patient Teaching: Inform the patient this and takes approximately 15 to 30 min.
procedure can assist in assessing the Sensitivity to social and cultural issues,as
brain. well as concern for modesty, is impor-
Obtain a history of the patients com- tant in providing psychological support
plaints or clinical symptoms, including before, during, and after the procedure.
a list of known allergens, especially Explain that an IV line may be inserted
allergies or sensitivities to latex, anes- to allow infusion of IV fluids (e.g., nor-
thetics, or contrast medium. mal saline), contrast medium, dye, or
Obtain a history of the patients mus- sedatives.
culoskeletal system, symptoms, and Inform the patient that he or she may
results of previously performed labora- experience nausea, a feeling of
tory tests and diagnostic and surgical warmth, a salty or metallic taste, or a
procedures. transient headache after injection of
Ensure results of coagulation testing contrast medium.
are obtained and recorded prior to the Instruct the patient to remove dentures
procedure; BUN and creatinine results and jewelry and other metallic objects
are also needed if contrast medium is from the area to be examined.
to be used. Note that there are no food or fluid
Note any recent procedures that can restrictions unless by medical direction.
interfere with test results, including Instruct the patient to avoid taking
examinations using barium- or iodine- anticoagulant medication or to reduce
based contrast medium. Ensure that dosage as ordered prior to the
procedure. Protocols may vary among Place the patient in the supine position
facilities. on an examination table.
Make sure a written and informed If contrast media is used, a rapid series
consent has been signed prior to the of images is taken during and after
procedure and before administering injection.
any medications. Instruct the patient to take slow, deep
breaths if nausea occurs during the
INTRATEST: procedure.
Potential Complications: Monitor the patient for complications
Injection of the contrast through IV related to the procedure (e.g., allergic C
reaction, anaphylaxis, bronchospasm)
tubing into a blood vessel is an inva-
if contrast is used.
sive procedure. Complications are
The needle is removed, and a pressure
rare but do include risk for allergic
dressing is applied over the puncture
reaction related to contrast reaction,
site.
cardiac arrhythmias, hematoma
Observe/assess the needle insertion
related to blood leakage into the
site for bleeding, inflammation, or
tissue following insertion of the IV
hematoma formation.
needle, or infection that might occur
if bacteria from the skin surface
is introduced at the IV needle POST-TEST:
insertion site. Inform the patient that a report of the
Observe standard precautions, and fol- results will be made available to the
low the general guidelines in Appendix requesting HCP, who will discuss the
A. Positively identify the patient. results with the patient.
Ensure the patient has complied with Instruct the patient to resume medica-
medication restrictions and pretesting tions and activity, as directed by the
preparations. HCP. Renal function should be
Ensure the patient has removed den- assessed before metformin is resumed,
tures and all external metallic objects if contrast was used.
from the area to be examined prior to Monitor vital signs and neurological
the procedure. status every 15 min for 1 hr, then every
Administer ordered prophylactic ste- 2 hr for 4 hr, and then as ordered by
roids or antihistamines before the pro- the HCP. Monitor temperature every
cedure if the patient has a history of 4 hr for 24 hr. Monitor intake and out-
allergic reactions to any substance or put at least every 8 hr. Compare with
drug. Use nonionic contrast medium baseline values. Notify the HCP if tem-
for the procedure. perature is elevated. Protocols may
Avoid the use of equipment containing vary among facilities.
latex if the patient has a history of aller- If contrast was used, observe for
gic reaction to latex. delayed allergic reactions, such as
Have emergency equipment readily rash, urticaria, tachycardia, hyperpnea,
available. hypertension, palpitations, nausea, or
Instruct the patient to cooperate fully vomiting.
and to follow directions. Instruct the Instruct the patient to immediately
patient to remain still throughout the report symptoms such as fast heart
procedure because movement pro- rate, difficulty breathing, skin rash,
duces unreliable results. itching, chest pain, persistent right
Establish an IV fluid line for the injec- shoulder pain, or abdominal pain.
tion of contrast medium, emergency Immediately report symptoms to the
drugs, and sedatives. appropriate HCP.
Administer an antianxiety agent, as Observe/assess the needle insertion
ordered, if the patient has claustro- site for bleeding, inflammation, or
phobia. Administer a sedative to hematoma formation.
a child or to an uncooperative adult, Instruct the patient in the care and
as ordered. assessment of the site.
Instruct the patient to apply cold com- Depending on the results of this proce-
presses to the puncture site as needed, dure, additional testing may be needed
to reduce discomfort or edema. to evaluate or monitor progression of
Instruct the patient to increase fluid the disease process and determine the
intake to help eliminate the contrast need for a change in therapy. Evaluate
medium, if used. test results in relation to the patients
Inform the patient that diarrhea may symptoms and other tests performed.
occur after ingestion of oral contrast
RELATED MONOGRAPHS:
medium.
C Recognize anxiety related to test Related tests include angiography
results. Discuss the implications of carotid, audiometry hearing loss, BUN,
abnormal test results on the patients CSF analysis, CBC, CBC hematocrit,
lifestyle. Provide teaching and informa- CBC hemoglobin, CT angiography,
tion regarding the clinical implications creatinine, EEG, EMG, evoked brain
of the test results, as appropriate. potentials, MR angiography, MRI brain,
Reinforce information given by the nerve fiber analysis, otoscopy, PET
patients HCP regarding further testing, brain, PT/INR, spondee speech recep-
treatment, or referral to another tion threshold, and tuning fork tests.
HCP. Answer any questions or address Refer to the Musculoskeletal System
any concerns voiced by the patient or table at the end of the book for related
family. tests by body system.
COMMON USE: To visualize and assess coronary artery status related to plaque
buildup, associated with coronary artery disease and heart failure. Used as an
evaluation tool for surgical, radiation, and medical therapeutic interventions.
CONTRAST: None.
If the score is greater than 400, the Information on the Image Gently
procedure has detected extensive Campaign can be found at the
calcified plaque in the coronary Alliance for Radiation Safety in
arteries, which may have caused a Pediatric Imaging (www.pedrad
critical narrowing of the vessels. .org/associations/5364/ig/).
A full medical assessment is needed Risks associated with radiation
as soon as possible. Further testing overexposure can result from fre-
may be needed, and treatment may quent x-ray procedures. Personnel
C be needed to reduce the risk of MI. in the room with the patient
should wear a protective lead
CRITICAL FINDINGS: N/A apron, stand behind a shield, or
leave the area while the examina-
INTERFERING FACTORS tion is being done. Personnel work-
ing in the examination area should
Factors that may impair clear wear badges to record their level of
imaging radiation exposure.
Retained barium or radiological
contrast from a previous radiologi-
cal procedure.
Metallic objects (e.g., jewelry, body
NURSING IMPLICATIONS
rings) within the examination field,
AND PROCEDURE
which may inhibit organ visualiza- PRETEST:
tion and cause unclear images.
Positively identify the patient using at
Improper adjustment of the radio- least two unique identifiers before pro-
graphic equipment to accommo- viding care, treatment, or services.
date obese or thin patients, Patient Teaching: Inform the patient this
which can cause overexposure or procedure can assist in assessing the
underexposure and a poor-quality coronary arteries for the presence of
study. plaque.
Patients with extreme claustropho- Obtain a history of the patients com-
bia unless sedation is given before plaints or clinical symptoms, including
the study. a list of known allergens, especially
allergies or sensitivities to latex, anes-
Inability of the patient to cooperate thetics, or sedatives.
or remain still during the proce- Obtain a history of patients cardiovas-
dure because of age, significant cular system, symptoms, and results of
pain, or mental status. previously performed laboratory tests
and diagnostic and surgical procedures.
Other considerations Note any recent procedures that can
The procedure may be terminated interfere with test results, including
if chest pain or severe cardiac examinations using barium- or iodine-
arrhythmias occur. based contrast medium. Ensure that
Consultation with the HCP should barium studies were performed more
occur before the procedure for than 4 days before the CT scan.
radiation safety concerns regarding Record the date of the last menstrual
younger patients or patients who period and determine the possibility of
are lactating. Pediatric & Geriatric pregnancy in perimenopausal women.
Obtain a list of the patients current medi-
Imaging Children and geriatric cations, including anticoagulants, aspirin
patients are at risk for receiving a and other salicylates, herbs, nutritional
higher radiation dose than neces- supplements, and nutraceuticals (see
sary if settings are not adjusted for Appendix H online at DavisPlus). Note the
their small size. Pediatric Imaging last time and dose of medication taken.
Review the procedure with the patient. Instruct the patient to cooperate fully
Address concerns about pain and and to follow directions. Instruct the
explain that there may be moments of patient to remain still throughout the
discomfort and some pain experi- procedure because movement
enced during the test. Inform the produces unreliable results.
patient the procedure is usually per- Record baseline vital signs, and
formed in a radiology suite by an HCP continue to monitor throughout the
specializing in this procedure, with procedure. Protocols may vary among
support staff, and takes approximately facilities.
30 to 60 min. Establish an IV fluid line for the C
Sensitivity to social and cultural issues, injection of emergency drugs and
as well as concern for modesty, is sedatives.
important in providing psychological Administer an antianxiety agent, as
support before, during, and after the ordered, if the patient has claustropho-
procedure. bia. Administer a sedative to a child or
Explain that an IV line may be to an uncooperative adult, as ordered.
inserted to allow infusion of IV fluids Place the patient in the supine position
(e.g., normal saline), anesthetics, or on an examination table. A rapid series
sedatives. of images is taken of the vessels to be
Note that there are no food, fluid, or examined.
medication restrictions unless by Instruct the patient to inhale deeply
medical direction. Protocols may vary and hold his or her breath while the
among facilities. x-ray images are taken, and then to
Instruct the patient to remove all exter- exhale after the images are taken.
nal metallic objects from the area to be Instruct the patient to take slow, deep
examined. breaths if nausea occurs during the
procedure.
INTRATEST: The IV needle is removed, and a
Potential Complications: pressure dressing is applied over the
puncture site.
Establishing an IV line is an invasive
Observe/assess the needle site for
procedure. Complications are rare but
bleeding, inflammation, or hematoma
do include risk for hematoma related
formation.
to blood leakage into the tissue fol-
lowing insertion of the IV needle or
infection that might occur if bacteria POST-TEST:
from the skin surface is introduced at Inform the patient that a report of the
the IV needle insertion site. results will be made available to the
Observe standard precautions, and fol- requesting HCP, who will discuss the
low the general guidelines in Appendix results with the patient.
A. Positively identify the patient. Instruct the patient to resume usual
Ensure the patient has complied with diet, fluids, medications, and activity,
pretesting preparations. as directed by the HCP.
Ensure that the patient has removed all Instruct the patient in the care and
external metallic objects from the area assessment of the IV site.
to be examined. Instruct the patient to apply cold com-
Administer ordered prophylactic steroids presses to the insertion site as needed,
or antihistamines before the procedure if to reduce discomfort or edema.
the patient has a history of allergic reac- Recognize anxiety related to test
tions to any substance or drug. results. Discuss the implications of
Have emergency equipment readily abnormal test results on the patients
available. lifestyle. Provide teaching and informa-
Instruct the patient to void prior to the tion regarding the clinical implications
procedure and to change into the of the test results, as appropriate.
gown, robe, and foot coverings Nutritional Considerations: Abnormal
provided. findings may be associated with
COMMON USE: To visualize and assess the rectum and colon related to identifica- C
tion and evaluation of large polyps, lesions, and tumors. Also used to assess the
effectiveness of therapeutic interventions such as surgery and primarily used for
patients who cannot tolerate conventional colonoscopy.
Ensure that the patient has complied Monitor the patient for complications
with dietary, fluids, and medication related to the procedure (e.g., allergic
restrictions and pretesting preparations; reaction, anaphylaxis, bronchospasm) if
ensure that food and fluids have been contrast is used.
restricted for at least 6 hr prior to the The needle is removed, and a pressure
procedure. dressing is applied over the puncture
Ensure that the patient has removed all site.
external metallic objects from the area Observe/assess the needle site for
to be examined prior to the procedure. bleeding, inflammation, or hematoma
Administer ordered prophylactic ste- formation. C
roids or antihistamines before the pro-
cedure if the patient has a history of POST-TEST:
allergic reactions to any substance or Inform the patient that a report of
drug. Use nonionic contrast medium the results will be made available
for the procedure. to the requesting HCP, who will discuss
Avoid the use of equipment containing the results with the patient.
latex if the patient has a history of aller- Instruct the patient to resume usual
gic reaction to latex. diet, fluids, medications, and activity, as
Have emergency equipment readily directed by the HCP. Renal function
available. should be assessed before metformin
Instruct the patient to void prior to the is resumed, if contrast was used.
procedure and to change into the gown, Monitor vital signs and neurological
robe, and foot coverings provided. status every 15 min for 1 hr, then every
Instruct the patient to cooperate fully 2 hr for 4 hr, and then as ordered by
and to follow directions. Instruct the the HCP. Monitor temperature every
patient to remain still throughout the 4 hr for 24 hr. Monitor intake and out-
procedure because movement pro- put at least every 8 hr. Compare with
duces unreliable results. baseline values. Notify the HCP if
Record baseline vital signs, and continue temperature is elevated. Protocols may
to monitor throughout the procedure. vary among facilities.
Protocols may vary among facilities. If contrast was used, observe for
Establish an IV fluid line for the injection delayed allergic reactions, such as
of contrast (if used), emergency drugs, rash, urticaria, tachycardia, hyperpnea,
and sedatives. hypertension, palpitations, nausea,
Administer an antianxiety agent, as or vomiting.
ordered, if the patient has claustropho- Instruct the patient to immediately
bia. Administer a sedative to a child or report symptoms such as fast heart
to an uncooperative adult, as ordered. rate, difficulty breathing, skin rash,
Place the patient in the supine position itching, chest pain, persistent right
on an examination table. shoulder pain, or abdominal pain.
The colon is distended with room air or Immediately report symptoms to the
carbon dioxide by means of a rectal appropriate HCP.
tube and balloon retention device. Observe/assess the needle/catheter
Maximal colonic distention is guided by insertion site for bleeding, inflammation,
patient tolerance. or hematoma formation.
If IV contrast is used, a rapid series of Instruct the patient in the care and
images is taken during and after injection. assessment of the site.
Instruct the patient to inhale deeply and Instruct the patient to apply cold com-
hold his or her breath while the x-ray presses to the puncture site as needed,
images are taken, and then to exhale to reduce discomfort or edema.
after the images are taken. Instruct the patient to increase fluid
The sequence of images is repeated in intake to help eliminate the contrast
the prone position. medium, if used.
Instruct the patient to take slow, deep Inform the patient that diarrhea may
breaths if nausea occurs during the occur after ingestion of oral contrast
procedure. media.
COMMON USE: To visualize and assess the pancreas toward assisting in diagnosing
tumors, masses, cancer, bleeding, infection, and abscess. Used as an evaluation
tool for surgical, radiation, and medical therapeutic interventions.
COMMON USE: To visualize and assess pelvic structures and vascularities related
to assisting in diagnosing bleeding, infection, masses, and cyst aspiration (needle-
guided biopsy). Used to monitor the effectiveness of medical, radiation, and
surgical therapeutic interventions.
COMMON USE: To visualize and assess portions of the brain and pituitary gland
for cancer, tumor, and bleeding. Used as an evaluation tool for surgical, radia-
tion, and medical therapeutic interventions.
This procedure is
tube and associated electronics. contraindicated for
A beam of x-rays irradiates the Patients who are pregnant or
patient as the table moves in and suspected of being pregnant,
out of the scanner in a series of unless the potential benefits of a
phases. Multiple detectors rotate procedure using radiation far out-
around the patient to produce weigh the risk of radiation expo-
cross-sectional views or slices. The sure to the fetus and mother.
slices can be viewed individually Patients who are claustrophobic. C
or as a three-dimensional image.
Multislice or multidetector CT Patients with conditions associ-
(MDCT) scanners continuously ated with adverse reactions to
collect images in a helical or spiral contrast medium (e.g., asthma, food
fashion instead of a series of indi- allergies, or allergy to contrast
vidual images as with standard medium).
scanners. Helical CT is capable of Although patients are still asked spe-
collecting many images over a cifically if they have a known allergy
short period of time (seconds), is to iodine or shellfish, it has been well
very sensitive in identifying small established that the reaction is not to
abnormalities, and produces high- iodine, in fact an actual iodine allergy
quality images. This procedure aids would be very problematic because
in the evaluation of pituitary iodine is required for the production
adenoma, craniopharyngioma, of thyroid hormones. In the case of
meningioma, aneurysm, metastatic shellfish the reaction is to a muscle
disease, exophthalmos, and cysts. protein called tropomyosin; in the
Visualization of bony septa in the case of iodinated contrast medium
sphenoid sinus and evaluation for the reaction is to the noniodinated
nonpneumatization of the sphe- part of the contrast molecule.
noid sinus are best performed Patients with a known hypersensi
with this procedure. Differences in tivity to the medium may benefit
tissue density are detected and from premedication with corticoste-
recorded and are viewable as com- roids and diphenhydramine; the use
puterized digital images. Slices or of nonionic contrast or an alternative
thin sections of certain anatomic noncontrast imaging study, if avail-
views of the pituitary and associat- able, may be considered for patients
ed vascular system are reviewed to who have severe asthma or who
allow differentiations of solid, cys- have experienced moderate to severe
tic, inflammatory, or vascular reactions to ionic contrast medium.
lesions, as well as identification of Patients with conditions associ-
suspected hematomas and aneu- ated with preexisting renal
rysms. The procedure may be insufficiency (e.g., renal failure,
repeated after intravenous injec- single kidney transplant, nephrecto-
tion of iodinated contrast medium my, diabetes, multiple myeloma,
for vascular evaluation. Images can treatment with aminoglycocides
be recorded on photographic or and NSAIDs) because iodinated
x-ray film or stored in digital for- contrast is nephrotoxic.
mat as digitized computer data. Elderly and compromised
Tumor progression, before and patients who are chronically
after therapy, and effectiveness of dehydrated before the test, because
medical interventions may be of their risk of contrast-induced
monitored by CT scanning. renal failure.
Access additional resources at davisplus.fadavis.com
from the area to be examined prior to Monitor intake and output at least every
the procedure. 8 hr. Compare with baseline values.
Administer ordered prophylactic ste- Notify the HCP if temperature is elevated.
roids or antihistamines before the pro- Protocols may vary among facilities.
cedure. Use nonionic contrast medium If contrast was used, observe for delayed
for the procedure if the patient has a allergic reactions, such as rash, urticaria,
history of allergic reactions to any sub- tachycardia, hyperpnea, hypertension,
stance or drug. palpitations, nausea, or vomiting.
Avoid the use of equipment containing Instruct the patient to immediately report
C latex if the patient has a history of aller- symptoms such as fast heart rate, diffi-
gic reaction to latex. culty breathing, skin rash, itching, chest
Have emergency equipment readily pain, persistent right shoulder pain, or
available. abdominal pain. Immediately report
Instruct the patient to cooperate fully symptoms to the appropriate HCP.
and to follow directions. Instruct the Observe/assess the needle insertion
patient to remain still throughout the site for bleeding, inflammation, or
procedure because movement pro- hematoma formation.
duces unreliable results. Instruct the patient in the care and
Establish an IV fluid line for the injec- assessment of the site.
tion of contrast medium, emergency Instruct the patient to apply cold com-
drugs, and sedatives. presses to the insertion site as needed,
Administer an antianxiety agent, as to reduce discomfort or edema.
ordered, if the patient has claustropho- Instruct the patient to increase fluid
bia. Administer a sedative to a child or intake to help eliminate the contrast
to an uncooperative adult, as ordered. medium, if used.
Place the patient in the supine position Inform the patient that diarrhea may
on an examination table. occur after ingestion of oral contrast
If IV contrast medium is used, a rapid medium.
series of images is taken during and Recognize anxiety related to test
after injection. results. Discuss the implications of
Instruct the patient to take slow, deep abnormal test results on the patients
breaths if nausea occurs during the lifestyle. Provide teaching and informa-
procedure. tion regarding the clinical implications
Monitor the patient for complications of the test results, as appropriate.
related to the procedure (e.g., allergic Reinforce information given by the
reaction, anaphylaxis, bronchospasm) patients HCP regarding further testing,
if contrast medium is used. treatment, or referral to another HCP.
The needle is removed, and a pressure Answer any questions or address any
dressing is applied over the puncture site. concerns voiced by the patient or family.
Observe/assess the needle site for Depending on the results of this proce-
bleeding, inflammation, or hematoma dure, additional testing may be needed
formation. to evaluate or monitor progression of
the disease process and determine the
POST-TEST: need for a change in therapy. Evaluate
Inform the patient that a report of the test results in relation to the patients
results will be made available to the symptoms and other tests performed.
requesting HCP, who will discuss the
RELATED MONOGRAPHS:
results with the patient.
Instruct the patient to resume usual Related tests include ACTH and
medications and activity, as directed by challenge tests, BUN, CT angiography,
the HCP. Renal function should be CBC, CBC hematocrit, CBC hemoglo-
assessed before metformin is resumed, bin, CT brain, cortisol and challenge
if contrast was used. tests, creatinine, MRA, MRI brain, PET
Monitor vital signs and neurological sta- brain, and PT/INR.
tus every 15 min for 1 hr, then every 2 hr Refer to the Endocrine System table at
for 4 hr, and then as ordered by the HCP. the end of the book for related tests by
Monitor temperature every 4 hr for 24 hr. body system.
COMMON USE: To visualize and assess the kidney and surrounding structures C
to assist in diagnosing cancer, tumor, infection, and congenital anomalies.
Used to evaluate the success of therapeutic medical, surgical, and radiation
interventions.
gown, robe, and foot coverings If contrast was used, observe for delayed
provided. allergic reactions, such as rash, urticaria,
Instruct the patient to cooperate fully tachycardia, hyperpnea, hypertension,
and to follow directions. Instruct the palpitations, nausea, or vomiting.
patient to remain still throughout the Instruct the patient to immediately
procedure because movement pro- report symptoms such as fast heart
duces unreliable results. rate, difficulty breathing, skin rash, itch-
Establish an IV fluid line for the injec- ing, chest pain, persistent right shoul-
tion of contrast, emergency drugs, and der pain, or abdominal pain.
sedatives. Immediately report symptoms to the C
Administer an antianxiety agent, as appropriate HCP.
ordered, if the patient has claustropho- Observe/assess the needle insertion
bia. Administer a sedative to a child or site for bleeding, inflammation, or
to an uncooperative adult, as ordered. hematoma formation.
Place the patient in the supine position Instruct the patient in the care and
on an examination table. assessment of the site.
If IV contrast is used, a rapid series Instruct the patient to apply cold com-
of images is taken during and after presses to the insertion site as needed,
injection. to reduce discomfort or edema.
Instruct the patient to inhale deeply Instruct the patient to increase fluid
and hold his or her breath while the intake to help eliminate the contrast
x-ray images are taken, and then to medium, if used.
exhale after the images are taken. Inform the patient that diarrhea may
Instruct the patient to take slow, deep occur after ingestion of oral contrast
breaths if nausea occurs during the medium.
procedure. Recognize anxiety related to test
Monitor the patient for complications results. Discuss the implications of
related to the procedure (e.g., allergic abnormal test results on the patients
reaction, anaphylaxis, bronchospasm) lifestyle. Provide teaching and informa-
if contrast is used. tion regarding the clinical implications
The needle is removed, and a pressure of the test results, as appropriate.
dressing is applied over the puncture Reinforce information given by the
site. patients HCP regarding further testing,
Observe/assess the needle site for treatment, or referral to another HCP.
bleeding, inflammation, or hematoma Answer any questions or address any
formation. concerns voiced by the patient or family.
Depending on the results of this proce-
POST-TEST: dure, additional testing may be needed
Inform the patient that a report of the to evaluate or monitor progression of
results will be made available to the the disease process and determine the
requesting HCP, who will discuss need for a change in therapy. Evaluate
the results with the patient. test results in relation to the patients
Instruct the patient to resume usual symptoms and other tests performed.
diet, fluids, medications, and activity,
as directed by the HCP. Renal function RELATED MONOGRAPHS:
should be assessed before metformin Related tests include ACTH,
is resumed, if contrast was used. angiography adrenal, renal biopsy,
Monitor vital signs and neurological BUN, calculus/kidney stone panel,
status every 15 min for 1 hr, then every catecholamines, CBC, CBC hemato-
2 hr for 4 hr, and then as ordered by crit, CBC hemoglobin, creatinine,
the HCP. Monitor temperature every CT abdomen, homovanillic acid, IVP,
4 hr for 24 hr. Monitor intake and KUB, MRI abdomen, PT/INR, US
output at least every 8 hr. Compare renal, and VMA.
with baseline values. Notify the HCP Refer to the Genitourinary System
if temperature is elevated. Protocols table at the end of the book for related
may vary among facilities. tests by body system.
C COMMON USE: To visualize and assess spinal structure related to tumor, injury,
bleeding, and infection. Used as an evaluation tool for surgical, radiation, and
medical therapeutic interventions.
examinations using barium- or iodine- Note that there are no food, fluid, or
based contrast medium. Ensure that medication restrictions unless by
barium studies were performed more medical direction. Instruct the patient
than 4 days before the CT scan. to avoid taking anticoagulant medica-
Record the date of the last menstrual tion or to reduce dosage as ordered
period and determine the possibility of prior to the procedure. Protocols may
pregnancy in perimenopausal women. vary among facilities.
Obtain a list of the patients current Make sure a written and informed
medications including anticoagulants, consent has been signed prior to the
aspirin and other salicylates, herbs procedure and before administering C
and nutritional supplements, and any medications.
nutraceuticals (see Appendix H online
at DavisPlus). Note the last time and INTRATEST:
dose of medication taken.
Note that if iodinated contrast medium Potential Complications:
is scheduled to be used in patients Injection of the contrast through IV
receiving metformin (Glucophage) for tubing into a blood vessel is an inva-
non-insulin-dependent (type 2) diabe- sive procedure. Complications are rare
tes, the drug should be discontinued but do include risk for allergic reaction
on the day of the test and continue to related to contrast reaction, cardiac
be withheld for 48 hr after the test. arrhythmias, hematoma related to
Iodinated contrast can temporarily blood leakage into the tissue follow-
impair kidney function, and failure to ing insertion of the IV needle, or
withhold metformin may indirectly infection that might occur if bacteria
result in drug-induced lactic acidosis, from the skin surface is introduced at
a dangerous and sometimes fatal side the IV needle insertion site.
effect of metformin related to renal Observe standard precautions, and
impairment that does not support follow the general guidelines in
sufficient excretion of metformin. Appendix A. Positively identify the
Review the procedure with the patient. patient.
Address concerns about pain and Ensure that the patient has complied
explain that there may be moments of with medication restrictions and
discomfort and some pain experi- pretesting preparations.
enced during the test. Inform the Ensure that the patient has removed
patient the procedure is usually per- all external metallic objects from the
formed in a radiology suite by an HCP area to be examined prior to the
specializing in this procedure, with procedure.
support staff, and takes approximately Administer ordered prophylactic
30 to 60 min. steroids or antihistamines before the
Sensitivity to social and cultural issues, procedure if the patient has a history
as well as concern for modesty, is of allergic reactions to any substance
important in providing psychological or drug. Use nonionic contrast medium
support before, during, and after the for the procedure.
procedure. Avoid the use of equipment containing
Explain that an IV line may be inserted latex if the patient has a history of
to allow infusion of IV fluids (e.g., nor- allergic reaction to latex.
mal saline), anesthetics, contrast Have emergency equipment readily
medium, or sedatives. available.
Inform the patient that he or she may Instruct the patient to void prior to the
experience nausea, a feeling of procedure and to change into the gown,
warmth, a salty or metallic taste, or a robe, and foot coverings provided.
transient headache after injection of Instruct the patient to cooperate
contrast medium. fully and to follow directions. Instruct
Instruct the patient to remove jewelry the patient to remain still throughout
and other metallic objects from the the procedure because movement
area to be examined. produces unreliable results.
COMMON USE: To visualize and assess the spleen and surrounding structure for C
tumor, bleeding, infection, and trauma. Used to monitor the effectiveness of
medical, surgical, and radiation therapeutic interventions.
Instruct the patient to void prior to the temperature is elevated. Protocols may
procedure and to change into the gown, vary among facilities.
robe, and foot coverings provided. If contrast was used, observe for
Instruct the patient to cooperate fully delayed allergic reactions, such as
and to follow directions. Instruct the rash, urticaria, tachycardia, hyperpnea,
patient to remain still throughout the hypertension, palpitations, nausea, or
procedure because movement pro- vomiting.
duces unreliable results. Instruct the patient to immediately report
Establish an IV fluid line for the injec- symptoms such as fast heart rate, diffi-
tion of contrast medium, emergency culty breathing, skin rash, itching, chest C
drugs, and sedatives. pain, persistent right shoulder pain, or
Administer an antianxiety agent, as abdominal pain. Immediately report
ordered, if the patient has claustropho- symptoms to the appropriate HCP.
bia. Administer a sedative to a child or Observe/assess the needle site for
to an uncooperative adult, as ordered. bleeding, inflammation, or hematoma
Place the patient in the supine position formation.
on an examination table. Instruct the patient in the care and
If IV contrast medium is used, a rapid assessment of the site.
series of images is taken during and Instruct the patient to apply cold com-
after injection. presses to the puncture site as
Instruct the patient to inhale deeply needed, to reduce discomfort or
and hold his or her breath while the edema.
x-ray images are taken, and then to Instruct the patient to increase fluid
exhale after the images are taken. intake to help eliminate the contrast
Instruct the patient to take slow, deep medium, if used.
breaths if nausea occurs during the Inform the patient that diarrhea may
procedure. occur after ingestion of oral contrast
Monitor the patient for complications medium.
related to the procedure (e.g., allergic Recognize anxiety related to test
reaction, anaphylaxis, bronchospasm) results. Discuss the implications of
if contrast medium is used. abnormal test results on the patients
The needle is removed, and a lifestyle. Provide teaching and informa-
pressure dressing is applied over tion regarding the clinical implications
the puncture site. of the test results, as appropriate.
Observe/assess the needle site for Reinforce information given by the
bleeding, inflammation, or hematoma patients HCP regarding further testing,
formation. treatment, or referral to another HCP.
Answer any questions or address any
POST-TEST: concerns voiced by the patient or family.
Inform the patient that a report of the Depending on the results of this proce-
results will be made available to the dure, additional testing may be needed
requesting HCP, who will discuss the to evaluate or monitor progression of
results with the patient. the disease process and determine the
Instruct the patient to resume usual need for a change in therapy. Evaluate
diet, fluids, medications, and activity, test results in relation to the patients
as directed by the HCP. Renal function symptoms and other tests performed.
should be assessed before metformin
is resumed, if contrast was used. RELATED MONOGRAPHS:
Monitor vital signs and neurological Related tests include angiography
status every 15 min for 1 hr, then every abdomen, BUN, CBC, CBC hematocrit,
2 hr for 4 hr, and then as ordered by CBC hemoglobin, creatinine, KUB film,
the HCP. Monitor temperature every 4 MRI abdomen, PT/INR, and US liver.
hr for 24 hr. Monitor intake and output Refer to the Hematopoietic System
at least every 8 hr. Compare with table at the end of the book for related
baseline values. Notify the HCP if tests by body system.
C COMMON USE: To visualize and assess structures within the thoracic cavity such
as the heart, lungs, and mediastinal structures to evaluate for aneurysm, cancer,
tumor, and infection. Used as an evaluation tool for surgical, radiation, and
medical therapeutic interventions.
patient to remain still throughout the If contrast was used, observe for
procedure because movement pro- delayed allergic reactions, such as
duces unreliable results. rash, urticaria, tachycardia, hyperpnea,
Establish an IV fluid line for the injec- hypertension, palpitations, nausea, or
tion of contrast medium, emergency vomiting.
drugs, and sedatives. Instruct the patient to immediately
Administer an antianxiety agent, as report symptoms such as fast heart
ordered, if the patient has claustropho- rate, difficulty breathing, skin rash, itch-
bia. Administer a sedative to a child or ing, chest pain, persistent right shoul-
C to an uncooperative adult, as ordered. der pain, or abdominal pain.
Place the patient in the supine position Immediately report symptoms to the
on an examination table. appropriate HCP.
If IV contrast medium is used, a rapid Observe/assess the needle site for
series of images is taken during and bleeding, inflammation, or hematoma
after injection. formation.
Ask the patient to inhale deeply and Instruct the patient in the care and
hold his or her breath while the x-ray assessment of the site.
images are taken, and then to exhale Instruct the patient to apply cold com-
after the images are taken. presses to the insertion site as needed,
Instruct the patient to take slow, deep to reduce discomfort or edema.
breaths if nausea occurs during the Instruct the patient to increase fluid
procedure. Monitor and administer an intake to help eliminate the contrast
antiemetic agent if ordered. Ready an medium, if used.
emesis basin for use. Recognize anxiety related to test
Monitor the patient for complications results. Discuss the implications of
related to the procedure (e.g., allergic abnormal test results on the patients
reaction, anaphylaxis, bronchospasm) lifestyle. Provide teaching and informa-
if contrast is used. tion regarding the clinical implications
The needle is removed, and a pressure of the test results, as appropriate.
dressing is applied over the puncture Reinforce information given by the
site. patients HCP regarding further testing,
Observe/assess the needle insertion treatment, or referral to another HCP.
site for bleeding, inflammation, or Answer any questions or address any
hematoma formation. concerns voiced by the patient or family.
Depending on the results of this proce-
POST-TEST: dure, additional testing may be needed
Inform the patient that a report of the to evaluate or monitor progression of
results will be made available to the the disease process and determine the
requesting HCP, who will discuss the need for a change in therapy. Evaluate
results with the patient. test results in relation to the patients
Instruct the patient to resume usual symptoms and other tests performed.
medications and activity, as directed by
the HCP. Renal function should be RELATED MONOGRAPHS:
assessed before metformin is resumed, Related tests include acetylcholine
if contrast was used. receptor antibody, biopsy bone mar-
Monitor vital signs and neurological row, BUN, chest x-ray, CBC, CBC
status every 15 min for 1 hr, then every hematocrit, CBC hemoglobin, creati-
2 hr for 4 hr, and then as ordered by nine, echocardiogram, gallium scan,
the HCP. Monitor temperature every lung scan, MRI chest, mediastinoscopy,
4 hr for 24 hr. Monitor intake and output MRI venography, pleural fluid analysis,
at least every 8 hr. Compare with and PT/INR.
baseline values. Notify the HCP if tem- Refer to the Respiratory System table
perature is elevated. Protocols may at the end of the book for related tests
vary among facilities. by body system.
COMMON USE: To detect associated conditions or drug therapies that can result
in cell hemolysis, such as found in hemolytic disease of newborns, and hemo- C
lytic transfusion reactions.
SPECIMEN: Serum (1 mL) collected in a red-top tube and whole blood (1 mL)
collected in a lavender-top (EDTA) tube.
POST-TEST: Knowledge
Parents state their understanding of
Inform the patient that a report of the the purpose for the recommended
results will be made available to the infant blood transfusion.
requesting health-care provider (HCP), Mother states her understanding of the
who will discuss the results with the purpose of Rh-immune immunoglobulin
patient. injection in relation to future pregnancies.
Recognize anxiety related to test results,
and inform the postpartum patient of the Skills
implications of positive test results in Parents demonstrate proficiency in plac-
cord blood; also assess newborns bili- ing the infant under the bilirubin light and
rubin and hematocrit levels. The results adhering to identified precautions.
COMMON USE: To check recipient serum for antibodies prior to blood transfusion.
Obtain a history of the patients hema- specimen, date, and time of collection.
topoietic system as well as results of Perform a venipuncture.
previously performed laboratory tests Remove the needle and apply direct
and diagnostic and surgical procedures. pressure with dry gauze to stop bleed-
Note any recent procedures that can ing. Observe/assess venipuncture site
interfere with test results. for bleeding or hematoma formation and
Obtain a list of the patients current secure gauze with adhesive bandage.
medications, including herbs, nutri- Promptly transport the specimen to the
tional supplements, and nutraceuticals laboratory for processing and analysis.
(see Appendix H online at DavisPlus). C
Review the procedure with the patient. POST-TEST:
Inform the patient that specimen collec- Inform the patient that a report of the
tion takes approximately 5 to 10 min. results will be made available to the
Address concerns about pain and requesting health-care provider (HCP),
explain that there may be some discom- who will discuss the results with the
fort during the venipuncture. Prenatal patient. It is important for the patient to
mothers may be concerned about blood be made aware of the presence of
collection from their newborn. Explain unusual antibodies. A person may have
that a cord sample of blood taken from circulating antibodies, other than ABO/
the infant at the time of delivery does Rh group antibodies, which may
not result in infant blood loss. respond to transfused blood. The anti-
Sensitivity to social and cultural issues,as bodies attach to the person's red blood
well as concern for modesty, is impor- cells, damaging the integrity of the cell
tant in providing psychological support wall, and hemolysis occurs. Therefore, it
before, during, and after the procedure. is important to screen for the presence
There are no food, fluid, or medication of antibodies in the recipient's serum
restrictions unless by medical direction. prior to transfusion. Unexpected anti-
INTRATEST: bodies, other than ABO/Rh, can develop
at any time. If present in maternal blood,
Potential Complications: they can be potentially harmful to the
Acute hemolytic reactions, whether fetus, which makes antibody screening
immune mediated or developed due to an important test in prenatal care.
drug sensitivities, can be immediate Inform pregnant women that negative
and life threatening. Chronic hemolytic tests during the first 12 wk of gestation
anemia is also a significant condition should be repeated at 28 wk to rule
that requires timely identification of the out the presence of an antibody.
problem in order to treat the condition. Positive test results in pregnant women
Positive findings in the pregnant patient after 28 wk of gestation indicate the
may require further investigation by need for antibody identification testing.
amniocentesis. Any sampling method Reinforce information given by the
that involves penetration of natural tis- patients HCP regarding further testing,
sue barriers carries the risk of infection. treatment, or referral to another HCP.
Avoid the use of equipment containing Answer any questions or address any
latex if the patient has a history of aller- concerns voiced by the patient or family.
gic reaction to latex. Depending on the results of this
Instruct the patient to cooperate fully procedure, additional testing may be
and to follow directions. Direct the performed to evaluate or monitor pro-
patient to breathe normally and to gression of the disease process and
avoid unnecessary movement. determine the need for a change in
Observe standard precautions, and therapy. Evaluate test results in relation
follow the general guidelines in to the patients symptoms and other
Appendix A. Positively identify the tests performed.
patient, and label the appropriate
specimen container with the corre- RELATED MONOGRAPHS:
sponding patient demographics, Related tests include bilirubin, blood
initials of the person collecting the groups and antibodies, CBC
Access additional resources at davisplus.fadavis.com
Copper
SYNONYM/ACRONYM: Cu.
SI Units (Conventional
Age Conventional Units Units 0.157)
Newborn5 days 946 mcg/dL 1.47.2 micromol/L
15 yr 80150 mcg/dL 12.623.6 micromol/L
69 yr 84136 mcg/dL 13.221.4 micromol/L
1014 yr 80120 mcg/dL 12.618.8 micromol/L
1519 yr 80171 mcg/dL 12.626.8 micromol/L
Adult
Male 71141 mcg/dL 11.122.1 micromol/L
Female 80155 mcg/dL 12.624.3 micromol/L
Pregnant female 118302 mcg/dL 18.547.4 micromol/L
Values for African Americans are 8% to 12% higher. Values increase in older adults.
Medication Recommended
Procedure Indications Administered Collection Times
ACTH Suspect adrenal 1 mcg (low-dose 3 cortisol levels:
stimulation, insufficiency physiologic baseline
rapid test (Addisons protocol) immediately
disease) or cosyntropin IM before bolus,
congenital or IV; 250 mcg 30 min after
adrenal (standard bolus, and
hyperplasia pharmacologic 60 min after
protocol) bolus. Note:
cosyntropin IM Baseline and
or IV 30 min levels
are adequate for
accurate
diagnosis using
either dosage;
low dose
protocol
sensitivity is
most accurate
for 30 min
level only
CRH stimulation Differential IV dose of 1 mg/ 8 cortisol and
diagnosis kg ovine or 8 ACTH levels:
between ACTH- human CRH baseline
dependent collected 15 min
conditions such before injection,
as Cushings 0 min before
disease injection, and
(pituitary then 5, 15, 30,
source) or 60, 120, and
Cushings 180 min after
syndrome injection
Medication Recommended
Procedure Indications Administered Collection Times
(ectopic source)
and ACTH-
independent
conditions such
as Cushings
syndrome C
(adrenal
source)
Dexamethasone Differential Oral dose of 1 mg Collect cortisol
suppression diagnosis dexamethasone at 8 a.m. on
(overnight) between ACTH- (Decadron) at the morning
dependent 11 p.m. after the
conditions such dexamethasone
as Cushings dose
disease
(pituitary
source) or
Cushings
syndrome
(ectopic source)
and ACTH-
independent
conditions such
as Cushings
syndrome
(adrenal
source)
Metyrapone Suspect Oral dose of Collect cortisol
stimulation hypothalamic/ 30 mg/kg and ACTH at
(overnight) pituitary metyrapone with 8 a.m. on the
disease such snack at morning after
as adrenal midnight the metyrapone
insufficiency, dose
ACTH-
dependent
conditions such
as Cushings
disease
(pituitary
source) or
Cushings
syndrome
(ectopic
source), and
ACTH-
(table continues on page 610)
Medication Recommended
Procedure Indications Administered Collection Times
independent
conditions such
as Cushings
syndrome
(adrenal source)
C
ACTH = adrenocorticotropic hormone; CRH = corticotropin-releasing hormone;
IM = intramuscular; IV = intravenous.
Cortisol
SI Units (Conventional
Time Conventional Units Units 27.6)
8 a.m.
Birth11 yr 10340 mcg/dL 2769384 nmol/L
1218 yr 10280 mcg/dL 2767728 nmol/L
Adult/older adult 525 mcg/dL 138690 nmol/L
4 p.m.
Birth11 yr 10330 mcg/dL 2769108 nmol/L
1218 yr 10272 mcg/dL 2767507 nmol/L
Adult/older adult 316 mcg/dL 83442 nmol/L
Long-term use of corticosteroids in patients, especially older adults, may be reflected by elevated
cortisol levels.
Corticotropin-
Releasing Hormone
Stimulated Test Conventional Units
SI Units (Conventional
Units 27.6)
Cortisol peaks at Greater than 552 nmol/L
greater than 20 mcg/
dL within 3060 min
Corticotropin-
Releasing Hormone
Stimulated Test Conventional Units
SI Units (Conventional
Units 0.22)
ACTH increases Twofold to fourfold
twofold to fourfold increase within
within 3060 min 3060 min C
Dexamethasone
Suppressed SI Units (Conventional
Overnight Test Conventional Units Units 27.6)
Cortisol less than Less than 49.7 nmol/L
1.8 mcg/dL next day
Metyrapone Stimulated
Overnight Test Conventional Units
SI Units (Conventional
Units 27.6)
Cortisol less than Less than 83 nmol/L
3 mcg/dL next day
SI Units (Conventional
Units 0.22)
ACTH greater than Greater than 16.5 pmol/L
75 pg/mL
SI Units (Conventional
Units 28.9)
11-deoxycortisol greater Greater than 202 nmol/L
than 7 mcg/dL
there may be some discomfort during Remove the needle and apply direct
the venipuncture. pressure with dry gauze to stop bleed-
Sensitivity to social and cultural issues,as ing. Observe/assess venipuncture site
well as concern for modesty, is impor- for bleeding or hematoma formation
tant in providing psychological support and secure gauze with adhesive
before, during, and after the bandage.
procedure. Promptly transport the specimen to the
Note that there are no food, fluid, or laboratory for processing and analysis.
medication restrictions unless by medi-
C cal direction. POST-TEST:
Drugs that enhance steroid metabolism Inform the patient that a report of the
may be withheld by medical direction results will be made available to the
prior to metyrapone stimulation testing. requesting health-care provider (HCP),
Instruct the patient to minimize stress who will discuss the results with
to avoid raising cortisol levels. the patient.
Recognize anxiety related to test
INTRATEST: results, and offer support.
Observe/assess the patient who has
Potential Complications: been administered metyrapone for
Adverse reactions to metyrapone signs and symptoms of an acute
include nausea and vomiting (N/V), adrenal (Addisonian) crisis which
abdominal pain, headache, dizziness, may include abdominal pain, nausea,
sedation, allergic rash, decreased vomiting, hypotension, tachycardia,
white blood cell count, or bone mar- tachypnia, dehydration, excessively
row depression. Monitor the patient increased perspiration of the face and
for hypotension, rapid and weak hands, sudden and significant fatigue
pulse, rapid respiratory rate, pallor, or weakness, confusion, loss of
and extreme weakness that may indi- consciousness, shock, coma.
cate the patient is in acute adrenocor- Potential interventions include
tical insufficiency (Addisonian crisis). immediate corticosteroid replacement
Other signs and symptoms include (IV or IM), airway protection and
cardiac arrhythmias, hypotension, maintenance, administration of dex-
dehydration, anxiety, confusion, trose for hypoglycemia, correction of
impairment of consciousness, N/V, electrolyte imbalance, and rehydration
epigastric pain, diarrhea, hyponatre- with IV fluids.
mia, and hyperkalemia. Depending on the results of this pro-
Have emergency equipment readily cedure, additional testing may be
available. performed to evaluate or monitor
Avoid the use of equipment containing progression of the disease process
latex if the patient has a history of aller- and determine the need for a change
gic reaction to latex. in therapy. Evaluate test results in
Instruct the patient to cooperate fully relation to the patients symptoms
and to follow directions. Direct the and other tests performed.
patient to breathe normally and to
avoid unnecessary movement. Patient Education:
Observe standard precautions, and fol- Instruct the patient to resume
low the general guidelines in Appendix usual medications, as directed
A. Positively identify the patient, and by the HCP.
label the appropriate specimen con- Discuss the implications of abnormal
tainer with the corresponding patient test results on the patients lifestyle.
demographics, initials of the person Provide teaching and information
collecting the specimen, date, regarding the clinical implications of the
and time of collection. Perform a test results, as appropriate.
venipuncture. Collect specimen Assess the patient with regard to the
between 6 and 8 a.m., when cortisol effects of abnormal cortisol levels, and
levels are highest. monitor blood glucose levels to identify
C-Peptide
SYNONYM/ACRONYM: Connecting peptide insulin, insulin C-peptide, proinsulin
C-peptide.
COMMON USE: To evaluate hypoglycemia, assess beta cell function, and distin-
guish between type 1 and type 2 diabetes.
SI Units (Conventional
Age Conventional Units Units 0.333)
9 yr 03.3 ng/mL 01.1 nmol/L
1016 yr 0.43.3 ng/mL 0.11.1 nmol/L
Greater than 16 yr 0.83.5 ng/mL 0.31.2 nmol/L
1 hr response to glucose 2.311.8 ng/mL 0.83.9 nmol/L
Stop Hypertension (DASH) diet makes onset and slows the progression of
additional recommendations for the diabetic retinopathy, nephropathy, and
reduction of dietary sodium. Both neuropathy. Educate the patient
dietary styles emphasize a reduction in regarding access to counseling ser-
consumption of red meats, which are vices, as appropriate. Provide contact
high in saturated fats and cholesterol, information, if desired, for the American
and other foods containing sugar, sat- Diabetes Association (www.diabetes.
urated fats, trans fats, and sodium. If org) or the American Heart Association
triglycerides also are elevated, the (www.americanheart.org).
C patient should be advised to eliminate Reinforce information given by the
or reduce alcohol. The nutritional patients HCP regarding further testing,
needs of each diabetic patient need to treatment, or referral to another HCP.
be determined individually (especially Answer any questions or address any
during pregnancy) with the appropriate concerns voiced by the patient or family.
health care professionals, particularly Depending on the results of this proce-
professionals trained in nutrition. dure, additional testing may be per-
Instruct the patient and caregiver to formed to evaluate or monitor progres-
report signs and symptoms of hypogly- sion of the disease process and deter-
cemia (weakness, confusion, diaphore- mine the need for a change in therapy.
sis, rapid pulse) or hyperglycemia Evaluate test results in relation to the
(thirst, polyuria, hunger, lethargy). patients symptoms and other tests
Emphasize, as appropriate, that good performed.
control of glucose levels delays the
onset and slows the progression of RELATED MONOGRAPHS:
diabetic retinopathy, nephropathy, and Related tests include CT cardiac scor-
neuropathy. ing, cortisol, creatinine, creatinine
Recognize anxiety related to test clearance, EMG, ENG, fluorescein
results, and be supportive of perceived angiography, fructose, fundus photog-
loss of independence and fear of raphy, glucagon, glucose, glucose tol-
shortened life expectancy. Discuss the erance tests, glycated hemoglobin,
implications of abnormal test results on insulin, insulin antibodies,
the patients lifestyle. Provide teaching microalbumin, plethysmography, and
and information regarding the clinical visual fields test.
implications of the test results, as Refer to the Endocrine System table at
appropriate. Emphasize, if indicated, the end of the book for related tests by
that good glycemic control delays the body system.
C-Reactive Protein
SYNONYM/ACRONYM: CRP.
High-sensitivity
immunoassay
(cardiac SI Units (Conventional
applications) Conventional Units Units 10)
Low risk Less than 1 mg/dL Less than 10 mg/L
Average risk 13 mg/dL 1030 mg/L
High risk Greater than 10 mg/dL Greater than 100 mg/L (after
(after repeat testing) repeat testing) C
SI Units (Conventional
Conventional Assay Conventional Units Units 10)
Adult 00.8 mg/dL 08 mg/L
COMMON USE: To monitor myocardial infarction and some disorders of the mus-
culoskeletal system such as Duchennes muscular dystrophy. C
SPECIMEN: Serum (1 mL) collected in a red- or red/gray-top tube. Serial speci-
mens are highly recommended. Care must be taken to use the same type of
collection container if serial measurements are to be taken.
Creatinine, Blood
SYNONYM/ACRONYM: N/A.
COMMON USE: To assess kidney function found in acute and chronic renal fail-
ure, related to drug reaction and disease such as diabetes.
Signs &
Problem Symptoms Interventions
Fluid volume Excess: edema, Record daily weight and monitor
(Related to shortness of trends; ensure accurate intake and C
excess fluid breath, output; monitor laboratory values
and sodium increased that reflect alterations in fluid status
intake; weight, ascites, (potassium, blood urea nitrogen,
compromised rales, rhonchi, creatinine, calcium, hemoglobin,
renal function) and diluted and hematocrit, sodium); manage
laboratory underlying cause of fluid alteration;
values; monitor urine characteristics and
distended neck respiratory status; establish
veins; baseline assessment data; assess
tachycardia; and trend heart rate and blood
restlessness pressure; assess for symptoms of
fluid overload such as Jugular
Venous Distension (JVD),
shortness of breath, dyspnea,
crackles; ensure low-sodium diet;
administer prescribed diuretic;
administer prescribed
antihypertensive; elevate feet when
sitting; monitor oxygenation with
pulse oximetry; administer oxygen
as appropriate; elevate the head of
the bed; administer prescribed
antihypertensives
Cardiac output Weak peripheral Assess peripheral pulses and
(Related to pulses; slow capillary refill; monitor blood
excess fluid capillary refill; pressure and check for orthostatic
volume; decreased changes; assess respiratory rate,
pericarditis; urinary output; breath sounds, and orthopnea;
electrolyte cool clammy assess skin color and
imbalance; skin; temperature; assess level of
toxin tachypnea; consciousness; monitor urinary
accumulation) dyspnea; output; use pulse oximetry to
altered level of monitor oxygenation; monitor
consciousness; EKG; administer ordered
abnormal heart inotropic and peripheral
sounds; fatigue; vasodilator medications,
hypoxia; loud nitrates; provide oxygen
holosystolic administration; administer as
murmur; EKG prescribed (sodium bicarbonate,
changes; glucose, insulin drip, potassium
increased JVD excretion resin, calcium salt)
(table continues on page 636)
Access additional resources at davisplus.fadavis.com
s pecimen collection takes approxi- vary widely and are in constant flux.
mately 5 to 10 min. Address concerns Anorexia, nausea, and vomiting com-
about pain and explain that there monly occur, prompting the need for
may be some discomfort during the continuous monitoring for malnutrition,
venipuncture. especially among patients receiving
Sensitivity to social and cultural issues, long-term hemodialysis therapy.
as well as concern for modesty, is Recognize anxiety related to test
important in providing psychological results and be supportive of impaired
support before, during, and after the activity related to fear of shortened life
procedure. expectancy. Help the patient to cope C
Note that there are no food, fluid, or with long-term implications.
medication restrictions unless by medi- Recognize that anticipatory anxiety
cal direction. and grief related to potential lifestyle
Instruct the patient to refrain from changes may be expressed when
excessive exercise for 8 hr before someone is faced with a chronic
the test. disorder.
Depending on the results of this pro-
INTRATEST: cedure, additional testing may be
Potential Complications: N/A performed to evaluate or monitor
progression of the disease process
Ensure that the patient has complied and determine the need for a change
with activity restrictions; assure that in therapy. Evaluate test results in
activity has been restricted for at least relation to the patients symptoms
8 hr prior to the procedure. and other tests performed.
Avoid the use of equipment containing
latex if the patient has a history of aller- Patient Education:
gic reaction to latex.
Instruct the patient to cooperate fully Discuss the implications of abnormal
and to follow directions. Direct the test results on the patients lifestyle.
patient to breathe normally and to Provide teaching and information
avoid unnecessary movement. regarding the clinical implications of the
Observe standard precautions, and fol- test results, as appropriate.
low the general guidelines in Appendix Educate the patient regarding access
A. Positively identify the patient, and to counseling services.
label the appropriate specimen con- Provide contact information, if desired,
tainer with the corresponding patient for the National Kidney Foundation
demographics, initials of the person (www.kidney.org) or the National
collecting the specimen, date, and time Kidney Disease Education Program
of collection. Perform a venipuncture. (www.nkdep.nih.gov).
Remove the needle and apply direct Expected Patient Outcomes:
pressure with dry gauze to stop bleed- Reinforce information given by the
ing. Observe/assess venipuncture site patients HCP regarding further testing,
for bleeding or hematoma formation and treatment, or referral to another HCP.
secure gauze with adhesive bandage. Answer any questions or address any
Promptly transport the specimen to the concerns voiced by the patient or family.
laboratory for processing and analysis. Instruct the patient to resume usual
POST-TEST:
activity as directed by the HCP.
Inform the patient that a report of the Knowledge
results will be made available to the States causes of decreased libido
requesting HCP, who will discuss the Identifies causes of anemia
results with the patient. Skills
Nutritional Considerations: Increased Demonstrates proficiency in taking pre-
creatinine levels may be associated scribed medication accurately
with kidney disease. The nutritional Demonstrates proficiency in selecting
needs of patients with kidney disease activities that decrease bleeding risk
COMMON USE: To assess and monitor kidney function related to acute or chronic
nephritis.
Instruct the patient to void all urine into adhesive strips on the collector bag
the collection device and then to pour and apply over the genital area. Diaper
the urine into the laboratory collection the child. When specimen is obtained,
container. Alternatively, the specimen place the entire collection bag in a
can be left in the collection device for a sterile urine container.
health-care staff member to add to the
laboratory collection container. Indwelling Catheter
Note that there are no fluid or medica- Put on gloves. Empty drainage tube
tion restrictions unless by medical of urine. It may be necessary to
C direction. clamp off the catheter for 15 to
Instruct the patient to refrain from eat- 30 min before specimen collection.
ing meat during the test. Protocols Cleanse specimen port with antiseptic
may vary among facilities. swab, and then aspirate 5 mL of
urine with a 21- to 25-gauge needle
INTRATEST: and syringe. Transfer urine to a sterile
container.
Potential Complications: N/A
Urinary Catheterization
Ensure that the patient has complied Place female patient in lithotomy posi-
with dietary and activity restrictions for tion or male patient in supine position.
24 hr prior to the procedure; assure Using sterile technique, open the
that ingestion of meat has been straight urinary catheterization kit and
restricted during the test. perform urinary catheterization. Place
Avoid the use of equipment containing the retained urine in a sterile specimen
latex if the patient has a history of aller- container.
gic reaction to latex.
Instruct the patient to cooperate fully Suprapubic Aspiration
and to follow directions. Place the patient in a supine position.
Observe standard precautions, and fol- Cleanse the area with antiseptic and
low the general guidelines in Appendix A. drape with sterile drapes. A needle is
Positively identify the patient, and label inserted through the skin into the blad-
the appropriate specimen container der. A syringe attached to the needle is
with the corresponding patient used to aspirate the urine sample. The
demographics, initials of the person needle is then removed and a sterile
collecting the specimen, date, and dressing is applied to the site. Place
time of collection. Perform a venipunc- the sterile sample in a sterile specimen
ture as appropriate. container.
Random Specimen (collect in early Do not collect urine from the pouch
morning) Clean-Catch Specimen from the patient with a urinary diversion
Instruct the male patient to (1) thor- (e.g., ileal conduit). Instead, perform
oughly wash his hands, (2) cleanse the catheterization through the stoma.
meatus, (3) void a small amount into Timed Specimen
the toilet, and (4) void directly into the Obtain a clean 3-L urine specimen
specimen container. container, toilet-mounted collection
Instruct the female patient to device, and plastic bag (for transport of
(1) thoroughly wash her hands; the specimen container). The speci-
(2) cleanse the labia from front to men must be refrigerated or kept on
back; (3) while keeping the labia ice throughout the entire collection
separated, void a small amount into period. If an indwelling urinary catheter
the toilet; and (4) without interrupting is in place, the drainage bag must be
the urine stream, void directly into the kept on ice.
specimen container. Begin the test between 6 and 8 a.m. if
Pediatric Urine Collector possible. Collect first voiding and dis-
Put on gloves. Appropriately cleanse card. Record the time the specimen
the genital area and allow the area to was discarded as the beginning of the
dry. Remove the covering over the timed collection period. The next
Cryoglobulin
SYNONYM/ACRONYM: Cryo.
This procedure is
infections caused by M. tubercu-
contraindicated for: N/A
losis and Mycobacterium avium
intracellulare. M. avium intracel-
lulare is acquired via the gastro- INDICATIONS
intestinal tract through ingestion Assist in the diagnosis of
of contaminated food or mycobacteriosis.
water.The organisms waxy cell Assist in the diagnosis of suspected
wall protects it from acids in the pulmonary tuberculosis secondary
C to AIDS.
human digestive tract. Isolation
of mycobacteria in the stool does Assist in the differentiation of
not mean the patient has tuber- tuberculosis from carcinoma or
culosis of the intestines because bronchiectasis.
mycobacteria in stool are most Investigate suspected pulmonary
often present in sputum that has tuberculosis.
been swallowed. Monitor the response to treatment
for pulmonary tuberculosis.
POTENTIAL DIAGNOSIS
been restricted for at least 8 hr, and bleeding, bronchial perforation, bron-
clear liquids have been restricted for chospasm, infection, laryngospasm,
at least 2 hr prior to general anesthe- and pneumothorax.
sia, regional anesthesia, or sedation/ Ensure that the patient has complied
analgesia (monitored anesthesia). The with dietary and medication restriction-
American Society of Anesthesiologists sprior to the bronchoscopy procedure.
has fasting guidelines for risk levels Have patient remove dentures, contact
according to patient status. More lenses, eyeglasses, and jewelry. Notify
information can be located at the HCP if the patient has permanent
C www.asahq.org. Patients on beta crowns on teeth. Have the patient
blockers before the surgical procedure remove clothing and change into a
should be instructed to take their gown for the procedure.
medication as ordered during the Avoid the use of equipment containing
perioperative period. Protocols may latex if the patient has a history of aller-
vary among facilities. gic reaction to latex.
Expectorated Specimen Have emergency equipment readily
Additional liquids the night before may available. Keep resuscitation equip-
assist in liquefying secretions during ment on hand in case of respiratory
expectoration the following morning. impairment or laryngospasm after the
Assist the patient with oral cleaning procedure.
before sample collection to reduce the Avoid using morphine sulfate in
amount of sample contamination by patients with asthma or other pulmo-
organisms that normally inhabit the nary disease. This drug can further
mouth. exacerbate bronchospasms and respi-
Instruct the patient not to touch the ratory impairment.
edge or inside of the container with the Assist the patient to a comfortable
hands or mouth. position, and direct the patient to
Other than antimicrobial drugs, there breathe normally during the beginning
are no medication restrictions unless of the local anesthesia and to avoid
by medical direction. unnecessary movement during the
There are no food or fluid restrictions local anesthetic and the procedure.
unless by medical direction. Instruct the patient to cooperate fully
and to follow directions.
Tracheal Suctioning Observe standard precautions, and
Assist in providing extra fluids, unless follow the general guidelines in
contraindicated, and proper humidifica- Appendix A. Positively identify the
tion to decrease tenacious secretions. patient, and label the appropriate
Inform the patient that increasing fluid collection container with the corre-
intake before retiring on the night sponding patient demographics,
before the test aids in liquefying date and time of collection, and any
secretions and may make it easier medication the patient is taking that
to expectorate in the morning. Also may interfere with test results (e.g.,
explain that humidifying inspired air antibiotics).
also helps liquefy secretions.
Other than antimicrobial drugs, there Bronchoscopy
are no medication restrictions unless Record baseline vital signs.
by medical direction. The patient is positioned in relation
Note that there are no food or to the type of anesthesia being used.
fluid restrictions unless by medical If local anesthesia is used, the
direction. patient is seated and the tongue and
oropharynx are sprayed and
INTRATEST: swabbed with anesthetic before the
bronchoscope is inserted. For gen-
Potential Complications: eral anesthesia, the patient is placed
Complications associated with in a supine position with the neck
bronchoscopy are rare but may include hyperextended. After anesthesia, the
patient is kept in supine or shifted to Using the sterile hand, attach the suc-
a side-lying position and the bron- tion catheter to the rubber tubing of
choscope is inserted. After inspec- the Lukens tube or in-line trap. Then
tion, the samples are collected from attach the suction tubing to the male
suspicious sites by bronchial brush adapter of the trap with the clean
or biopsy forceps. hand. Lubricate the suction catheter
Expectorated Specimen with sterile saline.
Ask the patient to sit upright, with Tell nonintubated patients to pro-
assistance and support (e.g., with an trude the tongue and to take a deep
overbed table) as needed. breath as the suction catheter is C
Ask the patient to take two or three passed through the nostril. When
deep breaths and cough deeply. Any the catheter enters the trachea, a
sputum raised should be expectorated reflex cough is stimulated; immedi-
directly into a sterile sputum collection ately advance the catheter into the
container. trachea and apply suction. Maintain
If the patient is unable to produce the suction for approximately 10 sec,
desired amount of sputum, several but never longer than 15 sec.
strategies may be attempted. One Withdraw the catheter without
approach is to have the patient drink applying suction. Separate the suc-
two glasses of water, and then assume tion catheter and suction tubing
the position for postural drainage of from the trap, and place the rubber
the upper and middle lung segments. tubing over the male adapter to seal
Effective coughing may be assisted by the unit.
placing either the hands or a pillow For intubated patients or patients
over the diaphragmatic area and with a tracheostomy, the previous
applying slight pressure. procedure is followed except that the
Another approach is to place a vapor- suction catheter is passed through
izer or other humidifying device at the the existing endotracheal or trache-
bedside. After sufficient exposure to ostomy tube rather than through the
adequate humidification, postural nostril. The patient should be hyper-
drainage of the upper and middle oxygenated before and after the pro-
lung segments may be repeated cedure in accordance with standard
before attempting to obtain the protocols for suctioning these
specimen. patients.
Other methods may include obtaining Generally, a series of three to five early
an order for an expectorant to be morning sputum samples are collected
administered with additional water in sterile containers. If leprosy is sus-
approximately 2 hr before attempting pected, obtain a smear from nasal
to obtain the specimen. Chest percus- scrapings or a biopsy specimen from
sion and postural drainage of all lung lesions in a sterile container.
segments may also be employed. If General
the patient is still unable to raise spu- Monitor the patient for complications
tum, the use of an ultrasonic nebulizer related to the procedure (e.g., allergic
(induced sputum) may be necessary; reaction, anaphylaxis, bronchospasm).
this is usually done by a respiratory Promptly transport the specimen to the
therapist. laboratory for processing and analysis.
Tracheal Suctioning
Obtain the necessary equipment, POST-TEST:
including a suction device, suction kit, Inform the patient that a report of the
and Lukens tube or in-line trap. results will be made available to the
Position the patient with head elevated requesting HCP, who will discuss the
as high as tolerated. results with the patient.
Put on sterile gloves. Maintain the Instruct the patient to resume preoper-
dominant hand as sterile and the non- ative diet, as directed by the HCP.
dominant hand as clean. Assess the patients ability to swallow
SPECIMEN: Sterile fluid or swab from affected area placed in transport media
tube provided by laboratory.
Sterile Fluids
The laboratory will select the Isolate and identify organisms
appropriate media for suspect before surrounding tissue becomes
organisms and will initiate antibi- infected.
otic sensitivity testing if indicated Determine effective antimicrobial
by test results. Sensitivity testing therapy specific to the identified
identifies the antibiotics to which pathogen.
organisms are susceptible to
C ensure an effective treatment Wound
plan. Detect abscess or deep-wound
infectious process.
This procedure is Determine if an infectious agent is
contraindicated for: N/A the cause of wound redness, warmth,
or edema with drainage at a site.
INDICATIONS Determine presence of infectious
agents in a stage 3 and stage 4
Anal/Genital decubitus ulcer.
Assist in the diagnosis of sexually Isolate and identify organisms
transmitted diseases. responsible for the presence of pus
Determine the cause of genital itch- or other exudate in an open wound.
ing or purulent drainage. Determine effective antimicrobial
Determine effective antimicrobial therapy specific to the identified
therapy specific to the identified pathogen.
pathogen.
Routine prenatal screening for vagi- POTENTIAL DIAGNOSIS
nal and rectal GBS colonization. Positive findings in
Ear
Anal/Endocervical/Genital
Isolate and identify organisms
responsible for ear pain, drainage, Infections or carrier states are caused
or changes in hearing. by the following organisms: C. tracho-
Isolate and identify organisms matis, obligate intra-cellular bacteria
responsible for outer-, middle-, or without a cell wall, gram variable
inner-ear infection. Gardnerella vaginalis, gram negative
Determine effective antimicrobial N. gonorrhoeae, Treponema palli-
therapy specific to the identified dum, and toxin-producing strains of
pathogen. gram positive Staphylococcus aureus,
and gram positive GBS.
Eye
Isolate and identify pathogenic Ear
microorganisms responsible for Commonly identified gram negative
infection of the eye. organisms include Escherichia coli,
Determine effective antimicrobial the Proteus spp., Pseudomonas aerugi-
rapy specific to identified pathogen. nosa, gram positive S. aureus, and
-hemolytic streptococci.
Skin
Isolate and identify organisms Eye
responsible for skin eruptions, drain- Commonly identified organisms include
age, or other evidence of infection. C. trachomatis (transmitted to new-
Determine effective antimicrobial borns from infected mothers), gram
therapy specific to the identified negative Haemophilus influenzae
pathogen. (transmitted to newborns from
the patient milk the penis to express exudate will be flushed into a sterile
discharge from the urethra. Insert a collection tube. If the lesion is not fluid
swab into the urethral orifice and rotate filled, open the lesion with a scalpel
the swab to obtain a sample of the and swab the area with a sterile
discharge. Place the swab in the cotton-tipped swab. Place the swab in
Culturette or Gen-Probe transport the Culturette tube, and squeeze the
tube, and squeeze the bottom of the bottom of the tube to release the
tube to release the transport medium. transport medium. Ensure that the end
Ensure that the end of the swab is of the swab is immersed in the
immersed in the medium. medium. C
Ear Sterile Fluid
Cleanse the area surrounding the site Refer to related body fluid monographs
with a swab containing cleaning solu- (i.e., amniotic fluid, cerebrospinal fluid,
tion to remove any contaminating pericardial fluid, peritoneal fluid, pleural
material or flora that have collected in fluid, synovial fluid) for specimen
the ear canal. If needed, assist the collection.
appropriate HCP in removing any ceru- Wound
men that has collected. Place the patient in a comfortable
Insert a Culturette swab approxi- position, and drape the site to be cul-
mately 1/4 in. into the external ear tured. Cleanse the area around the
canal. Rotate the swab in the area wound to remove flora indigenous to
containing the exudate. Carefully the skin.
remove the swab, ensuring that it Place a Culturette swab in a
does not touch the side or opening superficial wound where the exudate
of the ear canal. is the most excessive without touch-
Place the swab in the Culturette tube, ing the wound edges. Place the swab
and squeeze the bottom of the tube to in the Culturette tube, and squeeze
release the transport medium. Ensure the bottom of the tube to release the
that the end of the swab is immersed transport medium. Ensure that the
in the medium. end of the swab is immersed in the
Eye medium. Use more than one swab
Pass a moistened swab over the and Culturette tube to obtain speci-
appropriate site, avoiding eyelid and mens from other areas of the wound.
eyelashes unless those areas are To obtain a deep wound specimen,
selected for study. Collect any visible insert a sterile syringe and needle into
pus or other exudate. Place the swab the wound and aspirate the drainage.
in the Culturette or Gen-Probe trans- Following aspiration, inject the material
port tube, and squeeze the bottom of into a tube containing an anaerobic
the tube to release the transport culture medium.
medium. Ensure that the end of the General
swab is immersed in the medium. Promptly transport the specimen to
An appropriate HCP should perform the laboratory for processing and
procedures requiring eye culture. analysis.
Skin
Assist the appropriate HCP in obtain- POST-TEST:
ing a skin sample from several areas of Instruct the patient to resume usual
the affected site. If indicated, the dark, medication as directed by the HCP.
moist areas of the folds of the skin and Instruct the patient to report symptoms
outer growing edges of the infection such as pain related to tissue inflam-
where microorganisms are most likely mation or irritation.
to flourish should be selected. Place Instruct the patient to begin antibiotic
the scrapings in a collection container therapy, as prescribed. Instruct the
or spread on a slide. Aspirate any fluid patient in the importance of completing
from a pustule or vesicle using a sterile the entire course of antibiotic therapy
needle and tuberculin syringe. The even if no symptoms are present.
Inform the patient that a repeat culture regarding the clinical implications of the
may be needed in 1 wk after comple- test results, as appropriate.
tion of the antimicrobial regimen. Reinforce information given by the
Advise the patient that final test results patients HCP regarding further testing,
may take 24 to 72 hr depending on the treatment, or referral to another HCP.
organism suspected but that antibiotic Emphasize the importance of reporting
therapy may be started immediately. continued signs and symptoms of the
Anal/Endocervical/Genital infection. Provide information regarding
Inform the patient that final results may vaccine-preventable diseases where
C take from 24 hr to 4 wk, depending on indicated (e.g., cervical cancer, hepati-
the test performed. tis A and B, human papillomavirus).
Advise the patient to avoid sexual con- Provide contact information, if desired,
tact until test results are available. for the CDC (www.cdc.gov/vaccines/
Instruct the patient in vaginal supposi- vpd-vac). Answer any questions or
tory and medicated cream installation address any concerns voiced by the
and administration of topical medica- patient or family.
tion to treat specific conditions, as Instruct the patient in the use of any
indicated. ordered medications (oral, topical,
Inform infected patients that all sexual drops). Instruct the patient in the
partners must be tested for the proper use of sterile technique for
microorganism. cleansing the affected site and applica-
Inform the patient that positive culture tion of dressings, as directed. Explain
findings for certain organisms must be the importance of adhering to the ther-
reported to a local health department apy regimen. As appropriate, instruct
official, who will question him or her the patient in significant side effects
regarding sexual partners. and systemic reactions associated with
Social and Cultural Considerations: Offer the prescribed medication. Encourage
support, as appropriate, to patients him or her to review corresponding lit-
who may be the victims of rape or erature provided by a pharmacist.
sexual assault. Educate the patient Depending on the results of this pro-
regarding access to counseling ser- cedure, additional testing may be
vices. Provide a nonjudgmental, performed to evaluate or monitor pro-
nonthreatening atmosphere for gression of the disease process and
discussing the risks of sexually trans- determine the need for a change in
mitted diseases. It is also important therapy. Evaluate test results in rela-
to address problems the patient may tion to the patients symptoms and
experience (e.g., guilt, depression, other tests performed.
anger). RELATED MONOGRAPHS:
Wound Related tests include relevant amniotic
Instruct the patient in wound care and fluid analysis, antimicrobial drugs,
nutritional requirements (e.g., protein, audiometry hearing loss, biopsy site,
vitamin C) to promote wound healing. CSF analysis, culture viral, Gram stain,
General otoscopy, pericardial fluid analysis, Pap
Inform the patient that a report of the smear, peritoneal fluid analysis, pleural
results will be made available to the fluid analysis, procalcitonin, spondee
requesting HCP, who will discuss the speech reception threshold, synovial
results with the patient. fluid analysis, syphilis serology, tuning
Recognize anxiety related to test results. fork tests, vitamin C, and zinc.
Discuss the implications of abnormal Refer to the Immune System table at
test results on the patients lifestyle. the end of the book for related tests by
Provide teaching and information body system.
This procedure is
algorithms. T he complex software contraindicated for: N/A
allows for frequent monitoring of
growth throughout the day and
rapid interpretation of culture find- INDICATIONS
ings. With these systems as soon as Determine sepsis in the newborn
a positive culture is detected, usual- as a result of prolonged labor,
ly within 2472 hr, the bottle can early rupture of membranes,
be removed from the system and a maternal infection, or neonatal
C aspiration
gram stain performed to provide a
preliminary identification of the Evaluate chills and fever in patients
bacteria present. T his preliminary with infected burns, urinary tract
report provides an opportunity for infections, rapidly progressing tis-
the HCP to initiate therapy. A sam- sue infection, postoperative wound
ple from the positive blood culture sepsis, and indwelling venous or
bottle is then subcultured on the arterial catheter
appropriate plated media for Evaluate intermittent or continuous
growth, isolation, and positive temperature elevation of unknown
identification of the organism.The origin
plated organisms are also used for Evaluate persistent, intermittent fever
sensitivity testing, if indicated. associated with a heart murmur
Sensitivity testing identifies the anti- Evaluate a sudden change in pulse
biotics to which the organisms are and temperature with or without
susceptible to ensure an effective chills and diaphoresis
treatment plan and can take several Evaluate suspected bacteremia after
days. Negative cultures are generally invasive procedures
removed from the automated cul- Identify the cause of shock in the
ture system after 5 days and final- postoperative period
ized as having No Growth. T he
subspecialty of microbiology has POTENTIAL DIAGNOSIS
been revolutionized by molecular
diagnostics. Molecular diagnostics Positive findings in
involves the identification of specif- Bacteremia or septicemia: Gram-
ic sequences of DNA. T he applica- negative organisms such as
tion of molecular diagnostics tech- Aerobacter, Bacteroides, Brucella,
niques, such as PCR, has led to the Escherichia coli and other coliform
development of automated instru- bacilli, Haemophilus influenzae,
ments that can identify a single Klebsiella, Pseudomonas
infectious agent or multiple patho- aeruginosa, and Salmonella.
gens from a small amount of blood Bacteremia or septicemia: Gram-
in less than 2 hr. T
he instruments positive organisms such as
can detect the presence of gram Clostridium perfringens, Enterococci,
negative bacteria, gram positive Listeria monocytogenes, Staphylococ
bacteria, and yeast commonly cus aureus, S. epidermidis, and
associated with bloodstream infec- -hemolytic streptococci.
tions. T
he instruments can also Plague
detect mutations in the genetic Malaria (by special request, a
material of specific pathogens that stained capillary smear would be
code for antibiotic resistance. examined)
Typhoid fever
INDICATIONS
DESCRIPTION:This test involves col-
lecting a sputum specimen so the Culture
pathogen can be isolated and iden- Assist in the diagnosis of respiratory
tified. T
he test results will reflect infections, as indicated by the pres-
the type and number of organisms ence or absence of organisms in
present in the specimen as well as culture
the antibiotics to which the identi- Gram Stain
fied pathogenic organisms are sus- Assist in the differentiation
ceptible. Sputum collected by of gram-positive from gram-
expectoration or suctioning with negative bacteria in respiratory
catheters and by bronchoscopy infection
cannot be cultured for anaerobic Assist in the differentiation of
organisms; instead, transtracheal sputum from upper respiratory
aspiration or lung biopsy must be tract secretions, the latter being
used.The laboratory will initiate indicated by excessive squamous
antibiotic sensitivity testing if indi- cells or absence of polymorphonu-
cated by test results. Sensitivity test- clear leukocytes
ing identifies antibiotics to which
the organisms are susceptible to
ensure an effective treatment plan. POTENTIAL DIAGNOSIS
The major difficulty in evaluating
results is in distinguishing organ-
This procedure is isms infecting the lower respiratory
contraindicated for: N/A tract from organisms that have
CRITICAL FINDINGS
C. diphtheriae NURSING IMPLICATIONS
Legionella AND PROCEDURE
Note and immediately report to the PRETEST:
health-care provider (HCP) positive Positively identify the patient using
results for bacterial pathogens or at least two unique identifiers
parasites. before providing care, treatment, or
It is essential that a critical finding services.
Patient Teaching: Inform the patient this
be communicated immediately to the test can assist in identification of the
requesting health-care provider (HCP). organism causing infection.
Lists of specific organisms may vary Obtain a history of the patients com-
among facilities; specific organisms plaints, including a list of known allergens,
are required to be reported to local, especially allergies or sensitivities to latex.
Ensure that the patient has complied position and the bronchoscope is
with dietary and medication restrictions inserted. After inspection, the samples
prior to the bronchoscopy procedure. are collected from suspicious sites by
Have patient remove dentures, contact bronchial brush or biopsy forceps.
lenses, eyeglasses, and jewelry. Notify Expectorated Specimen
the HCP if the patient has permanent Ask the patient to sit upright, with
crowns on teeth. Have the patient assistance and support (e.g., with an
remove clothing and change into a overbed table) as needed.
gown for the procedure. Ask the patient to take two or three
Avoid the use of equipment containing deep breaths and cough deeply. Any C
latex if the patient has a history of sputum raised should be expectorated
allergic reaction to latex. directly into a sterile sputum collection
Have emergency equipment readily container.
available. Keep resuscitation equipment If the patient is unable to produce the
on hand in case of respiratory impairment desired amount of sputum, several
or laryngospasm after the procedure. strategies may be attempted. One
Avoid using morphine sulfate in approach is to have the patient drink
patients with asthma or other two glasses of water, and then assume
pulmonary disease. This drug can the position for postural drainage of
further exacerbate bronchospasms the upper and middle lung segments.
and respiratory impairment. Effective coughing may be assisted by
Avoid the use of equipment containing placing either the hands or a pillow
latex if the patient has a history of over the diaphragmatic area and
allergic reaction to latex. applying slight pressure.
Assist the patient to a comfortable Another approach is to place a vapor-
position and direct the patient to izer or other humidifying device at the
breathe normally during the beginning bedside. After sufficient exposure to
of the general anesthesia and to avoid adequate humidification, postural
unnecessary movement during the drainage of the upper and middle lung
local anesthetic and the procedure. segments may be repeated before
Instruct the patient to cooperate fully attempting to obtain the specimen.
and to follow directions. Other methods may include obtaining an
Observe standard precautions and fol- order for an expectorant to be
low the general guidelines in Appendix administered with additional water
A. Positively identify the patient, and approximately 2 hr before attempting to
label the appropriate tubes with the obtain the specimen. Chest percussion
corresponding patient demographics, and postural drainage of all lung seg-
date and time of collection, and any ments may also be employed. If the
medication the patient is taking that patient is still unable to raise sputum, the
may interfere with test results (e.g., use of an ultrasonic nebulizer (induced
antibiotics). Collect the specimen in the sputum) may be necessary; this is usu-
appropriate sterile collection container. ally done by a respiratory therapist.
Bronchoscopy Tracheal Suctioning
Record baseline vital signs. Obtain the necessary equipment,
The patient is positioned in relation to including a suction device, suction kit,
the type of anesthesia being used. If and Lukens tube or in-line trap.
local anesthesia is used, the patient is Position the patient with head elevated
seated and the tongue and oropharynx as high as tolerated.
are sprayed and swabbed with anes- Put on sterile gloves. Maintain the
thetic before the bronchoscope is dominant hand as sterile and the
inserted. For general anesthesia, the nondominant hand as clean.
patient is placed in a supine position Using the sterile hand, attach the
with the neck hyperextended. After suction catheter to the rubber tubing of
anesthesia, the patient is kept in the Lukens tube or in-line trap. Then
supine or shifted to a side-lying attach the suction tubing to the male
adapter of the trap with the clean temperature every 4 hr for 24 hr. Notify
hand. Lubricate the suction catheter the HCP if temperature is elevated.
with sterile saline. Protocols may vary among facilities.
Tell nonintubated patients to protrude Emergency resuscitation equipment
the tongue and to take a deep breath should be readily available if the vocal
as the suction catheter is passed cords become spastic after intubation.
through the nostril. When the catheter Observe for delayed allergic reactions,
enters the trachea, a reflex cough is such as rash, urticaria, tachycardia,
stimulated; immediately advance the hyperpnea, hypertension, palpitations,
C catheter into the trachea and apply nausea, or vomiting.
suction. Maintain suction for approxi- Observe the patient for hemoptysis,
mately 10 sec, but never longer than difficulty breathing, cough, air hunger,
15 sec. Withdraw the catheter without excessive coughing, pain, or absent
applying suction. Separate the suction breathing sounds over the affected
catheter and suction tubing from the area. Report any symptoms to the HCP.
trap, and place the rubber tubing over Evaluate the patient for symptoms
the male adapter to seal the unit. indicating the development of pneumo-
For intubated patients or patients with thorax, such as dyspnea, tachypnea,
a tracheostomy, the previous proce- anxiety, decreased breathing sounds,
dure is followed except that the suction or restlessness. A chest x-ray may be
catheter is passed through the existing ordered to check for the presence of
endotracheal or tracheostomy tube this complication.
rather than through the nostril. The Evaluate the patient for symptoms of
patient should be hyperoxygenated empyema, such as fever, tachycardia,
before and after the procedure in malaise, or elevated white blood cell
accordance with standard protocols for count.
suctioning these patients. Administer antibiotic therapy if ordered.
Generally, a series of three to five early Remind the patient of the importance
morning sputum samples are collected of completing the entire course of
in sterile containers. antibiotic therapy, even if signs and
General symptoms disappear before comple-
Monitor the patient for complications tion of therapy.
related to the procedure (e.g., allergic Nutritional Considerations: Malnutrition is
reaction, anaphylaxis, bronchospasm). commonly seen in patients with severe
Promptly transport the specimen to the respiratory disease for numerous
laboratory for processing and analysis. reasons including fatigue, lack of
appetite, and gastrointestinal distress.
Adequate intake of vitamins A and C
POST-TEST: are also important to prevent pulmo-
Inform the patient that a report of the nary infection and to decrease the
results will be made available to the extent of lung tissue damage.
requesting HCP, who will discuss the Recognize anxiety related to test
results with the patient. results. Discuss the implications of
Instruct the patient to resume preoper- abnormal test results on the patients
ative diet, as directed by the HCP. lifestyle. Provide teaching and informa-
Assess the patients ability to swallow tion regarding the clinical implications
before allowing the patient to attempt of the test results, as appropriate.
liquids or solid foods. Educate the patient regarding access
Inform the patient that he or she may to counseling services.
experience some throat soreness and Reinforce information given by the
hoarseness. Instruct patient to treat throat patients HCP regarding further testing,
discomfort with lozenges and warm treatment, or referral to another HCP.
gargles when the gag reflex returns. Instruct the patient to use lozenges or
Monitor vital signs and compare with gargle for throat discomfort. Inform the
baseline values every 15 min for 1 hr, patient of smoking cessation programs
then every 2 hr for 4 hr, and then as as appropriate. The importance of fol-
ordered by the HCP. Monitor lowing the prescribed diet should be
Instruct the patient to cooperate fully available a few hours after testing is
and to follow directions. Direct the completed. Instruct the patient about
patient to breathe normally and to the importance of completing the entire
avoid unnecessary movement. course of antibiotic therapy even if no
Observe standard precautions, and fol- symptoms are present. Note: Antibiotic
low the general guidelines in Appendix A. therapy is frequently contraindicated for
Positively identify the patient, and label Salmonella infection unless the infection
the appropriate collection containers has progressed to a systemic state.
with the corresponding patient demo- Recognize anxiety related to test
C graphics, date and time of collection, results. Discuss the implications of
and any medication the patient is abnormal test results on the patients
taking that may interfere with test lifestyle. Provide teaching and informa-
results (e.g., antibiotics). tion regarding the clinical implications
Collect a stool specimen directly into a of the test results, as appropriate.
clean container. If the patient requires a Reinforce information given by the
bedpan, make sure it is clean and dry, patients HCP regarding further testing,
and use a tongue blade to transfer the treatment, or referral to another HCP.
specimen to the container. Make sure Emphasize the importance of reporting
representative portions of the stool are continued signs and symptoms of the
sent for analysis. Note specimen appear- infection. Answer any questions or
ance on collection container label. address any concerns voiced by the
Promptly transport the specimen to the patient or family.
laboratory for processing and analysis. Depending on the results of this proce-
dure, additional testing may be performed
POST-TEST: to evaluate or monitor progression of the
Inform the patient that a report of the disease process and determine the need
results will be made available to the for a change in therapy. Evaluate test
requesting HCP, who will discuss results in relation to the patients symp-
the results with the patient. toms and other tests performed.
Instruct the patient to resume usual
medication as directed by the HCP. RELATED MONOGRAPHS:
Instruct the patient to report symptoms Related tests include capsule endos-
such as pain related to tissue inflam- copy, colonoscopy, fecal analysis,
mation or irritation. Gram stain, ova and parasites, and
Advise the patient that final test results for proctosigmoidoscopy.
culture may take up to 72 hr but that anti- Refer to the Gastrointestinal and Immune
biotic therapy may be started immediately. systems tables at the end of the book
Test results for PCR methods are generally for related tests by body system.
Instruct the patient to resume usual Instruct the patient to use lozenges or
medication as directed by the HCP. gargle for throat discomfort. Inform the
Instruct the patient to notify the HCP patient of smoking cessation programs
immediately if difficulty in breathing or as appropriate. Emphasize the impor-
swallowing occurs or if bleeding occurs. tance of reporting continued signs and
Instruct the patient to perform mouth care symptoms of the infection. Provide
after the specimen has been obtained. information regarding vaccine-
Provide comfort measures and treatment preventable diseases where indicated
such as antiseptic gargles; inhalants; and (e.g., diphtheria H1N1 flu, Haemophilus
warm, moist applications as needed. A influenza, seasonal influenza, pneumo- C
cool beverage may aid in relieving throat coccal disease). Provide contact
irritation caused by coughing or suctioning. information, if desired, for the Centers
Administer antibiotic therapy if ordered. for Disease Control and Prevention
Remind the patient of the importance of (www.cdc.gov/vaccines/vpd-vac).
completing the entire course of antibiotic Answer any questions or address
therapy, even if signs and symptoms any concerns voiced by the patient or
disappear before completion of therapy. family.
Nutritional Considerations: Dehydration Depending on the results of this
can been seen in patients with a bac- procedure, additional testing may be
terial throat infection due to pain with performed to evaluate or monitor pro-
swallowing. Pain medications reduce gression of the disease process and
patients dysphagia and allow for ade- determine the need for a change in
quate intake of fluids and foods. therapy. Evaluate test results in relation
Recognize anxiety related to test to the patients symptoms and other
results. Discuss the implications of tests performed.
abnormal test results on the patients
lifestyle. Provide teaching and informa- RELATED MONOGRAPHS:
tion regarding the clinical implications Related tests include CBC, Gram stain,
of the test results, as appropriate. and group A streptococcal (rapid) screen.
Reinforce information given by the Refer to the Immune and Respiratory
patients HCP regarding further testing, systems tables at the end of the book
treatment, or referral to another HCP. for related tests by body system.
Culture, Fungal
SYNONYM/ACRONYM: N/A.
POTENTIAL DIAGNOSIS
DESCRIPTION: Fungi, organisms
that normally live in soil, can be Positive findings in
introduced into humans through Blood
the accidental inhalation of Candida albicans
spores or inoculation of spores Histoplasma capsulatum
into tissue through trauma. Cerebrospinal fluid
Individuals most susceptible to Coccidioides immitis
fungal infection usually are debili- Cryptococcus neoformans
tated by chronic disease, are Members of the order Mucorales
Paracoccidioides brasiliensis
receiving prolonged antibiotic
Sporothrix schenckii
therapy, or have impaired immune
systems. Fungal diseases may be Hair
Epidermophyton
classified according to the
Microsporum
involved tissue type: dermatophy- Trichophyton
toses involve superficial and Nails
cutaneous tissue; there are also sub- C. albicans
cutaneous and systemic mycoses. Cephalosporium
Epidermophyton
This procedure is Trichophyton
contraindicated for: N/A Skin
Actinomyces israelii
INDICATIONS C. albicans
Determine antimicrobial sensitivity C. immitis
of the organism Epidermophyton
Isolate and identify organisms Microsporum
responsible for neonatal thrush Trichophyton
Isolate and identify organisms Tissue
responsible for nail infections or A. israelii
abnormalities Aspergillus
Isolate and identify organisms C. albicans
responsible for skin eruptions, drain- Nocardia
age, or other evidence of infection P. brasiliensis
Culture, Viral
SYNONYM/ACRONYM: N/A.
SPECIMEN: Urine, semen, blood, body fluid, stool, tissue, or swabs from the
affected site.
This procedure is
DESCRIPTION: Viruses, the most contraindicated for: N/A
common cause of human infec-
tion, are submicroscopic organ- INDICATIONS
isms that invade living cells. Assist in the identification of viral
They can be classified as either infection
RNA- or DNA-type viruses. Viral
titers are highest in the early POTENTIAL DIAGNOSIS
stages of disease before the
host has begun to manufacture Positive findings in
significant antibodies against AIDS
the invader. Specimens need to HIV
be collected as early as possible Acute respiratory failure
in the disease process. The Hantavirus
subspecialty of microbiology Anorectal infections
HSV
has been revolutionized by
HPV
molecular diagnostics. Molecular
diagnostics involves the Bronchitis
Parainfluenza virus
identification of specific
RSV
sequences of DNA. The applica-
Cervical cancer
tion of molecular diagnostics HPV
techniques, such as PCR, has led Condylomata
to the development of automated HPV
instruments that can identify Conjunctivitis/keratitis
a single infectious agent or Adenovirus
multiple pathogens from a small Epstein-Barr virus
amount of specimen in less than HSV
2 hr. The instruments can detect Measles virus
the presence of bacteria and Parvovirus
viruses commonly associated Rubella virus
with viral infections. Varicella zoster virus (shingles)
Cystometry
SYNONYM/ACRONYM: CMG, urodynamic testing of bladder function.
CONTRAST: None.
Access additional resources at davisplus.fadavis.com
Instruct the patient to report pain, the patient indicates the urge to void,
sweating, nausea, headache, and the the bladder is considered full. The
urge to void during the study. patient is instructed to void, and urina-
Note that there are no food, fluid, or tion amounts as well as start and stop
medication restrictions unless by medi- times are then recorded.
cal direction. Pressure and volume readings are
Make sure a written and informed recorded and graphed for response to
consent has been signed prior to the heat, full bladder, urge to void, and
procedure and before administering ability to inhibit voiding. The patient is
C any medications. requested to void without straining,
and pressures are taken and recorded
INTRATEST: during this activity.
Potential Complications: After completion of voiding, the blad-
der is emptied of any other fluid, and
UTI related to use of a catheter
the catheter is withdrawn, unless fur-
Observe standard precautions, and fol-
ther testing is planned.
low the general guidelines in Appendix A.
Further testing may be done to deter-
Positively identify the patient.
mine if abnormal bladder function is
Avoid the use of equipment containing
being caused by muscle incompetence
latex if the patient has a history of
or interruption in innervation; anticho-
allergic reaction to latex.
linergic medication (e.g., atropine) or
Have emergency equipment readily
cholinergic medication (e.g.,
available.
bethanechol [Urecholine]) can be
Instruct the patient to change into the
injected and the study repeated in
gown, robe, and foot coverings pro-
20 or 30 min.
vided, but not to void.
Position the patient in a supine or
lithotomy position on the examination POST-TEST:
table. If spinal cord injury is present, Inform the patient that a report of the
the patient can remain on a stretcher results will be made available to the
in a supine position and be draped requesting HCP, who will discuss the
appropriately. results with the patient.
Ask the patient to void. During voiding, Monitor fluid intake and urinary output
note characteristics such as start time; for 24 hr after the procedure.
force and continuity of the stream; vol- Monitor vital signs after the procedure
ume voided; presence of dribbling, every 15 min for 2 hr or as directed.
straining, or hesitancy; and stop time. Monitor intake and output at least
Instruct the patient to cooperate fully every 8 hr. Elevated temperature may
and to follow directions. Instruct indicate infection. Notify the HCP if
the patient to remain still during the temperature is elevated. Protocols may
procedure. vary among facilities.
A urinary catheter is inserted into the Instruct the patient to immediately report
bladder under sterile conditions, and symptoms such as fast heart rate, diffi-
residual urine is measured and culty breathing, skin rash, itching, chest
recorded. A test for sensory response pain, persistent right shoulder pain, or
to temperature is done by instilling abdominal pain. Immediately report
30 mL of room-temperature sterile symptoms to the appropriate HCP.
water followed by 30 mL of warm ster- Inform the patient that he or she may
ile water. Sensations are assessed and experience burning or discomfort on
recorded. urination for a few voidings after the
Fluid is removed from the bladder, and procedure.
the catheter is connected to a cystom- Persistent flank or suprapubic pain,
eter that measures the pressure. fever, chills, blood in the urine, difficulty
Sterile normal saline, distilled water, or urinating, or change in urinary pattern
carbon dioxide gas is instilled in con- must be reported immediately to
trolled amounts into the bladder. When the HCP.
Recognize anxiety related to test the disease process and determine the
results. Discuss the implications of need for a change in therapy. Evaluate
abnormal test results on the patients test results in relation to the patients
lifestyle. Provide teaching and informa- symptoms and other tests performed.
tion regarding the clinical implications
of the test results, as appropriate. RELATED MONOGRAPHS:
Reinforce information given by the Related tests include bladder cancer
patients HCP regarding further testing, markers, calculus kidney stone panel,
treatment, or referral to another HCP. Chlamydia group antibody, CBC, CBC
Answer any questions or address hematocrit, CBC hemoglobin, CT pel- C
any concerns voiced by the patient vis, culture urine, cytology urine, IVP,
or family. MRI pelvis, PT/INR, US pelvis, and UA.
Depending on the results of this proce- Refer to the Genitourinary System
dure, additional testing may be needed table at the end of the book for related
to evaluate or monitor progression of tests by body system.
Cystoscopy
SYNONYM/ACRONYM: Cystoureterography, prostatography.
COMMON USE: To assess the urinary tract for bleeding, cancer, tumor, and pros-
tate health.
CONTRAST: None.
before cystoscopy. The urethroscope intake and output at least every 8 hr.
has a sheath that may be left in place, Compare with baseline values.
and the cystoscope is inserted through Notify the HCP if temperature is
it, avoiding multiple instrumentations. elevated. Protocols may vary among
After insertion of the cystoscope, a facilities.
sample of residual urine may be Instruct the patient to immediately
obtained for culture or other analysis. report symptoms such as fast heart
The bladder is irrigated via an irrigation rate, difficulty breathing, skin rash, itch-
system attached to the scope. The ing, chest pain, persistent right shoul-
C irrigation fluid aids in bladder der pain, or abdominal pain.
visualization. Immediately report symptoms to the
If a prostatic tumor is found, a biopsy appropriate HCP.
specimen may be obtained by means Inform the patient that burning or
of a cytology brush or biopsy discomfort on urination can be
forceps inserted through the scope. experienced for a few voidings after
If the tumor is small and localized, the procedure and that the urine
it can be excised and fulgurated. may be blood-tinged for the first
This procedure is termed and second voidings after the
transurethral resection of the procedure.
bladder. Polyps can also be identified Persistent flank or suprapubic pain,
and excised. fever, chills, blood in the urine, difficulty
Ulcers or bleeding sites can be fulgu- urinating, or change in urinary pattern
rated using electrocautery. must be reported immediately to
Renal calculi can be crushed the HCP.
and removed from the ureters and Recognize anxiety related to test
bladder. results. Discuss the implications
Ureteral catheters can be inserted via of abnormal test results on the
the scope to obtain urine samples from patients lifestyle. Provide teaching
each kidney for comparative analysis and information regarding the clinical
and radiographic studies. implications of the test results, as
Ureteral and urethral strictures can also appropriate.
be dilated during this p rocedure. Reinforce information given by the
Upon completion of the examination patients HCP regarding further testing,
and related procedures, the cysto- treatment, or referral to another
scope is withdrawn. HCP. Answer any questions or
Place obtained specimens in proper address any concerns voiced by the
containers, label them properly, and patient or family.
immediately transport them to the Depending on the results of this
laboratory. procedure, additional testing may be
needed to evaluate or monitor
POST-TEST: progression of the disease process
Inform the patient that a report of the and determine the need for a change
results will be made available to the in therapy. Evaluate test results in rela-
requesting HCP, who will discuss the tion to the patients symptoms and
results with the patient. other tests performed.
Instruct the patient to resume his or
her usual diet and medications, as RELATED MONOGRAPHS:
directed by the HCP. Related tests include biopsy kidney,
Encourage the patient to drink biopsy prostate, calculus kidney stone
increased amounts of fluids (125 mL/hr panel, Chlamydia group antibody, CT
for 24 hr) after the procedure. pelvis, culture urine, cytology urine,
Monitor vital signs and neurological IVP, MRI pelvis, PSA, US pelvis,
status every 15 min for 1 hr, then and UA.
every 2 hr for 4 hr, and then as Refer to the Genitourinary System
ordered by the HCP. Take the tem- table at the end of the book for related
perature every 4 hr for 24 hr. Monitor tests by body system.
Cystourethrography, Voiding
SYNONYM/ACRONYM: Voiding cystourethrography (VCU), voiding cystourethro-
gram (VCUG), micturating cystourethrogram (MCUG).
COMMON USE: To visualize and assess the bladder during voiding for evaluation C
of chronic urinary tract infections.
allergic reactions to any substance the HCP. Take the temperature every
or drug. 4 hr for 24 hr. Monitor intake and
Avoid the use of equipment containing output at least every 8 hr. Compare
latex if the patient has a history of aller- with baseline values. Notify the HCP
gic reaction to latex. if temperature is elevated. Protocols
Have emergency equipment readily may vary among facilities.
available. Monitor for reaction to iodinated
Instruct the patient to void prior to the contrast medium, including rash,
procedure and to change into the urticaria, tachycardia, hyperpnea,
C gown, robe, and foot coverings hypertension, palpitations, nausea,
provided. or vomiting.
Insert a Foley catheter before the pro- Instruct the patient to immediately
cedure, if ordered. Inform the patient report symptoms such as fast heart
that he or she may feel some pressure rate, difficulty breathing, skin rash, itch-
when the catheter is inserted and ing, chest pain, persistent right shoul-
when the contrast medium is instilled der pain, or abdominal pain.
through the catheter. Immediately report symptoms to the
Place the patient on the table in a appropriate HCP.
supine or lithotomy position. Maintain the patient on adequate
A kidney, ureter, and bladder radio- hydration after the procedure.
graph (KUB) is taken to ensure that no Encourage the patient to drink
barium or stool obscures visualization increased amounts of fluids (125 mL/hr
of the urinary system. for 24 hr) after the procedure to pre-
A catheter is filled with contrast vent stasis and bacterial buildup.
medium to eliminate air pockets and is Recognize anxiety related to test
inserted until the balloon reaches the results. Discuss the implications of
meatus if not previously inserted in the abnormal test results on the patients
patient. lifestyle. Provide teaching and
When three-fourths of the contrast information regarding the clinical
medium has been injected, a radio- implications of the test results, as
graphic exposure is made while the appropriate.
remainder of the contrast medium is Reinforce information given by the
injected. patients HCP regarding further testing,
When the patient is able to void, treatment, or referral to another HCP.
the catheter is removed and the Answer any questions or address
patient is asked to urinate while any concerns voiced by the patient
images of the bladder and urethra or family.
are recorded. Depending on the results of this proce-
Monitor the patient for complications dure, additional testing may be needed
related to the procedure (e.g., to evaluate or monitor progression of
allergic reaction, anaphylaxis, the disease process and determine
bronchospasm). the need for a change in therapy.
Evaluate test results in relation to
POST-TEST: the patients symptoms and other
Inform the patient that a report of the tests performed.
results will be made available to the
requesting HCP, who will discuss the RELATED MONOGRAPHS:
results with the patient. Related tests include biopsy prostate,
Instruct the patient to resume usual bladder cancer markers, BUN, CT pel-
diet and medications, as directed by vis, creatinine cytology urine, IVP, MRI
the HCP. pelvis, PSA, PT/INR, and US pelvis.
Monitor vital signs and neurological Refer to the Genitourinary System
status every 15 min for 1 hr, then every table at the end of the book for related
2 hr for 4 hr, and then as ordered by tests by body system.
Cytology, Sputum
SYNONYM/ACRONYM: N/A.
Ask the patient to take two or three as the suction catheter is passed
deep breaths and cough deeply. Any through the nostril. When the
sputum raised should be expectorated catheter enters the trachea, a reflex
directly into a sterile sputum collection cough is stimulated; immediately
container. advance the catheter into the trachea
If the patient is unable to produce and apply suction. Maintain suction
the desired amount of sputum, for approximately 10 sec, but never
several strategies may be attempted. longer than 15 sec. Withdraw the
One approach is to have the patient catheter without applying suction.
C drink two glasses of water, and then Separate the suction catheter and
assume the position for postural suction tubing from the trap, and
drainage of the upper and middle place the rubber tubing over the male
lung segments. Effective coughing adapter to seal the unit.
may be assisted by placing either For intubated patients or patients with
the hands or a pillow over the a tracheostomy, the previous proce-
diaphragmatic area and applying dure is followed except that the suction
slight pressure. catheter is passed through the existing
Another approach is to place a endotracheal or tracheostomy tube
vaporizer or other humidifying device rather than through the nostril. The
at the bedside. After sufficient expo- patient should be hyperoxygenated
sure to adequate humidification, before and after the procedure in
postural drainage of the upper and accordance with standard protocols for
middle lung segments may be suctioning these patients.
repeated before attempting to obtain Generally, a series of three to five
the specimen. early-morning sputum samples are
Other methods may include obtaining collected in sterile containers.
an order for an expectorant to be General
administered with additional water Monitor the patient for complications
approximately 2 hr before attempting related to the procedure (e.g., allergic
to obtain the specimen. Chest percus- reaction, anaphylaxis, bronchospasm).
sion and postural drainage of all lung Promptly transport the specimen to
segments may also be employed. the laboratory for processing and
If the patient is still unable to raise analysis.
sputum, the use of an ultrasonic
nebulizer (induced sputum) may POST-TEST:
be necessary; this is usually done Inform the patient that a report of
by a respiratory therapist. the results will be made available
Tracheal Suctioning to the requesting HCP, who will
Obtain the necessary equipment, discuss the results with the patient.
including a suction device, suction Instruct the patient to resume usual
kit, and Lukens tube or in-line trap. diet, as directed by the HCP. Assess
Position the patient with head elevated the patients ability to swallow before
as high as tolerated. allowing the patient to attempt liquids
Put on sterile gloves. Maintain the or solid foods.
dominant hand as sterile and the Inform the patient that he or she may
nondominant hand as clean. experience some throat soreness and
Using the sterile hand, attach the hoarseness. Instruct patient to treat
suction catheter to the rubber tubing throat discomfort with lozenges and
of the Lukens tube or in-line trap. warm gargles when the gag reflex
Then attach the suction tubing to returns.
the male adapter of the trap with the Monitor vital signs and compare with
clean hand. Lubricate the suction baseline values every 15 min for 1 hr,
catheter with sterile saline. then every 2 hr for 4 hr, and then as
Tell nonintubated patients to protrude ordered by the HCP. Monitor
the tongue and to take a deep breath temperature every 4 hr for 24 hr.
Cytology, Urine
SYNONYM/ACRONYM: N/A.
COMMON USE: To identify the presence of neoplasms of the urinary tract and
C assist in the diagnosis of urinary tract infections.
SPECIMEN: Urine (180 mL for an adult; at least 10 mL for a child) collected in a
clean wide-mouth plastic container.
sample. The needle is then removed signs and symptoms disappear before
and a sterile dressing is applied to the completion of therapy.
site. Place the sterile sample in a sterile Recognize anxiety related to test
specimen container. results, and be supportive of fear of
Do not collect urine from the pouch shortened life expectancy. Discuss the
from a patient with a urinary diversion implications of abnormal test results on
(e.g., ileal conduit). Instead perform the patients lifestyle. Provide teaching
catheterization through the stoma. and information regarding the clinical
General implications of the test results, as
C Promptly transport the specimen to the appropriate. Educate the patient regard-
laboratory for processing and analysis. ing access to counseling s ervices.
If a delay in transport is expected, add Reinforce information given by the
an equal volume of 50% alcohol to the patients HCP regarding further testing,
specimen as a preservative. treatment, or referral to another HCP.
Answer any questions or address
POST-TEST: any concerns voiced by the
Inform the patient that a report of the patient or family.
results will be made available to the Depending on the results of this pro-
requesting HCP, who will discuss the cedure, additional testing may be
results with the patient. performed to evaluate or monitor
Instruct the patient to resume usual progression of the disease process
medication as directed by the HCP. and determine the need for a change
Instruct the patient to report symptoms in therapy. Evaluate test results in
such as pain related to tissue inflam- relation to the patients symptoms
mation, pain or irritation during void, and other tests performed.
bladder spasms, or alterations in uri-
RELATED MONOGRAPHS:
nary elimination.
Observe for signs of inflammation if the Related tests include biopsy kidney,
specimen is obtained by suprapubic bladder cancer markers, cystoscopy,
aspiration. CMV IgG and IgM, Pap smear, UA,
Administer antibiotic therapy as and US bladder.
ordered. Remind the patient of the Refer to the Genitourinary and Immune
importance of completing the entire systems tables at the end of the book
course of antibiotic therapy, even if for related tests by body system.
Cytomegalovirus, Immunoglobulin G,
and Immunoglobulin M
SYNONYM/ACRONYM: CMV.
Signs &
Problem Symptoms Interventions
Infection (Related Fever, fatigue, loss Promote good hygiene; assist
C to viral infection of appetite; with hygiene as needed;
secondary to malaise; muscle administer prescribed antivirals
blood aches; headache; as appropriate, antipyretics;
transfusion; irregular administer cooling measures;
organ heartbeat; stiff monitor vital signs and trend
transplant; neck; shortness temperatures; encourage oral
sexual contact; of breath; swollen fluids; adhere to standard or
exposure to liver or spleen; universal precautions; provide
respiratory tachycardia; rash; isolation as appropriate; obtain
droplets) sore throat; cultures as ordered; assess
increased blood nutritional status and provide
pressure; supplements as needed
elevated IgM, IgG
Fatigue (Related Report of tiredness; Discuss the implementation of
to infection and inability to energy conservation activities
inflammation) maintain activities (even pace when working,
of daily living at frequent rest periods, frequent
current level; items in easy reach, push items
inability to restore instead of pulling); limit naps to
energy after rest increase nighttime sleeping; set
or sleep priorities for energy
expenditures; administer
ordered antibiotics
Sexuality Reduced sexual Assess perception of reported
(Related to function; change in sexual function;
positive CMV decreased sexual assess emotional impact of
[herpes virus]) satisfaction; herpes diagnosis (depression,
reports of altered self-esteem, altered
alteration in personal relationships); assess
relationship with need for counseling; encourage
partner verbalization of feelings; discuss
alternative forms of intimate
expression; discuss medical
treatments that may improve
sexual interaction
707
PRETEST: INTRATEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before pro- Avoid the use of equipment containing
viding care, treatment, or services. latex if the patient has a history of aller-
Patient Teaching: Inform the patient this gic reaction to latex.
test can assist in diagnosing and Instruct the patient to cooperate
evaluating conditions affecting normal fully and to follow directions.
blood clot formation. Direct the patient to breathe
Obtain a history of the patients normally and to avoid unnecessary
complaints, including a list of known movement.
allergens, especially allergies or Observe standard precautions, and
sensitivities to latex. follow the general guidelines in
Obtain a history of hematological Appendix A. Positively identify the
diseases and recent surgery. patient, and label the appropriate
Obtain a history of the patients cardio- specimen container with the corre-
vascular, hematopoietic, and respiratory sponding patient demographics, initials
systems; symptoms; and results of pre- of the person collecting the specimen,
viously performed laboratory tests and date, and time of collection.
diagnostic and surgical procedures. Perform a venipuncture. Fill tube com-
Obtain a list of the patients current pletely. Important note: When multiple
medications, including herbs, nutri- specimens are drawn, the blue-top
tional supplements, and nutraceuticals tube should be collected after sterile
(see Appendix H online at DavisPlus). (i.e., blood culture) tubes. Otherwise,
Review the procedure with the patient. when using a standard vacutainer
Inform the patient that specimen col- system, the blue top is the first tube
lection takes approximately 5 to 10 collected. When a butterfly is used
min. Address concerns about pain and and due to the added tubing, an extra
explain that there may be some dis- red-top tube should be collected before
comfort during the venipuncture. the blue-top tube to ensure complete
Sensitivity to social and cultural issues,as filling of the blue-top tube.
well as concern for modesty, is impor- Remove the needle and apply direct
tant in providing psychological support pressure with dry gauze to stop
before, during, and after the procedure. bleeding. Observe/assess venipuncture
Note that there are no food, fluid, or site for bleeding or hematoma forma-
medication restrictions unless by medi- tion and secure gauze with adhesive
cal direction. bandage.
Dehydroepiandrosterone Sulfate
SYNONYM/ACRONYM: DHEAS.
Female SI
Male SI Units Units
Male micromol/L Female micromol/L
Conventional (Conventional Conventional (Conventional
Age Units mcg/dL Units 0.027) Units mcg/dL Units 0.027)
Newborn 108607 2.916.4 108607 2.916.4
730 d 32431 0.911.6 32431 0.911.6
15 mo 3124 0.13.3 3124 0.13.3
635 mo 030 00.8 030 00.8
D 36 yr 050 01.4 050 01.4
79 yr 5115 0.13.1 594 0.12.5
1014 yr 22332 0.69 22255 0.66.9
1519 yr 88483 2.413 63373 1.710
2029 yr 280640 7.617.3 65380 1.810.3
3039 yr 120520 3.214 45270 1.27.3
4049 yr 95530 2.614.3 32240 0.96.5
5059 yr 70310 1.98.4 26200 0.75.4
6069 yr 42290 1.17.8 13130 0.43.5
70 yr and 28175 0.84.7 1090 0.32.4
older
Female SI
Male SI Units Units
Male micromol/L Female micromol/L
Tanner Conventional (Conventional Conventional (Conventional
Stage Units mcg/dL Units 0.027) Units mcg/dL Units 0.027)
I 7209 0.25.6 7126 0.23.4
II 28260 0.87 13241 0.46.5
III 39390 1.110.5 32446 0.912
IV & V 81488 2.213.2 65371 1.810
Drugs of Abuse
Amphetamines Opiates
Ethanol (Alcohol) Cocaine
Cannabinoids Phencyclidine
SPECIMEN: For ethanol, serum (1 mL) collected in a red-top tube; plasma (1 mL)
collected in a gray-top (sodium fluoride/potassium oxalate) tube is also accept-
able. For drug screen, urine (15 mL) collected in a clean plastic container.
Gastric contents (20 mL) may also be submitted for testing.
Workplace drug-screening programs, because of the potential medicolegal
consequences associated with them, require collection of urine and blood
specimens using a chain of custody protocol. The protocol provides securing
the sample in a sealed transport device in the presence of the donor and a
representative of the donors employer, such that tampering would be obvious.
The protocol also provides a written document of specimen transfer from
donor to specimen collection personnel, to storage, to analyst, and to disposal.
INDICATIONS
phencyclidines (PCPs) as the most Differentiate alcohol intoxication
commonly abused illicit drugs. from diabetic coma, cerebral trau-
Alcohol is the most commonly ma, or drug overdose
encountered legal substance of Investigate suspected drug abuse
abuse. Chronic alcohol abuse can Investigate suspected drug overdose
lead to liver disease, high blood Investigate suspected noncompli-
pressure, cardiac disease, and ance with drug or alcohol treat-
birth defects. ment program
Monitor ethanol levels when
D administered to treat methanol
This procedure is intoxication
contraindicated for: N/A Routine workplace screening
Screening Confirmatory
Cutoff Cutoff
Concentra Concentra
tions for tions for Detectable
Drugs of Drugs of Detectable Duration
Abuse Abuse Duration After Last
Recom- Recommen After Last Dose:
mended by ded by Single- Prolonged
SAMHSA SAMHSA Use Dose Use
Hallucinogens
Cannabinoids 50 ng/mL 15 ng/mL 27 days 12 mo
Phencyclidine 25 ng/mL 25 ng/mL 1 wk 24 wk
Opiates 2,000 ng/mL 2,000 ng/mL 13 days 13 days
6Acetylmorphine 10 ng/mL 10 ng/mL 20 hr 17 days
Stimulants
Amphetamines 500 ng/mL 250 ng/mL 48 hr 710 days
(either
amphetamine or
methamphetamine)a
Cocaine 150 ng/mL 100 ng/mL 3 days 4 days
MDMA (either 500 ng/mL 250 ng/mL 24 hr 24 hr
methylenedioxy
methamphetamine,
methylenedioxy
amphetamine, or
methylenedioxy
ethylamphetamine)
a To be reported as positive for methamphetamine, the specimen must also contain amphetamine
amount into the toilet; and (4) without Educate the patient regarding access
interrupting the urine stream, void to counseling services. Provide support
directly into the specimen container. and information regarding detoxifica-
Follow the chain-of-custody protocol, if tion programs, as appropriate. Provide
required. Monitor specimen collection, contact information, if desired, for the
labeling, and packaging to prevent National Institute on Drug Abuse (www
tampering. This protocol may vary by .nida.nih.gov).
institution. Reinforce information given by the
Promptly transport the specimen to the patients HCP regarding further testing,
laboratory for processing and analysis. treatment, or referral to another HCP.
Answer any questions or address any
POST-TEST: concerns voiced by the patient or family.
Inform the patient that a report of Depending on the results of this D
the results will be made available procedure, additional testing may be
to the requesting HCP, who will dis- performed to evaluate or monitor pro-
cuss the results with the patient. gression of the disease process and
Ensure that results are communicated determine the need for a change in
to the proper individual, as indicated in therapy. Evaluate test results in relation
the chain-of-custody protocol. to the patients symptoms and other
Recognize anxiety related to test tests performed.
results. Discuss the implications of
abnormal test results on the patients RELATED MONOGRAPHS:
lifestyle. Provide teaching and informa- Refer to the Therapeutic/Toxicology
tion regarding the clinical implications table at the end of the book for related
of the test results, as appropriate. tests.
Ductography
SYNONYM/ACRONYM: Breast ductoscopy, fiberoptic ductoscopy, galactography.
COMMON USE: To visualize and assess the breast ducts for disease and malig-
nancy in women with nipple discharge.
SI Units (Conventional
Dose Given Conventional Units Units 0.0666)
Plasma
Infant dose 0.5 g/kg Greater than 15 mg/dL Greater than 1 mmol/L
(max. 25 g) after 2 hr
Pediatric dose 0.5 g/kg Greater than 20 mg/dL Greater than 1.3 mmol/L
(max. 25 g) after 2 hr
Adult dose
25 g Greater than 25 mg/dL Greater than 1.7 mmol/L
after 2 hr
SI Units (Conventional
Dose Given Conventional Units Units 0.0666)
5 g (given if patient is Greater than 20 mg/dL Greater than 1.3 mmol/L
known or expected to after 2 hr
have severe
symptoms)
Urine
Children Greater than 16%40% of dose in 5 hr D
urine sample
Adults Greater than 16% or greater than 4 g
of dose in 5 hr urine sample
Older adults (age 65 years and Greater than 14% or greater than 3.5 g
older) of dose in 5 hr urine sample
720
Metallic objects (e.g., jewelry, body Review the procedure with the patient.
rings) within the examination field, Address concerns about pain related
which may inhibit organ visualiza- to the procedure and explain that
tion and cause unclear images. there should be no discomfort during
the procedure. Inform the patient the
The presence of chronic obstruc- procedure is performed in a US or
tive pulmonary disease or use of cardiology department, usually by
mechanical ventilation, which an HCP, and takes approximately
increases the air between the heart 30 to 60 min.
and chest wall (hyperinflation) and Explain that an IV line may be inserted
can attenuate the ultrasound waves. to allow infusion of IV fluids such as
Obese patients due to the enlarged normal saline, anesthetics, sedatives,
space between the transducer and contrast medium, or emergency
the heart. medications.
E Sensitivity to social and cultural issues,
Inability of the patient to cooperate as well as concern for modesty, is
or remain still during the proce- important in providing psychological
dure because of age, significant support before, during, and after the
pain, or mental status. procedure.
The presence of arrhythmias. Instruct the patient to remove jewelry,
and other metallic objects from the
area to be examined.
NURSING IMPLICATIONS Note that there are no food or fluid
restrictions unless by medical direction.
AND PROCEDURE
INTRATEST:
PRETEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before Observe standard precautions, and
providing care, treatment, or services. follow the general guidelines in
Patient Teaching: Inform the patient this Appendix A. Positively identify the
procedure can assist in assessing car- patient.
diac (heart) function. Ensure the patient has removed all
Obtain a history of the patients com- external metallic objects from the area
plaints or clinical symptoms, including to be examined prior to the procedure.
a list of known allergens, especially Avoid the use of equipment containing
allergies or sensitivities to latex, latex if the patient has a history of
anesthetics, contrast medium, allergic reaction to latex.
or sedatives. Have emergency equipment readily
Obtain a history of the patients cardio- available.
vascular system, symptoms, and Instruct the patient to void prior to the
results of previously performed labora- procedure and to change into the gown,
tory tests and diagnostic and surgical robe, and foot coverings provided.
procedures. Instruct the patient to cooperate fully
Note any recent procedures that can and to follow directions. Instruct the
interfere with test results (i.e., barium patient to remain still throughout
procedures, surgery, or biopsy). Ensure the procedure because movement
that barium studies were performed at produces unreliable results.
least 24 hr before this test. Place the patient in a supine position
Record the date of the last menstrual on a flat table with foam wedges to
period and determine the possibility of help maintain position and
pregnancy in perimenopausal women. immobilization.
Obtain a list of the patients current Establish an IV fluid line for the injec-
medications, including herbs, nutri- tion of saline, anesthetics, sedatives,
tional supplements, and nutraceuticals contrast medium, or emergency
(see Appendix H online at DavisPlus). medications.
Expose the chest, and attach electro- overweight and with high blood
cardiogram leads for simultaneous pressure, to safely decrease sodium
tracings, if desired. intake, achieve a normal weight,
Apply conductive gel to the chest. ensure regular participation in
Place the transducer on the chest moderate aerobic physical activity
surface along the left sternal border, three to four times per week,
the subxiphoid area, suprasternal eliminate tobacco use, and adhere
notch, and supraclavicular areas to to a heart-healthy diet. If triglycerides
obtain views and tracings of the por- also are elevated, the patient should
tions of the heart. Scan the areas by be advised to eliminate or reduce
systematically moving the probe in a alcohol. The 2013 Guideline on
perpendicular position to direct the Lifestyle Management to Reduce
ultrasound waves to each part of Cardiovascular Risk published by
the heart. the American College of Cardiology
To obtain different views or (ACC) and the American Heart E
information about heart function, Association (AHA) in conjunction
position the patient on the left side with the National Heart, Lung, and
and/or sitting up, or request that the Blood Institute (NHLBI) recommends
patient breathe slowly or hold the a Mediterranean-style diet rather
breath during the procedure. To evalu- than a low-fat diet. The new
ate heart function changes, the patient guideline emphasizes inclusion
may be asked to inhale amyl nitrate of vegetables, whole grains, fruits,
(vasodilator). low-fat dairy, nuts, legumes, and non-
Administer contrast medium, if tropical vegetable oils (e.g., olive,
ordered. A second series of images is canola, peanut, sunflower, flaxseed)
obtained. along with fish and lean poultry.
A similar dietary pattern known as
POST-TEST: the Dietary Approach to Stop
Inform the patient that a report of Hypertension (DASH) makes
the results will be made available additional recommendations for
to the requesting HCP, who will the reduction of dietary sodium.
discuss the results with the patient. Both dietary styles emphasize a
When the study is completed, remove reduction in consumption of red
the gel from the skin. meats, which are high in saturated
Recognize anxiety related to test fats and cholesterol, and other
results, and offer support. Discuss the foods containing sugar, saturated
implications of abnormal test results on fats, trans fats, and sodium.
the patients lifestyle. Provide teaching Social and Cultural Considerations:
and information regarding the clinical Numerous studies point to the
implications of the test results, as prevalence of excess body weight in
appropriate. American children and adolescents.
Nutritional Considerations: Abnormal Experts estimate that obesity is
findings may be associated with present in 25% of the population
cardiovascular disease. Nutritional ages 6 to 11 yr. The medical, social,
therapy is recommended for the and emotional consequences of
patient identified to be at risk for excess body weight are significant.
developing CAD or for individuals Special attention should be given to
who have specific risk factors and/or instructing the child and caregiver
existing medical conditions (e.g., regarding health risks and weight
elevated LDL cholesterol levels, other control education.
lipid disorders, insulin-dependent Recognize anxiety related to test
diabetes, insulin resistance, or meta- results, and be supportive of fear of
bolic syndrome). Other changeable shortened life expectancy. Discuss
risk factors warranting patient educa- the implications of abnormal test
tion include strategies to encourage results on the patients lifestyle.
patients, especially those who are Provide teaching and information
Echocardiography, Transesophageal
SYNONYM/ACRONYM: Echo, TEE.
INDICATIONS
the ultrasound (US) instrument Confirm diagnosis if conventional
allow the beam to be directed to echocardiography does not corre-
the back of the heart. The echoes late with other findings
are amplified and recorded on a Detect and evaluate congenital
screen for visualization and heart disorders
recorded on graph paper or Detect atrial tumors (myxomas)
videotape. The depth of the Detect or determine the severity of
endoscope and movement of the valvular abnormalities and
transducer is controlled to obtain regurgitation
various images of the heart struc- Detect subaortic stenosis as evi-
tures. TEE is usually performed denced by displacement of the
during surgery; it is also used on anterior atrial leaflet and reduction
patients who are in the intensive in aortic valve flow, depending on E
care unit, in whom the transmis- the obstruction
sion of waves to and from the Detect thoracic aortic dissection
chest has been compromised and and coronary artery disease (CAD)
more definitive information is Detect ventricular or atrial mural
needed. The images obtained by thrombi and evaluate cardiac
TEE have better resolution than wall motion after myocardial
those obtained by routine trans- infarction
thoracic echocardiography Determine the presence of pericar-
because TEE uses higher frequen- dial effusion
cy sound waves and offers closer Evaluate aneurysms and ventricular
proximity of the transducer to the thrombus
cardiac structures. Cardiac con- Evaluate or monitor biological and
trast medium such as DEFINITY prosthetic valve function
or Optison, is used to improve the Evaluate septal defects
visualization of viable myocardial Measure the size of the hearts
tissue within the heart. chambers and determine if
hypertrophic cardiomyopathy
This procedure is or congestive heart failure is
contraindicated for: N/A present
A variety of circumstances that may Monitor cardiac function during
be considered absolute or relative open heart surgery (most
depending on the facilitys providers: sensitive method for monitoring
ischemia)
Barrett esophagus Reevaluate after inadequate
Bleeding disorders visualization with conventional
Esophageal obstruction (e.g., echocardiography as a result of
spasm, stricture, tumor) obesity, trauma to or deformity
Esophageal trauma (e.g., laceration, of the chest wall, or lung
perforation) hyperinflation associated with
Esophageal varices COPD
Known upper esophagus disease
Tracheoesophageal fistula
POTENTIAL DIAGNOSIS
Recent esophageal surgery
(e.g., esophagectomy or Normal findings in
esophagogastrectomy) Normal appearance of the size,
Unstable cardiac or respiratory status position, structure, movements of
Zenker diverticulum the heart valves and heart muscle
Access additional resources at davisplus.fadavis.com
walls, and chamber blood filling; no name of the person giving the report,
evidence of valvular stenosis or and name of the person receiving the
insufficiency, cardiac tumor, foreign report. Documentation of notification
bodies, or CAD. The established val- should be made in the medical record
ues for the measurement of heart with the name of the HCP notified,
activities obtained by the study time and date of notification, and any
may vary by health-care provider orders received. Any delay in a timely
(HCP) and institution. report of a critical finding may require
completion of a notification form with
Abnormal findings in review by Risk Management.
Aortic aneurysm
Aortic valve abnormalities INTERFERING FACTORS
CAD
E Cardiomyopathy Factors that may impair clear
Congenital heart defects imaging
Congestive heart failure Incorrect placement of the trans-
Mitral valve abnormalities ducer over the desired test site.
Myocardial infarction Retained barium from a previous
Myxoma radiological procedure.
Pericardial effusion Patients who are dehydrated, result-
Pulmonary hypertension ing in failure to demonstrate the
Pulmonary valve abnormalities boundaries between organs and
Septal defects tissue structures.
Shunting of blood flow Large diaphragmatic hernia.
Thrombus Unknown upper esophageal
Ventricular hypertrophy pathology.
Ventricular or atrial mural Conditions such as esophageal
thrombi dysphagia and irradiation of the
mediastinum related to difficulty
manipulating the US probe once
CRITICAL FINDINGS it has been inserted in the
Aortic aneurysm esophagus.
Aortic dissection The presence of COPD or use of
mechanical ventilation, which
It is essential that a critical finding be
increases the air between the heart
communicated immediately to the
and chest wall (hyperinflation) and
requesting health-care provider (HCP).
can attenuate the US waves.
A listing of these findings varies among
Obese patients due to the enlarged
facilities.
space between the transducer and
Timely notification of a critical
the heart.
finding for lab or diagnostic studies is
The presence of arrhythmias.
a role expectation of the professional
Inability of the patient to cooperate
nurse. Notification processes will vary
or remain still during the proce-
among facilities. Upon receipt of the
dure because of age, significant
critical value the information should
pain, or mental status.
be read back to the caller to verify
accuracy. Most policies require imme- Other considerations
diate notification of the primary HCP, Failure to follow dietary restrictions
Hospitalist, or on-call HCP. Reported before the procedure may cause
information includes the patients the procedure to be canceled or
name, unique identifiers, critical value, repeated.
Establish an IV fluid line for the injec- Recognize anxiety related to test
tion of saline, sedatives, contrast results, and offer support. Discuss the
medium, or emergency medications. implications of abnormal test results on
Expose the chest, and attach electro- the patients lifestyle. Provide teaching
cardiogram leads for simultaneous and information regarding the clinical
tracings, if desired. implications of the test results, as
Spray or swab the patients throat with appropriate.
a local anesthetic, and place the oral Nutritional Considerations: Abnormal
bridge device in the mouth to prevent findings may be associated with
biting of the endoscope. cardiovascular disease. Nutritional
Place the patient in a left side-lying therapy is recommended for the
position on a flat table with foam patient identified to be at risk for
wedges to help maintain position and developing CAD or for individuals who
immobilization. The pharyngeal area have specific risk factors and/or exist-
E is anesthetized, and the endoscope ing medical conditions (e.g., elevated
with the ultrasound device attached LDL cholesterol levels, other lipid dis-
to its tip is inserted 30 to 50 cm to the orders, insulin-dependent diabetes,
posterior area of the heart, as in any insulin resistance, or metabolic syn-
esophagogastroduodenoscopy drome). Other changeable risk factors
procedure. warranting patient education include
Ask the patient to swallow as the strategies to encourage patients,
scope is inserted. When the transducer especially those who are overweight
is in place, the scope is manipulated and with high blood pressure, to safely
by controls on the handle to obtain decrease sodium intake, achieve a
scanning that provides real-time normal weight, ensure regular partici-
images of the heart motion and record- pation in moderate aerobic physical
ings of the images for viewing. Actual activity three to four times per week,
scanning is usually limited to 15 min eliminate tobacco use, and adhere to
or until the desired number of image a heart-healthy diet. If triglycerides
planes is obtained at different depths also are elevated, the patient should
of the scope. be advised to eliminate or reduce
Administer contrast medium, if alcohol. The 2013 Guideline on
ordered. A second series of images is Lifestyle Management to Reduce
obtained. Cardiovascular Risk published by
the American College of Cardiology
POST-TEST: (ACC) and the American Heart
Inform the patient that a report of Association (AHA) in conjunction with
the results will be made available the National Heart, Lung, and Blood
to the requesting HCP, who will Institute (NHLBI) recommends a
discuss the results with the patient. Mediterranean-style diet rather than
Monitor vital signs and neurological a low-fat diet. The new guideline
status every 15 min for 1 hr, then emphasizes inclusion of vegetables,
every 2 hr for 4 hr, and as ordered. whole grains, fruits, low-fat dairy, nuts,
Take temperature every 4 hr for 24 hr. legumes, and nontropical vegetable
Monitor intake and output at least oils (e.g., olive, canola, peanut, sun-
every 8 hr. Compare with baseline flower, flaxseed) along with fish and
values. Notify the HCP if temperature lean poultry. A similar dietary pattern
is elevated. Protocols may vary known as the Dietary Approach to
among facilities. Stop Hypertension (DASH) makes
Instruct the patient to resume usual additional recommendations for the
diet and activity 4 to 6 hr after the reduction of dietary sodium. Both
test, as directed by the HCP. dietary styles emphasize a reduction in
Instruct the patient to treat throat consumption of red meats, which are
discomfort with lozenges and high in saturated fats and cholesterol,
warm gargles when the gag reflex and other foods containing sugar, sat-
returns. urated fats, trans fats, and sodium.
Electrocardiogram
SYNONYM/ACRONYM: ECG, EKG.
COMMON USE: To evaluate the electrical impulses generated by the heart during
the cardiac cycle to assist with diagnosis of cardiac arrhythmias, blocks, dam-
age, infection, or enlargement.
CONTRAST: None.
Increased patient anxiety, causing Note that there are no food, fluid, or
hyperventilation or deep medication restrictions unless by medi-
respirations. cal direction.
Medications such as barbiturates
and digitalis. INTRATEST:
Strenuous exercise before the Potential Complications: N/A
procedure. Observe standard precautions, and
follow the general guidelines in
Appendix A. Positively identify the
NURSING IMPLICATIONS patient.
AND PROCEDURE Ensure the patient has complied with
pretesting preparations.
PRETEST: Ensure the patient has removed all
Positively identify the patient using external metallic objects from the E
at least two unique identifiers before area to be examined prior to the
providing care, treatment, or procedure.
services. Instruct the patient to void prior to
Patient Teaching: Inform the patient this the procedure and to change into
procedure can assist in assessing car- the gown, robe, and foot coverings
diac (heart) function. provided.
Obtain a history of the patients com- Record baseline values.
plaints or clinical symptoms, including Place patient in a supine position.
a list of known allergens, especially Expose and appropriately drape the
allergies or sensitivities to latex, anes- chest, arms, and legs.
thetics, or sedatives. Ask if the patient Instruct the patient to cooperate fully
has had a heart transplant, implanted and to follow directions. Instruct the
pacemaker, or internal cardiac patient to remain still throughout the
defibrillator. procedure because movement pro-
Obtain a history of the patients duces unreliable results.
cardiovascular system, symptoms, Prepare the skin surface with alcohol
and results of previously performed and remove excess hair. Use clippers to
laboratory tests and diagnostic and remove hair from the site, if a ppropriate.
surgical procedures. Dry skin sites.
Obtain a list of the patients current Avoid the use of equipment containing
medications, including herbs, nutri- latex if the patient has a history of
tional supplements, and nutraceuticals allergic reaction to latex.
(see Appendix H online at DavisPlus). Apply the electrodes in the proper
Review the procedure with the position. When placing the six unipolar
patient. Inform the patient that it may chest leads, place V1 at the fourth
be necessary to remove hair from the intercostal space at the border of the
site before the procedure. Address right sternum, V2 at the fourth inter-
concerns about pain related to the costal space at the border of the left
procedure and explain that there sternum, V3 between V2 and V4, V4
should be no discomfort related to the at the fifth intercostal space at the
procedure. Inform the patient that the midclavicular line, V5 at the left anterior
procedure is performed by an HCP axillary line at the level of V4 horizon-
and takes approximately 15 min. tally, and V6 at the level of V4 horizon-
Sensitivity to social and cultural issues, tally and at the left midaxillary line. The
as well as concern for modesty, is wires are connected to the matched
important in providing psychological electrodes and the ECG machine.
support before, during, and after the Chest leads (V1, V2, V3, V4, V5, and V6)
procedure. record data from the horizontal plane
Instruct the patient to remove jewelry of the heart.
and other metallic objects from the Place three limb bipolar leads (two
area to be examined. electrodes combined for each) on the
arms and legs. Lead I is the combina- LDL cholesterol levels, other lipid
tion of two arm electrodes, lead II is disorders, insulin-dependent diabetes,
the combination of right arm and left insulin resistance, or metabolic
leg electrodes, and lead III is the syndrome). Other changeable risk
combination of left arm and left leg factors warranting patient education
electrodes. Limb leads (I, II, III, aVl, include strategies to encourage
aVf, and aVr) record data from the patients, especially those who are
frontal plane of the heart. overweight and with high blood pres-
The machine is set and turned on sure, to safely decrease sodium
after the electrodes, grounding, con- intake, achieve a normal weight,
nections, paper supply, computer, ensure regular participation of
and data storage device are moderate aerobic physical activity
checked. three to four times per week,
If the patient has any chest discomfort eliminate tobacco use, and adhere to
E or pain during the procedure, mark a heart-healthy diet. If triglycerides
the ECG strip indicating that also are elevated, the patient should
occurrence. be advised to eliminate or reduce
alcohol. The 2013 Guideline on
Lifestyle Management to Reduce
POST-TEST: Cardiovascular Risk published by
Inform the patient that a report of the American College of Cardiology
the results will be made available (ACC) and the American Heart
to the requesting HCP, who will Association (AHA) in conjunction
discuss the results with the patient. with the National Heart, Lung, and
When the procedure is complete, Blood Institute (NHLBI) recommends
remove the electrodes and clean a Mediterranean-style diet rather
the skin where the electrode was than a low-fat diet. The new guideline
applied. emphasizes inclusion of vegetables,
Evaluate the results in relation to whole grains, fruits, low-fat dairy,
previously performed ECGs. Denote nuts, legumes, and nontropical
cardiac rhythm abnormalities on the vegetable oils (e.g., olive, canola,
strip. peanut, sunflower, flaxseed) along
Monitor vital signs and compare with with fish and lean poultry. A similar
baseline values. Protocols may vary dietary pattern known as the Dietary
among facilities. Approach to Stop Hypertension
Instruct the patient to immediately (DASH) makes additional recommen-
notify an HCP of chest pain, changes dations for the reduction of dietary
in pulse rate, or shortness of breath. sodium. Both dietary styles emphasize
Recognize anxiety related to the test a reduction in consumption of red
results and be supportive of perceived meats, which are high in saturated
loss of independence and fear of fats and cholesterol, and other foods
shortened life expectancy. Discuss the containing sugar, saturated fats, trans
implications of abnormal test results on fats, and sodium.
the patients lifestyle. Provide teaching Social and Cultural Considerations:
and information regarding the clinical Numerous studies point to the
implications of the test results, as prevalence of excess body weight in
appropriate. American children and adolescents.
Nutritional Considerations: Abnormal Experts estimate that obesity is
findings may be associated with present in 25% of the population
cardiovascular disease. Nutritional ages 6 to 11 yr. The medical, social,
therapy is recommended for the and emotional consequences of
patient identified to be at risk for excess body weight are significant.
developing coronary artery disease Special attention should be given to
(CAD) or for individuals who have instructing the child and caregiver
specific risk factors and/or existing regarding health risks and weight
medical conditions (e.g., elevated control education.
R
5 mm (0.2 sec)
PR (1 mm)
Segment
0.04
ST sec
Segment
T
P
Q
PR Interval S
QRS
Complex
QT Interval
Electroencephalography
SYNONYM/ACRONYM: Electrical activity (for sleep disturbances), EEG.
COMMON USE: To assess the electrical activity in the brain toward assisting in
diagnosis of brain death, injury, infection, and bleeding.
CONTRAST: None.
E
DESCRIPTION:Electroencephalo the brain. To evaluate abnormal
graphy (EEG) is a noninvasive EEG waves further, the patient
study that measures the brains may be connected to an ambula
electrical activity and records that tory EEG system similar to a
activity on graph paper. These Holter monitor for the heart.
electrical impulses arise from the Patients keep a journal of their
brain cells of the cerebral cortex. activities and any symptoms that
Electrodes, placed at 8 to 20 sites occur during the monitoring
(or pairs of sites) on the patients period.
scalp, transmit the different fre
quencies and amplitudes of
This procedure is
the brains electrical activity to the
contraindicated for: N/A
EEG machine, which records the
results in graph form on a moving
paper strip. This procedure can INDICATIONS
evaluate responses to various stim Confirm brain death
uli, such as flickering light, hyper Confirm suspicion of increased
ventilation, auditory signals, or intracranial pressure caused by
somatosensory signals generated trauma or disease
by skin electrodes. The procedure Detect cerebral ischemia during
is usually performed in a room endarterectomy
designed to eliminate electrical Detect intracranial cerebrovascular
interference and minimize distrac lesions, such as hemorrhages and
tions. An EEG can be done at the infarcts
bedside, and a health-care provid Detect seizure disorders and identify
er (HCP) analyzes the waveforms. focus of seizure and seizure activity,
The test is used to detect epilepsy, as evidenced by abnormal spikes
intracranial abscesses, or tumors; and waves recorded on the graph
to evaluate cerebral involvement Determine the presence of tumors,
due to head injury or meningitis; abscesses, or infection
and to monitor for cerebral tissue Evaluate the effect of drug intoxica
ischemia during surgery when tion on the brain
cerebral vessels must be occlud Evaluate sleeping disorders, such as
ed. EEG is also used to confirm sleep apnea and narcolepsy
brain death, which can be defined Identify area of abnormality in
as absence of electrical activity in dementia
supplements, and nutraceuticals (see Ensure the patient has complied with
Appendix H online at DavisPlus). pretesting preparations. Ensure that
Review the procedure with the patient. caffeine-containing beverages were
Address concerns about pain related to withheld for 8 hr before the procedure
the procedure and assure the patient and that a meal was ingested before
there is no discomfort during the proce- the study.
dure, but if needle electrodes are used, Ensure that all substances with the
a slight pinch may be felt. Explain that potential to interfere with test results
electricity flows from the patients body, were withheld for 24 to 48 hr before
not into the body, during the procedure. the test.
Explain that the procedure reveals brain Ensure that the patient is able to
activity only, not thoughts, feelings, or relax; report any extreme anxiety or
intelligence. Inform the patient the pro- restlessness.
cedure is performed in a neurodiagnos- Ensure that hair is clean and free of
E tic department, usually by an HCP and hair sprays, creams, or solutions.
support staff, and takes approximately Avoid the use of equipment containing
30 to 60 min. latex if the patient has a history of aller-
Inform the patient that he or she may gic reaction to latex.
be asked to alter breathing pattern; be Place the patient in the supine position
asked to follow simple commands in a bed or in a semi-Fowlers position
such as opening or closing eyes, blink- on a recliner in a special room pro-
ing, or swallowing; be stimulated with tected from any noise or electrical
bright light; or be given a drug to interferences that could affect the
induce sleep during the study. tracings.
Sensitivity to social and cultural issues, Remind the patient to relax and not to
as well as concern for modesty, is move any muscles or parts of the face
important in providing psychological or head. The HCP should be able to
support before, during, and after the observe the patient for movements or
procedure. other interferences through a window
Instruct the patient to clean the hair into the test room.
and to refrain from using hair sprays, The electrodes are prepared and
creams, or solutions before the test. applied to the scalp. Electrodes are
Instruct the patient to limit sleep to 5 hr placed in as many as 20 locations over
for an adult and 7 hr for a child the the frontal, temporal, parietal, and
night before the study. Young infants occipital areas, and amplifier wires are
and children should not be allowed to attached. An electrode is also attached
nap before the study. to each earlobe as grounding elec-
Instruct the patient to eat a meal trodes. At this time, a baseline
before the study and to avoid stimu- recording can be made with the
lants such as caffeine and nicotine for patient at rest.
8 hr prior to the procedure. Under Recordings are made with the patient
medical direction, the patient should at rest and with eyes closed.
avoid sedatives, anticonvulsants, anx- Recordings are stopped about every
iolytics, and alcohol for 24 to 48 hr 5 min to allow the patient to move.
before the test. Recordings are also made during a
Make sure a written and informed drowsy and sleep period, depending
consent has been signed prior to the on the patients clinical condition and
procedure and before administering symptoms.
any medications. Procedures (e.g., stroboscopic light
stimulation, hyperventilation to induce
INTRATEST: alkalosis, and sleep induction by
administration of sedative to detect
Potential Complications: N/A abnormalities that occur only during
Observe standard precautions, and fol- sleep) may be done to bring out
low the general guidelines in Appendix A. abnormal electrical activity or other
Positively identify the patient. brain abnormalities.
Observations for seizure activity are results on the patients lifestyle. Provide
carried out during the study, and a teaching and information regarding the
description and time of activity is noted clinical implications of the test results,
by the HCP. as appropriate.
Reinforce information given by the
POST-TEST: patients HCP regarding further testing,
Inform the patient that a report of treatment, or referral to another HCP.
the results will be made available Answer any questions or address
to the requesting HCP, who will dis- any concerns voiced by the patient or
cuss the results with the patient. family.
When the procedure is complete, Depending on the results of this
remove electrodes from the hair and procedure, additional testing may be
remove paste by cleansing with oil or performed to evaluate or monitor pro-
witch hazel. gression of the disease process and
Allow the patient to recover if a seda- determine the need for a change in E
tive was given during the test. Bedside therapy. Evaluate test results in relation
rails are put in the raised position for to the patients symptoms and other
safety. tests performed.
Instruct the patient to resume medica-
tions, as directed by the HCP. RELATED MONOGRAPHS:
Instruct the patient to report any Related tests include CSF analysis, CT
seizure activity. brain, evoked brain potentials (SER,
Recognize anxiety related to test VER), MRI brain, and PET brain.
results, and be supportive of perceived Refer to the Musculoskeletal System
loss of independent function. Discuss table at the end of the book for related
the implications of abnormal test tests by body system.
Electromyography
SYNONYM/ACRONYM: Electrodiagnostic study, EMG, neuromuscular junction testing.
COMMON USE: To assess the electrical activity within the skeletal muscles to
assist in diagnosing diseases such as muscular dystrophy, Guillain-Barr, polio,
and other myopathies.
CONTRAST: None.
COMMON USE: To assess urinary sphincter electrical activity to assist with diag-
nosis of urinary incontinence.
CONTRAST: None.
E
floor muscle dysfunction of the
DESCRIPTION: Pelvic floor sphinc- anal sphincter
ter electromyography, also known
as rectal electromyography, is per- CRITICAL FINDINGS: N/A
formed to measure electrical
activity of the external urinary INTERFERING FACTORS
sphincter. This procedure, often
done in conjunction with cystom- Factors that may impair the
etry and voiding urethrography as results of the examination
part of a full urodynamic study, Inability of the patient to cooperate
helps to diagnose neuromuscular or remain still during the proce-
dysfunction and incontinence. dure because of age, significant
pain, or mental status.
This procedure is Age-related decreases in electrical
contraindicated for activity.
Patients with bleeding disor- Medications such as muscle
ders because the puncture relaxants, cholinergics, and
sites may not stop bleeding. anticholinergics.
Other considerations
INDICATIONS Failure to follow dietary restrictions
Evaluate neuromuscular dysfunction before the procedure may cause
and incontinence the procedure to be canceled or
repeated.
POTENTIAL DIAGNOSIS
Normal findings in
Normal urinary and anal sphincter NURSING IMPLICATIONS
muscle function; increased electro- AND PROCEDURE
myographic signals during the fill-
ing of the urinary bladder and at PRETEST:
the conclusion of voiding; absence Positively identify the patient using at
of signals during the actual voiding; least two unique identifiers before pro-
no incontinence viding care, treatment, or services.
Patient Teaching: Inform the patient this
Abnormal findings in procedure can assist in measuring the
Neuromuscular dysfunction of electrical activity of the pelvic floor
lower urinary sphincter, pelvic muscles.
requesting HCP, who will discuss the the implications of abnormal test
results with the patient. results on the patients lifestyle. Provide
Instruct the patient to resume usual teaching and information regarding the
diet, fluids, medications, and activity, clinical implications of the test results,
as directed by the HCP. as appropriate.
Monitor vital signs and neurological Reinforce information given by the
status every 15 min for 1 hr, then every patients HCP regarding further testing,
2 hr for 4 hr, and as ordered. Take treatment, or referral to another HCP.
temperature every 4 hr for 24 hr. Answer any questions or address any
Monitor intake and output at least concerns voiced by the patient or family.
every 8 hr. Compare with baseline Depending on the results of this proce-
values. Protocols may vary dure, additional testing may be needed
among facilities. to evaluate or monitor progression of
Instruct the patient to increase fluid the disease process and determine the
intake unless contraindicated. need for a change in therapy. Evaluate E
If tested with needle electrodes, warn test results in relation to the patients
female patients to expect hematuria symptoms and other tests performed.
after the first voiding.
Advise the patient to report symptoms RELATED MONOGRAPHS:
of urethral irritation, such as dysuria, Related tests include CT pelvis, cys-
persistent or prolonged hematuria, and tometry, cystoscopy, cystourethrogra-
urinary frequency. phy voiding, IVP, and US bladder.
Recognize anxiety related to test Refer to the Genitourinary System
results, and be supportive of perceived table at the end of the book for related
loss of independent function. Discuss tests by body system.
Electroneurography
SYNONYM/ACRONYM: Electrodiagnostic study, nerve conduction study, ENG.
CONTRAST: None.
Sensitivity to social and cultural issues,as Calculate the conduction velocity. The
well as concern for modesty, is impor- conduction velocity is converted to
tant in providing psychological support meters per second (m/sec) and com-
before, during, and after the procedure. puted using the following equation:
Note that there are no food, fluid, or
Conduction velocity (m/sec) = [distance
medication restrictions unless by medi-
cal direction. (m)] / [total latency distal latency]
Instruct the patient to remove jewelry When the procedure is complete,
and other metallic objects from the remove the electrodes and clean the
area to be examined. skin where the electrodes were applied.
Make sure a written and informed Monitor electrode sites for inflammation.
consent has been signed prior to the
procedure and before administering POST-TEST:
any medications. Inform the patient that a report of the
INTRATEST: results will be made available to E
the requesting HCP, who will discuss
Potential Complications: N/A the results with the patient.
Observe standard precautions, and fol- If residual pain is noted after the proce-
low the general guidelines in Appendix A. dure, instruct the patient to apply warm
Positively identify the patient. compresses and to take analgesics, as
Ensure the patient has removed all ordered.
external metallic objects from the area Instruct the patient to resume usual
to be examined prior to the procedure. diet, medication, and activity, as
Instruct the patient to void prior to the directed by the HCP.
procedure and to change into the gown, Recognize anxiety related to test results,
robe, and foot coverings provided. and be supportive of perceived loss of
Place the patient in a supine or sitting independent function. Discuss the impli-
position, depending on the location of cations of abnormal test results on the
the muscle to be tested. patients lifestyle. Provide teaching and
Avoid the use of equipment containing information regarding the clinical implica-
latex if the patient has a history of aller- tions of the test results, as appropriate.
gic reaction to latex. Reinforce information given by the
Use clippers to remove hair from the patients HCP regarding further testing,
site if appropriate, and cleanse the skin treatment, or referral to another HCP.
thoroughly with alcohol pads. Answer any questions or address any
Apply electrode gel and place a concerns voiced by the patient or family.
recording electrode at a known dis- Depending on the results of this proce-
tance from the stimulation point. dure, additional testing may be per-
Measure the distance between the formed to evaluate or monitor progres-
stimulation point and the site of the sion of the disease process and deter-
recording electrode in centimeters. mine the need for a change in therapy.
Place a reference electrode nearby on Evaluate test results in relation to the
the skin surface. patients symptoms and other tests
The nerve is electrically stimulated by a performed.
shock-emitter device; the time
between nerve impulse and electrical RELATED MONOGRAPHS:
contraction, measured in milliseconds Related tests include acetylcholine
(distal latency), is shown on a monitor. receptor antibody, biopsy muscle, CK,
The nerve is also electrically stimulated EMG, evoked brain potentials (SER,
at a location proximal to the area of VER), fluorescein angiography, fundus
suspected injury or disease. photography, glucose, glycated hemo-
The time required for the impulse to globin, insulin, microalbumin, and
travel from the stimulation site to plethysmography.
location of the muscle contraction Refer to the Musculoskeletal System
(total latency) is recorded in table at the end of the book for related
milliseconds. tests by body system.
Access additional resources at davisplus.fadavis.com
Endoscopy, Sinus
SYNONYM/ACRONYM: N/A.
E CONTRAST: N/A
Abnormal findings in
DESCRIPTION: Sinus endoscopy,
Foreign bodies in the nose
done with a narrow flexible tube,
Growths in the nasal passages
is used to help diagnose damage
Polyps
to the sinuses, nose, and throat.
Sinusitis
The tube contains an optical
device with a magnifying lens with
CRITICAL FINDINGS: N/A
a bright light; the tube is inserted
through the nose and threaded
INTERFERING FACTORS
through the sinuses to the throat.
Inability of the patient to cooperate
A camera, monitor, or other view-
or remain still during the test
ing device is connected to the
because of age, significant pain, or
endoscope to record areas being
mental status may interfere with
examined. Sinus endoscopy helps
the test results.
to diagnose structural defects
(e.g., polyps or other abnormal
growths), damage, and acute or
recurring infection to the nose, NURSING IMPLICATIONS
sinuses, and throat. The procedure AND PROCEDURE
is usually done in a health-care PRETEST:
providers (HCPs) office, but if
done as a surgical procedure, the Positively identify the patient using at
least two unique identifiers before pro-
endoscope may be used to remove viding care, treatment, or services.
polyps from the nose or throat. Patient Teaching: Inform the patient
this procedure can assist in locating
This procedure is and treating infection of the sinus or
contraindicated for: N/A surrounding areas.
Obtain a history of the patients com-
plaints or clinical symptoms, including
INDICATIONS a list of known allergens, especially
Nasal obstruction allergies or sensitivities to latex, anes-
Recurrent sinusitis thetics, or sedatives.
Obtain a history of the patients
POTENTIAL DIAGNOSIS respiratory system, symptoms, and
results of previously performed labora-
Normal findings in tory tests and diagnostic and surgical
Normal soft tissue appearance procedures.
Eosinophil Count
SYNONYM/ACRONYM: Eos count, total eosinophil count.
E NORMAL FINDINGS: (Method: Manual count using eosinophil stain and hemocy-
tometer or automated analyzer)
Absolute count: 50 to 500 cells/microL [SI units (0.050.5 109/L)]
Relative percentage: 1% to 4%
E This procedure is
DESCRIPTION:The erythrocyte sedi- contraindicated for: N/A
mentation rate (ESR) is a measure
of the rate of sedimentation of red INDICATIONS
blood cells (RBCs) in an anticoagu- Assist in the diagnosis of acute
lated whole blood sample over a infection, such as tuberculosis or
specified period of time.The basis tissue necrosis
of the ESR test is the alteration of Assist in the diagnosis of acute
blood proteins by inflammatory inflammatory processes
and necrotic processes that cause Assist in the diagnosis of chronic
the RBCs to stick together, become infections
heavier, and rapidly settle at the Assist in the diagnosis of rheuma-
bottom of a vertically held, calibrated toid or autoimmune disorders
tube over time.The most common Assist in the diagnosis of temporal
promoter of rouleaux is an arthritis and polymyalgia
increase in circulating fibrinogen rheumatica
levels. In general, relatively little Monitor inflammatory and malig-
settling occurs in normal blood nant disease
because normal RBCs do not form
rouleaux and would not stack
together.The sedimentation rate is POTENTIAL DIAGNOSIS
proportional to the size or mass of Increased in
the falling RBCs and is inversely Increased rouleaux formation is
proportional to plasma viscosity. associated with increased levels of
The test is a nonspecific indicator fibrinogen and/or production of cyto-
of disease but is fairly sensitive and kines and other acute-phase reactant
is frequently the earliest indicator proteins in response to inflammation.
of widespread inflammatory Anemia of chronic disease as well as
reaction due to infection or auto- acute anemia influence the ESR
immune disorders. Prolonged because the decreased number of
elevations are also present in malig- RBCs falls faster with the relatively
nant disease.The ESR can also be increased plasma volume.
used to monitor the course of a
disease and the effectiveness of Acute myocardial infarction
therapy.The most commonly Anemia (RBCs fall faster with
increased plasma volume)
used method to measure the ESR
is the Westergren (or modified Carcinoma
Westergren) method. Cat scratch fever (Bartonella
henselae)
Erythropoietin
SYNONYM/ACRONYM: EPO.
Esophageal Manometry
SYNONYM/ACRONYM: Esophageal function study, esophageal acid study (Tuttle
test), acid reflux test, Bernstein test (acid perfusion), esophageal motility study.
Make sure a written and informed Provide an emesis basin for the
consent has been signed prior to the increased saliva and encourage the
procedure and before administering patient to spit out saliva since the gag
any medications. reflex may be impaired.
Monitor the patient for complications
INTRATEST: related to the procedure (e.g., aspira-
Potential Complications: tion of stomach contents into the
lungs, dyspnea, tachypnea, adventi-
Establishing an IV site and injection of
tious sounds).
contrast medium by catheter are inva-
Suction the mouth, pharynx, and tra-
sive procedures. Complications are
chea, and administer oxygen as
rare but do include risk for bleeding
ordered.
from the puncture site related to a
bleeding disorder, or the effects of Esophageal Manometry
natural products and medications One or more small tubes are inserted
E known to act as blood thinners, through the nose into the esophagus
hematoma related to blood leakage and stomach.
into the tissue following needle inser- A small transducer is attached to the
tion, or infection that might occur if ends of the tubes to measure lower
bacteria from the skin surface is esophageal sphincter pressure,
introduced at the puncture site. intraluminal pressures, and regularity
Observe standard precautions, and and duration of peristaltic
follow the general guidelines in contractions.
Appendix A. Positively identify the Instruct the patient to swallow small
patient. amounts of water or flavored gelatin.
Ensure that the patient has complied
Esophageal Acid and Clearing
with dietary, fluids, and medication
(Tuttle Test)
restrictions and pretesting preparations
With the tube in place, a pH electrode
for at least 6 to 8 hr prior to the
probe is inserted into the esophagus
procedure.
with Valsalva maneuvers performed to
Ensure the patient has removed
stimulate reflux of stomach contents
dentures and eyewear prior to the
into the esophagus.
procedure.
If acid reflux is absent, 100 mL of 0.1%
Avoid using morphine sulfate in
hydrochloric acid is instilled into the
patients with asthma or other
stomach during a 3-min period, and
pulmonary disease. This drug can
the pH measurement is repeated.
further exacerbate bronchospasms
To determine acid clearing, hydrochlo-
and respiratory impairment.
ric acid is instilled into the esophagus
Avoid the use of equipment containing
and the patient is asked to swallow
latex if the patient has a history of aller-
while the probe measures the pH.
gic reaction to latex.
Have emergency equipment readily Acid Perfusion (Bernstein Test)
available. A catheter is inserted through the nose
Instruct the patient to void prior to the into the esophagus, and the patient is
procedure and to change into the gown, asked to inform the HCP when pain is
robe, and foot coverings provided. experienced.
Instruct the patient to cooperate fully Normal saline solution is allowed
and to follow directions. Instruct the to drip into the catheter at about
patient to remain still throughout the 10 mL/min. Then hydrochloric acid is
procedure because movement pro- allowed to drip into the catheter.
duces unreliable results. Pain experienced when the hydrochlo-
Establish an IV fluid line for the injec- ric acid is instilled determines the
tion of saline, anesthetics, sedatives, or presence of an esophageal
emergency medications. abnormality. If no pain is experienced,
Spray or swab the oropharynx with a symptoms are the result of some
topical local anesthetic. other condition.
Esophagogastroduodenoscopy
SYNONYM/ACRONYM: Esophagoscopy, gastroscopy, upper GI endoscopy, EGD.
COMMON USE: To visualize and assess the esophagus, stomach, and upper por-
tion of the duodenum to assist in diagnosis of bleeding, ulcers, inflammation,
tumor, and cancer.
Inform the patient that he or she will pretesting preparations for at least 8 hr
not be able to speak during the prior to the procedure.
procedure, but breathing will not be Ensure the patient has removed all
affected. Inform the patient that the external metallic objects from the
procedure is performed in a GI labora- area to be examined prior to the
tory or radiology department, usually procedure.
by an HCP and support staff, and Assess for completion of bowel prepa-
takes approximately 30 to 60 min. ration according to the institutions
Sensitivity to social and cultural issues,as procedure.
well as concern for modesty, is impor- Avoid the use of equipment containing
tant in providing psychological support latex if the patient has a history of
before, during, and after the procedure. allergic reaction to latex.
Explain that an IV line may be inserted Have emergency equipment readily
to allow infusion of IV fluids such as available.
E normal saline, anesthetics, sedatives, Instruct the patient to void prior to
or emergency medications. the procedure and to change into
Inform the patient that a laxative and the gown, robe, and foot coverings
cleansing enema may be needed provided.
the day before the procedure, with Instruct the patient to cooperate fully
cleansing enemas on the morning and to follow directions. Instruct the
of the procedure, depending on the patient to remain still throughout the
institutions policy. procedure because movement pro-
Inform the patient that dentures and duces unreliable results.
eyewear will be removed before the test. Observe standard precautions, and
Instruct the patient to remove jewelry follow the general guidelines in
and other metallic objects from the Appendix A. Positively identify the
area to be examined. patient, and label the appropriate
Instruct the patient that to reduce the specimen container with the corre-
risk of nausea and vomiting, solid food sponding patient demographics, initials
and milk or milk products have been of the person collecting the specimen,
restricted for at least 8 hr, and clear liq- date, and time of collection.
uids have been restricted for at least 2 Obtain and record baseline vital signs.
hr prior to general anesthesia, regional Establish an IV fluid line for the injec-
anesthesia, or sedation/analgesia tion of saline, sedatives, or emergency
(monitored anesthesia). The American medications. Administer ordered
Society of Anesthesiologists has fast- sedation.
ing guidelines for risk levels according Spray or swab the oropharynx with a
to patient status. More information can topical local anesthetic.
be located at www.asahq.org. Patients Provide an emesis basin for the
on beta blockers before the surgical increased saliva and encourage the
procedure should be instructed to take patient to spit out the saliva because
their medication as ordered during the the gag reflex may be impaired.
perioperative period. Protocols may Place the patient on an examination
vary among facilities. table in the left lateral decubitus
Make sure a written and informed position with the neck slightly flexed
consent has been signed prior to the forward.
procedure and before administering The endoscope is passed through
any medications. the mouth with a dental suction
device in place to drain secretions.
INTRATEST: A side-viewing flexible, fiberoptic endo-
scope is advanced, and visualization of
Potential Complications: the GI tract is started.
May include bleeding and cardiac Air is insufflated to distend the upper
arrhythmias. GI tract, as needed. Biopsy specimens
Ensure the patient has complied with are obtained and/or endoscopic
dietary and medication restrictions and surgery is performed.
Estradiol
SYNONYM/ACRONYM: E2.
COMMON USE: To assist in diagnosing female fertility problems that may occur
from tumor or ovarian failure.
SI Units (Conventional
Age Conventional Units Units 3.67)
6 mo10 yr
Male and female Less than 15 pg/mL Less than 55 pmol/L
1115 yr
Male Less than 40 pg/mL Less than 147 pmol/L
Female 10300 pg/mL 371,100 pmol/L
Adult male 1050 pg/mL 37184 pmol/L
Adult female
Early follicular phase 20150 pg/mL 73551 pmol/L
Late follicular phase 40350 pg/mL 1471,285 pmol/L
Midcycle peak 150750 pg/mL 5512,753 pmol/L
Luteal phase 30450 pg/mL 1101,652 pmol/L
Postmenopause Less than 20 pg/mL Less than 73 pmol/L
ankle and on the scalp at the sensory When the procedure is complete,
cortex of the hemisphere on the remove the electrodes and clean the
opposite side (the electrode that picks skin where the electrodes were
up the response and delivers it to the applied.
recorder). Additional electrodes can Recognize anxiety related to test
be positioned at the cervical or lumbar results, and be supportive of perceived
vertebrae for upper or lower limb loss of independent function. Discuss
stimulation. The rate at which the the implications of abnormal test
electric shock stimulus is delivered results on the patients lifestyle. Provide
to the nerve electrodes and travels to teaching and information regarding the
the brain is measured, computer ana- clinical implications of the test results,
lyzed, and recorded in waveforms for as appropriate.
analysis. Both sides of the area being Reinforce information given by the
examined can be tested by switching patients HCP regarding further testing,
E the electrodes and repeating the treatment, or referral to another
procedure. HCP. Answer any questions or address
Event-Related Potentials any concerns voiced by the patient or
Place the patient in a sitting position in family.
a chair in a quiet room. Earphones are Depending on the results of this proce-
placed on the patients ears and audi- dure, additional testing may be needed
tory cues administered. The patient is to evaluate or monitor progression of
asked to push a button when the the disease process and determine the
tones are recognized. Flashes of light need for a change in therapy. Evaluate
are also used as visual cues, with the test results in relation to the patients
client pushing a button when cues are symptoms and other tests performed.
noted. Results are compared to normal RELATED MONOGRAPHS:
EP waveforms for correct, incorrect, or
absent responses. Related tests include acetylcholine
receptor antibody, Alzheimers disease
POST-TEST: markers, biopsy muscle, CSF analysis,
CT brain, CK, EEG, ENG, MRI brain,
Inform the patient that a report of the plethysmography, and PET brain.
results will be made available to the Refer to the Musculoskeletal System
requesting HCP, who will discuss table at the end of the book for related
the results with the patient. tests by body system.
CONTRAST: None.
Remove the electrodes and cleanse Stop Hypertension (DASH) diet makes
the skin of any remaining gel or ECG additional recommendations for the
electrode adhesive. reduction of dietary sodium. Both
dietary styles emphasize a reduction in
POST-TEST: consumption of red meats, which
Inform the patient that a report of the are high in saturated fats and choles-
results will be made available to the terol, and other foods containing
requesting HCP, who will discuss sugar, saturated fats, trans fats, and
the results with the patient. sodium.
Instruct the patient to resume usual Social and Cultural Considerations:
activity, as directed by the HCP. Numerous studies point to the
Instruct the patient to contact the prevalence of excess body weight in
HCP to report any anginal pain or American children and adolescents.
other discomforts experienced after Experts estimate that obesity is
E the test. present in 25 % of the population ages
Nutritional Considerations: Abnormal 6 to 11 yr. The medical, social, and
findings may be associated with emotional consequences of excess
cardiovascular disease. Nutritional body weight are significant. Special
therapy is recommended for the attention should be given to instructing
patient identified to be at risk for the child and caregiver regarding
developing CAD or for individuals who health risks and weight control
have specific risk factors and/or education.
existing medical conditions (e.g., Recognize anxiety related to test
elevated LDL cholesterol levels, other results, and be supportive of fear of
lipid disorders, insulin-dependent shortened life expectancy. Discuss the
diabetes, insulin resistance, or meta- implications of abnormal test results on
bolic syndrome). Other changeable risk the patients lifestyle. Provide teaching
factors warranting patient education and information regarding the clinical
include strategies to encourage implications of the test results, as
patients, especially those who are appropriate. Educate the patient
overweight and with high blood regarding access to counseling
pressure, to safely decrease sodium services. Provide contact information,
intake, achieve a normal weight, if desired, for the American Heart
ensure regular participation of moder- Association (www.americanheart.org),
ate aerobic physical activity three to the NHLBI (www.nhlbi.nih.gov), or the
four times per week, eliminate tobacco Legs for Life (www.legsforlife.org).
use, and adhere to a heart-healthy Reinforce information given by the
diet. If triglycerides also are elevated, patients HCP regarding further
the patient should be advised to testing, treatment, or referral to another
eliminate or reduce alcohol. The 2013 HCP. Answer any questions or address
Guideline on Lifestyle Management to any concerns voiced by the patient or
Reduce Cardiovascular Risk published family.
by the American College of Cardiology Depending on the results of this
(ACC) and the American Heart procedure, additional testing may be
Association (AHA) in conjunction with performed to evaluate or monitor
the National Heart, Lung, and Blood progression of the disease process
Institute (NHLBI) recommends a and determine the need for a change
Mediterranean-style diet rather than a in therapy. Evaluate test results in
low-fat diet. The new guideline relation to the patients symptoms and
emphasizes inclusion of vegetables, other tests performed.
whole grains, fruits, low-fat dairy, nuts,
legumes, and nontropical vegetable RELATED MONOGRAPHS:
oils (e.g., olive, canola, peanut, Related tests include antiarrhythmic
sunflower, flaxseed) along with fish and drugs, apolipoprotein A and B, AST,
lean poultry. A similar dietary pattern atrial natriuretic peptide, BNP, blood
known as the Dietary Approach to gases, blood pool imaging, calcium,
chest x-ray, cholesterol (total, HDL, lung perfusion scan, magnesium, MRI
LDL), CT cardiac scoring, CT thorax, chest, MI infarct scan, myocardial per-
CRP, CK and isoenzymes, echocar- fusion heart scan, myoglobin, PET
diography, echocardiography trans- heart, potassium, pulse oximetry,
esophageal, electrocardiogram, glu- sodium, triglycerides, and troponin.
cose, glycated hemoglobin, Holter Refer to the Cardiovascular System
monitor, homocysteine, ketones, LDH table at the end of the book for related
and isos, lipoprotein electrophoresis, tests by body system.
COMMON USE: To assess for the presence of blood in the stool toward diagnos-
ing gastrointestinal bleeding, cancer, inflammation, and infection.
SPECIMEN: Stool.
778
Fecal Fat
SYNONYM/ACRONYM: Stool fat, fecal fat stain.
COMMON USE: To assess for the presence of fat in the stool toward diagnosing
malabsorption disorders such as Crohns disease and cystic fibrosis.
SPECIMEN: Stool (80 mL) aliquot from an unpreserved and homogenized 24- to
72-hr timed collection. Random specimens may also be submitted.
NORMAL FINDINGS: (Method: Stain with Sudan black or oil red O.Treatment with
ethanol identifies neutral fats; treatment with acetic acid identifies fatty acids.)
Random, Semiquantitative
Neutral fat Less than 60 fat globules/hpf*
Fatty acids Less than 100 fat globules/hpf
72-hr, Quantitative
Age (normal diet)
Infant (breast milk) Less than 1 g/24 hr
06 yr Less than 2 g/24 hr
Adult 27 g/24 hr; less than 20% of total solids
Adult (fat-free diet) Less than 4 g/24 hr
*hpf = high-power field.
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Ferritin
SYNONYM/ACRONYM: N/A.
POTENTIAL DIAGNOSIS
DESCRIPTION: Ferritin, a protein
manufactured in the liver, spleen, Increased in
and bone marrow, consists of a Alcoholism (active abuse, as evi- F
protein shell, apoferritin, and an denced by release of ferritin into
iron core. The amount of ferritin the circulation from damaged
in the circulation is usually pro- hepatocytes and red blood cells
portional to the amount of stored [RBCs])
iron (ferritin and hemosiderin) in Breast cancer (acute, related to
body tissues. Levels vary accord- release of ferritin as an acute-
ing to age and gender, but they phase reactant protein; chronic,
are not affected by exogenous pathophysiology is uncertain)
iron intake or subject to diurnal Hemochromatosis (related to
variations. Compared to iron and increased iron deposits in the
total iron-binding capacity, ferritin liver, which stimulate ferritin
is a more sensitive and specific production)
test for diagnosing iron-deficiency Hemolytic anemia (related to
anemia. Iron-deficiency anemia in increased iron levels from
adults is indicated at ferritin levels hemolyzed RBCs, which stimulate
less than 10 ng/mL; hemochroma- ferritin production)
tosis or hemosiderosis is indicated Hemosiderosis (related to
at levels greater than 400 ng/mL. increased iron levels, which stim-
ulate ferritin production)
Hepatocellular disease (acute,
This procedure is
related to release of ferritin as
contraindicated for: N/A
an acute-phase reactant protein;
INDICATIONS chronic, related to release of fer-
Assist in the diagnosis of iron- ritin into the circulation from
deficiency anemia damaged hepatocytes)
Assist in the differential diagnosis of Hodgkins disease (acute, related
microcytic, hypochromic anemias to release of ferritin as an
Monitor hematological responses acute-phase reactant protein;
during pregnancy, when serum iron chronic, pathophysiology is
is usually decreased and ferritin uncertain)
may be decreased Hyperthyroidism (possibly related
Support diagnosis of hemochroma- to the stimulating effect of
tosis or other disorders of iron thyroid-stimulating hormone on
metabolism and storage ferritin production)
Fetal Fibronectin
SYNONYM/ACRONYM: fFN.
`1-Fetoprotein
SYNONYM/ACRONYM: AFP.
COMMON USE: To assist in the evaluation of fetal health related to neural tube
defects and some forms of liver cancer.
MoM = multiples of the median. Serum values vary with maternal race, weight, weeks of
gestation, diabetic status, and number of fetuses, and variations exist between test methods.
Serial testing should be determined using the same test method.
Signs &
Problem Symptoms Interventions
Fear (Related to Expression of fear; Provide specific education related
prognosis preoccupation to disease process (neural tube
secondary to with fear; defect, liver disease); provide
diagnosis increased tension; specific information related to
[cancer]; increased blood treatment based on diagnosis
disabled child; pressure; or defect; access social
ability to function increased heart services; ensure education is
in caregiver role; rate; vomiting; culturally appropriate; assist the
risk of death diarrhea; nausea; patient and family to recognize
(cancer); loss of fatigue; effective coping strategies;
control; weakness; assist the patient and family to
ineffective insomnia; acknowledge their fear; provide
coping; shortness of a safe environment to discuss
unfamiliar breath; increased fear; explore cultural influences
therapeutic respiratory rate; that may enhance fear; utilize
regime; withdrawal; panic therapeutic touch as
unknown) attacks appropriate to decrease fear
Fatigue (Related to Decreased Assess for physical cause of
hepatic disease concentration; fatigue; pace activities to
process; increased preserve energy stores; rate
malnutrition; physical fatigue on a numeric scale to
anemia; complaints; trend degree of fatigue over
chemotherapy; inability to restore time; identify what aggravates
radiation therapy) energy with and decreases fatigue; assess
sleep; report of for related emotional factors
being tired; such as depression; evaluate
inability to current medications in relation to
maintain normal fatigue; assess for physiologic
routine factors such as anemia
(table continues on page 794)
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Signs &
Problem Symptoms Interventions
Confusion; altered Disorganized Treat the medical condition;
sensory thinking, restless, correlate confusion with the
perception irritable, altered need to reverse altered
(Related to an concentration electrolytes; evaluate
alteration in fluid and attention medications; prevent falls and
and electrolytes, span, changeable injury through appropriate use of
hepatic disease mental function postural support, bed alarm, or
and over the day, restraints; consider
encephalopathy; hallucinations; pharmacological interventions;
acute alcohol altered attention record accurate intake and
consumption; span; unable to output to assess fluid status;
hepatic metabolic follow directions; monitor blood ammonia level;
F insufficiency) disoriented to determine last alcohol use;
person, place, assess for symptoms of hepatic
time, and encephalopathy such as
purpose; confusion, sleep disturbances,
inappropriate incoherence; protect the patient
affect from physical harm; administer
lactulose as prescribed
Spirituality (Related Forgiveness; Encourage the verbalization of
to significant acceptance; feelings in a safe,
loss; fear of anger at spiritual nonjudgmental environment;
death; leaders; assess the desire for contact
debilitation expressed from associated spiritual
disease process; feelings of leader; foster a supportive
diagnosed child hopeless, relationship with the patient
disability) powerlessness; and family; encourage a
abandonment; display of objects (spiritual,
refusals or religious) that provide
inability to emotional relief; assess for
participate in expressions of hope
spiritual activities
(prayer);
expresses
feelings over lack
of meaning with
life or serenity
Fetoscopy
SYNONYM/ACRONYM: Endoscopic fetal surgery, fetal endoscopy.
COMMON USE: To facilitate diagnosis and treatment of the fetus. Evaluate for
disorders such as neural tube defects and congenital blood disorders, and assist
with fetal karyotyping.
CONTRAST: N/A.
Make sure a written and informed to the requesting HCP, who will dis-
consent has been signed prior to the cuss the results with the patient.
procedure and before administering When the study is completed, remove
any medications. the gel from the skin.
Observe/assess the incision for
INTRATEST: redness or leakage of fluid
Potential Complications: N/A or blood.
Instruct the patient in the care
Ensure that the patient has of the incision and to contact her
complied with dietary restrictions; HCP immediately if she is experiencing
ensure that food and fluid has been chills, fever, dizziness, moderate or
restricted for at least 8 hr prior to the severe abdominal cramping,
procedure. or fluid or blood loss from the vagina
Ensure that the patient has removed or incision.
external metallic objects prior to the Inform the patient that a follow-up
procedure. ultrasound will be completed the
Instruct the patient to void prior to the next day to assess the fetus and
F procedure and to change into the placenta.
gown, robe, and foot coverings Recognize anxiety related to test
provided. results. Discuss the implications of
Avoid the use of equipment containing abnormal test results on the patients
latex if the patient has a history of aller- lifestyle. Provide teaching and
gic reaction to latex. information regarding the clinical
Instruct the patient to cooperate fully implications of the test results, as
and to follow directions. Instruct the appropriate.
patient to remain still throughout the Reinforce information given by the
procedure because movement pro- patients HCP regarding further testing,
duces unreliable results. treatment, or referral to another HCP.
Instruct the patient to lie on her back. Answer any questions or address
The lower abdomen area is cleaned, any concerns voiced by the patient or
and a local anesthetic is administered family.
in the area where the incision will Depending on the results of this
be made. procedure, additional testing may be
Observe standard precautions, and needed to evaluate or monitor progres-
follow the general guidelines in sion of the disease process and deter-
Appendix A. Positively identify the mine the need for a change in therapy.
patient, and label the appropriate Evaluate test results in relation to the
specimen container with the corre- patients symptoms and other tests
sponding patient demographics, initials performed.
of the person collecting the specimen,
date, and time of collection if samples RELATED MONOGRAPHS:
are to be obtained on aspirated amni- Related tests include amniotic fluid
otic fluid or fetal material. analysis and L/S ratio, biopsy chorionic
Conductive gel is applied to the skin, villus, blood groups and antibodies,
and a Doppler transducer is moved chromosome analysis, culture
over the skin to locate the position of bacterial anal/genital, culture viral,
the fetus. fetal fibronectin, 1-fetoprotein,
Ask the patient to breathe normally hexosaminidase A and B, human
during the examination. If necessary for chorionic gonadotropin, KUB,
better fetal visualization, ask the patient Kleihauer-Betke test, prolactin, MRI
to inhale deeply and hold her breath. abdomen, and ultrasound biophysical
profile obstetric.
POST-TEST: Refer to the Reproductive System
Inform the patient that a report of table at the end of the book for related
the results will be made available tests by body system.
Fibrinogen
SYNONYM/ACRONYM: Factor I.
The CLSI recommendation for pro- address any concerns voiced by the
cessed and unprocessed samples patient or family.
stored in unopened tubes is that Depending on the results of this
testing should be completed within procedure, additional testing may be
1 to 4 hr of collection. performed to evaluate or monitor pro-
gression of the disease process and
POST-TEST: determine the need for a change in
Inform the patient that a report of therapy. Evaluate test results in relation
the results will be made available to the patients symptoms and other
to the requesting HCP, who will tests performed.
discuss the results with the patient.
Instruct the patient to report bruising, RELATED MONOGRAPHS:
petechiae, and bleeding from mucous Related tests include ALT, albumin,
membranes, hematuria, and occult ALP, AT-III, AST, bilirubin, biopsy bone,
blood. biopsy bone marrow, biopsy liver, clot
Inform the patient with a decreased retraction, coagulation factors, CBC
fibrinogen level of the importance of platelet count, CT cardiac scoring, CK
F taking precautions against bruising and and isoenzymes, CRP, d-dimer, echo-
bleeding, including the use of a soft cardiography, echocardiography trans-
bristle toothbrush, use of an electric esophageal, ECG, ESR, exercise stress
razor, avoidance of constipation, test, FDP, GGT, Holter monitor, IFE,
avoidance of acetylsalicylic acid and immunoglobulins, myocardial perfusion
similar products, and avoidance of heart scan, aPTT, plasminogen, procal-
intramuscular injections. citonin, protein S, and PT/INR.
Reinforce information given by the Refer to the Hematopoietic and
patients HCP regarding further test- Hepatobiliary systems tables at the
ing, treatment, or referral to another end of the book for related tests by
HCP. Answer any questions or body system.
POTENTIAL DIAGNOSIS
DESCRIPTION:This coagulation test
evaluates fibrin split products or Increased in
fibrin/fibrinogen degradation DIC (FDP can be positive in a
products (FDPs) that interfere number of conditions in which
with normal coagulation and for- the coagulation system has been
mation of the hemostatic platelet excessively stimulated as a result
plug. As thrombin initiates the for- of tissue injury and fibrin and/or
mation of the fibrin clot, it also fibrinogen is being degraded by
activates the fibrinolytic system to plasmin)
limit the size of clot formation and Excessive bleeding (clot formation
prevent venous occlusion. The related to depletion of platelets
d-dimer is specific to secondary and clotting factors will stimulate
fibrinolysis because it detects the fibrinolysis and increase circula-
disintegration of fibrin rather than tion of fibrin breakdown
fibrinogen. The FDP test detects products)
degradation products of primary Liver disease (related to F
fibrinolysis generated by the decreased hepatic clearance)
action of thrombin on fibrinogen Myocardial infarction (FDP can be
as well as degradation products of positive in a number of condi-
secondary fibrinolysis by the tions in which the coagulation
action of plasmin on fibrin. The system has been excessively stim-
two tests together can be useful ulated as a result of tissue injury
for differentiation and treatment and fibrin and/or fibrinogen is
of suspected cases of fibrinolysis. being degraded by plasmin)
In the case of primary fibrinolysis, Obstetric complications, such as
the FDP will be positive while the pre-eclampsia, abruptio placentae,
d-dimer is normal. In DIC, or sec- intrauterine fetal death (excessive
ondary fibrinolysis, both will be stimulation of the coagulation
elevated. FDPs are normally system; microthrombi are formed
cleared rapidly from circulation, and plasminogen is released to
however increased circulating dissolve the fibrin clots)
levels can interfere with hemosta- Postcardiothoracic surgery period
sis by interfering with fibrin (FDP can be positive in a number
polymerization and adhering to of conditions in which the coagu-
platelet cell membranes thereby lation system has been excessive-
inhibiting their normal function. ly stimulated as a result of tissue
injury and fibrin and/or fibrino-
gen is being degraded by
This procedure is plasmin)
contraindicated for: N/A Pulmonary embolism (FDP can be
positive in a number of condi-
INDICATIONS tions in which the coagulation
Assist in the diagnosis of suspected system has been excessively stim-
DIC ulated as a result of tissue injury
Evaluate response to therapy with and fibrin and/or fibrinogen is
fibrinolytic drugs being degraded by plasmin)
Monitor the effects on hemostasis Renal disease (FDP can be posi-
of trauma, extensive surgery, obstet- tive in a number of conditions in
ric complications, and disorders which the coagulation system
such as liver or renal disease has been excessively stimulated
Fluorescein Angiography
SYNONYM/ACRONYM: FA.
COMMON USE: To assist in detecting vascular changes in the eyes affecting vision
related to diseases such as diabetic retinopathy and macular degeneration.
INDICATIONS
DESCRIPTION: Fluorescein angiog- Detect arterial or venous occlusion
F raphy (FA) involves the color evidenced by the reduced, delayed,
radiographic examination of the or absent flow of the contrast
retinal vasculature following rapid medium through the vessels or
IV injection of a sodium fluores- possible vessel leakage of the
cein contrast medium. A special medium
camera allows images to be taken Detect possible vascular disorders
in sequence and manipulated by a affecting visual acuity
computer to provide views of the Detect presence of microaneu-
retinal vessels during filling and rysms caused by hypertensive
emptying of the dye. The camera retinopathy
allows only light waves in the Detect the presence of tumors, reti-
blue range to strike the fundus of nal edema, or inflammation, as evi-
the eye. When the fluorescein denced by abnormal patterns or
reaches the blood vessels in the degree of fluorescence
eye, blue light excites the dye Diagnose and manage diabetic
molecules to a higher state of retinopathy
activity and causes them to emit a Diagnose past reduced flow or
greenish-yellow fluorescence that patency of the vascular circulation
is recorded. of the retina, as evidenced by neo-
vascularization
This procedure is Diagnose presence of macular
contraindicated for degeneration and any other
Patients with a past history of degeneration and any associated
hypersensitivity to radiographic hemorrhaging
dyes. Address concerns about nau- Observe ocular effects resulting
sea and vomiting, as appropriate. from the long-term use of high-risk
Patients with narrow-angle medications
glaucoma if pupil dilation is
POTENTIAL DIAGNOSIS
performed; dilation can initiate a
severe and sight-threatening open- Normal findings in
angle attack. No leakage of dye from retinal
Patients with allergies to myd- blood vessels
riatics if pupil dilation using Normal retina and retinal and
mydriatics is performed. choroidal vessels
Instruct the patient to avoid eye medi- the gauze and an adhesive bandage or
cations (particularly miotic eye drops paper tape. Some patients experience
which may constrict the pupil prevent- a vasovagal reaction during the veni-
ing a clear view of the fundus and puncture procedure, evidenced by
mydriatic eyedrops in order to avoid sweating (diaphoresis), low blood
instigation of an acute open angle pressure (hypotension), fainting
attack in patients with narrow angle (syncope), or near fainting (near syn-
glaucoma) for at least 1 day prior to cope). The potential for a fall injury is
the test. a significant concern related to vasova-
Ensure that the patient understands gal reactions. Other more unusual
that he or she must refrain from driving complications of venipuncture include
until the pupils return to normal (about cellulitis, phlebitis, seizures, inadvertent
4 hr) after the test and has made arterial puncture, and sepsis. Sepsis
arrangements to have someone else can be caused by introduction of
be responsible for transportation after bacteria from the surface of the skin
the test. into the blood as the result of improper
Make sure a written and informed cleansing of the venipuncture site.
F consent has been signed prior to the Immunocompromised patients are
procedure and before administering at higher risk for developing this
any medications. complication.
Anaphylaxis, bronchospasm, cardiac
INTRATEST: arrest, laryngeal edema, myocardial
infarction, nausea, pruritus, urticaria, or
Potential Complications: vomiting can occur in response to the
Dilation can initiate a severe and sight- dye and extravasation of the dye can
threatening open-angle attack in occur during injection.
patients with narrow-angle glaucoma if Observe standard precautions, and fol-
pupil dilation is performed. low the general guidelines in Appendix A.
There are a number of complications Positively identify the patient.
associated with venipuncture. Pain is Ensure that the patient has complied
commonly associated with needles with medication restrictions; ensure
and while pain experienced during that eye medications, especially miot-
venipuncture is usually mild, on a rare ics and mydriatics, have been withheld
occasion the needle may strike a nerve for at least 1 day prior to the test.
causing severe and lasting pain. Avoid the use of equipment containing
Hematoma results when blood leaks latex if the patient has a history of aller-
into the tissue during or after a veni- gic reaction to latex.
puncture as evidenced by pain, bruis- Have emergency equipment readily
ing, and/or swelling at the venipuncture available.
site. The swelling can cause temporary Instruct the patient to cooperate fully
or permanent injury by compressing and to follow directions. Instruct the
the surrounding nerves. Hematomas patient to remain still during the proce-
occur more often in elderly or frail dure because movement produces
patients, or those with difficult veins to unreliable results.
access. Prolonged bleeding is a com- Seat the patient in a chair that faces
plication that occurs with patients who the camera. Instruct the patient to look
are taking blood thinners such as aspi- at a directed target while the eyes are
rin or warfarin, or who have coagulop- examined.
athies such as hemophilia. Bleeding or Administer the ordered mydriatic to
bruising can be prevented by applying each eye and repeat in 5 to 15 min, if
direct pressure to the site, once the dilation is to be performed. Drops are
needle has been removed, with gauze placed in the eye with the patient look-
for a minute or two. The site should ing up and the solution directed at the
then be observed/assessed for bleed- six oclock position of the sclera (white
ing or bruising. If no further action is of the eye) near the limbus (gray, semi-
required, the site can be covered by transparent area of the eyeball where
the cornea and sclera meet). Neither and the American Heart Association
dropper nor bottle should touch the (AHA) in conjunction with the National
eyelashes. Heart, Lung, and Blood Institute (NHLBI)
Insert an intermittent infusion device, recommends a Mediterranean-style
as ordered, for subsequent injection of diet rather than a low-fat diet. The new
the contrast media or emergency guideline emphasizes inclusion of vege-
medications. tables, whole grains, fruits, low-fat dairy,
After the eyedrops are administered nuts, legumes, and nontropical vegeta-
but before the dye is injected, color ble oils (e.g., olive, canola, peanut, sun-
fundus photographs are taken. flower, flaxseed) along with fish and lean
Instruct the patient to place the chin in poultry. A similar dietary pattern known
the chin rest and gently press the fore- as the Dietary Approaches to Stop
head against the support bar. Instruct Hypertension (DASH) diet makes addi-
the patient to open his or her eyes tional recommendations for the reduc-
wide and look at the desired target. tion of dietary sodium. Both dietary
Fluorescein dye is injected into the bra- styles emphasize a reduction in con-
chial vein using the intermittent infusion sumption of red meats, which are high
device, and a rapid sequence of pho- in saturated fats and cholesterol, and F
tographs are taken and repeated after other foods containing sugar, saturated
the dye has reached the retinal vascu- fats, trans fats, and sodium. If triglycer-
lar system. Follow-up photographs are ides also are elevated, the patient
taken in 20 to 30 min. should be advised to eliminate or
At the conclusion of the procedure, reduce alcohol. The nutritional needs of
remove the IV needle and apply direct each diabetic patient need to be deter-
pressure with dry gauze to stop bleed- mined individually (especially during
ing. Observe venipuncture site for pregnancy) with the appropriate HCPs,
bleeding or hematoma formation and particularly professionals trained
secure gauze with adhesive bandage. in nutrition.
Observe for hypersensitive reaction to Recognize anxiety related to test
the dye. The patient may become nau- results, and be supportive of impaired
seous and vomit. activity related to vision loss or antici-
pated loss of driving privileges. Discuss
POST-TEST: the implications of abnormal test
Inform the patient that a report of the results on the patients lifestyle. Provide
results will be made available to the teaching and information regarding the
requesting HCP, who will discuss clinical implications of the test results,
the results with the patient. as appropriate. Emphasize, as appro-
Instruct the patient to resume usual priate, that good glycemic control
medications, as directed by the HCP. delays the onset of and slows the pro-
Nutritional Considerations: Increased gression of diabetic retinopathy,
glucose levels may be associated with nephropathy, and neuropathy. Provide
diabetes. There is no diabetic diet; education regarding smoking cessa-
however, many meal-planning tion, as appropriate. Provide contact
approaches with nutritional goals are information regarding vision aids, if
endorsed by the American Dietetic desired, for ABLEDATA (sponsored by
Association. Patients who adhere to the National Institute on Disability and
dietary recommendations report a bet- Rehabilitation Research [NIDRR], avail-
ter general feeling of health, better able at www.abledata.com).
weight management, greater control of Information can also be obtained from
glucose and lipid values, and improved the American Macular Degeneration
use of insulin. Instruct the patient, as Foundation (www.macular.org), the
appropriate, in nutritional management Glaucoma Research Foundation
of diabetes. The 2013 Guideline on (www.glaucoma.org), the American
Lifestyle Management to Reduce Diabetes Association (www.diabetes
Cardiovascular Risk published by the .org), or the American Heart
American College of Cardiology (ACC) Association (www.americanheart.org).
Folate
SYNONYM/ACRONYM: Folic acid, vitamin B9.
SI Units (Conventional
Conventional Units Units 2.265)
Normal Greater than 5.4 ng/mL Greater than 12.2 nmol/L
Intermediate 3.45.4 ng/mL 7.712.2 nmol/L
Deficient Less than 3.4 ng/mL Less than 7.7 nmol/L
Values may be slightly decreased in older adults due to the effects of medications and the
presence of multiple chronic or acute diseases with or without muted symptoms.
Follicle-Stimulating Hormone
SYNONYM/ACRONYM: Follitropin, FSH.
PRETEST: INTRATEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before pro- Avoid the use of equipment containing
viding care, treatment, or services. latex if the patient has a history of aller-
Patient Teaching: Inform the patient this gic reaction to latex.
test can assist in evaluating distur- Instruct the patient to cooperate fully
bances in hormone levels. and to follow directions. Direct the
Obtain a history of the patients com- patient to breathe normally and to
plaints, including a list of known aller- avoid unnecessary movement.
gens, especially allergies or sensitivities Observe standard precautions, and fol-
to latex. low the general guidelines in Appendix A.
Obtain a history of the patients endo- Positively identify the patient, and label
crine and reproductive systems, as the appropriate specimen container
well as phase of menstrual cycle, with the corresponding patient demo-
symptoms, and results of previously graphics, initials of the person collect-
performed laboratory tests and diag- ing the specimen, date, and time of
nostic and surgical procedures. collection. Perform a venipuncture.
Obtain a list of the patients current Remove the needle and apply direct
medications, including herbs, nutri- pressure with dry gauze to stop bleed-
tional supplements, and nutraceuticals ing. Observe/assess venipuncture site
(see Appendix H online at DavisPlus). for bleeding or hematoma formation and
Review the procedure with the patient. secure gauze with adhesive bandage.
Inform the patient that specimen Promptly transport the specimen to the
collection takes approximately 5 to laboratory for processing and analysis.
10 min. Address concerns about pain
and explain that there may be some
discomfort during the venipuncture. POST-TEST:
Sensitivity to social and cultural issues, Inform the patient that a report of the
as well as concern for modesty, is results will be made available to the
important in providing psychological requesting health-care provider (HCP),
support before, during, and after the who will discuss the results with the
procedure. patient.
Note that there are no food, fluid, or Recognize anxiety related to test
medication restrictions unless by medi- results and provide a supportive, non-
cal direction. judgmental environment when assisting
a patient through the process of fertility Inform the patient that multiple speci-
testing. Osteoporosis, which can result mens may be required.
in a tendency to develop bone frac- Answer any questions or address any
tures, can occur in both female and concerns voiced by the patient or family.
male patients with this hormone defi-
ciency. Encourage patients to discuss Expected Patient Outcomes:
their feelings about the impact test Knowledge
results may have on their life and the States understanding of family planning
life of their partner. information provided.
Depending on the results of this States understanding that osteoporosis
procedure, additional testing may be can occur with this hormone deficiency
performed to evaluate or monitor pro- and takes recommended calcium
gression of the disease process and replacement.
determine the need for a change in
therapy. Evaluate test results in relation Skills
to the patients symptoms and other Demonstrates proficient
tests performed. self-administration of medication to
treat infertility F
Patient Education: Describes the benefits of attending an
Discuss the implications of abnormal infertility support group
test results on the patients lifestyle. Attitude
Provide teaching and information Agrees to abstain from alcohol use
regarding the clinical implications of the Shares anxieties related to possible
test results, as appropriate. treatment to decrease barriers to the
Educate the patient and partner plan of care
regarding access to counseling
services, as appropriate. RELATED MONOGRAPHS:
Educate the female patient regarding Related tests include antibodies
the potential effects of FSH deficiency, antisperm, BMD, Chlamydia group
which may include an absence of antibody, chromosome analysis, CT
menstrual cycles, infertility, decreased pituitary, estradiol, laparoscopy gyne-
sex drive, and vaginal dryness; edu- cologic, LH, MRI pituitary, prolactin,
cate male patients regarding testosterone, semen analysis, and US
decreased sex drive, erectile dysfunc- scrotal.
tion, and infertility. Refer to the Endocrine and
Reinforce information given by the Reproductive systems tables at the
patients HCP regarding further testing, end of the book for related tests by
treatment, or referral to another HCP. body system.
Fructosamine
SYNONYM/ACRONYM: Glycated albumin.
SI Units (Conventional
Status Conventional Units Units 0.01)
Normal 174286 micromol/L 1.742.86 mmol/L
Diabetic (values vary 210563 micromol/L 2.105.63 mmol/L
with degree of control)
Fundus Photography
SYNONYM/ACRONYM: N/A.
COMMON USE: To evaluate vascular and structural changes in the eye in assess-
ing the progression of diseases such as glaucoma, diabetic retinopathy, and
macular degeneration.
CONTRAST: N/A.
826
child may experience during the proce- insertion, infection that might occur
dure (e.g., the child may feel a pinch or if bacteria from the skin surface is
minor discomfort when the IV needle is introduced at the puncture site, or
inserted) and to use words that they nerve injury that might occur if the
know their child will understand. needle strikes a nerve.
Toddlers and preschool-age children Observe standard precautions, and fol-
have a very short attention span, so low the general guidelines in Appendix A.
the best time to talk about the test is Positively identify the patient.
right before the procedure. The child Ensure that the patient has removed all
should be assured that he or she will external metallic objects from the area
be allowed to bring a favorite comfort to be examined prior to the procedure.
item into the examination room, and if Administer ordered prophylactic steroids
appropriate, that a parent will be with or antihistamines before the procedure if
the child during the procedure. Explain the patient has a history of allergic reac-
the importance of remaining still while tions to any substance or drug.
the images are taken. Avoid the use of equipment containing
Sensitivity to social and cultural issues,as latex if the patient has a history of aller-
well as concern for modesty, is impor- gic reaction to latex.
tant in providing psychological support Have emergency equipment readily
before, during, and after the procedure. available.
G Explain that an IV line may be inserted Instruct the patient to void prior to the
to allow infusion of IV fluids such as procedure and to change into the gown,
normal saline, anesthetics, sedatives, robe, and foot coverings provided.
radionuclides, medications used in the Record baseline vital signs and assess
procedure, or emergency medications. neurological status. Protocols may vary
Instruct the patient to remove jewelry among facilities.
and other metallic objects from the Establish an IV fluid line for the injection
area to be examined. of saline, anesthetics, sedatives, radio-
Note that there are no food, fluid, or nuclides, or emergency medications.
medication restrictions unless by medical Instruct the patient to cooperate fully
direction. and to follow directions. Instruct the
Make sure a written and informed con- patient to lie still during the procedure
sent has been signed prior to the pro- because movement produces unclear
cedure and before administering any images.
medications. Administer a sedative to a child or to
an uncooperative adult, as ordered.
INTRATEST: Place the patient in a supine position
on a flat table with foam wedges,
Potential Complications: which help maintain position and
Although it is rare, there is the possibil- immobilization.
ity of allergic reaction to the radionu- IV radionuclide is administered, and the
clide. Have emergency equipment and patient is instructed to return for scan-
medications readily available. If the ning at a designated time after injec-
patient has a history of allergic reac- tion. Typical scanning occurs at 6, 24,
tions to any substance or drug, admin- 48, 72, 96, and/or 120 hr postinjection
ister ordered prophylactic steroids or depending on diagnosis.
antihistamines before the procedure. If an abdominal abscess or infection is
Establishing an IV site and injection of suspected, laxatives or enemas may
radionuclides is an invasive procedure. be ordered before imaging at 48 or
Complications are rare but do include 72 hr after the injection.
bleeding from the puncture site related Monitor the patient for complications
to a bleeding disorder, or the effects related to the procedure (e.g., allergic
of natural products and medications reaction, anaphylaxis, bronchospasm).
known to act as blood thinners, The needle or catheter is removed,
hematoma related to blood leakage and a pressure dressing is applied over
into the tissue following needle the puncture site.
f-Glutamyltranspeptidase
SYNONYM/ACRONYM: Serum -glutamyltransferase, -glutamyl transpeptidase,
GGT, SGGT.
POTENTIAL DIAGNOSIS
Conventional &
Age SI Units Increased in
GGT is released from any damaged
Newborn6 mo 12122 units/L
cell in which it is stored, so conditions
7 mo and older
that affect the liver, kidneys, or pan-
Male 030 units/L
creas and cause cellular destruction
Female 024 units/L
demonstrate elevated GGT levels.
Values may be elevated in older adults due to
the effects of medications and the presence
Cirrhosis
of multiple chronic or acute diseases with or Diabetes with hypertension
without muted symptoms. Hepatitis
Hepatobiliary tract disorders
Hepatocellular carcinoma
Hyperthyroidism (there is a strong
DESCRIPTION:Glutamyltransferase
association with concurrent liver
(GGT) assists with the reabsorp-
abnormalities)
tion of amino acids and
Infectious mononucleosis
peptides from the glomerular
Obstructive liver disease
G filtrate and intestinal lumen.
Pancreatitis
Hepatobiliary, renal tubular, and
Renal transplantation
pancreatic tissues contain large
Significant alcohol ingestion
amounts of GGT. Other sources
include the prostate gland, Decreased in
brain, and heart. GGT is elevated Hypothyroidism
in all types of liver disease and (related to decreased enzyme
is more responsive to biliary production by the liver)
obstruction, cholangitis, or cho-
lecystitis than any of the other CRITICAL FINDINGS: N/A
enzymes used as markers for
liver disease. INTERFERING FACTORS
Drugs and substances that may
increase GGT levels include
acetaminophen, alcohol, aminoglu-
This procedure is tethimide, anticonvulsants, auro-
contraindicated for: N/A thioglucose, barbiturates, captopril,
cetirizine, dactinomycin, dantrolene,
dexfenfluramine, estrogens, flucyto-
INDICATIONS sine, halothane, labetalol, medroxy-
Assist in the diagnosis of progesterone, meropenem,
obstructive jaundice in methyldopa, naproxen, niacin,
neonates nortriptyline, oral contraceptives,
Detect the presence of liver pegaspargase, phenothiazines,
disease piroxicam, probenecid, rifampin,
Evaluate and monitor patients streptokinase, tocainide, and
with known or suspected trifluoperazine.
alcohol abuse (levels rise after Drugs that may decrease GGT levels
ingestion of small amounts of include clofibrate conjugated estro-
alcohol) gens and ursodiol.
COMMON USE: To evaluate gastric fluid and the amount of gastric acid secreted
toward diagnosing gastrointestinal disorders such as ulcers, cancers, and
inflammation.
COMMON USE: To visualize and assess the time frame for gastric emptying to
assist in the diagnosis of diseases such as gastroenteritis and dumping syndrome.
POTENTIAL DIAGNOSIS
DESCRIPTION: A gastric emptying
scan quantifies gastric emptying Normal findings in
physiology. The procedure is indi- Mean time emptying of liquid
G cated for patients with gastric phase: 30 min (range, 11 to 49 min)
motility symptoms, including dia- Mean time emptying of solid phase:
betic gastroparesis, anorexia ner- 40 min (range, 28 to 80 min)
vosa, gastric outlet obstruction No delay in gastric emptying rate
syndromes, postvagotomy and
Abnormal findings in
postgastrectomy syndromes, and
Decreased rate:
assessment of medical and surgi- Dumping syndrome
cal treatments for diseases known Duodenal ulcer
to affect gastric motility. A radio- Malabsorption syndromes
nuclide is administered, and the Zollinger-Ellison syndrome
clearance of solids and liquids Increased rate:
may be evaluated. The images are Amyloidosis
recorded electronically, showing Anorexia nervosa
the gastric emptying function Diabetes
over time. Gastric outlet obstruction
Gastric ulcer
Gastroenteritis
This procedure is Gastroesophageal reflux
contraindicated for Hypokalemia, hypomagnesemia
Patients who are pregnant or Postgastric surgery period
suspected of being pregnant, Postoperative ileus
unless the potential benefits of a Postradiation therapy period
procedure using radiation far Scleroderma
outweigh the risks to the fetus and
mother.
Patients with esophageal motor dis- CRITICAL FINDINGS: N/A
orders or swallowing difficulties.
INTERFERING FACTORS
INDICATIONS Factors that may impair clear
Investigate the cause of rapid or imaging
slow rate of gastric emptying Inability of the patient to cooperate
Measure gastric emptying rate or remain still during the procedure
because of age, significant pain, or Patient Teaching: Inform the patient this
mental status. procedure can assist in evaluating the
Metallic objects (e.g., jewelry, body time it takes for the stomach to empty.
rings) within the examination field, Obtain a history of the patients com-
plaints or clinical symptoms, including a
which may inhibit organ visualiza- list of known allergens, especially aller-
tion and cause unclear images. gies or sensitivities to eggs, latex, anes-
Retained barium from a previous thetics, sedatives, or radionuclides.
radiological procedure. Obtain a history of the patients gastro-
Other nuclear scans done within intestinal system, symptoms, and
the previous 24 to 48 hr. results of previously performed labora-
Administration of certain medica- tory tests and diagnostic and surgical
tions (e.g., gastrin, cholecystokinin), procedures.
which may interfere with gastric Note any recent procedures that can
interfere with test results, including
emptying. examinations using barium- or iodine-
Other considerations based contrast medium.
Failure to follow dietary restrictions Record the date of the last menstrual
before the procedure may cause period and determine the possibility of
pregnancy in perimenopausal women.
the procedure to be canceled or Obtain a list of the patients current G
repeated. medications, including herbs, nutri-
Consultation with a health-care pro- tional supplements, and nutraceuticals
vider (HCP) should occur before (see Appendix H online at DavisPlus).
the procedure for radiation safety Review the procedure with the patient.
concerns regarding younger Address concerns about pain related to
patients or patients who are lactat- the procedure and explain that some
ing. Pediatric & Geriatric pain may be experienced during the
Imaging Children and geriatric test, and there may be moments of
discomfort. Reassure the patient that
patients are at risk for receiving a the radionuclide poses no radioactive
higher radiation dose than neces- hazard and rarely produces side
sary if settings are not adjusted for effects. Inform the patient that the
their small size. Pediatric Imaging procedure is performed in a nuclear
Information on the Image Gently medicine department by an HCP spe-
Campaign can be found at the cializing in this procedure, with support
Alliance for Radiation Safety in staff, and takes approximately 30 to
Pediatric Imaging (www.pedrad 120 min. Pediatric Considerations
.org/associations/5364/ig/). Preparing children for a gastric empty-
ing scan depends on the age of the
Risks associated with radiation over-
child. Encourage parents to be truthful
exposure can result from frequent about what the child may experience
x-ray or radionuclide procedures. during the procedure (e.g., length of
Personnel working in the examina- time the exam will take and the need to
tion area should wear badges to intermittently have scans performed),
record their level of radiation. stressing the importance of eating as
much of the breakfast as possible so
the test is successful, and to use words
that they know their child will under-
NURSING IMPLICATIONS stand. Toddlers and preschool-age chil-
AND PROCEDURE dren have a very short attention span,
so the best time to talk about the test
PRETEST: is right before the procedure. The child
Positively identify the patient using at should be assured that he or she will
least two unique identifiers before pro- be allowed to bring a favorite comfort
viding care, treatment, or services. item into the examination room, and if
Recognize anxiety related to test results, test results in relation to the patients
and be supportive of perceived loss of symptoms and other tests performed.
independent function. Discuss the impli-
cations of abnormal test results on the RELATED MONOGRAPHS:
patients lifestyle. Provide teaching and Related tests include barium swallow,
information regarding the clinical biopsy kidney, biopsy liver, biopsy lung,
implications of the test results, as calcitonin stimulation, calcium, capsule
appropriate. endoscopy, CT abdomen, esophageal
Reinforce information given by the manometry, EGD, fecal analysis,
patients HCP regarding further testing, gastric fluid analysis and gastric acid
treatment, or referral to another HCP. stimulation test, gastrin and gastrin
Answer any questions or address stimulation test, GI blood loss scan,
any concerns voiced by the patient or glucose, glycated hemoglobin, H. pylori
family. antibodies, liver and spleen scan, mag-
Depending on the results of this proce- nesium, PTH, UGI and small bowel
dure, additional testing may be needed series, and vitamin B12.
to evaluate or monitor progression of Refer to the Gastrointestinal System
the disease process and determine the table at the end of the book for related
need for a change in therapy. Evaluate tests by body system.
G
SI Units (Conventional
Age Conventional Units Units 0.481)
01 mo 70190 pg/mL 33.791.4 pmol/L
2 mo-15 yr 55185 pg/mL 26.489 pmol/L
16 yr and older Less than 100 pg/mL Less than 48.1 pmol/L
Values represent fasting levels.
Stimulation Tests
Gastrin stimulation test No response or slight increase over baseline;
with secretin; 0.4 mcg/ increase of greater than 200 pg/ml above baseline
kg by IV bolus is considered abnormal
into the tissue following needle body, unless contraindicated. Tell the
insertion, infection that might occur if patient that radionuclide is eliminated
bacteria from the skin surface is from the body within 6 to 24 hr.
introduced at the puncture site, or Monitor vital signs and neurological sta-
nerve injury that might occur if the tus every 15 min for 1 hr, then every 2 hr
needle strikes a nerve. for 4 hr, and then as ordered by the
Observe standard precautions, and fol- HCP. Monitor intake and output at least
low the general guidelines in Appendix A. every 8 hr. Compare with baseline val-
Positively identify the patient. ues. Protocols may vary among facilities.
Ensure that the patient has removed No other radionuclide tests should be
all external metallic objects from the scheduled for 24 to 48 hr after this
area to be examined prior to the procedure.
procedure. Instruct the patient to resume usual
Instruct the patient to void prior to the diet, fluids, medication, and activity, as
procedure and to change into the gown, directed by the HCP.
robe, and foot coverings provided. Instruct the patient in the care and
Record baseline vital signs and assess assessment of the injection site.
neurological status. Protocols may vary If a woman who is breastfeeding must
among facilities. have a nuclear scan, she should not
Establish an IV fluid line for the injection breastfeed the infant until the radionu-
of saline, anesthetics, sedatives, radio- clide has been eliminated. This could G
nuclides, or emergency medications. take as long as 3 days. She should be
Avoid the use of equipment containing instructed to express the milk and dis-
latex if the patient has a history of aller- card it during the 3-day period to pre-
gic reaction to latex. vent cessation of milk production.
Have emergency equipment readily Instruct the patient to immediately flush
available. the toilet and to meticulously wash
Instruct the patient to cooperate fully hands with soap and water after each
and to follow directions. Instruct the voiding for 24 hr after the procedure.
patient to remain still throughout the Instruct all caregivers to wear gloves
procedure because movement pro- when discarding urine for 24 hr after
duces unreliable results. the procedure. Wash gloved hands
Administer a sedative to a child or to with soap and water before removing
an uncooperative adult, as ordered. gloves. Then wash hands after the
Place the patient in a supine position on gloves are removed.
a flat table with foam wedges to help Nutritional Considerations: A low-fat,
maintain position and immobilization. low-cholesterol, and low-sodium diet
The radionuclide is administered IV, should be consumed to reduce cur-
and images are recorded immediately rent disease processes. High fat con-
and every 5 min over a period of sumption increases the amount of bile
60 min in various positions. acids in the colon and should be
The needle or catheter is removed, avoided.
and a pressure dressing is applied over Recognize anxiety related to test
the puncture site. results, and be supportive of perceived
Observe/assess the needle/catheter loss of independent function. Discuss
insertion site for bleeding, inflamma- the implications of abnormal test
tion, or hematoma formation. results on the patients lifestyle. Provide
teaching and information regarding the
POST-TEST: clinical implications of the test results,
Inform the patient that a report of as appropriate.
the results will be made available Reinforce information given by the
to the requesting HCP, who will patients HCP regarding further testing,
discuss the results with the patient. treatment, or referral to another HCP.
Advise the patient to drink increased Answer any questions or address
amounts of fluids for 24 to 48 hr to any concerns voiced by the patient or
eliminate the radionuclide from the family.
Genetic Testing
G SYNONYM/ACRONYM: Related terms: personalized medicine, companion diagnos-
tics, molecular diagnostics.
NORMAL FINDINGS: Method: Methods are specific to the study of interest and
preferred specimen type. Methods include polymerase chain reaction (PCR),
immunohistochemical assay, DNA probe using fluorescence in situ hybridization
(FISH), gene amplification using chromogenic in situ hybridization (CISH), cell
culture with karyotyping. Absence of findings consistent with genetic abnor-
malities related to disease or the ability to metabolize medications normally.
need to return to have additional sam- chlamydia group antibody, chloride sweat,
ples taken, if ordered. Answer any chromosome analysis, coagulation fac-
questions or address any concerns tors, CBC platelet count, culture and
voiced by the patient or family. smear mycobacteria, culture bacterial
(anal/genital, ear, eye, skin, and wound),
Patient Education: N/A cytomegalovirus, fecal analysis, glucose,
group A strep screen, hexosaminidase
Expected Patient Outcomes: N/A A & B, human leukocyte antigen B27,
immunosuppressant drugs, leukocyte
RELATED MONOGRAPHS: alkaline phosphatase enzyme, newborn
Related tests include 1-antitrypsin, screening, parvovirus B19, prothrombin
Alzheimers disease markers, amino acid time and INR, red blood cell cholinester-
screen blood & urine, amniotic fluid anal- ase, and varicella antibodies.
ysis, antibodies gliadin, anticonvulsant Refer to the Gastrointestinal, Genitouri-
drugs, antidepressant drugs, antipsy- nary, Hematopoietic, Hepatobiliary,
chotic drugs, biopsy breast, biopsy cho- Immune, Musculoskeletal, and
rionic villus, biopsy skin, biopsy Respiratory System tables at the end
thyroid, bladder cancer markers, cancer of the book for related tests by body
antigens, CD4/CD8 enumeration, system.
G
Glucagon
SYNONYM/ACRONYM: N/A.
Glucose
SYNONYM/ACRONYM: Blood sugar, fasting blood sugar (FBS), postprandial glu-
cose, 2-hr PC.
SI Units (Conventional
Age Conventional Units Units 0.0555)
Fasting
Cord blood 4596 mg/dL 2.55.3 mmol/L
Premature infant 2080 mg/dL 1.14.4 mmol/L
Access additional resources at davisplus.fadavis.com
SI Units (Conventional
Age Conventional Units Units 0.0555)
Newborn 2 days2 yr 30100 mg/dL 1.75.6 mmol/L
Child 60100 mg/dL 3.35.6 mmol/L
Adult-older adult Less than 100 mg/dL Less than 5.6 mmol/L
Prediabetes or 100125 mg/dL 5.66.9 mmol/L
impaired fasting
glucose
2-hr postprandial 65139 mg/dL 3.67.7 mmol/L
Prediabetes or impaired 140199 mg/dL 7.811 mmol/L
2-hr sample
Random Less than 200 mg/dL Less than 11.1 mmol/L
The American Diabetes Association and National Institute of Diabetes and Digestive and Kidney
Diseases consider a confirmed fasting blood glucose greater than 126 mg/dL to be consistent
with a diagnosis of diabetes. Values tend to increase in older adults.
Obtain a list of medications the patient Promptly transport the specimen to the
is taking, including herbs, nutritional laboratory for processing and analysis.
supplements, nutraceuticals (see
Appendix H online at DavisPlus), insu- POST-TEST:
lin, and any other substances used to Inform the patient that a report of
regulate glucose levels. the results will be made available
Review the procedure with the to the requesting HCP, who will
patient. Inform the patient that speci- discuss the results with the patient.
men collection takes approximately Instruct the patient to resume usual
5 to 10 min. Address concerns diet, as directed by the HCP.
about pain and explain that there Nutritional Considerations: Increased glu-
may be some discomfort during the cose levels may be associated with
venipuncture. diabetes. There is no diabetic diet;
Sensitivity to social and cultural issues,as however, many meal-planning
well as concern for modesty, is impor- approaches with nutritional goals are
tant in providing psychological support endorsed by the American Dietetic
before, during, and after the procedure. Association. Patients who adhere to
Instruct the patient to fast for at least dietary recommendations report a bet-
12 hr before specimen collection for ter general feeling of health, better
the fasting glucose test. weight management, greater control of
G Instruct the patient to follow the glucose and lipid values, and improved
instructions given for 2-hr postprandial use of insulin. Instruct the patient, as
glucose test. Some HCPs may order appropriate, in nutritional management
administration of a standard glucose of diabetes. The 2013 Guideline on
solution, whereas others may instruct Lifestyle Management to Reduce
the patient to eat a meal with a known Cardiovascular Risk published by the
carbohydrate composition. American College of Cardiology (ACC)
INTRATEST: and the American Heart Association
(AHA) in conjunction with the National
Potential Complications: N/A Heart, Lung, and Blood Institute
Ensure that the patient has complied (NHLBI) recommends a
with dietary restrictions and other pre- Mediterranean-style diet rather than a
testing preparations; assure that food low-fat diet. The new guideline empha-
has been restricted for at least 12 hr sizes inclusion of vegetables, whole
prior to the fasting procedure. grains, fruits, low-fat dairy, nuts,
Avoid the use of equipment containing legumes, and nontropical vegetable oils
latex if the patient has a history of aller- (e.g., olive, canola, peanut, sunflower,
gic reaction to latex. flaxseed) along with fish and lean poul-
Instruct the patient to cooperate fully try. A similar dietary pattern known as
and to follow directions. Direct the the Dietary Approaches to Stop
patient to breathe normally and to Hypertension (DASH) diet makes addi-
avoid unnecessary movement. tional recommendations for the reduc-
Observe standard precautions, and fol- tion of dietary sodium. Both dietary
low the general guidelines in Appendix A. styles emphasize a reduction in con-
Positively identify the patient, and label sumption of red meats, which are high
the appropriate specimen container in saturated fats and cholesterol, and
with the corresponding patient demo- other foods containing sugar, saturated
graphics, initials of the person collecting fats, trans fats, and sodium. If triglycer-
the specimen, date, and time of collec- ides also are elevated, the patient
tion. Perform a venipuncture. should be advised to eliminate or reduce
Remove the needle and apply direct alcohol. The nutritional needs of each
pressure with dry gauze to stop bleed- diabetic patient need to be determined
ing. Observe/assess venipuncture site individually (especially during pregnancy)
for bleeding or hematoma formation and with the appropriate HCPs, particularly
secure gauze with adhesive bandage. professionals trained in nutrition.
Glucose-6-Phosphate Dehydrogenase
SYNONYM/ACRONYM: G6PD.
SI Units (Conventional
G Age Conventional Units Units 0.0645)
Newborn 7.814.4 international 0.50.93 micro units/mol
units/g hemoglobin hemoglobin
Adultolder adult 5.59.3 international 0.350.60 micro units/mol
units/g hemoglobin hemoglobin
SI Units (Conventional
Conventional Units Units 0.0555)
Fasting Less than 93 mg/dL Less than Less than
sample (SI: Less than 95 mg/dL 105 mg/dL
5.2 mmol/L) (SI: Less than (SI: Less than
5.3 mmol/L) 5.8 mmol/L)
1-hr sample Less than 181 mg/dL Less 180 mg/dL Less than
(SI: Less than (SI: Less than 190 mg/dL
10 mmol/L) 10 mmol/L) (SI: Less than
10.5 mmol/L)
2-hr sample Less than 154 mg/dL Less than Less than
(SI: Less than 155 mg/dL 165 mg/dL
8.5 mmol/L) (SI: Less than (SI: Less than
8.6 mmol/L) 9.2 mmol/L)
3-hr sample N/A Less than Less than
140 mg/dL 145 mg/dL
(SI: Less than (SI: Less than
G 7.8 mmol/L) 8 mmol/L)
Plasma glucose values are reported to be 10% to 20% higher than serum values. According
to recommendations of the ADA, the diagnosis of gestational diabetes is made if any of the
four thresholds are met or exceeded. According to recommendations of the ACOG or National
Diabetes Data Group, the diagnosis of gestational diabetes is made if any two of the four
thresholds are met or exceeded.
ACOG = American Congress of Obstetricians and Gynecologists; ADA = American Diabetes
Association.
Glycated Hemoglobin
SYNONYM/ACRONYM: Hemoglobin A1c, A1c.
A1c 4.05.5%
Prediabetes 5.76.4%
ADA recommended treatment goal 6.5% or less
Values vary widely by method. American Diabetes Association (ADA).
This procedure is
DESCRIPTION: Glycosylated or contraindicated for: N/A
glycated hemoglobin is the com-
bination of glucose and hemoglo- INDICATIONS
bin into a ketamine; the rate at Assess long-term glucose control in
which this occurs is proportional individuals with diabetes
to glucose concentration. The
average life span of a red blood POTENTIAL DIAGNOSIS
cell (RBC) is approximately
120 days; measurement of glycated Increased in
hemoglobin is a way to monitor Diabetes (poorly controlled or
long-term diabetic management. uncontrolled) (related to and
The average plasma glucose can evidenced by elevated glucose
be estimated using the formula: levels)
Pregnancy (evidenced by gesta-
Average plasma glucose tional diabetes)
(mg/dL) = [(A1c 28.7) 46.7] Splenectomy (related to prolonged
For example, an A1c value of 6% RBC survival, which extends the
would reflect an average plasma amount of time hemoglobin is G
glucose of 125.5 mg/dL or [(6 available for glycosylation)
28.7) 46.7]. Decreased in
Diabetes is a group of diseases Chronic blood loss (related to
characterized by hyperglycemia or decreased concentration of RBC-
elevated glucose levels. bound glycated hemoglobin due
Hyperglycemia results from a to blood loss)
defect in insulin secretion (type 1 Chronic renal failure (low RBC
diabetes), a defect in insulin action, count associated with this condi-
or a combination of dysfunctional tion reflects corresponding
secretion and action (type 2 diabe- decrease in RBC-bound glycated
tes).The chronic hyperglycemia of hemoglobin)
diabetes over time results in dam- Conditions that decrease RBC life
age, dysfunction, and eventually span (evidenced by anemia and
failure of the eyes, kidneys, nerves, low RBC count, reflecting a corre-
heart, and blood vessels. sponding decrease in RBC-bound
Hemoglobin A1c levels are not age glycated hemoglobin)
dependent and are not affected by Hemolytic anemia (evidenced by low
exercise, diabetic medications, or RBC count due to hemolysis, reflect-
nonfasting state before specimen ing a corresponding decrease in
collection.The hemoglobin A1c RBC-bound glycated hemoglobin)
assay would not be useful for Pregnancy (evidenced by anemia
patients with hemolytic anemia or and low RBC count, reflecting a
abnormal hemoglobins (e.g., hemo- corresponding decrease in RBC-
globin S) accompanied by abnor- bound glycated hemoglobin)
mal RBC turnover.These patients
would be screened, diagnosed, and CRITICAL FINDINGS: N/A
managed using symptoms, clinical
risk factors, short-term glycemic INTERFERING FACTORS
indicators (glucose), and intermedi- Drugs that may increase glycated
ate glycemic indicators (1,5 anhy- hemoglobin A1c values include insu-
droglucitol or glycated albumin). lin and sulfonylureas.
also are elevated, the patient should be Educate the patient regarding access
advised to eliminate or reduce alcohol. to counseling services, as appropriate.
The nutritional needs of each diabetic Provide contact information, if desired,
patient need to be determined individu- for the American Diabetes Association
ally (especially during pregnancy) with (ADA; www.diabetes.org) or the AHA
the appropriate HCPs, particularly pro- (www.americanheart.org) or the NHLBI
fessionals trained in nutrition. (www.nhlbi.nih.gov).
Social and Cultural Considerations: Reinforce information given by the
Numerous studies point to the preva- patients HCP regarding further testing,
lence of excess body weight in treatment, or referral to another HCP.
American children and adolescents. Instruct the patient in the use of home
Experts estimate that obesity is pres- test kits approved by the U.S. Food
ent in 25% of the population ages 6 to and Drug Administration, if prescribed.
11 yr. The medical, social, and emo- Answer any questions or address any
tional consequences of excess body concerns voiced by the patient or family.
weight are significant. Special attention
should be given to instructing the child Expected Patient Outcomes:
and caregiver regarding health risks Knowledge
and weight control education. States understanding that diabetes is a
Recognize anxiety related to test disease that can adversely affect multi-
G results, and be supportive of perceived ple body systems if not accurately
loss of independence and fear of controlled
shortened life expectancy. The ADA States understanding that this labora-
recommends A1c testing 4 times a year tory study is a way to assess blood
for patients whose treatment plan has glucose control over time
changed or who are not meeting treat-
ments goals and twice a year for Skills
patients who are meeting treatment Demonstrates proficiency in the ability to
goals and have stable, good glycemic perform a self-check glucose accurately
control. Demonstrates proficiency in the ability
Depending on the results of this to perform insulin self-administration
procedure, additional testing may be correctly or to take oral agent
performed to evaluate or monitor pro- Attitude
gression of the disease process and Complies with the request for periodic
determine the need for a change in A1C laboratory studies to better man-
therapy. Evaluate test results in relation age the disease process over time
to the patients symptoms and other Complies with recommended diet
tests performed. and exercise to better control blood
glucose
Patient Education:
Instruct the patient and caregiver to RELATED MONOGRAPHS:
report signs and symptoms of hypogly- Related tests include C-peptide, cho-
cemia (weakness, confusion, diaphore- lesterol (total and HDL), CT cardiac
sis, rapid pulse) or hyperglycemia scoring, creatinine/eGFR, EMG, ENG,
(thirst, polyuria, hunger, lethargy). fluorescein angiography, fructosamine,
Discuss the implications of abnormal fundus photography, gastric emptying
test results on the patients lifestyle. scan, glucagon, glucose, glucose tol-
Provide teaching and information erance tests, insulin, insulin antibodies,
regarding the clinical implications of the ketones, microalbumin, plethysmogra-
test results, as appropriate. phy, slit-lamp biomicroscopy, triglycer-
Emphasize, if indicated, that good gly- ides, and visual fields test.
cemic control delays the onset and Refer to the Endocrine System table at
slows the progression of diabetic reti- the end of the book for related tests by
nopathy, nephropathy, and neuropathy. body system.
Gonioscopy
SYNONYM/ACRONYM: N/A.
CONTRAST: N/A.
POTENTIAL DIAGNOSIS
Normal findings in
Normal appearance of anterior NURSING IMPLICATIONS
chamber structures and wide, AND PROCEDURE
unblocked, normal angle PRETEST:
Abnormal findings in Positively identify the patient using
Corneal endothelial disorders at least two unique identifiers
(Fuchs endothelial dystrophy, irido- before providing care, treatment, or
services.
corneal endothelial syndrome)
Patient Teaching: Inform the patient this
Glaucoma procedure can assist in evaluating the
Lens disorders eye for disease.
(cataract, displaced lens) Obtain a history of the patients
Malignant ocular neoplasm in angle complaints, including a list of known
Neovascularization in angle allergens, especially allergies or
Ocular hemorrhage sensitivities to latex.
PAS Obtain a history of the patients
Schwartzs syndrome known or suspected vision loss;
changes in visual acuity, including type
Trauma
and cause, use of glasses or contact
Tumors lenses, eye conditions with treatment
Uveitis regimens, and eye surgery; as well as
results of previously performed labora-
CRITICAL FINDINGS: N/A tory tests and diagnostic and surgical
procedures.
INTERFERING FACTORS Obtain a list of the patients current
medications, including herbs, nutri-
Inability of the patient to cooperate tional supplements, and nutraceuticals
or remain still during the test (see Appendix H online at DavisPlus).
because of age, significant pain, or Instruct the patient to remove
mental status may interfere with contact lenses or glasses, as appropri-
the test results. ate. Instruct the patient regarding
the importance of keeping the eyes nor the bottle should touch the
open for the test. eyelashes.
Review the procedure with the patient. Ask the patient to place the chin in
Explain that the patient will be the chin rest and gently press the
requested to fixate the eyes during the forehead against the support bar.
procedure. Address concerns about Ask the patient to open his or her eyes
pain related to the procedure. wide and look at desired target.
Explain that no pain will be experi- Explain that the HCP or optometrist
enced during the test, but there may will place a lens on the eye while a
be moments of discomfort. Explain narrow beam of light is focused
that some discomfort may be on the eye.
experienced after the test when the
numbness wears off from anesthetic POST-TEST:
drops administered prior to the test. Inform the patient that a report of the
Inform the patient that the test is results will be made available to the
performed by a health-care provider requesting HCP, who will discuss
(HCP) or optometrist specially trained the results with the patient.
to perform this procedure and takes Recognize anxiety related to test
about 5 min to complete. results, and be supportive of impaired
Sensitivity to social and cultural issues,
as well as concern for modesty, is
activity related to vision loss or G
anticipated loss of driving privileges.
important in providing psychological Discuss the implications of abnormal
support before, during, and after the test results on the patients
procedure. lifestyle. Provide teaching and
Note that there are no food, fluid, or information regarding the clinical
medication restrictions unless by medical implications of the test results, as
direction. appropriate.
Reinforce information given by the
INTRATEST: patients HCP regarding further
Potential Complications: N/A testing, treatment, or referral to
another HCP. Answer any questions
Observe standard precautions,
or address any concerns voiced by
and follow the general guidelines in
the patient or family.
Appendix A. Positively identify the
Depending on the results of this
patient.
procedure, additional testing may be
Instruct the patient to cooperate fully
performed to evaluate or monitor
and to follow directions. Ask the
progression of the disease process
patient to remain still during the proce-
and determine the need for a
dure because movement produces
change in therapy. Evaluate test
unreliable results.
results in relation to the patients
Seat the patient comfortably. Instill
symptoms and other tests
topical anesthetic in each eye, as
performed.
ordered, and allow time for it to work.
Topical anesthetic drops are placed in
the eye with the patient looking up RELATED MONOGRAPHS:
and the solution directed at the Related tests include fundus photogra-
six oclock position of the sclera phy, pachymetry, slit-lamp biomicros-
(white of the eye) near the limbus copy, and visual field testing.
(gray, semitransparent area of the Refer to the Ocular System table at the
eyeball where the cornea and end of the book for related tests by
sclera meet). Neither the dropper body system.
Gram Stain
SYNONYM/ACRONYM: N/A.
POTENTIAL DIAGNOSIS
Gram Positive
Actinomadura Actinomyces Bacillus Clostridium Corynebac
terium
Enterococcus Erysipelothrix Lactobacillus Listeria Micrococcus
Mycobacterium Peptostrep Propioni Rhodococcus Staphy
(gram variable) tococcus bacterium lococcus
Streptococcus
Gram Negative
Acinetobacter Aeromonas Alcaligenes Bacteroides Bordetella
Borrelia Brucella Campy Citrobacter Chlamydia
lobacter
Enterobacter Escherichia Flavo Francisella Fusobacterium
bacterium G
Gardnerella Haemophilus Helicobacter Klebsiella Legionella
Leptospira Moraxella Neisseria Pasteurella Plesiomonas
Porphy Prevotella Proteus Pseudomonas Rickettsia
romonas
Salmonella Serratia Shigella Vibrio Xanthomonas
Yersinia
SPECIMEN: Throat swab (two swabs should be submitted so that a culture can
be performed if the screen is negative).
This procedure is
DESCRIPTION: Rheumatic fever is a contraindicated for: N/A
possible sequela to an untreated
streptococcal infection. Early G
diagnosis and treatment appear INDICATIONS
to lessen the seriousness of symp- Assist in the rapid determination
toms during the acute phase and of the presence of group A
overall duration of the infection streptococci
and sequelae. The onset of strep
throat is sudden and includes POTENTIAL DIAGNOSIS
symptoms such as chills, head-
ache, sore throat, malaise, and Positive findings in
exudative gray-white patches on Rheumatic fever
the tonsils or pharynx. The group Scarlet fever
A streptococcal screen should Strep throat
not be ordered unless the results Streptococcal glomerulonephritis
would be available within 1 to Tonsillitis
2 hr of specimen collection to
make rapid, effective therapeutic CRITICAL FINDINGS: N/A
decisions. A positive result can be
a reliable basis for the initiation INTERFERING FACTORS
of therapy. A negative result is Polyester (rayon or Dacron)
presumptive for infection and swabs are favored over cotton for
should be backed up by culture best chance of detection. Fatty
results. In general, specimens acids are created on cotton fibers
showing growth of less than during the sterilization process.
10 colonies on culture yield nega- Detectable target antigens on the
tive results by the rapid screening streptococcal cell wall are
method. Evidence of group A destroyed without killing the
streptococci disappears rapidly organism when there is contact
after the initiation of antibiotic between the specimen and the
therapy. A nucleic acid probe fatty acids on the cotton collection
method has also been developed swab. False-negative test results
for rapid detection of group A can be obtained on specimens
streptococci. collected with cotton tip swabs.
COMMON USE: To assess pituitary function and evaluate the amount of secreted
growth hormone to assist in diagnosing diseases such as giantism and dwarfism.
Growth Hormone
SI Units (Conventional
Age Conventional Units Units 1)
Cord blood 840 ng/mL 840 mcg/L
1 day 550 ng/mL 550 mcg/L
1 wk 525 ng/mL 525 mcg/L
Child 210 ng/mL 210 mcg/L
SI Units (Conventional
Age Conventional Units Units 1)
Adult
Male 05 ng/mL 05 mcg/L
Female 010 ng/mL 010 mcg/L
Male older 010 ng/mL 010 mcg/L
than 60 yr
Female older 014 ng/mL 014 mcg/L
than 60 yr
Stimulation Tests
Rise above baseline Greater than 5 ng/mL Greater than 5 mcg/L
Peak response Greater than 10 ng/mL Greater than 10 mcg/L
Suppression Tests 02 ng/mL 02 mcg/L
Haptoglobin
SYNONYM/ACRONYM: Hapto, HP, Hp.
892
Decreased in
(RBCs) are lysed. The complexed Autoimmune hemolysis (related to
hemoglobin is then removed from increased excretion rate of hapto-
circulation by the spleen. globin bound to free hemoglobin;
Haptoglobin is used as a marker for rate of excretion exceeds the liv-
intravascular hemolysis because the ers immediate ability to replenish)
amount of free hemoglobin from a Hemolysis due to drug reaction
significant number of lysed RBCs (related to increased excretion
will exceed the amount of hapto- rate of haptoglobin bound to free
globin normally available for binding. hemoglobin; rate of excretion
In conditions such as hemolytic exceeds the livers immediate
anemia (e.g., drug induced, inher- ability to replenish)
ited, acute transfusion reaction) the Hemolysis due to mechanical
liver is unable to compensate so con- destruction (e.g., artificial heart
sumption exceeds production, and valves, contact sports, subacute
haptoglobin levels are decreased. bacterial endocarditis) (related to
increased excretion rate of hapto-
This procedure is globin bound to free hemoglobin;
contraindicated for: N/A rate of excretion exceeds the liv-
ers immediate ability to replenish)
INDICATIONS Hemolysis due to RBC membrane H
Assist in the investigation of or metabolic defects (related to
suspected transfusion reaction increased excretion rate of
Evaluate known or suspected haptoglobin bound to free hemo-
chronic liver disease, as indicated globin; rate of excretion exceeds
by decreased levels of haptoglobin the livers immediate ability to
Evaluate known or suspected disor- replenish)
ders characterized by excessive Hemolysis due to transfusion
RBC hemolysis, as indicated by reaction (related to increased
decreased levels of haptoglobin excretion rate of haptoglobin
Evaluate known or suspected bound to free hemoglobin; rate of
disorders involving a diffuse excretion exceeds the livers
inflammatory process or tissue immediate ability to replenish)
destruction, as indicated by Hypersplenism (related to increased
elevated levels of haptoglobin excretion rate of haptoglobin
POTENTIAL DIAGNOSIS bound to free hemoglobin due to
increased red blood cell destruction;
Increased in rate of excretion exceeds the livers
Haptoglobin is an acute-phase reac- immediate ability to replenish)
tant protein, and any condition that Ineffective hematopoiesis due to
stimulates an acute-phase response conditions such as folate deficiency
will result in elevations of haptoglobin. or hemoglobinopathies (related to
Biliary obstruction decreased numbers of RBCs or
Disorders involving tissue destruc- dysfunctional binding in the pres-
tion, such as cancers, burns, and ence of abnormal hemoglobins)
acute myocardial infarction Liver disease (related to decreased
Infection or inflammatory diseases, production)
such as ulcerative colitis, arthritis, Pregnancy (related to effect of
and pyelonephritis estrogen)
Neoplasms
Steroid therapy CRITICAL FINDINGS: N/A
Access additional resources at davisplus.fadavis.com
COMMON USE: To test blood for findings that would indicate past or current
Helicobacter pylori infection.
Hemoglobin Electrophoresis
SYNONYM/ACRONYM: N/A.
Hgb A
Adult Greater than 95%
Hgb A2
Adult 1.53.7%
Hgb F
Newborns and infants
1 day3 wk 7077%
69 wk 4264%
34 mo 739%
6 mo 37%
811 mo 0.62.6%
Adultolder adult Less than 2%
Hemosiderin
SYNONYM/ACRONYM: Hemosiderin stain, Pappenheimer body stain, iron stain.
Hepatitis A Antibody
SYNONYM/ACRONYM: HAV serology.
COMMON USE: To test blood for the presence of antibodies that would indicate
a past or current hepatitis A infection.
PRETEST: POST-TEST:
Positively identify the patient using Inform the patient that a report of the
at least two unique identifiers before results will be made available to the
providing care, treatment, or services. requesting health-care provider (HCP),
Patient Teaching: Inform the patient who will discuss the results with the
this test can assist in evaluating for patient.
hepatitis infection. Nutritional Considerations: Dietary recom-
Obtain a history of the patients mendations may be indicated and will
complaints, including a list of known vary depending on the type and severity
allergens, especially allergies or of the condition. Elimination of alcohol
sensitivities to latex. ingestion and a diet optimized for conva-
Obtain a history of the patients lescence are commonly included in the
hepatobiliary and immune systems, treatment plan. Explain the importance
symptoms, and results of previously of providing an adequate daily fluid
performed laboratory tests and intake of at least 4 L. Monitor the
diagnostic and surgical procedures. patients weight, intake, and output each
Obtain a list of the patients current day and assess for development of asci-
medications, including herbs, nutri- tes. Elimination of alcohol ingestion and
tional supplements, and nutraceuticals a diet optimized for convalescence are
(see Appendix H online at DavisPlus). commonly included in the treatment
Review the procedure with the patient. plan. As a general rule, small, frequent
Inform the patient that specimen meals that are high in carbohydrates and
collection takes approximately 5 to low in fat will provide the required energy H
10 min. Address concerns about pain while not burdening the inflamed liver.
and explain that there may be some Social and Cultural Considerations:
discomfort during the venipuncture. Recognize anxiety related to test
Note that there are no food, fluid, or results, and offer support. Discuss the
medication restrictions unless by implications of abnormal test results on
medical direction. the patients lifestyle. Provide teaching
and information regarding the clinical
INTRATEST: implications of the test results, as
appropriate. Counsel the patient, as
Potential Complications: N/A appropriate, regarding risk of transmis-
Avoid the use of equipment containing sion and proper prophylaxis. Stress the
latex if the patient has a history of importance of hand hygiene to prevent
allergic reaction to latex. transmission of the virus. Immune
Instruct the patient to cooperate fully globulin can be given before exposure
and to follow directions. Direct the (in the case of individuals who may be
patient to breathe normally and to traveling to a location where the dis-
avoid unnecessary movement. ease is endemic) or after exposure,
Observe standard precautions, and during the incubation period.
follow the general guidelines in Prophylaxis is most effective when
Appendix A. Positively identify the administered 2 wk after exposure.
patient, and label the appropriate Depending on the results of this
specimen container with the corre- procedure, additional testing may be
sponding patient demographics, initials performed to evaluate or monitor
of the person collecting the specimen, progression of the disease process
date, and time of collection. Perform and determine the need for a change
a venipuncture. in therapy. Evaluate test results in
Remove the needle and apply direct relation to the patients symptoms
pressure with dry gauze to stop bleed- and other tests performed.
ing. Observe/assess venipuncture site
for bleeding or hematoma formation and Patient Education:
secure gauze with adhesive bandage. Reinforce information given by the
Promptly transport the specimen to the patients HCP regarding further testing,
laboratory for processing and analysis. treatment, or referral to another HCP.
Access additional resources at davisplus.fadavis.com
COMMON USE: To test blood for the presence of antibodies that would indicate
a past or current hepatitis B infection.
Hepatitis C Antibody
SYNONYM/ACRONYM: HCV serology, hepatitis non-A/non-B.
COMMON USE: To test blood for the presence of antibodies that would indicate
a past or current hepatitis C infection.
Hepatitis D Antibody
SYNONYM/ACRONYM: Delta hepatitis.
COMMON USE: To test blood for the presence of antibodies that would indicate
a past or current hepatitis D infections.
POTENTIAL DIAGNOSIS
CRITICAL FINDINGS: N/A
Positive findings in
Individuals currently infected with
HDV
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).
Hepatitis E Antibody
SYNONYM/ACRONYM: HEV.
COMMON USE: To test blood for the presence of antibodies that would indicate
a past or current hepatitis E infection.
H
SPECIMEN: Serum (1 mL) collected in a gold-, red-, or red/gray-top tube. Place
separated serum into a standard transport tube within 2 h of collection.
POTENTIAL DIAGNOSIS
CRITICAL FINDINGS: N/A
Positive findings in
Individuals with current HEV
infection
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).
Hepatobiliary Scan
SYNONYM/ACRONYM: Biliary tract radionuclide scan, cholescintigraphy, hepato-
biliary imaging, hepatobiliary scintigraphy, gallbladder scan, HIDA (a techne-
tium-99m diisopropyl analogue) scan.
COMMON USE: To visualize and assess the cystic and common bile ducts of the
gall bladder toward diagnosing obstructions, stones, inflammation, and tumor.
before, during, and after the Record baseline vital signs and assess
procedure. neurological status. Protocols may vary
Instruct the patient to remove jewelry among facilities.
and other metallic objects from the Establish an IV fluid line for the
area to be examined prior to the injection of saline, anesthetics,
procedure. sedatives, radionuclides, or emergency
Instruct the patient to restrict food and medications.
fluids for 4 to 6 hr prior to the Avoid the use of equipment containing
procedure. Protocols may vary among latex if the patient has a history of
facilities. allergic reaction to latex.
Make sure a written and informed Have emergency equipment readily
consent has been signed prior to the available.
procedure and before administering Instruct the patient to cooperate fully
any medications. and to follow directions. Instruct the
patient to lie still during the procedure
INTRATEST: because movement produces unclear
images.
Potential Complications: Administer sedative to a child or
Although it is rare, there is the to an uncooperative adult, as
possibility of allergic reaction to the ordered.
radionuclide. Place the patient in a supine
Establishing an IV site and injection of position on a flat table with foam
H radionuclides is an invasive procedure. wedges to help maintain position and
Complications are rare but do include immobilization.
bleeding from the puncture site related IV radionuclide is administered,
to a bleeding disorder, or the effects and the upper right quadrant of the
of natural products and medications abdomen is scanned immediately,
known to act as blood thinners; with images then taken every 5 min
hematoma related to blood leakage for the first 30 min and every 10 min
into the tissue following needle for the next 30 min. If the gallbladder
insertion; infection that might occur cannot be visualized, delayed views
if bacteria from the skin surface is are taken in 2, 4, and 24 hr in
introduced at the puncture site; or order to differentiate acute from
nerve injury that might occur if the chronic cholecystitis or to detect
needle strikes a nerve. the degree of obstruction.
Observe standard precautions, and IV morphine may be administered
follow the general guidelines in during the study to initiate
Appendix A. Positively identify the spasms of the sphincter of Oddi,
patient. forcing the radionuclide into the
Ensure that the patient has complied gallbladder, if the organ is not
with dietary, fluids, and medication visualized within 1 hr of injection of
restrictions for 4 to 6 hr prior to the the radionuclide. Imaging is then
procedure. done 20 to 50 min later to determine
Ensure that the patient has removed all delayed visualization or nonvisualization
external metallic objects prior to the of the gallbladder.
procedure. If gallbladder function or bile reflux is
Administer ordered prophylactic ste- being assessed, the patient will be
roids or antihistamines before the pro- given a fatty meal or cholecystokinin
cedure if the patient has a history of 60 min after the injection.
allergic reactions to radionuclides or Remove the needle or catheter and
medications. apply a pressure dressing over the
Instruct the patient to void prior to puncture site.
the procedure and to change into the Observe the needle/catheter insertion
gown, robe, and foot coverings site for bleeding, inflammation, or
provided. hematoma formation.
Hexosaminidase A and B
SYNONYM/ACRONYM: N/A.
SPECIMEN: Serum (3 mL) collected in a red-top tube. After the specimen is col-
lected, it must be brought immediately to the laboratory. Once in the laboratory,
the specimen must be allowed to clot for 1 to 1.5 hr in the refrigerator. The
serum should then be removed and frozen immediately.
SI Units (Conventional
Hexosaminidase A Conventional Units Units 0.0167)
Noncarrier 456592 nmol/hr/mL 7.629.88 units/L
Heterozygote 197323 nmol/hr/mL 3.295.39 units/L
Tay-Sachs 0 nmol/hr/mL 0 units/L
homozygote
SI Units (Conventional
Hexosaminidase B Conventional Units Units 0.0167)
H Noncarrier 1232 nmol/hr/mL 0.20.54 units/L
Heterozygote 2181 nmol/hr/mL 0.351.35 units/L
Tay-Sachs Greater than 305 nmol/ Greater than 5.09 units/L
homozygote hr/mL
Holter Monitor
SYNONYM/ACRONYM: Ambulatory electrocardiography, ambulatory monitoring,
event recorder, Holter electrocardiography.
CONTRAST: None.
INDICATIONS
DESCRIPTION: The Holter monitor Detect arrhythmias that occur
records electrical cardiac activity on during normal daily activities and
a continuous basis for 24 to 72 hr. correlate them with symptoms
This noninvasive study includes experienced by the patient
the use of a portable device worn Evaluate activity intolerance related H
around the waist or over the to oxygen supply and demand
shoulder that records cardiac imbalance
electrical impulses on a magnetic Evaluate chest pain, dizziness, syn-
tape. The recorder has a clock cope, and palpitations
that allows accurate time mark- Evaluate the effectiveness of antiar-
ings on the tape and the patient is rhythmic medications for dosage
asked to keep a log or diary of adjustment, if needed
daily activities and record any Evaluate pacemaker function
occurrence of cardiac Monitor for ischemia and arrhythmias
symptoms. When the patient after myocardial infarction or cardiac
pushes a button indicating that surgery before changing rehabilita-
symptoms (e.g., pain, palpitations, tion and other therapy regimens
dyspnea, syncope) have occurred,
an event marker is placed on the POTENTIAL DIAGNOSIS
tape for later comparison with Normal findings in
the cardiac activity recordings Normal sinus rhythm
and the daily activity log. Some
recorders allow the data to be Abnormal findings in
transferred to the physicians Arrhythmias such as premature ven-
office by telephone, where the tricular contractions, bradyarrhyth-
tape is interpreted by a computer mias, tachyarrhythmias, conduction
to detect any significantly abnor- defects, and bradycardia
mal variations in the recorded Cardiomyopathy
waveform patterns. Hypoxic or ischemic changes
Mitral valve abnormality
Palpitations
This procedure is
contraindicated for: N/A CRITICAL FINDINGS: N/A
COMMON USE: To assist in evaluating increased risk for blood clots, plaque forma-
tion, and platelet aggregations associated with atherosclerosis and stroke risk.
and determine the need for a change differential, CRP, CK and isoenzymes,
in therapy. Evaluate test results in rela- creatinine, folate, glucose, glycated
tion to the patients symptoms and hemoglobin, ketones, LDH and isoen-
other tests performed. zymes, lipoprotein electrophoresis,
magnesium, myoglobin, osteocalcin,
RELATED MONOGRAPHS: PTH, pericardial fluid analysis, potas-
Related tests include antiarrhythmic sium, prealbumin, renogram, triglycer-
drugs, apolipoprotein A and B, AST, ides, troponin, US kidney, UA, and
ANP, blood gases, BMD, BNP, BUN, vitamin B12.
calcitonin, calcium, cholesterol Refer to the Cardiovascular and
(total, HDL, and LDL), CBC, CBC RBC Hematopoietic systems tables at the
count, CBC RBC indices, CBC RBC end of the book for related tests by
morphology, CBC WBC count and body system.
Homovanillic Acid
SYNONYM/ACRONYM: HVA. H
SPECIMEN: Urine (10 mL) from a timed specimen collected in a clean plastic
collection container with 6N HCl as a preservative.
SI Units (Conventional
Conventional Units Units 1)
Males and Less than 5 milli Less than 5 international
H nonpregnant international units/mL units/L
females
Pregnant females by
week of gestation:
2 wk 5100 milli 5100 international units/L
international units/mL
3 wk 2003,000 milli 2003,000 international units/L
international units/mL
4 wk 10,00080,000 milli 10,00080,000 international
international units/mL units/L
512 wk 90,000500,000 milli 90,000500,000 international
international units/mL units/L
1324 wk 5,00080,000 milli 5,00080,000 international
international units/mL units/L
2628 wk 3,00015,000 milli 3,00015,000 international
international units/mL units/L
POTENTIAL DIAGNOSIS
inhibin-A, and estriol in prenatal
screening for neural tube defects. Increased in
These prenatal measurements are Choriocarcinoma (related to
also known as triple or quad HCG-producing tumor)
markers, depending on which Ectopic HCG-producing tumors
tests are included. Serial measure- (stomach, lung, colon, pancreas,
ments are needed for an accurate liver, breast) (related to
estimate of gestational stage and HCG-producing tumor)
determination of fetal viability. Erythroblastosis fetalis
Triple- and quad-marker testing (hemolytic anemia as a result of
has also been used to screen for fetal sensitization by incompati-
trisomy 21 (Down syndrome). ble maternal blood group
(To compare HCG to other tests antigens such as Rh, Kell, Kidd,
in the triple- and quad-marker and Duffy is associated with
screening procedure, see mono- increased HCG levels)
graph titled 1-Fetoprotein.) Germ cell tumors (ovary and
HCG is also produced by some testes) (related to HCG-producing
germ cell tumors. Most assays tumors)
measure both the intact and Hydatidiform mole (related to
free -HCG subunit, but if HCG HCG-secreting mole)
H
is to be used as a tumor marker, Islet cell tumors (related to
the assay must be capable of HCG-producing tumors)
detecting both intact and Multiple gestation pregnancy
free -HCG. (related to increased levels
produced by the presence of
multiple fetuses)
This procedure is Pregnancy (related to increased
contraindicated for: N/A production by placenta)
Decreased in
INDICATIONS
Any condition associated with dimin-
Assist in the diagnosis of suspected
ished viability of the placenta will
HCG-producing tumors, such
reflect decreased levels.
as choriocarcinoma, germ cell
tumors of the ovary and testes, Ectopic pregnancy (HCG levels
or hydatidiform moles increase slower than in viable
Confirm pregnancy, assist in intrauterine pregnancies, plateau,
the diagnosis of suspected and then decrease prior to
ectopic pregnancy, or determine rupture)
threatened or incomplete Incomplete abortion
abortion Intrauterine fetal demise
Determine adequacy of hormonal Spontaneous abortion
levels to maintain pregnancy Threatened abortion
Monitor effects of surgery or
chemotherapy CRITICAL FINDINGS: N/A
Monitor ovulation induction
treatment INTERFERING FACTORS
Prenatally detect neural tube defects Drugs that may decrease HCG levels
and trisomy 21 (Down syndrome) include epostane and mifepristone.
COMMON USE: Test blood for the presence of antibodies that would indicate a
human immunodeficiency virus (HIV) infection.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Place separated serum into
a standard transport tube within 2 h of collection.
PRETEST: INTRATEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before pro- Avoid the use of equipment containing
viding care, treatment, or services. latex if the patient has a history of aller-
Patient Teaching: Inform the patient that gic reaction to latex.
this laboratory test can assist in evalu- Instruct the patient to cooperate fully
ating for HIV infection. and to follow directions. Direct the
Obtain a history of the patients com- patient to breathe normally and to
plaints, including a list of known aller- avoid unnecessary movement.
gens, especially allergies or sensitivities Observe standard precautions, and fol-
to latex. low the general guidelines in Appendix A.
Obtain a history of the patients immune Positively identify the patient, and label
system, a history of high-risk behaviors, the appropriate specimen container with
symptoms, and results of previously the corresponding patient demograph-
performed laboratory tests and ics, initials of the person collecting the
diagnostic and surgical procedures. specimen, date, and time of collection.
Obtain a list of the patients current Perform a venipuncture.
medications, including herbs, nutri- Remove the needle and apply direct
tional supplements, and nutraceuticals pressure with dry gauze to stop bleed-
(see Appendix H online at DavisPlus). ing. Observe/assess venipuncture site
Review the procedure with the patient. for bleeding or hematoma formation and
Inform the patient that specimen col- secure gauze with adhesive bandage.
lection takes approximately 5 to 10 Promptly transport the specimen to the
min. Address concerns about pain and laboratory for processing and analysis.
explain that there may be some dis-
comfort during the venipuncture.
Note that there are no food, fluid, or POST-TEST:
medication restrictions unless by medi- Inform that patient that a report of the
cal direction. results will be made available to the
COMMON USE: To test the blood for the presence of antibodies that would indi-
cate past or current human T-lymphocyte virus (HTLV) infection. Helpful in
diagnosing certain types of leukemia.
SPECIMEN: Serum (1 mL) collected in a red-top tube. Place separated serum into
a standard transport tube within 2 hr of collection.
5-Hydroxyindoleacetic Acid
SYNONYM/ACRONYM: 5-HIAA.
SPECIMEN: Urine (10 mL) from a timed specimen collected in a clean plastic
collection container with boric acid as a preservative.
H
NORMAL FINDINGS: (Method: High-pressure liquid chromatography)
SPECIMEN: Serum (2 mL) collected in a red-top tube. Place separated serum into
a standard transport tube within 2 hr of collection.
Hysterosalpingography
SYNONYM/ACRONYM: Hysterogram, uterography, uterosalpingography.
COMMON USE: To visualize and assess the uterus and fallopian tubes to assess
for obstruction, adhesions, malformations, or injuries that may be related to
infertility.
Review the procedure with the Ensure the patient has removed all
patient. Address concerns about pain external metallic objects from the area
related to the procedure and explain to be examined prior to the procedure.
that some pain may be experienced Assess for completion of bowel prepa-
during the test, and there may be ration according to the institutions
moments of discomfort. Explain to procedure. Administer enemas or
the patient that she may feel tempo- suppositories on the morning of the
rary sensations of nausea, dizziness, test, as ordered.
slow heartbeat, and menstrual-like Avoid the use of equipment containing
cramping during the procedure, as latex if the patient has a history of
well as shoulder pain from subphrenic allergic reaction to latex.
irritation from the contrast medium as Have emergency equipment readily
it spills into the peritoneal cavity. available.
Inform the patient that the procedure Instruct the patient to void prior to the
is performed in a radiology depart- procedure and to change into the gown,
ment by a health-care provider (HCP), robe, and foot coverings provided.
with support staff, and takes approxi- Instruct the patient to cooperate fully
mately 30 to 60 min. and to follow directions. Instruct the
Sensitivity to social and cultural issues, patient to remain still throughout the
as well as concern for modesty, is procedure because movement pro-
important in providing psychological duces unreliable results.
support before, during and after the Place the patient in a lithotomy position
H procedure. on the fluoroscopy table.
Instruct the patient to take a laxative or A kidney, ureter, and bladder film is
a cathartic, as ordered, on the evening taken to ensure that no stool, gas, or
before the examination. barium will obscure visualization of the
Instruct the patient to remove jewelry uterus and fallopian tubes.
and other metallic objects from the A speculum is inserted into the vagina,
area to be examined. and contrast medium is introduced into
Note that there are no food, fluid, or the uterus through the cervix via a can-
medication restrictions unless by nula, after which both fluoroscopic and
medical direction or department radiographic images are taken.
protocol.
Make sure a written and informed POST-TEST:
consent has been signed prior to the Inform the patient that a report of the
procedure and before administering results will be made available to the
any medications. requesting HCP, who will discuss the
results with the patient.
INTRATEST: Instruct the patient to resume usual
medications and activity, as directed by
Potential Complications: the HCP.
Risks from HSG can include uterine Observe for delayed reaction to iodin-
perforation, exposure to radiation, ated contrast medium, including rash,
infection, allergic reaction to contrast urticaria, tachycardia, hyperpnea,
medium, heavy vaginal bleeding, uter- hypertension, palpitations, nausea, or
ine perforation, severe abdominal pain vomiting.
or cramping, pelvic infection (uterine or Instruct the patient to immediately
of the fallopian tubes), and pulmonary report symptoms such as fast heart
embolism. rate, difficulty breathing, skin rash,
Observe standard precautions, and fol- itching, chest pain, persistent right
low the general guidelines in Appendix A. shoulder pain, or abdominal pain.
Positively identify the patient. Immediately report symptoms to the
Ensure the patient has complied with appropriate HCP.
pretesting preparations prior to the Inform the patient that a vaginal
procedure. discharge is common and that it may
Hysteroscopy
SYNONYM/ACRONYM: N/A.
COMMON USE: To visualize and assess the endometrial lining of the uterus to
assist in diagnosing disorders such as fibroids, cancer, and polyps.
954
Signs &
Problem Symptoms Interventions
Powerlessness Expression of Assess need to be in control;
(Related chronic loss of control assess feelings of
illness; treatment for over situation, hopelessness, depression,
illness; loss of ability self, outcome apathy; assist to identify
to provide self-care; of disease; situations that contribute to a
progressive passive; feeling of powerlessness;
debilitation; terminal apathetic; assess the impact of the
prognosis) submissive; sense of powerlessness on
decreased the patients sense of self;
participation in encourage verbalization of
self-care; feelings; discuss therapeutic
reluctant to options offered by health-care I
express provider (HCP); assist to
feelings identify strengths; identify
coping strategies; encourage
being responsible for self-care
and personal environment to
increase sense of control;
give positive feedback
Hopelessness (Related Decreased Assess role of illness in
to chronic illness; affect; relation to expressions of
impaired decreased helplessness; assess
functionality; response to grooming (energy to provide
prolonged pain and stimuli; feeling good personal hygiene);
discomfort) of emptiness; assess level of appetite;
alterations in assess verbalization of
sleep patterns helplessness; provide
and appetite; opportunities to express
expressions of feelings in a safe
apathy; environment; support
withdrawn; development of a trusting
states life has relationship to decrease
no meaning feelings of isolation;
encourage verbalization of
personal strengths and
weaknesses; encourage
realistic hope; assist in
identification of coping skills
Signs &
Problem Symptoms Interventions
Mobility (Related to Decreased Assess the patients ability to
pain; weakness; purposeful perform independent range-of-
depression; fatigue; movement; motion exercises; encourage
decreased muscle difficulty performance of range-of-
strength; decreased completing motion exercises; encourage
coordination) activities of and assist in moving every
daily living; 2 hr to relieve tissue pressure;
limited range assist with activities of daily
of motion; living; encourage use of
reluctance to assistive devices as needed to
move; pain support mobility
Protection (Related to Bleeding; Monitor and trend HGB/HCT;
failure of bone infection; monitor and trend platelets
marrow; replacement anemia and red blood cells (RBCs);
of bone marrow by monitor for symptoms of
neoplastic cells; infection; take temperature
insufficient every 4 hr; institute bleeding
autoimmune precautions, soft
response; toothbrushes, avoid aspirin,
I chemotherapy; bone avoid IM or IV injections,
marrow transplant) coordinate laboratory draws
to minimize venipuncture;
administer prescribed
steroids, erythropoietin;
administer prescribed blood
and blood products; avoid
at-risk activities that could
cause trauma; discuss
exposure to microbes that
could result in infection
the patient that all urine must be saved meatus, (3) void a small amount into
during that 24-hr period. Instruct the the toilet, and (4) void directly into the
patient not to void directly into the lab- specimen container.
oratory collection container. Instruct Instruct the female patient to (1) thor-
the patient to avoid defecating in the oughly wash her hands; (2) cleanse the
collection device and to keep toilet labia from front to back; (3) while keep-
tissue out of the collection device to ing the labia separated, void a small
prevent contamination of the speci- amount into the toilet; and (4) without
men. Place a sign in the bathroom to interrupting the urine stream, void
remind the patient to save all urine. directly into the specimen container.
Instruct the patient to void all urine into
the collection device and then to pour Blood or Urine
the urine into the laboratory collection Promptly transport the specimen to the
container. Alternatively the specimen laboratory for processing and analysis.
can be left in the collection device for a
health-care staff member to add to the POST-TEST:
laboratory collection container. Inform the patient that a report of the
Sensitivity to social and cultural issues, as results will be made available to the
well as concern for modesty, is impor- requesting health-care provider (HCP),
tant in providing psychological support who will discuss the results with the
before, during, and after the procedure. patient.
Note that there are no food, fluid, Depending on the results of this
or medication restrictions unless by procedure, additional testing may be
medical direction. performed to evaluate or monitor pro-
gression of the disease process and
INTRATEST:
determine the need for a change in I
Potential Complications: N/A
therapy. Evaluate test results in relation
to the patients symptoms and other
Avoid the use of equipment containing tests performed.
latex if the patient has a history of aller-
gic reaction to latex. Patient Education:
Instruct the patient to cooperate fully Reinforce information given by the
and to follow directions. Direct the patients HCP regarding further
patient to breathe normally and to testing, treatment, or referral to
avoid unnecessary movement. another HCP.
Observe standard precautions, and fol- Answer any questions or address any
low the general guidelines in Appendix A. concerns voiced by the patient or family.
Positively identify the patient, and label Provide contact information for
the appropriate specimen container with support groups.
the corresponding patient demographics,
initials of the person collecting the speci- Expected Patient Outcomes:
men, date, and time of collection.
Knowledge
Perform a venipuncture as appropriate.
States understanding of the impor-
Blood tance of ambulation to prevent
Perform a venipuncture. demineralization and support bone
Remove the needle and apply direct health
pressure with dry gauze to stop bleed- States understanding of the importance
ing. Observe/assess venipuncture site of using assistive devices to support
for bleeding or hematoma formation and mobility and decrease injury risk.
secure gauze with adhesive bandage. Skills
Urine Strictly avoids at-risk activities that
could result in trauma and bleeding
Clean-Catch Specimen Makes dietary selections that include
Instruct the male patient to (1) thor- omitting fresh fruit to decrease
oughly wash his hands, (2) cleanse the exposure to bacteria
Immunoglobulin E
SYNONYM/ACRONYM: IgE.
Immunoglobulins A, D, G, and M
SYNONYM/ACRONYM: IgA, IgD, IgG, and IgM.
Immunosuppressants: Cyclosporine,
Methotrexate, Everolimus, Sirolimus,
and Tacrolimus
SYNONYM/ACRONYM: Cyclosporine (Sandimmune), methotrexate (MTX, ame-
thopterin, Folex, Rheumatrex), methotrexate sodium (Mexate), everolimus
(Afinitor, Certican, Zortress), sirolimus (Rapamycin), tacrolimus (Prograf).
Route of
Immunosuppressant Administration Recommended Collection Time
I Cyclosporine Oral or 12 hr after dose or immediately
intravenous prior to next dose
Methotrexate Oral Varies according to dosing
protocol
Intramuscular Varies according to dosing
protocol
Everolimus Oral Immediately prior to next dose
Sirolimus Oral Immediately prior to next dose
Tacrolimus Oral Immediately prior to next dose
Leucovorin therapy, also called leucovorin rescue, is used in conjunction with administration of
methotrexate. Leucovorin, a fast-acting form of folic acid, protects healthy cells from the toxic
effects of methotrexate.
Monograph_I_968-989.indd 969
Units 0.832)
Cyclosporine 100300 ng/mL renal transplant 83250 nmol/L 824 46 90 Renal
200350 ng/mL cardiac, hepatic, pancreatic 166291 nmol/L 824 46 90 Renal
transplant
100300 ng/mL bone marrow transplant 83250 nmol/L 824 46 90 Renal
Methotrexate Dependent on therapeutic approach 59 0.41 5070 Renal
Low dose: 0.51 micromol/L
High dose: Less than 5 micromol/L at 24 h;
less than 0.5 micromol/L at 48 h; less
than 0.1 micromol/L at 72 h
Conventional Units SI Units
(Conventional
Units 0.832)
Everolimus Transplant: 38 ng/mL 1835 (kidney); 128589 75 Biliary
3035 (liver)
Oncology: 510 ng/mL 1835 128589 75 Biliary
Sirolimus Maintenance phase: renal transplant: 4678 420 92 Biliary
412 ng/mL; liver transplant: 1220 ng/mL
Tacrolimus Maintenance phase: renal transplant: 1014 1.5 99 Biliary
612 ng/mL; liver transplant: 410 ng/mL;
pancreas transplant: 1018 ng/mL; bone
marrow transplant: 1020 ng/mL
Immunosuppressants
Therapeutic targets for the initial phase post-transplantation are slightly higher than during the maintenance phase and are influenced by the specific therapy
chosen for each patient with respect to coordination of treatment for other conditions and corresponding therapies. Therapeutic ranges for everolimus, sirolimus, and
tacrolimus assume concomitant administration of cyclosporine and steroids.
969
30/10/14 2:22 PM
970 Daviss Comprehensive Laboratory and Diagnostic Handbookwith Nursing Implications
COMMON USE: To assess for Epstein-Barr virus and assist with diagnosis of infec-
tious mononucleosis.
PRETEST: INTRATEST:
Positively identify the patient Potential Complications: N/A
using at least two unique identifiers
Avoid the use of equipment containing
before providing care, treatment, or
I latex if the patient has a history of aller-
services.
gic reaction to latex.
Patient Teaching: Inform the patient this
Instruct the patient to cooperate fully
test can assist with diagnosing a
and to follow directions. Direct the
mononucleosis infection.
patient to breathe normally and to
Obtain a history of the patients com-
avoid unnecessary movement.
plaints, including a list of known aller-
Observe standard precautions, and
gens, especially allergies or sensitivities
follow the general guidelines in
to latex. Obtain a history of exposure.
Appendix A. Positively identify the
Obtain a history of the patients
patient, and label the appropriate
hepatobiliary and immune systems,
specimen container with the corre-
symptoms, and results of previously
sponding patient demographics, initials
performed laboratory tests and
of the person collecting the specimen,
diagnostic and surgical procedures.
date, and time of collection. Perform
Note any recent therapies that can
a venipuncture.
interfere with test results.
Remove the needle and apply direct
Obtain a list of the patients current
pressure with dry gauze to stop bleed-
medications, including herbs, nutri-
ing. Observe/assess venipuncture site
tional supplements, and nutraceuticals
for bleeding or hematoma formation
(see Appendix H online at DavisPlus).
and secure gauze with adhesive
Review the procedure with the patient.
bandage.
Inform the patient that specimen collec-
Promptly transport the specimen to the
tion takes approximately 5 to 10 min.
Address concerns about pain and laboratory for processing and analysis.
explain that there may be some dis-
POST-TEST:
comfort during the venipuncture.
Sensitivity to social and cultural issues, as Inform the patient that a report of
well as concern for modesty, is important the results will be made available
in providing psychological support before, to the requesting HCP, who will
during, and after the procedure. discuss the results with the patient.
Note that there are no food, fluid, or Recognize anxiety related to test results,
medication restrictions unless by and inform the patient that signs and
medical direction. symptoms of infection include fever,
chills, sore throat, enlarged lymph nodes, Emphasize the importance of self-care
and fatigue. Self-care while the disease while the disease runs its course, which
runs its course include adequate fluid includes adequate fluid and nutritional
and nutritional intake along with sufficient intake along with sufficient rest.
rest. Activities that cause fatigue or stress
should be avoided. Advise the patient to Expected Patient Outcomes:
refrain from direct contact with others Knowledge
because the disease is transmitted Verbalizes understanding of how to
through saliva. pace activities to conserve energy and
Reinforce information given by the manage fatigue in relation to activities
patients HCP regarding further testing, of daily living
treatment, or referral to another HCP. States the importance of lengthy rest
Advise the patient to refrain from direct periods for recovery from mononucleosis
contact with others because the disease Skills
is transmitted through saliva. Answer Follows the recommendation to
any questions or address any concerns increase fluid intake (water and juice)
voiced by the patient or family. Follows the recommendation to take
Depending on the results of this over-the-counter ibuprofen or acet-
procedure, additional testing may be aminophen for comfort as needed
performed to evaluate or monitor pro-
gression of the disease process and Attitude
determine the need for a change in Complies with the request to get plenty
therapy. Evaluate test results in relation of rest to facilitate the recovery process
to the patients symptoms and other Complies with the recommendation to
tests performed. avoid kissing to prevent infection of
another individual with mononucleosis I
Patient Education:
Inform the patient that approximately RELATED MONOGRAPHS:
10% of all results are false-negative or Related tests include CBC with periph-
false-positive. eral blood smear evaluation and US
Inform the patient that signs and abdomen.
symptoms of infection include fever, Refer to the Hepatobiliary and Immune
chills, sore throat, enlarged lymph systems tables at the end of the book
nodes, and fatigue. for related tests by body system.
Insulin Antibodies
SYNONYM/ACRONYM: N/A.
COMMON USE: To assess the function of the extraocular muscle to assist with
diagnosis of strabismus, amblyopia, and other ocular disorders.
I AREA OF APPLICATION: Eyes.
CONTRAST: N/A.
moves. When testing is completed, the focusing power of the eye. The patient
procedure is repeated using the other and family should be educated that the
eye. The procedure is performed at a chosen therapy involves a process of
distance and near, first with and then mental retraining. The mode of therapy
without corrective lenses. The examiner in itself does not correct vision.
should determine the range of ocular It is the process by which the brain
movements in all gaze positions, usually becomes readapted to accept,
to include up and out, in, down and out, receive, and store visual images
up and in, down and in, and out. received by the eye that results in
vision correction. Therefore, the patient
POST-TEST: must be prepared to be alert,
Inform the patient that a report of the cooperative, and properly motivated.
results will be made available to the Answer any questions or address any
requesting HCP, who will discuss the concerns voiced by the patient or
results with the patient. family.
Recognize anxiety related to test Depending on the results of this
results, and be supportive of impaired procedure, additional testing may be
activity related to vision loss, antici- performed to evaluate or monitor
pated loss of driving privileges, or the progression of the disease process
possibility of requiring corrective lenses and determine the need for a change
(self-image). in therapy. Evaluate test results in
Reinforce information given by the relation to the patients symptoms
patients HCP regarding further testing, and other tests performed.
treatment, or referral to another HCP.
Educate the patient, as appropriate, RELATED MONOGRAPHS:
I that he or she may be referred for spe- Related tests include refraction and
cial therapy to correct the anomaly, slit-lamp biomicroscopy.
which may include glasses, prisms, Refer to the Ocular System table at the
eye exercises, eye patches, or chemi- end of the book for related tests by
cal patching with drugs that modify the body system.
Intraocular Pressure
SYNONYM/ACRONYM: IOP.
CONTRAST: N/A.
Intravenous Pyelography
SYNONYM/ACRONYM: Antegrade pyelography, excretory urography (EUG), intra-
venous urography (IVU, IUG), IVP.
This procedure is
DESCRIPTION: Intravenous pyelog- contraindicated for
raphy (IVP) is most commonly Patients who are pregnant or
performed to determine urinary suspected of being pregnant,
tract dysfunction or renal dis- unless the potential benefits of a
ease. IVP uses IV radiopaque procedure using radiation far out-
contrast medium to visualize the weigh the risk of radiation expo-
kidneys, ureters, bladder, and sure to the fetus and mother.
I renal pelvis. The contrast medi- Patients with conditions associ-
um concentrates in the blood ated with adverse reactions to
and is filtered out by the glomer- contrast medium (e.g., asthma, food
uli passing out through the renal allergies, or allergy to contrast
tubules and concentrated in the medium). Although patients are still
urine. Renal function is reflected asked specifically if they have a
by the length of time it takes the known allergy to iodine or shellfish,
contrast medium to appear and it has been well established that
to be excreted by each kidney. the reaction is not to iodine, in fact
A series of images is performed an actual iodine allergy would be
during a 30-min period to view very problematic because iodine is
passage of the contrast through required for the production of
the kidneys and ureters into the thyroid hormones. In the case of
bladder. Tomography may be shellfish the reaction is to a muscle
employed during the IVP to per- protein called tropomyosin; in the
mit the examination of an indi- case of iodinated contrast medium
vidual layer or plane of the the reaction is to the noniodinated
organ that may be obscured by part of the contrast molecule.
surrounding overlying struc- Patients with a known hypersensi-
tures. Many facilities have tivity to the medium may benefit
replaced the IVP with computed from premedication with cortico-
tomography (CT) studies. CT steroids and diphenhydramine; the
provides better detail of the ana- use of nonionic contrast or an alter-
tomical structures in the urinary native noncontrast imaging study, if
system and therefore greater available, may be considered for
sensitivity in identification of patients who have severe asthma
renal pathology. or who have experienced moderate
Assess for completion of bowel prepa- Instruct the patient to resume usual
ration according to the institutions pro- diet, fluids, medications, and activity,
cedure. Administer enemas or suppos- as directed by the HCP. Renal function
itories on the morning of the test, as should be assessed before metformin
ordered. is resumed if contrast was used.
Administer ordered prophylactic ste- Observe for delayed reaction to iodin-
roids or antihistamines before the pro- ated contrast medium, including rash,
cedure if the patient has a history of urticaria, tachycardia, hyperpnea,
allergic reactions to any substance or hypertension, palpitations, nausea, or
drug. Use nonionic contrast medium vomiting.
for the procedure. Observe/assess the needle/catheter
Avoid the use of equipment containing insertion site for bleeding, inflamma-
latex if the patient has a history of aller- tion, or hematoma formation.
gic reaction to latex. Instruct the patient in the care and
Have emergency equipment readily assessment of the injection site.
available. Instruct the patient to apply cold com-
Instruct the patient to void prior to the presses to the puncture site as needed,
procedure and to change into the gown, to reduce discomfort or edema.
robe, and foot coverings provided. Monitor urinary output after the proce-
Instruct the patient to cooperate fully dure. Decreased urine output may indi-
and to follow directions. Instruct the cate impending renal failure.
patient to remain still throughout the Recognize anxiety related to test
procedure because movement pro- results, and offer support. Discuss the
duces unreliable results. implications of abnormal test results on
Place the patient in the supine position the patients lifestyle. Provide teaching
on an examination table. and information regarding the clinical I
A kidney, ureter, and bladder (KUB) or implications of the test results, as
plain film is taken to ensure that no appropriate.
barium or stool obscures visualization Reinforce information given by the
of the urinary system. patients HCP regarding further testing,
Insert an IV line, if one is not already in treatment, or referral to another HCP.
place, and inject the contrast medium. Answer any questions or address any
Instruct the patient to take slow, deep concerns voiced by the patient or
breaths if nausea occurs during the family.
procedure. Depending on the results of this proce-
Monitor the patient for complications dure, additional testing may be needed
related to the procedure (e.g., allergic to evaluate or monitor progression of
reaction, anaphylaxis, bronchospasm). the disease process and determine the
Images are taken at 1, 5, 10, 15, 20, need for a change in therapy. Evaluate
and 30 min following injection of the test results in relation to the patients
contrast medium into the urinary sys- symptoms and other tests performed.
tem. Instruct the patient to exhale
deeply and to hold his or her breath RELATED MONOGRAPHS:
while each image is taken. Related tests include biopsy bladder,
Remove the needle or catheter and biopsy kidney, biopsy prostate, BUN,
apply a pressure dressing over the CT abdomen, CT pelvis, creatinine,
puncture site. cystometry, cystoscopy, gallium scan,
Instruct the patient to void if a post- KUB, MRI abdomen, renogram, retro-
voiding exposure is required to visual- grade ureteropyelography, US abdo-
ize the empty bladder. men, US bladder, US kidney, US pros-
tate, urine markers of bladder cancer,
POST-TEST: urinalysis, urine cytology, and voiding
Inform the patient that a report of cystourethrography.
the results will be made available Refer to the Genitourinary System
to the requesting HCP, who will table at the end of the book for related
discuss the results with the patient. tests by body system.
Iron
SYNONYM/ACRONYM: Fe.
COMMON USE: To monitor and assess blood iron levels related to treatment,
blood loss, metabolism, anemia, and storage disorders.
This procedure is
DESCRIPTION: Iron plays a princi- contraindicated for: N/A
pal role in erythropoiesis, the
formation and maturation of red INDICATIONS
blood cells (RBCs), and is Assist in the diagnosis of blood
required for hemoglobin (Hgb) loss, as evidenced by decreased
synthesis.The human body con- serum iron
tains between 4 and 5 grams of Assist in the diagnosis of hemo-
iron, about 65% of which is pres- chromatosis or other disorders of
ent in hemoglobin and 3% of iron metabolism and storage
which is present in myoglobin, Determine the differential diagnosis
the oxygen storage protein of anemia
found in skeletal and cardiac Determine the presence of disor-
muscle. A small amount is also ders that involve diminished pro-
found in cellular enzymes that tein synthesis or defects in iron
catalyze the oxidation and reduc- absorption
tion of iron. Excess iron is stored Evaluate accidental iron poisoning
in the liver and spleen as ferritin Evaluate iron overload in dialysis
and hemosiderin. Any iron pres- patients or patients with
ent in the serum is in transit transfusion-dependent anemias
between the alimentary tract, Evaluate thalassemia and sideroblas-
the bone marrow, and available tic anemia
iron storage forms. Sixty to sev- Monitor hematological responses
enty percent of the bodys iron is I
during pregnancy, when serum
carried by its specific transport iron is usually decreased
protein, transferrin. Normally, Monitor response to treatment for
iron enters the body by oral anemia
ingestion; only 10% is absorbed,
but as much as 2030% can be
POTENTIAL DIAGNOSIS
absorbed in patients with iron-
deficiency anemia. Unbound iron Increased in
is highly toxic, but there is gen- Acute iron poisoning (children)
erally an excess of transferrin (related to excessive intake)
available to prevent the buildup Acute leukemia
of unbound iron in the circula- Acute liver disease (possibly relat-
tion. Iron overload is as clinically ed to decrease in synthesis of
significant as iron deficiency. An iron storage proteins by dam-
example of acute iron overload aged liver; iron accumulates and
is the accidental poisoning of levels increase)
children caused by excessive Aplastic anemia (related to
intake of iron-containing multivi- repeated blood transfusions)
tamins. Chronic iron overload Excessive iron therapy (related to
can occur in patients receiving excessive intake)
serial therapeutic transfusions Hemochromatosis (inherited dis-
of red blood cells over time for order of iron overload; the iron
treatment of various cancers, is not excreted in proportion to
hemoglobinopathies such as the rate of accumulation)
sickle cell anemia, the thalas- Hemolytic anemias (related to
semias, and other hemolytic release of iron from lysed
anemias. RBCs)
COMMON USE: To monitor iron replacement therapy and assess blood iron lev-
els to assist in diagnosing types of anemia such as iron deficiency.
This procedure is
DESCRIPTION: Iron plays a princi- contraindicated for: N/A
pal role in erythropoiesis, the
formation and maturation of red
INDICATIONS
blood cells (RBCs), and is
Assist in the diagnosis of iron-
required for hemoglobin (Hgb)
deficiency anemia
synthesis.The human body con-
Differentiate between iron-deficiency
tains between 4 and 5 grams of
anemia and anemia secondary to
iron, about 65% of which is pres-
chronic disease
ent in hemoglobin and 3% of
Monitor hematological response to
which is present in myoglobin,
therapy during pregnancy and iron-
the oxygen storage protein
deficiency anemias
found in skeletal and cardiac
Provide support for diagnosis of
muscle. A small amount is also I
hemochromatosis or diseases of
found in cellular enzymes that
iron metabolism and storage
catalyze the oxidation and reduc-
tion of iron. Excess iron is stored
in the liver and spleen as ferritin POTENTIAL DIAGNOSIS
and hemosiderin. Any iron pres- Increased in
ent in the serum is in transit Acute liver disease
between the alimentary tract, Hypochromic (iron-deficiency)
the bone marrow, and available anemias (insufficient circulating
iron storage forms. Sixty to sev- iron levels to saturate binding
enty percent of the bodys iron sites)
is carried by its specific trans- Late pregnancy
port protein, transferrin. For this
reason, total iron-binding capaci- Decreased in
ty (TIBC) and transferrin are Chronic infections (transferrin is
sometimes referred to inter- a negative acute-phase reactant
changeably, even though other protein and during periods of
proteins carry iron and contrib- inflammation will demonstrate
ute to the TIBC. Unbound iron is decreased levels)
highly toxic, but there is general- Cirrhosis (transferrin is a nega-
ly an excess of transferrin avail- tive acute-phase reactant protein
able to prevent the buildup of and during periods of inflamma-
unbound iron in the circulation. tion will demonstrate decreased
The percentage of iron satura- levels)
tion is calculated by dividing the Hemochromatosis (occurs early in
serum iron value by the TIBC the disease as intestinal absorp-
value and multiplying by 100. tion of iron available for binding
increases)
SPECIMEN: Serum (1 mL) collected from gold-, red-, or red/gray-top tube. Urine
(5 mL), random or timed specimen, collected in a clean plastic collection
container.
1004
Blood
NURSING IMPLICATIONS Avoid the use of equipment containing
AND PROCEDURE latex if the patient has a history of
allergic reaction to latex.
PRETEST: Instruct the patient to cooperate fully
Positively identify the patient using and to follow directions. Direct the
at least two unique identifiers before patient to breathe normally and to
providing care, treatment, or services. avoid unnecessary movement.
Patient Teaching: Inform the patient this Positively identify the patient, and label
test can assist in diagnosing metabolic the appropriate specimen container
disorders such as diabetes. with the corresponding patient demo-
Obtain a history of the patients graphics, initials of the person collect-
complaints, including a list of known ing the specimen, date, and time of
allergens, especially allergies or collection. Perform a venipuncture.
sensitivities to latex. Alternatively, a fingerstick or heel stick
Obtain a history of the patients endo- method of specimen collection can be
crine system, symptoms, and results used.
of previously performed laboratory Remove the needle and apply direct
tests and diagnostic and surgical pressure with dry gauze to stop
procedures. bleeding. Observe/assess venipuncture
Obtain a list of the patients current site for bleeding or hematoma formation
medications, including herbs, nutri- and secure gauze with adhesive
tional supplements, and nutraceuticals bandage.
(see Appendix H online at DavisPlus). Urine
Review the procedure with the Review the procedure with the patient.
patient. Inform the patient that blood Explain to the patient how to collect a
specimen collection takes approxi- second-voided midstream void, then
mately 5 to 10 min. The amount of drink a glass of water, wait 30 min, and
K time required to collect a urine then try to void again.
specimen depends on the level of Instruct the patient to avoid excessive
cooperation from the patient. Address exercise and stress before specimen
concerns about pain and explain that collection.
there may be some discomfort during
the venipuncture. Clean-Catch Specimen
Sensitivity to social and cultural issues, Instruct the male patient to (1) thoroughly
as well as concern for modesty, is wash his hands, (2) cleanse the meatus,
important in providing psychological (3) void a small amount into the toilet,
support before, during, and after the and (4) void directly into the specimen
procedure. container.
Note that there are no food, fluid, or Instruct the female patient to (1) thor-
medication restrictions, unless by oughly wash her hands; (2) cleanse
medical direction. the labia from front to back; (3) while
keeping the labia separated, void a
INTRATEST:
small amount into the toilet; and
(4) without interrupting the urine stream,
Potential Complications: N/A void directly into the specimen
Observe standard precautions, and fol- container.
low the general guidelines in Appendix A. Blood or Urine
Positively identify the patient, and label Promptly transport the specimen to
the appropriate specimen container the laboratory for processing and
with the corresponding patient analysis.
demographics, initials of the person
collecting the specimen, date, and time POST-TEST:
of collection. Perform a venipuncture as Inform the patient that a report of the
appropriate. results will be made available to the
requesting HCP, who will discuss the intake in an unbalanced diet; therefore,
results with the patient. the body breaks down fat instead of
Nutritional Considerations: Increased lev- carbohydrate for energy. Increasing
els of ketone bodies may be associated carbohydrate intake in the patients diet
with diabetes. There is no diabetic reduces the levels of ketone bodies.
diet; however, many meal-planning Carbohydrates can be found in
approaches with nutritional goals are starches and sugars. Starch is a com-
endorsed by the American Dietetic plex carbohydrate that can be found in
Association. Patients who adhere to foods such as grains (breads, cereals,
dietary recommendations report a better pasta, rice) and starchy vegetables
general feeling of health, better weight (corn, peas, potatoes). Sugar is a sim-
management, greater control of glucose ple carbohydrate that can be found in
and lipid values, and improved use of natural foods (fruits and natural honey)
insulin. Instruct the patient, as appropri- and processed foods (desserts and
ate, in nutritional management of diabe- candy).
tes. The 2013 Guideline on Lifestyle Recognize anxiety related to test
Management to Reduce Cardiovascular results, and be supportive of perceived
Risk published by the American College loss of independence and fear of
of Cardiology (ACC) and the American shortened life expectancy. Discuss the
Health Association (AHA) in conjunction implications of abnormal test results on
with the National Heart, Lung, and the patients lifestyle. Provide teaching
Blood Institute (NHLBI) recommends a and information regarding the clinical
Mediterranean-style diet rather than a implications of the test results, as
low-fat diet. The new guideline empha- appropriate. Emphasize, if indicated,
sizes inclusion of vegetables, whole that good glycemic control delays the
grains, fruits, low-fat dairy, nuts, onset and slows the progression of
legumes, and nontropical vegetable oils diabetic retinopathy, nephropathy, and
(e.g., olive, canola, peanut, sunflower, neuropathy. Educate the patient
flaxseed) along with fish and lean poul- regarding access to counseling K
try. A similar dietary pattern known as services, as appropriate. Provide
the Dietary Approaches to Stop contact information, if desired, for the
Hypertension (DASH) diet makes addi- American Diabetes Association (www
tional recommendations for the reduc- .diabetes.org) or the American Heart
tion of dietary sodium. Both dietary Association (www.americanheart.org).
styles emphasize a reduction in con- Reinforce information given by the
sumption of red meats, which are high patients HCP regarding further testing,
in saturated fats and cholesterol, and treatment, or referral to another HCP.
other foods containing sugar, saturated Answer any questions or address any
fats, trans fats, and sodium. If triglycer- concerns voiced by the patient or family.
ides also are elevated, the patient Depending on the results of this
should be advised to eliminate or reduce procedure, additional testing may be
alcohol. The nutritional needs of each performed to evaluate or monitor pro-
diabetic patient need to be determined gression of the disease process and
individually (especially during pregnancy) determine the need for a change in
with the appropriate HCPs, particularly therapy. The ADA recommends A1C
professionals trained in nutrition. testing 4 times a year for insulin-
Impaired glucose tolerance may be dependent type 1 or type 2 diabetes
associated with diabetes. Instruct the and twice a year for non-insulin-
patient and caregiver to report signs dependent type 2 diabetes. The ADA
and symptoms of hypoglycemia (weak- also recommends that testing for diabe-
ness, confusion, diaphoresis, rapid tes commence at age 45 for asymp-
pulse) or hyperglycemia (thirst, poly- tomatic individuals and continue every
uria, hunger, lethargy). 3 yr in the absence of symptoms.
Nutritional Considerations: Increased Evaluate test results in relation to the
levels of ketone bodies may be patients symptoms and other tests
associated with poor carbohydrate performed.
COMMON USE: To visualize and assess the abdominal organs for obstruction or
abnormality related to mass, trauma, bleeding, stones, or congenital anomaly.
CONTRAST: None.
K
DESCRIPTION: A kidney, ureter, and abnormal gas accumulation, and
bladder (KUB) x-ray examination ascites.
provides information regarding
the structure, size, and position
of the abdominal organs; it also
indicates whether there is any This procedure is
obstruction or abnormality of contraindicated for
the abdomen caused by disease Patients who are pregnant
or congenital malformation. or suspected of being
Calcifications of the renal caly- pregnant, unless the potential
ces, renal pelvis, and any radi- benefits of a procedure using radia-
opaque calculi present in the tion far outweigh the risk of radia-
urinary tract or surrounding tion exposure to the fetus and
organs may be visualized in addi- mother.
tion to normal air and gas pat-
terns within the intestinal tract.
Perforation of the intestinal tract INDICATIONS
or an intestinal obstruction can Determine the cause of acute
be visualized on erect KUB images. abdominal pain or palpable mass
KUB x-rays are among the first Evaluate the effects of lower
examinations done to diagnose abdominal trauma, such as internal
intra-abdominal diseases such hemorrhage
as intestinal obstruction, Evaluate known or suspected intes-
masses, tumors, ruptured organs, tinal obstructions
can be found at the Alliance for Sensitivity to social and cultural issues,
Radiation Safety in Pediatric Imaging as well as concern for modesty, is
(www.pedrad.org/associations/ important in providing psychological
5364/ig/). support before, during, and after the
procedure.
Risks associated with radiation Instruct the patient to remove all
overexposure can result from fre- metallic objects from the area to be
quent x-ray procedures. Personnel examined.
in the room with the patient Note that there are no food, fluid,
should wear a protective lead or medication restrictions unless by
apron, stand behind a shield, or medical direction.
leave the area while the examina- INTRATEST:
tion is being done. Personnel work-
ing in the examination area should Potential Complications: N/A
wear badges to record their level Observe standard precautions, and
of radiation exposure. follow the general guidelines in
Appendix A. Positively identify the
patient.
Ensure the patient has removed all
NURSING IMPLICATIONS metallic objects from the area to be
AND PROCEDURE examined prior to the procedure.
PRETEST:
Instruct the patient to void prior to the
procedure and to change into the
Positively identify the patient using gown, robe, and foot coverings
at least two unique identifiers before provided.
providing care, treatment, or services. Instruct the patient to cooperate fully
Patient Teaching: Inform the patient this and follow directions. Instruct the
procedure can assist in assessing the
K status of the abdomen.
patient to remain still throughout
the procedure because movement
Obtain a history of the patients com- produces unreliable results.
plaints or clinical symptoms, including Avoid the use of equipment containing
a list of known allergens, especially latex if the patient has a history of
allergies or sensitivities to latex. allergic reaction to latex.
Obtain a history of the patients gastro- Place the patient on the table in a
intestinal and genitourinary systems, supine position with hands relaxed
symptoms, and results of previously at the side.
performed laboratory tests and diag- Instruct the patient to inhale deeply
nostic and surgical procedures. and hold his or her breath while the
Record the date of the last menstrual x-ray images are taken, and then to
period and determine the possibility exhale after the images are taken.
of pregnancy in perimenopausal
women.
Obtain a list of the patients current POST-TEST:
medications, including herbs, nutri- Inform the patient that a report of
tional supplements, and nutraceuticals the results will be made available
(see Appendix H online at DavisPlus). to the requesting HCP, who will
Review the procedure with the patient. discuss the results with the patient.
Address concerns about pain and Reinforce information given by the
explain that little to no pain is expected patients HCP regarding further testing,
during the test, but there may be treatment, or referral to another HCP.
moments of discomfort. Inform the Answer any questions or address any
patient that the procedure is performed concerns voiced by the patient or family.
in the radiology department or at the Depending on the results of this
bedside by a registered radiologic procedure, additional testing may be
technologist and takes approximately performed to evaluate or monitor pro-
5 to 15 min to complete. gression of the disease process and
determine the need for a change in abdomen, CT pelvis, CT renal, IVP, and
therapy. Evaluate test results in relation MRI abdomen, retrograde ureteropy-
to the patients symptoms and other elography, US abdomen, US kidney,
tests performed. US pelvis, and UA.
Refer to the Gastrointestinal and
RELATED MONOGRAPHS: Genitourinary systems tables at the
Related tests include angiography end of the book for related tests by
renal, calculus kidney stone panel, CT body system.
Kleihauer-Betke Test
SYNONYM/ACRONYM: Fetal hemoglobin, hemoglobin F, acid elution slide test.
1012
Lactic Acid
SYNONYM/ACRONYM: Lactate.
COMMON USE: To assess for lactic acid acidosis related to poor organ perfusion
and liver failure. May also be used to differentiate between lactic acid acidosis
and ketoacidosis by evaluating blood glucose levels.
concerns about pain and explain that site for bleeding or hematoma forma-
there may be some discomfort during tion and secure gauze with adhesive
the venipuncture. bandage.
Instruct the patient to fast and to Promptly transport the specimen to
restrict fluids overnight. Instruct the the laboratory for processing and
patient not to ingest alcohol for 12 hr analysis.
before the test. Protocols may vary
among facilities. POST-TEST:
Sensitivity to social and cultural issues, as Inform the patient that a report of
well as concern for modesty, is impor- the results will be made available
tant in providing psychological support to the requesting HCP, who will
before, during, and after the procedure. discuss the results with the patient.
Note that there are no medication Instruct the patient to resume usual
restrictions unless by medical direction. diet and fluids, as directed by the
Prepare an ice slurry in a cup or plastic HCP.
bag to have on hand for immediate Nutritional Considerations: Instruct
transport of the specimen to the patients to consume water when exer-
laboratory. cising. Dehydration may occur when
the body loses water during exercise.
INTRATEST: Early signs of dehydration include dry
mouth, thirst, and concentrated dark
Potential Complications: N/A yellow urine. If replacement fluids are
Ensure that the patient has complied not consumed at this time, the patient
with dietary restrictions and other may become moderately dehydrated
pretesting preparations; ensure that and exhibit symptoms of extreme
food and liquids have been restricted thirst, dry oral mucus membranes,
for at least 12 hr prior to the inability to produce tears, decreased
procedure. urinary output, and lightheadedness.
Avoid the use of equipment containing Severe dehydration manifests as con-
latex if the patient has a history of aller- fusion, lethargy, vertigo, tachycardia,
gic reaction to latex. anuria, diaphoresis, and loss of con- L
Instruct the patient to cooperate fully sciousness.
and to follow directions. Direct the Note that depending on the results of
patient to breathe normally and to this procedure, additional testing may
avoid unnecessary movement. be performed to evaluate or monitor
Observe standard precautions, and fol- progression of the disease process
low the general guidelines in Appendix A. and determine the need for a change
Positively identify the patient, and label in therapy. Evaluate test results in rela-
the appropriate specimen container tion to the patients symptoms and
with the corresponding patient demo- other tests performed.
graphics, initials of the person collect-
ing the specimen, date, and time of Patient Education:
collection. Instruct the patient not to Reinforce information given by the
clench and unclench fist immediately patients HCP regarding further testing,
before or during specimen collection. treatment, or referral to another HCP.
Do not use a tourniquet. Perform a Answer any questions or address any
venipuncture. The tightly capped sam- concerns voiced by the patient or
ple should be placed in an ice slurry family.
immediately after collection.
Information on the specimen label Expected Patient Outcomes:
should be protected from water in the Knowledge
ice slurry by first placing the specimen States understanding that an untreated
in a protective plastic bag. elevated lactic acid has the potential to
Remove the needle and apply direct be life threatening
pressure with dry gauze to stop States understanding of abstaining
bleeding. Observe/assess venipuncture from alcohol to protect liver function
*Compared to fasting sample for infants, children, adults, and older adults.
Laparoscopy, Abdominal
SYNONYM/ACRONYM: Abdominal peritoneoscopy.
COMMON USE: To visualize and assess the liver, gallbladder, and spleen to assist
with surgical interventions, staging tumor, and performing diagnostic biopsies.
performed laboratory tests and diag- has fasting guidelines for risk levels
nostic and surgical procedures. according to patient status. More infor-
Ensure that this procedure is per- mation can be located at www.asahq.
formed before any barium studies. org. Patients on beta blockers before
Record the date of the last menstrual the surgical procedure should be
period and determine the possibility of instructed to take their medication as
pregnancy in perimenopausal women. ordered during the perioperative
Obtain a list of the patients current period. Protocols may vary among
medications, including anticoagulants, facilities.
aspirin and other salicylates, herbs, Make sure a written and informed
nutritional supplements, and nutraceu- consent has been signed prior to the
ticals, especially those known to affect procedure and before administering
coagulation (see Appendix H online at any medications.
DavisPlus). Such products should be
discontinued by medical direction for INTRATEST:
the appropriate number of days prior
to a surgical procedure. Note the last Potential Complications:
time and dose of medication taken. Complications of the procedure may
Review the procedure with the patient. include bleeding and cardiac arrhyth-
Address concerns about pain related mias. Patients with acute infection or
to the procedure and explain that advanced malignancy involving the
some pain may be experienced during abdominal wall are at increased risk for
the test, and there may be moments of infection because organisms may be
discomfort. Inform the patient that the introduced into the normally sterile
procedure is performed in a surgery peritoneal cavity.
department, by an HCP, with support Observe standard precautions, and
staff, and takes approximately 30 to follow the general guidelines in
60 min. Appendix A. Positively identify the
Sensitivity to social and cultural issues, patient.
as well as concern for modesty, is Ensure that the patient has complied
important in providing psychological with dietary, fluid, and medication L
support before, during, and after the restrictions for at least 8 hr prior to the
procedure. procedure.
Explain that an IV line may be inserted Ensure the patient has removed all
to allow infusion of IV fluids such as external metallic objects from the area
normal saline, anesthetics, sedatives, to be examined.
or emergency medications. Ensure that nonallergy to anesthesia is
Inform the patient that a laxative and confirmed before the procedure is per-
cleansing enema may be needed the formed under general anesthesia.
day before the procedure, with cleans- Assess for completion of bowel prepa-
ing enemas on the morning of the pro- ration according to the institutions
cedure, depending on the institutions procedure.
policy. Avoid the use of equipment containing
Instruct the patient to remove jewelry latex if the patient has a history of aller-
and other metallic objects from the gic reaction to latex.
area to be examined prior to the Have emergency equipment readily
procedure. available.
Instruct the patient that to reduce the Instruct the patient to void prior to
risk of nausea and vomiting, solid food the procedure and to change into
and milk or milk products have been the gown, robe, and foot coverings
restricted for at least 8 hr, and clear provided.
liquids have been restricted for at least Instruct the patient to cooperate fully
2 hr prior to general anesthesia, and to follow directions. Instruct the
regional anesthesia, or sedation/ patient to remain still throughout
analgesia (monitored anesthesia). The the procedure because movement
American Society of Anesthesiologists produces unreliable results.
Obtain and record baseline vital signs. values. Notify the HCP if temperature is
Establish an IV fluid line for the injec- elevated. Protocols may vary among
tion of saline, sedatives, or emergency facilities.
medications. Instruct the patient to restrict activity
Administer medications, as ordered, to for 2 to 7 days after the procedure.
reduce discomfort and to promote Instruct the patient in the care and
relaxation and sedation. assessment of the incision site.
Place the patient on the laparoscopy If indicated, inform the patient of a
table. If general anesthesia is to be follow-up appointment for the removal
used, it is administered at this time. of sutures.
Place the patient in a modified lithot- Inform the patient that shoulder
omy position with the head tilted discomfort may be experienced for
downward. Cleanse the abdomen with 1 or 2 days after the procedure as a
an antiseptic solution, and drape and result of abdominal distention caused
catheterize the patient, if ordered. by insufflation of CO2 into the abdo-
The HCP identifies the site for the scope men and that mild analgesics and cold
insertion and administers local anes- compresses, as ordered, can be used
thesia if that is to be used. After deeper to relieve the discomfort.
layers are anesthetized, a pneumoperi- Emphasize that any persistent shoulder
toneum needle is placed between the pain, abdominal pain, vaginal bleeding,
visceral and parietal peritoneum. fever, redness, or swelling of the inci-
CO2 is insufflated through the pneumo- sional area must be reported to the
peritoneum needle to separate the HCP immediately.
abdominal wall from the viscera and to Recognize anxiety related to test
aid in visualization of the abdominal results. Discuss the implications of
structures. The pneumoperitoneum abnormal test results on the patients
needle is removed, and the trocar and lifestyle. Provide teaching and informa-
laparoscope are inserted through the tion regarding the clinical implications
incision. of the test results, as appropriate.
After the examination, collection of Reinforce information given by the
L tissue samples, and performance of patients HCP regarding further testing,
therapeutic procedures, the scope is treatment, or referral to another HCP.
withdrawn. All possible CO2 is evacu- Answer any questions or address any
ated via the trocar, which is then concerns voiced by the patient or family.
removed. The skin incision is closed Depending on the results of this proce-
with sutures, clips, or sterile strips, dure, additional testing may be needed
and a small dressing or adhesive strip to evaluate or monitor progression of
is applied. the disease process and determine the
Observe/assess the incision site for need for a change in therapy. Evaluate
bleeding, inflammation, or hematoma test results in relation to the patients
formation. symptoms and other tests performed.
POST-TEST: RELATED MONOGRAPHS:
Inform the patient that a report of Related tests include amylase, barium
the results will be made available swallow, biopsy bone marrow, CBC,
to the requesting HCP, who will CBC WBC count and differential, CT
discuss the results with the patient. abdomen, CT biliary tract and liver, CT
Instruct the patient to resume usual pancreas, CRP, ESR, gallium scan,
diet, fluids, and medication, as directed hepatobiliary scan, KUB, lipase, liver
by the HCP. and spleen scan, lymphangiogram, MRI
Monitor vital signs and neurological abdomen, MRI pelvis, peritoneal fluid
status every 15 min for 1 hr, then every analysis, US abdomen, and US pelvis.
2 hr for 4 hr, and as ordered. Take Refer to the Gastrointestinal and
temperature every 4 hr for 24 hr. Hepatobiliary systems tables at the
Monitor intake and output at least end of the book for related tests by
every 8 hr. Compare with baseline body system.
Laparoscopy, Gynecologic
SYNONYM/ACRONYM: Gynecologic pelviscopy, gynecologic laparoscopy, pelvic
endoscopy, peritoneoscopy.
COMMON USE: To visualize and assess the ovaries, fallopian tubes, and uterus
toward diagnosing inflammation, malformations, cysts, and fibroids and to
evaluate causes of infertility.
Patient Teaching: Inform the patient this for at least 8 hr, and clear liquids have
procedure can assist in assessing the been restricted for at least 2 hr prior to
abdominal and pelvic organs. general anesthesia, regional anesthesia,
Obtain a history of the patients com- or sedation/analgesia (monitored anes-
plaints or clinical symptoms, including thesia). The American Society of
a list of known allergens, especially Anesthesiologists has fasting guidelines
allergies or sensitivities to latex, anes- for risk levels according to patient sta-
thetics, or sedatives. tus. More information can be located at
Obtain a history of the patients repro- www.asahq.org. Patients on beta block-
ductive system, symptoms, and results ers before the surgical procedure should
of previously performed laboratory tests be instructed to take their medication as
and diagnostic and surgical procedures. ordered during the perioperative period.
Ensure that this procedure is per- Protocols may vary among facilities.
formed before any barium studies. Make sure a written and informed
Record the date of the last menstrual consent has been signed prior to the
period and determine the possibility of procedure and before administering
pregnancy in perimenopausal women. any medications.
Obtain a list of the patients current
medications, including anticoagulants, INTRATEST:
aspirin and other salicylates, herbs,
nutritional supplements, and nutraceu- Potential Complications:
ticals, especially those known to affect Complications of the procedure may
coagulation (see Appendix H online at include bleeding and cardiac arrhythmias.
DavisPlus). Such products should be Patients with acute infection or advanced
discontinued by medical direction for malignancy involving the abdominal wall
the appropriate number of days prior are at increased risk for infection because
to a surgical procedure. Note the last organisms may be introduced into the
time and dose of medication taken. normally sterile peritoneal cavity.
Review the procedure with the patient. Observe standard precautions, and fol-
Address concerns about pain related low the general guidelines in Appendix A.
to the procedure and explain that Positively identify the patient. L
some pain may be experienced during Ensure that the patient has complied with
the test, and there may be moments of dietary, fluid, and medication restrictions
discomfort. Inform the patient that the for at least 8 hr prior to the procedure.
procedure is performed in a surgery Ensure the patient has removed all
department by an HCP and support staff external metallic objects from the area
and takes approximately 30 to 60 min. to be examined.
Sensitivity to social and cultural issues, as Ensure that nonallergy to anesthesia is
well as concern for modesty, is impor- confirmed before the procedure is per-
tant in providing psychological support formed under general anesthesia.
before, during, and after the procedure. Assess for completion of bowel prepa-
Explain that an IV line may be inserted ration according to the institutions
to allow infusion of IV fluids such as procedure.
normal saline, anesthetics, sedatives, Avoid the use of equipment containing
or emergency medications. latex if the patient has a history of aller-
Inform the patient that a laxative and gic reaction to latex.
cleansing enema may be needed the day Have emergency equipment readily
before the procedure, with cleansing available.
enemas on the morning of the proce- Instruct the patient to void prior to the
dure, depending on the institutions policy. procedure and to change into the gown,
Instruct the patient to remove jewelry robe, and foot coverings provided.
and other metallic objects from the area Instruct the patient to cooperate fully
to be examined prior to the procedure. and to follow directions. Instruct the
Instruct the patient that to reduce the risk patient to remain still throughout the
of nausea and vomiting, solid food and procedure because movement
milk or milk products have been restricted produces unreliable results.
Obtain and record baseline vital signs. Monitor vital signs and neurological
Establish an IV fluid line for the injec- status every 15 min for 1 hr, then every
tion of saline, sedatives, or emergency 2 hr for 4 hr, and as ordered. Take tem-
medications. perature every 4 hr for 24 hr. Monitor
Administer medications, as ordered, to intake and output at least every 8 hr.
reduce discomfort and to promote Compare with baseline values. Notify
relaxation and sedation. the HCP if temperature is elevated.
Place the patient on the laparoscopy Protocols may vary among facilities.
table. If general anesthesia is to be Instruct the patient to restrict activity
used, it is administered at this time. for 2 to 7 days after the procedure.
Place the patient in a modified lithot- Instruct the patient in the care and
omy position with the head tilted assessment of the incision site.
downward. Cleanse the abdomen with If indicated, inform the patient of a
an antiseptic solution, and drape and follow-up appointment for the removal
catheterize the patient, if ordered. of sutures.
The HCP identifies the site for the scope Inform the patient that shoulder dis-
insertion and administers local anesthe- comfort may be experienced for 1 or
sia if that is to be used. After deeper 2 days after the procedure as a result
layers are anesthetized, a pneumoperi- of abdominal distention caused by
toneum needle is placed between the insufflation of CO2 into the abdomen
visceral and parietal peritoneum. and that mild analgesics and cold
CO2 is insufflated through the pneumo- compresses, as ordered, can be used
peritoneum needle to separate the to relieve the discomfort.
abdominal wall from the viscera and to Emphasize that any persistent shoulder
aid in visualization of the abdominal pain, abdominal pain, vaginal bleeding,
structures. The pneumoperitoneum nee- fever, redness, or swelling of the inci-
dle is removed, and the trocar and lapa- sional area must be reported to the
roscope are inserted through the incision. HCP immediately.
The HCP inserts a uterine manipulator Recognize anxiety related to test
through the vagina and cervix and into results. Discuss the implications of
L the uterus so that the uterus, fallopian abnormal test results on the patients
tubes, and ovaries can be moved to lifestyle. Provide teaching and informa-
permit better visualization. tion regarding the clinical implications
After the examination, collection of tis- of the test results, as appropriate.
sue samples, and performance of ther- Reinforce information given by the
apeutic procedures (e.g., tubal ligation), patients HCP regarding further testing,
the scope is withdrawn. All possible treatment, or referral to another HCP.
CO2 is evacuated via the trocar, which Answer any questions or address any
is then removed. The skin incision is concerns voiced by the patient or family.
closed with sutures, clips, or sterile Depending on the results of this proce-
strips and a small dressing or adhesive dure, additional testing may be needed
strip is applied. After the perineum is to evaluate or monitor progression of
cleansed, the uterine manipulator is the disease process and determine the
removed and a sterile pad applied. need for a change in therapy. Evaluate
Observe/assess the incision site for test results in relation to the patients
bleeding, inflammation, or hematoma symptoms and other tests performed.
formation.
RELATED MONOGRAPHS:
POST-TEST: Related tests include cancer antigens,
Inform the patient that a report of Chlamydia group antibody, CT abdo-
the results will be made available men, CT pelvis, HCG, MRI pelvis, Pap
to the requesting HCP, who will dis- smear, progesterone, US pelvis, and
cuss the results with the patient. uterine fibroid embolization.
Instruct the patient to resume usual Refer to the Reproductive System
diet, fluids, and medication, as directed table at the end of the book for related
by the HCP. tests by body system.
Latex Allergy
SYNONYM/ACRONYM: N/A.
Positive findings in
Latex allergy
Find and print out the full monograph at DavisPlus (http://davisplus.fadavis
.com, keyword Van Leeuwen).
Lead
SYNONYM/ACRONYM: Pb.
L
COMMON USE: To assess for lead toxicity and monitor exposure to lead to assist
in diagnosing lead poisoning.
SI Units (Conventional
Conventional Units Units 0.0483)
Children and adults (WHO, Less than 10 mcg/dL Less than
CDC; environmental 0.48 micromol/L
exposure)
OSHA (occupational Less than 40 mcg/dL Less than
exposure standard) 1.93 micromol/L
OSHA = Occupational Safety and Health Administration; WHO = World Health Organization;
CDC = Centers for Disease Control and Prevention.
Lipase
SYNONYM/ACRONYM: Triacylglycerol acylhydrolase.
POTENTIAL DIAGNOSIS
Conventional & SI Units
Increased in
Newbornolder adult
Lipase is contained in pancreatic
060 units/L
tissue and is released into the
serum when cell damage or necro-
sis occurs.
DESCRIPTION: Lipases are digestive
enzymes secreted by the pancreas Acute cholecystitis
into the duodenum. There are Obstruction of the pancreatic duct
different lipolytic enzymes with Pancreatic carcinoma (early)
specific substrates, but they are Pancreatic cyst or pseudocyst
collectively described as lipase. Pancreatic inflammation
Lipase participates in fat digestion Pancreatitis (acute and chronic) L
by breaking down triglycerides Renal failure (related to decreased
into fatty acids and glycerol so renal excretion)
the fatty acids can be absorbed Decreased in: N/A
and either used for energy or
stored for later use. Lipase is CRITICAL FINDINGS: N/A
released into the bloodstream
when damage occurs to the INTERFERING FACTORS
pancreatic acinar cells. Its pres- Drugs that may increase lipase
ence in the blood indicates levels include acetaminophen,
pancreatic disease because the asparaginase, azathioprine, calcitri-
pancreas is the only organ that ol, cholinergics, codeine, deoxy-
secretes this enzyme. cholate, diazoxide, didanosine,
felbamate, glycocholate, hydrocor-
tisone, indomethacin, meperidine,
This procedure is
methacholine, methylprednisolone,
contraindicated for: N/A
metolazone, morphine, narcotics,
nitrofurantoin, pancreozymin,
INDICATIONS pegaspargase, pentazocine, and
Assist in the diagnosis of acute and taurocholate.
chronic pancreatitis Drugs that may decrease lipase
Assist in the diagnosis of pancreatic levels include protamine and saline
carcinoma (IV infusions).
Lipoprotein Electrophoresis
SYNONYM/ACRONYM: Lipid fractionation; lipoprotein phenotyping; 3ga1-lipo-
protein cholesterol, high-density lipoprotein (HDL); -lipoprotein cholesterol,
low-density lipoprotein (LDL); pre--lipoprotein cholesterol, very-low-density
lipoprotein (VLDL).
Hyperlipoproteinemia: Specimen
Fredrickson Type Appearance Electrophoretic Pattern
Type I Clear with creamy Heavy chylomicron band
top layer
Type IIa Clear Heavy band
Type IIb Clear or faintly Heavy and pre- bands
turbid
Type III Slightly to Heavy band L
moderately turbid
Type IV Slightly to Heavy pre- band
moderately turbid
Type V Slightly to Intense chylomicron band
moderately turbid and heavy and pre-
with creamy top bands
layer
COMMON USE: To visualize and assess the liver and spleen related to tumors,
inflammation, cysts, abscess, trauma, and portal hypertension.
the procedure and explain that some Observe standard precautions, and fol-
pain may be experienced during the low the general guidelines in Appendix A.
test, or there may be moments of dis- Positively identify the patient.
comfort. Reassure the patient that the Ensure that the patient has removed all
radionuclide poses no radioactive haz- external metallic objects from the area
ard and rarely produces side effects. to be examined prior to the procedure.
Inform the patient the procedure is Administer ordered prophylactic steroids
performed in a nuclear medicine or antihistamines before the procedure if
department by an HCP specializing in the patient has a history of allergic reac-
this procedure, with support staff, and tions to any substance or drug.
takes approximately 30 to 60 min. Avoid the use of equipment containing
Sensitivity to social and cultural issues,as latex if the patient has a history of aller-
well as concern for modesty, is impor- gic reaction to latex.
tant in providing psychological support Have emergency equipment readily
before, during, and after the procedure. available.
Explain that an IV line may be inserted Instruct the patient to void prior to the
to allow infusion of IV fluids such as procedure and to change into the gown,
normal saline, anesthetics, sedatives, robe, and foot coverings provided.
radionuclides, medications used in the Record baseline vital signs and assess
procedure, or emergency medications. neurological status. Protocols may vary
Instruct the patient to remove jewelry among facilities.
and other metallic objects from the Establish an IV fluid line for the injec-
area to be examined. tion of saline, anesthetics, sedatives,
Note that there are no food, fluid, or radionuclides, or emergency
medication restrictions unless by medications.
medical direction. Instruct the patient to cooperate fully
Make sure a written and informed and to follow directions. Instruct the
consent has been signed prior to the patient to remain still throughout the
procedure and before administering procedure because movement
any medications. produces unreliable results.
Administer sedative to a child or to L
INTRATEST: an uncooperative adult, as ordered.
Place the patient in a supine position
Potential Complications: on a flat table with foam wedges,
Although it is rare, there is the possibil- which help maintain position and
ity of allergic reaction to the radionu- immobilization.
clide. Have emergency equipment and IV radionuclide is administered, and the
medications readily available. If the abdomen is scanned immediately to
patient has a history of allergic reac- screen for vascular lesions with images
tions to any substance or drug, admin- taken in various positions.
ister ordered prophylactic steroids or Monitor the patient for complications
antihistamines before the procedure. related to the procedure (e.g., allergic
Establishing an IV site and injection of reaction, anaphylaxis, bronchospasm).
radionuclides is an invasive procedure. Remove the needle or catheter and
Complications are rare but do include apply a pressure dressing over the
bleeding from the puncture site related puncture site.
to a bleeding disorder, or the effects Observe/assess the needle/catheter
of natural products and medications insertion site for bleeding, inflamma-
known to act as blood thinners, tion, or hematoma formation.
hematoma related to blood leakage The patient may be imaged by SPECT
into the tissue following needle techniques to further clarify areas of
insertion, infection that might occur if suspicious radionuclide localization.
bacteria from the skin surface is
introduced at the puncture site, or POST-TEST:
nerve injury that might occur if the Inform the patient that a report of the
needle strikes a nerve. results will be made available to the
requesting HCP, who will discuss the should be consumed to reduce current
results with the patient. disease processes. High fat consump-
Instruct the patient to resume usual tion increases the amount of bile acids
medication and activity, as directed by in the colon and should be avoided.
the HCP. Recognize anxiety related to test
Unless contraindicated, advise patient results, and be supportive of perceived
to drink increased amounts of fluids for loss of independent function. Discuss
24 to 48 hr to eliminate the radionu- the implications of abnormal test
clide from the body. Inform the patient results on the patients lifestyle. Provide
that radionuclide is eliminated from the teaching and information regarding the
body within 6 to 24 hr. clinical implications of the test results,
No other radionuclide tests should be as appropriate.
scheduled for 24 to 48 hr after this Reinforce information given by the
procedure. patients HCP regarding further testing,
Instruct the patient in the care and treatment, or referral to another HCP.
Answer any questions or address any
assessment of the injection site. concerns voiced by the patient or
If a woman who is breastfeeding must family.
have a nuclear scan, she should not Depending on the results of this proce-
breastfeed the infant until the radionu- dure, additional testing may be needed
clide has been eliminated. This could to evaluate or monitor progression of
take as long as 3 days. She should be the disease process and determine the
instructed to express the milk and dis- need for a change in therapy. Evaluate
card it during the 3-day period to test results in relation to the patients
prevent cessation of milk production. symptoms and other tests performed.
Instruct the patient to immediately flush
the toilet and to meticulously wash
hands with soap and water after each RELATED MONOGRAPHS:
voiding for 24 hr after the procedure. Related tests include ALT, antibodies
Instruct all caregivers to wear gloves antimitochondrial, AST, bilirubin, biopsy
when discarding urine for 24 hr after liver, CT abdomen, CT biliary tract and
L the procedure. Wash gloved hands liver, GGT, HAV, HBV, HCV, hepatobili-
with soap and water before removing ary scan, MRI abdomen, and US liver.
gloves. Then wash hands after the Refer to the Hematopoietic,
gloves are removed. Hepatobiliary, and Immune systems
Nutritional Considerations: A low-fat, tables at the end of the book for
low-cholesterol, and low-sodium diet related tests by body system.
This procedure is
DESCRIPTION:The lung perfusion contraindicated for
scan is a nuclear medicine study Patients who are pregnant or
performed to evaluate a patient suspected of being pregnant,
for pulmonary embolus (PE) or unless the potential benefits of a
other pulmonary disorders. procedure using radiation far
Technetium (Tc-99m) is injected outweigh the risk of radiation
IV and distributed throughout exposure to the fetus and
the pulmonary vasculature mother.
because of the gravitational Patients with atrial and ventric-
effect on perfusion. The scan, ular septal defects because the
which produces a visual image MAA particles will not reach the
of pulmonary blood flow, is use- lungs.
ful in diagnosing or confirming Patients with pulmonary
pulmonary vascular obstruction. hypertension.
The diameter of the IV-injected
macroaggregated albumin (MAA) INDICATIONS
is larger than that of the pulmo- Aid in the diagnosis of PE in a
nary capillaries; therefore, the patient with a normal chest x-ray
MAA temporarily becomes Detect malignant tumor
lodged in the pulmonary vascula- Differentiate between PE and other
ture. A gamma camera detects pulmonary diseases, such as
the radiation emitted from the pneumonia, pulmonary effusion,
injected radioactive material, and atelectasis, asthma, bronchitis,
a representative image of the emphysema, and tumors
lung is obtained. This procedure Evaluate perfusion changes associ-
is often done in conjunction ated with congestive heart failure
with the lung ventilation scan to
obtain clinical information that
and pulmonary hypertension L
Evaluate pulmonary function pre-
assists in differentiating among operatively in a patient with
the many possible pathological pulmonary disease
conditions revealed by the pro-
cedure. The results are correlated
POTENTIAL DIAGNOSIS
with other diagnostic studies,
such as pulmonary function, Normal findings in
chest x-ray, pulmonary angiogra- Diffuse and homogeneous uptake
phy, and arterial blood gases. of the radioactive material by the
A recent chest x-ray is essential lungs
for accurate interpretation of the
Abnormal findings in
lung perfusion scan. An area of
Asthma
nonperfusion seen in the same
Atelectasis
area as a pulmonary parenchy-
Bronchitis
mal abnormality on the chest
Chronic obstructive pulmonary
x-ray indicates that a PE is not
disease
present; the defect may repre-
Emphysema
sent some other pathological
Left atrial or pulmonary
condition, such as pneumonia.
hypertension
Record the date of the last menstrual bleeding from the puncture site related
period and determine the possibility of to a bleeding disorder, or the effects
pregnancy in perimenopausal women. of natural products and medications
Obtain a list of the patients current known to act as blood thinners,
medications, including herbs, nutri- hematoma related to blood leakage
tional supplements, and nutraceuticals into the tissue following needle
(see Appendix H online at DavisPlus). insertion, infection that might occur if
Review the procedure with the patient. bacteria from the skin surface is
Address concerns about pain related introduced at the puncture site, or
to the procedure and explain that nerve injury that might occur if the
some pain may be experienced during needle strikes a nerve.
the test, or there may be moments of Observe standard precautions, and fol-
discomfort. Reassure the patient that low the general guidelines in Appendix A.
the radionuclide poses no radioactive Positively identify the patient.
hazard and rarely produces side Ensure that the patient has removed all
effects. Inform the patient that the external metallic objects from the area
procedure is performed in a nuclear to be examined prior to the procedure.
medicine department, by an HCP spe- Administer ordered prophylactic
cializing in this procedure, with support steroids or antihistamines before the
staff, and takes approximately 60 min. procedure if the patient has a history
Sensitivity to social and cultural issues, of allergic reactions to any substance
as well as concern for modesty, is or drug.
important in providing psychological Avoid the use of equipment containing
support before, during, and after the latex if the patient has a history of aller-
procedure. gic reaction to latex.
Explain that an IV line may be inserted Have emergency equipment readily
to allow infusion of IV fluids such as available.
normal saline, anesthetics, sedatives, Instruct the patient to void prior to
radionuclides, medications used in the the procedure and to change into
procedure, or emergency medications. the gown, robe, and foot coverings
Instruct the patient to remove jewelry provided. L
and other metallic objects from the Record baseline vital signs and assess
area to be examined prior to the neurological status. Protocols may vary
procedure. among facilities.
Note that there are no food, fluid, or Establish an IV fluid line for the injec-
medication restrictions unless by medi- tion of saline, anesthetics, sedatives,
cal direction. radionuclides, or emergency
Make sure a written and informed medications.
consent has been signed prior to the Instruct the patient to cooperate fully
procedure and before administering and to follow directions. Instruct the
any medications. patient to remain still throughout the
procedure because movement pro-
INTRATEST: duces unreliable results.
Administer a sedative to a child or to
Potential Complications: an uncooperative adult, as ordered.
Although it is rare, there is the possibil- Place the patient in a supine position
ity of allergic reaction to the radionu- on a flat table with foam wedges,
clide. Have emergency equipment and which help maintain position and
medications readily available. If the immobilization.
patient has a history of allergic reac- IV radionuclide is administered, and the
tions to any substance or drug, admin- abdomen is scanned immediately to
ister ordered prophylactic steroids or screen for vascular lesions with images
antihistamines before the procedure. taken in various positions.
Establishing an IV site and injection of Monitor the patient for complications
radionuclides is an invasive procedure. related to the procedure (e.g., allergic
Complications are rare but do include reaction, anaphylaxis, bronchospasm).
Remove the needle or catheter and discard it during the 3-day period to
apply a pressure dressing over the prevent cessation of milk production.
puncture site. Instruct the patient to immediately flush
Observe/assess the needle/catheter the toilet and to meticulously wash
insertion site for bleeding, inflamma- hands with soap and water after each
tion, or hematoma formation. voiding for 24 hr after the procedure.
Instruct all caregivers to wear gloves
POST-TEST: when discarding urine for 24 hr after
Inform the patient that a report of the procedure. Wash gloved hands
the results will be made available with soap and water before removing
to the requesting HCP, who will gloves. Then wash hands after the
discuss the results with the patient. gloves are removed.
Unless contraindicated, advise patient Recognize anxiety related to test
to drink increased amounts of fluids for results, and be supportive of perceived
24 to 48 hr to eliminate the radionu- loss of independent function. Discuss
clide from the body. Inform the patient the implications of abnormal test
that radionuclide is eliminated from the results on the patients lifestyle.
body within 6 to 24 hr. Provide teaching and information
No other radionuclide tests should be regarding the clinical implications of the
scheduled for 24 to 48 hr after this test results, as appropriate.
procedure. Reinforce information given by the
Monitor vital signs and neurological patients HCP regarding further testing,
status every 15 min for 1 hr, then every treatment, or referral to another HCP.
2 hr for 4 hr, and then as ordered by Answer any questions or address any
the HCP. Compare with baseline val- concerns voiced by the patient or
ues. Protocols may vary among family.
facilities. Depending on the results of this proce-
Instruct the patient to resume usual dure, additional testing may be needed
medication and activity, as directed by to evaluate or monitor progression of
the HCP. the disease process and determine the
L Observe for delayed allergic reactions, need for a change in therapy. Evaluate
such as rash, urticaria, tachycardia, test results in relation to the patients
hyperpnea, hypertension, palpitations, symptoms and other tests performed.
nausea, or vomiting.
RELATED MONOGRAPHS:
Instruct the patient to immediately
report symptoms such as fast heart Related tests include -1 AT, eosinophil
rate, difficulty breathing, skin rash, itch- count, ACE, alveolar/arterial gradient,
ing, chest pain, persistent right shoul- angiography pulmonary, biopsy lung,
der pain, or abdominal pain. blood gases, blood pool imaging, bron-
Immediately report symptoms to the choscopy, carbon dioxide, chest x-ray,
appropriate HCP. CBC, CBC WCB count and differential,
Observe/assess the needle/catheter CT thoracic, culture and smear myco-
insertion site for bleeding, inflamma- bacteria, culture blood, culture throat,
tion, or hematoma formation. culture sputum, culture viral, cytology
Instruct the patient in the care and sputum, ESR, IgE, gallium scan, lung
assessment of the injection site. ventilation scan, MRI chest, MRI veno-
If a woman who is breastfeeding must graphy, mediastinoscopy, plethysmo-
have a nuclear scan, she should not graphy, pleural fluid analysis, PET heart,
breastfeed the infant until the radionu- PFT, pulse oximetry, and TB skin tests.
clide has been eliminated. This could Refer to the Respiratory System table
take as long as 3 days. She should at the end of the book for related tests
be instructed to express the milk and by body system.
NORMAL FINDINGS: (Method: Dilute Russell viper venom test time) Negative.
Luteinizing Hormone
SYNONYM/ACRONYM: LH, luteotropin, interstitial cellstimulating hormone
(ICSH).
COMMON USE: To assess gonadal function related to fertility issues and response
to therapy.
Lyme Antibody
SYNONYM/ACRONYM: N/A.
COMMON USE: To detect antibodies to the organism that causes Lyme disease.
NORMAL FINDINGS: (Method: Enzyme immunoassay) Less than 0.91 index; posi-
tives are confirmed by Western blot analysis.
PRETEST: INTRATEST:
Positively identify the patient using at Potential Complications: N/A
least two unique identifiers before
providing care, treatment, or services. Avoid the use of equipment containing
Patient Teaching: Inform the patient this latex if the patient has a history of aller-
test can assist in diagnosing Lyme gic reaction to latex.
disease. Instruct the patient to cooperate fully
Obtain a history of the patients com- and to follow directions. Direct the
plaints, including a list of known aller- patient to breathe normally and to
gens, especially allergies or sensitivities avoid unnecessary movement.
to latex. Discuss history of exposure; Observe standard precautions, and fol-
ask the patient if he or she lives in or low the general guidelines in Appendix A.
visits wooded areas, wears long pants Positively identify the patient, and label
the appropriate specimen container
L and long-sleeved shirts when in
with the corresponding patient demo-
wooded areas or when doing yard
work, or has ever been bitten by a tick. graphics, initials of the person collect-
Obtain a history of the patients immune ing the specimen, date, and time of
and musculoskeletal systems, symp- collection. Perform a venipuncture.
toms, a history of exposure, and results Remove the needle and apply direct
of previously performed laboratory tests pressure with dry gauze to stop bleed-
and diagnostic and surgical procedures. ing. Observe/assess venipuncture site
Obtain a list of the patients current for bleeding or hematoma formation and
medications, including herbs, nutri- secure gauze with adhesive bandage.
tional supplements, and nutraceuticals Promptly transport the specimen to the
(see Appendix H online at DavisPlus). laboratory for processing and analysis.
Review the procedure with the patient.
Inform the patient that several tests POST-TEST:
may be necessary to confirm diagno- Inform the patient that a report of
sis. Inform the patient that specimen the results will be made available
collection takes approximately 5 to to the requesting HCP, who will
10 min. Address concerns about pain discuss the results with the patient.
and explain that there may be some Recognize anxiety related to test
discomfort during the venipuncture. results, and be supportive of impaired
Sensitivity to social and cultural issues,as activity related to perceived loss of
well as concern for modesty, is impor- independence and fear of shortened
tant in providing psychological support life expectancy. Lyme disease can be
before, during, and after the procedure. debilitating and can result in significant
Note that there are no food, fluid, or changes in lifestyle. Discuss the impli-
medication restrictions unless by medi- cations of abnormal test results on the
cal direction. patients lifestyle. Provide teaching and
information regarding the clinical impli- Answer any questions or address any
cations of the test results, as appropri- concerns voiced by the patient or family.
ate. Educate the patient regarding
access to counseling services. Expected Patient Outcomes:
Reinforce information given by the Knowledge
patients HCP regarding further testing, States understanding that tick bite risk
treatment, or referral to another HCP. increases in specific designated geo-
Reinforce information given by the graphical areas
patients HCP regarding further testing, States understanding of the impor-
treatment, or referral to another HCP. tance of taking prescribed antibiotic to
Warn the patient that false-positive treat infection, including that repeated
test results can occur and that false- antibiotic treatments may be necessary
negative test results frequently occur. Skills
Answer any questions or address any Describes clothing that would be appro-
concerns voiced by the patient or family. priate to use in prevention of tick bites
Depending on the results of this Demonstrates proficiency in the self-
procedure, additional testing may be administering of the prescribed antibiotic
performed to evaluate or monitor pro-
gression of the disease process and Attitude
determine the need for a change in Follows recommendation to take
therapy. Evaluate test results in relation measures to prevent future tick bites
to the patients symptoms and other Complies with recommendation to
tests performed. attend support group to decreased
anxiety and increase understanding of
Patient Education: disease process
Advise the patient to wear light-colored
clothing that covers extremities when RELATED MONOGRAPHS:
in areas infested by deer ticks and to Related tests include ANA, CBC, ESR,
check body for ticks after returning rheumatoid factor, and synovial fluid
from infested areas. analysis.
Emphasize the importance of reporting Refer to the Immune and Musculoskeletal L
continued signs and symptoms of the systems tables at the end of the book for
infection. related tests by body system.
Lymphangiography
SYNONYM/ACRONYM: Lymphangiogram.
COMMON USE: To visualize and assess the lymphatic system related to diagnosis
of lymphomas such as Hodgkins disease.
Instruct the patient to maintain bedrest Depending on the results of this proce-
up to 24 hr to reduce extremity swell- dure, additional testing may be needed
ing after the procedure, or as ordered. to evaluate or monitor progression of
Instruct the patient to resume usual the disease process and determine the
medications, as directed by the HCP. need for a change in therapy. Evaluate
Recognize anxiety related to test test results in relation to the patients
results, and be supportive of perceived symptoms and other tests performed.
loss of independent function. Discuss
the implications of abnormal test RELATED MONOGRAPHS:
results on the patients lifestyle. Related tests include biopsy bone
Provide teaching and information marrow, biopsy lymph nodes, CBC,
regarding the clinical implications of the CBC WBC count and differential, CT
test results, as appropriate. abdomen, CT pelvis, CT thoracic, gal-
Reinforce information given by the lium scan, laparoscopy abdominal, liver
patients HCP regarding further testing, and spleen scan, MRI abdomen, medi-
treatment, or referral to another HCP. astinoscopy, and US lymph nodes.
Answer any questions or address any Refer to the Endocrine and Immune
concerns voiced by the patient or systems tables at the end of the book
family. for tests by related body system.
1071
Magnesium, Urine
SYNONYM/ACRONYM: Urine Mg2+.
COMMON USE: To visualize and assess blood flow in diseased and normal vessels
toward diagnosis of vascular disease and to monitor and evaluate therapeutic
interventions.
Note that there are no food, fluid, or occur during the test. Instruct the
medication restrictions unless by patient to communicate with the tech-
medical direction. nologist during the examination via a
microphone within the scanner.
INTRATEST: Apply MRI-safe electrodes to the
appropriate sites if an electrocardio-
Potential Complications: gram or respiratory gating is to be per-
Injection of the contrast is an invasive formed in conjunction with the scan.
procedure. Complications are rare but Establish IV fluid line for the injection IV
do include risk for allergic reaction fluids such as saline, anesthetics, con-
related to contrast reaction; cardiac trast medium, or sedatives.
arrhythmias; hematoma related to Administer an antianxiety agent, as
blood leakage into the tissue follow- ordered, if the patient has
ing needle insertion; bleeding from the claustrophobia. Administer a sedative
puncture site related to a bleeding dis- to a child or to an uncooperative adult,
order, or the effects of natural prod- as ordered.
ucts and medications known to act as Assist the patient onto the examination
blood thinners; vascular or nerve injury table and into the appropriate position
that might occur if the needle strikes for imaging to begin.
a nerve or nearby blood vessel; or Imaging can begin shortly after the
infection that might occur if bacteria injection, if contrast is used.
from the skin surface is introduced at Ask the patient to inhale deeply and
the puncture site. hold his or her breath while the images
Some patients are at risk for develop- are taken, and then to exhale after the
ing nephrogenic systemic fibrosis (NSF) images are taken.
as a result of the use of gadolinium- Instruct the patient to take slow, deep
based contrast agents related to inef- breaths if nausea occurs during the
fective renal clearance in patients procedure.
with impaired renal function. Monitor the patient for complications
Observe standard precautions, and fol- related to the procedure (e.g., allergic
low the general guidelines in Appendix A. reaction, anaphylaxis, bronchospasm).
Positively identify the patient. Remove the needle or catheter and
Ensure that the patient has removed apply a pressure dressing over the
external metallic objects from the area puncture site. M
to be examined prior to the procedure. Observe/assess the needle/catheter
Administer ordered prophylactic ste- insertion site for bleeding, inflamma-
roids or antihistamines before the tion, or hematoma formation.
procedure if the patient has a history
of allergic reactions to any substance POST-TEST:
or drug. Inform the patient that a report of
Avoid the use of equipment containing the results will be made available
latex if the patient has a history of to the requesting HCP, who will
allergic reaction to latex. discuss the results with the patient.
Have emergency equipment readily Observe for delayed allergic reactions,
available. such as rash, urticaria, tachycardia,
Instruct the patient to void prior to hyperpnea, hypertension, palpitations,
the procedure and to change into nausea, or vomiting.
the gown, robe, and foot coverings Instruct the patient to immediately
provided. report symptoms such as fast heart
Instruct the patient to cooperate fully rate, difficulty breathing, skin rash, itch-
and to follow directions. Instruct the ing, chest pain, persistent right shoul-
patient to remain still throughout der pain, or abdominal pain.
the procedure because movement Immediately report symptoms to the
produces unreliable results. appropriate HCP.
Supply earplugs to the patient to block Instruct the patient in the care and
out the loud, banging sounds that assessment of the injection site.
Instruct the patient to apply cold com- Depending on the results of this
presses to the puncture site as needed procedure, additional testing may be
to reduce discomfort or edema. performed to evaluate or monitor pro-
Recognize anxiety related to test gression of the disease process and
results. Discuss the implications of determine the need for a change in
abnormal test results on the patients therapy. Evaluate test results in relation
lifestyle. Provide teaching and to the patients symptoms and other
information regarding the clinical tests performed.
implications of the test results, as
appropriate. Provide contact
information, if desired, for the American RELATED MONOGRAPHS:
Heart Association (www.americanheart Related tests include angiography of
.org), the NHLBI (www.nhlbi.nih.gov), the body area of interest, BUN, CT
or Legs for Life (www.legsforlife.org). angiography, creatinine, US arterial
Reinforce information given by the Doppler carotid, and US venous
patients HCP regarding further testing, Doppler.
treatment, or referral to another HCP. Refer to the Cardiovascular System
Answer any questions or address any table at the end of the book for related
concerns voiced by the patient or family. tests by body system.
COMMON USE: To visualize and assess abdominal and hepatic structures toward
diagnosis of tumors, metastasis, aneurysm, and abscess. Also used to monitor
M medical and surgical therapeutic interventions.
supplements, and nutraceuticals (see occur if bacteria from the skin surface
Appendix H online at DavisPlus). is introduced at the puncture site.
Review the procedure with the patient. Observe standard precautions, and fol-
Address concerns about pain related low the general guidelines in Appendix A.
to the procedure and explain that no Positively identify the patient.
pain will be experienced during the Ensure that the patient has removed all
test, but there may be moments of external metallic objects from the area
discomfort. Reassure the patient that to be examined prior to the procedure.
if contrast is used, it poses no radioac- Administer ordered prophylactic steroids
tive hazard and rarely produces side or antihistamines before the procedure if
effects. Inform the patient that the the patient has a history of allergic reac-
procedure is performed in an MRI tions to any substance or drug.
department by a health-care provider Avoid the use of equipment containing
(HCP) who specializes in this proce- latex if the patient has a history of aller-
dure, with support staff, and takes gic reaction to latex.
approximately 30 to 60 min. Have emergency equipment readily
Inform the patient that the technologist available.
will place him or her in a prone position Instruct the patient to void prior to the
on a special imaging table in a large procedure and to change into the gown,
cylindrical scanner. robe, and foot coverings provided.
Tell the patient to expect to hear loud Instruct the patient to cooperate fully
banging from the scanner and possibly and to follow directions. Instruct the
to see magnetophosphenes (flickering patient to remain still throughout the
lights in the visual field); these will stop procedure because movement pro-
when the procedure is over. duces unreliable results.
Sensitivity to social and cultural issues, as Supply earplugs to the patient to block
well as concern for modesty, is impor- out the loud, banging sounds that
tant in providing psychological support occur during the test. Instruct the
before, during, and after the procedure. patient to communicate with the tech-
Explain that an IV line may be inserted nologist during the examination via a
to allow infusion of IV fluids such as microphone within the scanner.
saline, anesthetics, contrast medium, Establish IV fluid line for the injection of
or sedatives. IV fluids such as saline, anesthetics,
M Instruct the patient to remove jewelry and contrast medium, or sedatives.
all other metallic objects from the area to Administer an antianxiety agent, as
be examined prior to the procedure. ordered, if the patient has claustropho-
Note that there are no food, fluid, bia. Administer a sedative to a child or
or medication restrictions unless by to an uncooperative adult, as ordered.
medical direction. Assist the patient onto the examination
table, designed for breast imaging, and
INTRATEST: into the appropriate position for imag-
ing to begin.
Potential Complications: Imaging can begin shortly after the
Injection of the contrast is an invasive injection, if contrast is used.
procedure. Complications are rare but Ask the patient to inhale deeply and
do include risk for allergic reaction hold his or her breath while the images
related to contrast reaction; cardiac are taken and then to exhale after the
arrhythmias; hematoma related to images are taken.
blood leakage into the tissue Instruct the patient to take slow, deep
following needle insertion; bleeding breaths if nausea occurs during the
from the puncture site related to a procedure.
bleeding disorder, or the effects of Monitor the patient for complications
natural products and medications related to the procedure (e.g., allergic
known to act as blood thinners; vas- reaction, anaphylaxis, bronchospasm).
cular or nerve injury that might occur if Remove the needle or catheter and
the needle strikes a nerve or nearby apply a pressure dressing over the
blood vessel; or infection that might puncture site.
the risks and if essential diagnostic burns to the skin related to energy
information is not available using conducted through the metal
noncontrast-enhanced diagnostic which is converted to heat
studies. during the MRI. Other metallic
Patients with cardiac pacemak- objects on the skin may also
ers that can be deactivated cause burns.
by MRI. Patients who are
Patients with metal in their claustrophobic.
body, such as dental amalgams,
metallic body piercing items,
tattoo inks containing iron (includ- INDICATIONS
ing tattooed eyeliners), shrapnel, Confirm diagnosis of cardiac and
bullet, ferrous metal in the eye, pericardiac masses
certain ferrous metal prosthetics, Detect aortic aneurysms
valves, aneurysm clips, IUD, inner Detect myocardial infarction and
ear prostheses, or other metallic cardiac muscle ischemia
objects; these items can impair Detect pericardial abnormalities
image quality. Metallic objects are Detect pleural effusion
also a significant safety issue for Detect thoracic aortic diseases
patients and health-care staff in Determine blood, fluid, or fat accu-
the examination room during mulation in tissues, pleuritic space, or
performance of an MRI. The MRI vessels
equipment consists of an extreme- Determine cardiac ventricular
ly powerful magnet that can function
inactivate, move, or shift metallic Differentiate aortic aneurysms from
objects inside a patient. Many tumors near the aorta
metallic objects currently used in Evaluate cardiac chambers and
health-care procedures are made pulmonary vessels
of materials that do not interfere Evaluate postoperative angioplasty
with MRI studies; it is important sites and bypass grafts
for patients to provide specific Identify congenital heart diseases M
information regarding medical Monitor and evaluate the
procedures they have undergone effectiveness of medical or
in order to identify whether their surgical therapeutic regimen
device is safe to undergo MRI.
Required information includes POTENTIAL DIAGNOSIS
the date of the procedure and
Normal findings in
identification of the device.
Normal heart and lung structures,
Metallic objects are not allowed
soft tissue, and function, including
inside the room with the MRI
blood flow rate
equipment because items such
as watches, credit cards, and car Abnormal findings in
keys can become dangerous Aortic dissection
projectiles. Congenital heart diseases, including
Patients with transdermal pulmonary atresia, aortic coarcta-
patches containing metallic tion, agenesis of the pulmonary
components. The patchs liner con- artery, and transposition of the
tains a metal that controls absorp- great vessels
tion of the substance from the Constrictive pericarditis
patch (e.g., drugs, nicotine, steroids, Intramural and periaortic
hormones). The patch may cause hematoma
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Monitor the patient for complications abnormal test results on the patients
related to the procedure (e.g., allergic lifestyle. Provide teaching and informa-
reaction, anaphylaxis, bronchospasm). tion regarding the clinical implications
Remove the needle or catheter and of the test results, as appropriate.
apply a pressure dressing over the Reinforce information given by the
puncture site. patients HCP regarding further testing,
Observe/assess the needle/catheter treatment, or referral to another HCP.
insertion site for bleeding, inflamma- Answer any questions or address any
tion, or hematoma formation. concerns voiced by the patient or
family.
POST-TEST: Depending on the results of this
Inform the patient that a report of procedure, additional testing may be
the results will be made available performed to evaluate or monitor pro-
to the requesting HCP, who will gression of the disease process and
discuss the results with the patient. determine the need for a change in
Observe for delayed allergic reactions, therapy. Evaluate test results in relation
such as rash, urticaria, tachycardia, to the patients symptoms and other
hyperpnea, hypertension, palpitations, tests performed.
nausea, or vomiting.
Instruct the patient to immediately RELATED MONOGRAPHS:
report symptoms such as fast heart Related tests include AST, BNP, blood
rate, difficulty breathing, skin rash, gases, blood pool imaging, BUN, chest
itching, chest pain, persistent right x-ray, CT cardiac scoring, CT thorax,
shoulder pain, or abdominal pain. CRP, CK and isoenzymes, creatinine,
Immediately report symptoms to the echocardiography, exercise stress test,
appropriate HCP. Holter monitor, myocardial infarct scan,
Instruct the patient in the care and myocardial perfusion heart scan, myo-
assessment of the injection site. globin, pleural fluid analysis, PET scan
Instruct the patient to apply cold com- of the heart, and troponins.
presses to the puncture site as needed Refer to the Cardiovascular and
to reduce discomfort or edema. Respiratory systems tables at the end
Recognize anxiety related to test of the book for related tests by body
results. Discuss the implications of system.
M
COMMON USE: To visualize and assess bones, joints, and surrounding structures
to assist in diagnosing defects, cysts, tumors, and fracture.
COMMON USE: To visualize and assess the pancreas for structural defects, tumor,
masses, staging cancer, and evaluating the effectiveness of medical and surgical
interventions.
the radio waves and change their uses the noniodinated paramagnet-
position. This change in the ener- ic contrast medium gadopentetate
gy field is detected by the equip- dimeglumine (Magnevist), which is
ment, and an image is generated administered IV to enhance con-
by the equipments computer sys- trast differences between normal
tem. MRI produces cross-sectional and abnormal tissues.
images of the pancreas in multi-
ple planes without the use of ion-
izing radiation or the interference This procedure is
of bone or surrounding tissue. contraindicated for
Images can be obtained in two- Patients who are pregnant or
dimensional (series of slices) or suspected of being pregnant,
three-dimensional sequences. unless the potential benefits of the
Standard or closed MRI equip- MRI far outweigh the risks to the
ment has the appearance of an fetus and mother. In pregnancy,
open tube or tunnel; open MRI gadolinium-based contrast agents
equipment has no sides and pro- (GBCAs) cross the placental barrier,
vides an alternative for people enter the fetal circulation, and
who suffer from claustrophobia, pass via the kidneys into the amni-
pediatric patients, or patients who otic fluid. Although no definite
are obese. IV gadolinium-based adverse effects of GBCA adminis-
contrast media may be used to tration on the human fetus have
better visualize the vessels and tis- been documented, the potential
sues in the area of interest. Clear, bioeffects of fetal GBCA exposure
high-quality images of abnormali- are not well understood. GBCA
ties and disease processes signifi- administration should therefore be
cantly improve the diagnostic avoided during pregnancy unless
value of the study. no suitable alternative imaging is
MRI of the pancreas is possible and the benefits of con-
M employed to evaluate small pan- trast administration outweigh the
creatic adenocarcinomas, islet cell potential risk to the fetus.
tumors, ductal abnormalities and Patients with moderate to
calculi, or parenchymal abnormali- marked renal impairment
ties. A T1-weighted, fat-saturation (glomerular filtration rate less than
series of images is probably best 30 mL/min/1.73 m2). Patients should
for evaluating the pancreatic be screened for renal dysfunction
parenchyma. This sequence is ideal prior to administration. The use of
for showing fat planes between GBCAs should be avoided in these
the pancreas and peripancreatic patients unless the benefits of the
structures and for identifying studies outweigh the risks and if
abnormalities such as fatty infiltra- essential diagnostic information is
tion of the pancreas, hemorrhage, not available using noncontrast-
adenopathy, and carcinomas. enhanced diagnostic studies.
T2-weighted images are most use- Patients with cardiac pacemakers
ful for depicting intrapancreatic or that can be deactivated by MRI.
peripancreatic fluid collections, Patients with metal in their
pancreatic neoplasms, and calculi. body, such as dental amalgams,
Imaging sequences can be adjust- metallic body piercing items, tattoo
ed to display fluid in the biliary inks containing iron (including
tree and pancreatic ducts. MRI tattooed eyeliners), shrapnel, bullet,
COMMON USE: To visualize and assess the pelvis and surrounding structure for
tumor, masses, staging cancer, and inflammation and to evaluate the effective-
ness of medical and surgical interventions.
to the requesting HCP, who will dis- regarding the clinical implications of the
cuss the results with the patient. test results, as appropriate.
Observe for delayed allergic reactions, Reinforce information given by the
such as rash, urticaria, tachycardia, patients HCP regarding further testing,
hyperpnea, hypertension, palpitations, treatment, or referral to another HCP.
nausea, or vomiting. Answer any questions or address any
Instruct the patient to immediately concerns voiced by the patient or family.
report symptoms such as fast heart Depending on the results of this
rate, difficulty breathing, skin rash, procedure, additional testing may be
itching, chest pain, persistent right performed to evaluate or monitor pro-
shoulder pain, or abdominal pain. gression of the disease process and
Immediately report symptoms to the determine the need for a change in
appropriate HCP. therapy. Evaluate test results in relation
Instruct the patient in the care and to the patients symptoms and other
assessment of the injection site. tests performed.
Instruct the patient to apply cold
compresses to the puncture site RELATED MONOGRAPHS:
as needed, to reduce discomfort or Related tests include BUN, CT pelvis,
edema. creatinine, cystourethrography voiding,
Recognize anxiety related to test results. IVP, KUB study, renogram, and US pelvis.
Discuss the implications of abnormal Refer to the Genitourinary System
test results on the patients lifestyle. table at the end of the book for related
Provide teaching and information tests by body system.
COMMON USE: To visualize and assess the pituitary and surrounding structures
of the brain for lesions, hemorrhage, cysts, abscess, tumors, cancer, and
infection.
This procedure is
the radio waves and change their contraindicated for
position. This change in the ener- Patients who are pregnant or
gy field is detected by the equip- suspected of being pregnant,
ment, and an image is generated unless the potential benefits of the
by the equipment's computer sys- MRI far outweigh the risks to the
tem. MRI produces cross-sectional fetus and mother. In pregnancy,
images of the vessels in multiple gadolinium-based contrast
planes without the use of ionizing agents (GBCAs) cross the placen-
radiation or the interference of tal barrier, enter the fetal circu-
bone or surrounding tissue. lation, and pass via the kidneys
Images can be obtained in two- into the amniotic fluid. Although
dimensional (series of slices) or no definite adverse effects of
three-dimensional sequences. GBCA administration on the
Standard or closed MRI equipment human fetus have been docu-
has the appearance of an open mented, the potential bioeffects
tube or tunnel; open MRI equip- of fetal GBCA exposure are not
ment has no sides and provides an well understood. GBCA adminis-
alternative for people who suffer tration should therefore be
from claustrophobia, pediatric avoided during pregnancy unless
patients, or patients who are no suitable alternative imaging is
obese. IV gadolinium-based con- possible and the benefits of con-
trast media may be used to better trast administration outweigh
visualize the pituitary gland and the potential risk to the fetus.
parasellar region in the area of Patients with moderate to
interest. Clear, high-quality images marked renal impairment
of abnormalities and disease pro- (glomerular filtration rate less than
cesses significantly improve the 30 mL/min/1.73 m2). Patients should
diagnostic value of the study. be screened for renal dysfunction
Pituitary MRI shows the rela- prior to administration. The use of
tionship of pituitary lesions to the GBCAs should be avoided in these M
optic chiasm and cavernous sinus- patients unless the benefits of the
es. MRI has the capability of dis- studies outweigh the risks and if
tinguishing the solid, cystic, and essential diagnostic information is
hemorrhagic components of not available using noncontrast-
lesions. Rapidly flowing blood on enhanced diagnostic studies.
spin-echo MRI appears as an Patients with cardiac pacemak-
absence of signal or a void in the ers that can be deactivated
vessels lumen. Blood flow can be by MRI.
evaluated in the cavernous and Patients with metal in their
carotid arteries. Suprasellar aneu- body, such as dental amalgams,
rysms may be diagnosed without metallic body piercing items, tattoo
angiography, and old clotted inks containing iron (including tat-
blood in the walls of the aneu- tooed eyeliners), shrapnel, bullet,
rysms appears white. MRI uses ferrous metal in the eye, certain
the noniodinated paramagnetic ferrous metal prosthetics, valves,
contrast medium gadopentetate aneurysm clips, IUD, inner ear pros-
dimeglumine (Magnevist) that is theses, or other metallic objects;
administered IV to enhance con- these items can impair image quality.
trast differences between normal Metallic objects are also a signifi-
and abnormal tissues. cant safety issue for patients and
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Patient Teaching: Inform the patient this Inform the patient that the technologist
procedure can assist in assessing the will place him or her in a supine posi-
pituitary gland and surrounding brain tion on a flat table in a large cylindrical
tissue. scanner.
Obtain a history of the patients com- Tell the patient to expect to hear loud
plaints or clinical symptoms, including banging from the scanner and
a list of known allergens, especially possibly to see magnetophosphenes
allergies or sensitivities to latex, anes- (flickering lights in the visual field);
thetics, contrast medium, or sedatives. these will stop when the procedure
Patients with a known hypersensitivity is over.
to contrast medium may benefit from Sensitivity to social and cultural issues,
premedication with corticosteroids and as well as concern for modesty, is
diphenhydramine. important in providing psychological
Obtain a history of the patients cardio- support before, during, and after the
vascular and endocrine systems, procedure.
symptoms, and results of previously Explain that an IV line may be inserted
performed laboratory tests and diag- to allow infusion of IV fluids such as
nostic and surgical procedures. Obtain saline, anesthetics, contrast medium,
a history of renal dysfunction if the use or sedatives.
of GBCA is anticipated. Instruct the patient to remove jewelry
Ensure the results of BUN, creatinine, and all other metallic objects from
and eGFR (estimated glomerular filtration the area to be examined prior to the
rate) are obtained if GBCA is to be used. procedure.
Determine if the patient has ever had Note that there are no food, fluid, or
any device implanted into his or her medication restrictions unless by
body, including copper intrauterine medical direction.
devices, pacemakers, ear implants,
and heart valves. INTRATEST:
Obtain occupational history to deter-
mine the presence of metal in the Potential Complications:
body, such as shrapnel or flecks of Injection of the contrast is an invasive
ferrous metal in the eye (which can procedure. Complications are rare but
cause retinal hemorrhage). do include risk for allergic reaction
Note any recent procedures that can related to contrast reaction; cardiac M
interfere with test results, including arrhythmias; hematoma related to
examinations using barium- or iodine- blood leakage into the tissue
based contrast medium. following needle insertion; bleeding
Record the date of the last menstrual from the puncture site related to a
period and determine the possibility of bleeding disorder, or the effects of
pregnancy in perimenopausal women. natural products and medications
Obtain a list of the patients current known to act as blood thinners;
medications, including herbs, nutri- vascular or nerve injury that might
tional supplements, and nutraceuticals occur if the needle strikes a nerve
(see Appendix H online at DavisPlus). or nearby blood vessel; or infection
Review the procedure with the patient. that might occur if bacteria from the
Address concerns about pain related skin surface is introduced at the
to the procedure and explain that no puncture site.
pain will be experienced during the Observe standard precautions, and
test, but there may be moments of follow the general guidelines in
discomfort. Inform the patient the Appendix A. Positively identify the
procedure is performed in an MRI patient.
department by a health-care provider Ensure that the patient has removed
(HCP) specializing in this procedure, all external metallic objects from
with support staff, and takes approxi- the area to be examined prior to
mately 30 to 60 min. the procedure.
COMMON USE: To visualize and assess blood flow in diseased and normal veins
toward diagnosis of vascular disease and to monitor and evaluate therapeutic
interventions.