Uric Acid test

Interpretation

Normal Results

In men, 3.4 to 7 mg/dl (SI, 202 to 416 µmol/L) In women, 2.3 to 6 mg/dl (SI, 143 to 357 µmol/L)

Abnormal Results

Increased uric acid levels may indicate gout or impaired kidney function. Levels may also rise in hjeart failure, glycogen storage disease (type I, von Gierke’s

disease), infection, hemolytic and sickle cell anemia, polycythemia, neoplasms, and psoriasis.

Low uric acid levels may indicate defective tubular absorption (such as Fanconi’s syndrome) or acute hepatic atrophy.

Interpretation

Normal Results

Varying levels, depending on age and sex In men, 44 to 180 mg/dl (SI, 0.44 to 2.01 mmol/L) In women, 10 to 190 mg/dl (SI, 0.11 to 2.21 mmol/L)

Abnormal Results

An increased or decreased serum triglycerides level is abnormal; additional tests are required for a definitive diagnosis.

A mild to moderate increase in serum triglyceride levels indicates biliary obstruction, diabetes mellitus, nephrotic syndrome, or over consumption of alcohol.

Markedly increased levels without an identifiable cause reflect congenital hyperlipoproteinemia and necessitate lipoprotein phenotyping to confirm the diagnosis.

Decresed serum triglyceride levels are rare and occur mainly in malnutrition and abetalipoproteinemia.

As a qualitative analysis of urine levels of human chorionic gonadotropin (hCG), this test can detect pregnancy as early as 14 days after ovulation. A glycoprotein that is produced after conception, hCG prevents degeneration of the corpus luteum at the end of a normal menstrual cycle.

During the first trimester, hCG levels rise steadily and rapidly, peaking around 10 weeks’ gestation, and subsequently taper off to less than 10% of peak levels. The most common and inexpensive method of evaluating qualitative and quantitative hCG levels is through

hemagglutination inhibition of a urine sample. The serum hCG test (beta-subunit assay) is a more expensive alternative.

Purpose

To detect and confirm pregnancy. To help diagnose hydatiform mole of hCG-secreting tumors, threatened abortion, or dead

fetus.

Procedure

Patient Preparation

1. If appropriate, explain to the patient that the urine hCG test determines whether she’s pregnant or determines the status of her pregnancy.

2. Alternatively, explain how the test functions as a screen for some types of cancer. 3. Tell the patient that she need not to restrict food but should restrict fluids for 8 hours

before the test. 4. Inform the patient that the test requires a first-voided morning specimen or urine

collection over a 24-hour period, depending on whether the test is qualitative or quantitative.

5. Notify the laboratory and physician of drugs the patient is taking that may affect test results; it may be necessary to restrict them.

Implementation

1. For verification of pregnancy (qualitative analysis), collect a first-voided morning specimen. If this isn’t possible, collect a random specimen.

2. For quantitative analysis of hCG, collect the patient’s urine over a 24-hour period in the appropriate container, discarding the first specimen and retaining the last.

3. Specify the date of the patient’s last menstrual period on the laboratory request. 4. Refrigerate the 24 hour specimen or keep it on ice during the collection period. 5. Be sure the test occurs at least 5 days after a missed period to avoid a false-negative

result.

Nursing Interventions

1. Instruct the patient to resume her usual diet and medications.

Interpretation

Normal Results

In a qualitative immunoassay analysis, results are negative (nonpregnant) or positive (pregnant) for hCG.

In a qualitative analysis, urine hCG levels in the first trimester of a normal pregnancy may be as high as 500,000 IU/24 hours; in the second trimester, from 10,000 to 25,000 IU/24 hours.

Measurable hCG levels don’t normally appear in the urine of men or nonpregnant women.

Abnormal Results

During pregnancy, elevated urine hCG levels may indicate multiple pregnancy or erythoblastosis fetalis; depressed urine hCG levels may indicate threatened abortion or ectopic pregnancy.

Measurable levels of hCG in men and nonpregnant women may indicate choriocarcinoma, ovarian or testicular tumors, melanoma, multiple myeloma, or gastric, hepatic, pancreatic or breast cancer.

Interfering Factors

Gross proteinuria (greater than 1g/24 hours), hematuria, or an elevated erythrocyte sedimentation rate (possible false-positive; depending on the laboratory method).

Early pregnancy, ectopic pregnancy, or threatened abortion (possible false-positive). Phenothiazine (possible false negative or false positive)

Complication

None known.

Direct laryngoscopy allows visualization of the larynx by the use of a fiberoptic endoscope or laryngoscope passed through the mouth or nose and pharynx and larynx. It’s indicated for any condition requiring direct visualization or specimen samples for diagnosis, such as in patients with strong gag reflexes resulting from anatomic abnormalities and in those who have had no response to short-term therapy for symptoms of pharyngeal or laryngeal disease, such as chronic hoarseness, stridor, and hemoptysis.

Secretions or tissue may be removed during this procedure for further study. The test is usually contraindicated in patients with epiglottitis, but it may be performed on them in an operating room with resuscitative equipment.

Purpose of Direct Laryngoscopy

To detect lesions, strictures, or foreign bodies. To remove benign lesions or foreign bodies from the larynx. To help diagnose laryngeal or upper airway abnormalities. To examine the larynx when indirect laryngoscopy is inadequate.

Direct Laryngoscopy Procedure

Preparation

1. Make sure the patient has signed an appropriate consent form.2. Note and report all allergies.3. Check the patient’s history for hypersensitivity to the anesthetic.4. Instruct the patient to fast for 6 to 8 hours before the test.5. Give the patient a sedative to help him relax and a drug to reduce secretions.6. Give a general or local anesthetic to numb the gag reflex.7. Explain that the study takes about 30 minutes; it takes longer if minor surgery is

performed as part of the procedure.

Implementation

1. The patient is assisted into the supine position.2. A general anesthetic is given, or the mouth or nose and throat are sprayed with local

anesthetic.3. The laryngoscope is inserted through the mouth.4. The larynx is examined for abnormalities.5. Specimens may be collected for further study.6. Minor surgery (polyp removal) may occur at this time.

Nursing Interventions

1. Place the conscious patient in semi-Fowler’s position. Place the unconscious patient on his side with his head slightly elevated to prevent aspiration.

2. Check the patient’s vital signs according to facility protocol, or every 15 minutes until the patient is stable and then every 30 minutes for 2 hours, every hour for the next 4 hours, and then every 4 hours for 24 hours.

3. Immediately report to the practitioner any adverse reaction to the anesthetic or sedative such as tachycardia, palpitations, hypertension, euphoria, excitation, and rapid, deep aspirations.

4. Apply an ice collar per institution protocol to minimize laryngeal edema.5. Provide an emesis basin, and instruct the patient to spit out saliva rather than swallow it.6. Observe sputum for blood, and report excessive bleeding immediately.7. Instruct the patient to refrain from clearing his throat and coughing to prevent

hemorrhaging at the biopsy site.8. Advise the patient to avoid smoking until his vital signs are stable and there’s no

evidence of comlications.9. Immediately report subcutaneous crepitus around the patient’s face and neck, which may

indicate tracheal perforation.10. Listen to the patient’s neck with a stethoscope for signs of stridor and airway obstruction.

Interpretation

Normal Results

No inflammation, lesions, strictures, or foreign bodies are found.

Abnormal Results

Combine with the results of a biopsy, abnormal lesions suggest possible laryngeal cancer or benign lesions.

Narrowing suggests stricture. Inflammation suggests possible laryngeal edema secondary to radiation or tumor. Asynchronous vocal cords suggest possible vocal cord dysfunction

Fecal occult blood test is also known as stool occult blood test, hemoccult test, guiaic smear test, gFOBT, or occult blood test. Fecal occult blood is detected by microscopic analysis or by chemical tests for hemoglobin, such as the guiaic test. Normally, stools contain small amounts of blood (2-2.5 mL/day); therefore, test for occult blood detect quantities larger than this. Testing is indicated when clinical symptoms and preliminary blood studies suggest GI bleeding. Additional tests are required to pinpoint the origin of the bleeding.

Purpose

To detect gastro intestinal bleeding. To aid in the early diagnosis of colorectal cancer.

Procedure

Preparation

1. Explain the patient that this test detects abnormal GI bleeding.2. Instruct the patient to maintain a high-fiber diet and to refrain from eating red meats,

turnips, and horseradish for 48 to 72 hours before the test as well as throughout the collection period.

3. Tell the patient that the test usually requires three fecal specimens but that sometimes only one sample is needed.

4. Instruct the patient to avoid contaminating the fecal specimen with toilet tissue or urine.5. Notify the laboratory and physician of drugs the patient is taking that may affect test

results; it may be necessary to restrict them. If the patient must continue using this drugs, note this on the laboratory request.

Implementation

1. Collect three fecal specimens or a random fecal specimen.2. Obtain specimens from two different areas of each fecal specimen.

Hematest

1. Use a wooden applicator to smear a bit of the fecal specimen on the filter paper supplied with the kit. Or, after performing a digital rectal examination, wipe the finger you used

for the examination on a square of the filter paper. Place the filter paper with the fecal smear on a glass plate.

2. Remove a reagent tablet from the bottle and immediately replace the cap tightly. Place the tablet in the center of the fecal smear on the filter paper. Add 1 drop of water to the tablet, and allow it to soak in for 5 to 10 seconds. Add a second drop, letting it run from the tablet onto the specimen and filter paper.

3. After 2 minutes, the filter paper will turn blue if the test result is positive. Don’t read the color that appears on the tablet itself or develops on the filter paper after the 2-minute period. Note the results and discard the filter paper. Remove and discard your gloves and wash your hands thoroughly.

Hematocrit test

1. Open the flap on the side pack and use a wooden applicator to apply a thin smear of the fecal specimen to the guiaic-impregnated filter paper exposed in a box. Apply a second smear from another part of the specimen to the filter paper exposed in box B.

2. Let the specimen dry for 3 to 5 minutes. Open the flap at the near of the slide package and place 2 drops of hematocrit developing solution on the paper over each smear. A positive result yields a blue reaction in 30 to 60 seconds. Record the results and discard the slide package. Remove and discard your gloves and wash your hands thoroughly.

Instant-View Fecal Occult Blood Test

1. Add a fecal sample to the collection tube. Shake it to mix the sample with the extraction buffer, and then dispose 4 drops into the sample well of the cassette.

2. Results will appear on the test region and the control region of the cassette in 5 to 10 minutes, indicating whether the hemoglobin level is > 0.05 pg/ml of feces.

Nursing Interventions

1. Send the specimen to the laboratory or perform the test immediately, depending on which test is used.

2. Inform the patient that he may resume his usual diet and medications as ordered.3. Single digital office-based test may not be as accurate as serial home collected test.

Interpretations

Normal Results

Less than 2.5 ml of blood in feces, resulting in a green reaction.

Abnormal Results

GI bleeding, this may result from many disorders, such as varices, a peptic ulcer, carcinoma, ulcerative colitis, dysentery, hemorrhagic disease.

Interfering Factors

Failure to observe pretest reactions. Failure to test the specimen immediately or to send it to the laboratory immediately after

collection. Bromides, colchicines, indomethacin, iron preparation, phenylbutazone, rauwolfia

derivatives, and steroids (possible increase from GI blood loss). Ascorbic acid (false-negative, even with significant bleeding). Ingestion of 2 to 5 ml of blood (for example, from bleeding gums). Active bleeding from hemorrhoids (possible false-positive results).

Electromyography (EMG) is the recording of electrical activity of selected skeletal muscle groups at rest and during voluntary contraction. In this test, a needle electrode is inserted percutaneously into a muscle. The muscle’s electrical discharge (or motor unit potential) is then measured and displayed on an oscilloscope screen.

Purpose

To aid in differentiating between primary muscle disorders, such as the muscular dystrophies, and secondary disorders.

To help assess diseases characterized by central neuronal degeneration such as ALS. To help diagnose neuromascular disorders such as myasthenia gravis. To help diagnose radiculopathies.

Procedure

Preparation

1. Make sure the patient has signed an appropriate consent form.2. Note and report all allergies.3. Check for and note drugs that may interfere with test results such as cholinergics,

anticholinergics, anticoagulants, and skeletal muscle relaxants.4. Tell the patient he need not restrict food and fluids before the test but that it may be

necessary to restrict cigarettes, coffee, tea, and cola for 2 to 3 hours beforehand.5. Warn the patient that he might experience some discomfort as a needle is inserted into

selected muscles.6. Explain that the test takes at least 1 hour.

Implementation

1. The patient is positioned in a way that relaxes the muscle to be rested.2. Needle electrodes are quickly inserted into the selected muscle.3. A metal plate lies under the patient to serve as a reference electrode.4. The resulting electrical signal is recorded during rest and contraction, amplified 1 million

times, and displayed on an oscilloscope or computer screen.

5. Lead wires are usually attached to an audio-amplifier so that voltage fluctuations within the muscle are audible.

Nursing Interventions

1. Assess the patient’s pain level. If the patient experiences residual pain, apply warm compresses and administer prescribed analgesics.

2. Tell the patient that he may resume his usual medications as ordered.3. Monitor the patient for signs and symptoms of infection at the needle electrode sites.

Interpretation

Normal Results

1. At rest, muscle exhibits minimal electrical activity.2. During voluntary contraction, electrical activity increased markedly.3. A sustained contraction, or one of increasing strength, produces a rapid “train” of motor

unit potentials.

Abnormal Results

1. Short (low-amplitute) motor unit potentials, with frequent, irregular discharges suggest possible primary muscle disease such as muscular dystrophies.

2. Isolated and irregular motor unit potentials with increased amplitude and duration suggest possible disorders such as ALS and peripheral nerve disorders.

3. Initially normal motor unit potentials that progressively diminish in amplitude with continuing contractions suggest possible myasthenia gravis.

Interfering Factors

The patient’s inability to comply with instructions. Drugs affecting myoneural junctions, such as anticholinergics, cholinergics, and skeletal

muscle relaxants.

Precaution

EMG is contraindicated in the patient with a blessing disorder.

Complications

Infection at the insertion site.

The fasting plasma glucose (or fasting blood sugar) test is used to measure plasma glucose levels after a fast of at least 8 hours. This test is commonly used to screen for diabetes mellitus and prediabetes, in which absence of deficiency of insulin allows persistently high glucose levels.

Purpose

To screen for diabetes mellitus and prediabetes. To monitor drug or diet therapy in the patient with diabetes mellitus. To monitor for hyperglycemia and hypoglycemia.

Fasting Plasma Glucose Procedure

Preparation

1. Explain to the patient that this test detects disorders of glucose metabolism and aids in the diagnosis of diabetes.

2. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when.

3. Explain to the patient that he may experience slight discomfort from the tourniquet and needle puncture.

4. Instruct the patient to fast for 12 to 14 hours before the test.5. Notify the laboratory and physician of medications the patient is taking that may affect

test results; it may be necessary to restrict them.6. Alert the patient to the symptoms of hypoglycemia such as weakness, restlessness,

nervousness, hunger, and sweating and tell him to report such symptoms immediately.

Implementation

1. Perform a venipucture and collect the sample in a 5-ml clot-activator tube.2. Send the sample to the laboratory immediately.3. Note on the laboratory results when the patient last ate, when the sample was collected,

and when the patient received the last pretest dose of insulin or oral antidiabetic drug (if applicable).

Nursing Interventions

1. Apply direct pressure to the venipucture site until bleeding stops.2. Provide a balanced meal or a snack.3. Instruct the patient that he may resume his usual medications that were stopped before the

test.

Interpretation

Normal Results

Results vary according to the laboratory procedure. After at least an 8-hour fast, 70 to 100 mg of true glucose per deciliter of blood (SI, 3.9 to

5.6 mmol/L).

Abnormal Results

Elevated Levels

Diabetes mellitus (fasting plasma glucose levels of 126 mg/dL {SI, 7 mmol/L} or more obtained on two or more occasions).

Impaired fasting glucose or impaired glucose tolerance (levels ranging from 110-125 mg/dL).

Pancreatitis, recent acute illness (such as myocardial infarction), Cushing’s syndrome, acromegaly, and pheochromocytoma.

Acute stress Hyperthyroidism Pancreatic cancer Hyperlipoproteinemia

Interfering Factors

1. Recent illness, infection,, or pregnancy (possible increase).2. Glycolisis resulting from failure to refrigerate the sample or to send it to the laboratory

immediately (possible false negative).3. Acetaminophen, if using the glucose oxidase or hexokinase method (possible false

positive).4. Arginine, benzodiazepines, chlorthalidone, corticosteroids, and dextrothyroxine may

cause an increase.5. Ethacrynic acid may cause hyperglycemia; large doses in patients with uremia can cause

hypoglycemia.6. Alcohol, beta-adrenergic blockers, insulin, monoamine oxidase inhibitors, and oral

antidiabetic agents (possible decrease).7. Stenous exercise (decrease)8. Drug interactions: numerous medications may alter blood glucose levels.

Complications

Hematoma at the venipuncture site.

Doppler ultrasonography evaluates blood flow in the major blood vessels of the arms and legs and in the extracranial cerebrovascular system. A handheld transducer directs high- frequency sound waves to the artery or vein being tested. The sound wave strike moving red blood cells and are reflected back to the transducer at frequencies that corresponds to blood flow velocity through the vessel. The transducer then amplifies the sound waves to permit direct listening and graphic recording of blood flow. Measurement of systolic pressure helps detect the presence, location, and extent of peripheral arterial occlusive disease.

Pulse volume recorder testing may be performed along with Doppler ultrasonography to yield a quantitative recording of changes in blood volume or flow in extremity or organ.

Purpose of Doppler Ultrasonography

To help diagnose venous insufficiency and superficial and deep vein thrombosis (popliteal, femoral, and iliac).

To help diagnose peripheral artery disease and arterial occlusion. To monitor the patient who has had arterial reconstruction and bypass grafts. To detect abnormalities of carotid artery blood flow associated with such conditions as

aortic stenosis. To evaluate possible arterial trauma.

Doppler Ultrasonography Procedure

Patient Preparation

1. Explain to the patient that Doppler ultrasonography is used to evaluate blood flow in the arms and legs or neck. Tell him who will perform the test and when.

2. Reassure the patient that the test doesn’t involve risk or discomfort.3. Inform the patient that he’ll be asked to move his arms to different positions and to

perform breathing exercises as measurements are taken.4. Advise him that a small ultrasonic probe resembling a microphone is placed at various

sites along veins or arteries, and blood pressure is checked at several sites.5. Check with the vascular laboratory about special equipment or instructions.

Implementation

1. Doppler ultrasonography is performed bilaterally.2. The patient is assisted into the supine position on the examination table with his arms at

his sides.

Peripheral arterial evaluation

1. For peripheral arterial evaluation in the leg, the usual test sites are the common and superficial femoral, popliteal, posterior tibial, and dorsalis pedis arteries.

2. For peripheral arterial evaluation in the arm, the usual test sites are the subclavian, brachial, radial, and ulnar arteries.

3. Brachial blood pressure is measured, and the transducer is placed at various points along the test arteries.

4. The signals are monitored, and the waveforms are recorded for later analysis.5. The blood flow velocity is monitored and recorded over the test artery.6. Segmental limb blood pressures are obtained to localize arterial occlusive disease.

Peripheral venous evaluation

1. For peripheral venous evaluation in the leg, the usual test sites are the popliteal, superficial and common femoral veins, and posterior tibial vein.

2. For extracranial cerebrovascular evaluation, usual test sites are the supraorbital artery; the common, external, and internal carotid a arteries; the vertebral arteries; and the brachial, axillary, subclavian, and jugular veins.

3. The transducer is placed over the appropriate vessel, waveforms are recorded, and respiratory modulations are noted.

4. Proximal limb compression maneuvers are performed.5. Augmentation after release of compression is noted to evaluate venous valve

competency.6. For test involving the legs and feet, the patient is asked to perform Valsalva’s maneuver,

and venous blood flow is recorded.

Nursing Interventions

1. Remove the conductive gel from the patient’s skin.2. Assist the patient to a comfortable position.

Interfering Factors

Unknown

Precautions

Bradyarrhythmias may occur if the probe is placed near the carotid sinus. Make sure that the Doppler probe isn’t placed over an open or draining lesion

A quantitative analysis of serum creatinine levels, the serum creatinine test provides a more sensitive measure of renal damage than do blood urea nitrogen levels because renal impairment is virtually the only cause of creatinine elevation.

Creatinine is a non-protein end product of creatinine metabolism that appears in serum in amount proportional to the body’s muscle mass.

Purpose of Serum Creatinine Test

To assess glomerular filtration. To screen for renal damage.

Serum Creatinine Test Procedure

Patient Preparation

1. Confirm the patient’s identity using two patient identifiers according to facility policy.2. Explain to the patient that the serum creatinine test is used to evaluate kidney function.3. Tell the patient that the test requires a blood sample.4. Explain to the patient that he may experience slight discomfort from the tourniquet and

the needle puncture.5. Instruct the patient that he doesn’t need to restrict food and fluids.6. Notify the laboratory and the practitioner of medications the patient is taking that may

affect test results; they may need to be restricted.

Implementation

1. Perform a venipuncture and collect the sample in a 3 or 4 ml clot activator tube.2. Handle the sample gently to prevent hemolysis.3. Send the sample to the laboratory immediately.

Nursing Interventions

1. Send the sample to the laboratory immediately.2. Apply direct pressure to the venipuncture site until bleeding stops.3. Assess the venipuncture site for hematoma formation; if one develops, apply pressure.4. Inform the patient that he may resume his usual medications that were discontinued

before the test, as ordered.

Interpretation

Normal Results

In men, 0.8 to 1.2 mg/dl (SI, 62 to 115 pmol/L) In women, 0.6 to 0.9 mg/dl (SI, 53 to 97 pmil/L)

Abnormal Results

Elevated levels generally indicate renal disease that has seriously damaged 50% or more of the nephrons.

Elevated levels may also indicate gigantism and acromegaly.

Interfering Factors

Ascorbic acid, barbiturates, and diuretics that may possibly increase. Exceptionally large muscle mass, such as found in athletes that may possibly increase

despite normal renal function. Phenolsulfonphthalein given within the previous 24 hours (possible increase, if the test is

based on Jaffe’s reaction.

Complications

Hematoma to the puncture site

Electrocardiography is the most commonly used test for evaluating cardiac status, graphically records the electrical current (electrical potential) generated by the heart. This current radiates from the heart in all directions and, on reaching the skin, is measured by electrodes connected to an amplier and strip chart recorder. The standard resting ECG uses five electrodes to measure the electrical potential from 12 different leads; the standard limb leads (I,II,III), the augmented limb leads (aVf, aVL, and aVr), and the precordial, or chest, leads (V1 through V6).

ECG tracings normally consist of three identifiable waveforms: the P wave, the QRS complex, and the T wave. The P wave depicts atrial depolarization; the QRS complex, ventricular depolarization; and the T wave, ventricular repolarization.

Computerized ECG machines use small electrode tabs that peel off a sheet and adhere to the patient’s skin. The entire ECG tracing is displayed on a screen so abnormalities can be corrected before printing; then it’s printed on one sheet of paper. Electrode tabs can remain on the patient’s chest, arms, and legs to provide continuous lead placement for serial ECG studies.

Purpose of Electrocardiography (ECG)

To help identify primary conduction abnormalities, cardiac arrhythmias, cardiac hypertrophy, pericarditis, electrolyte imbalances, myocardial ischemia, and the site and extent of myocardial infarction.

To monitor recovery from an MI. To evaluate the effectiveness of cardiac medication. To assess pacemaker performance To determine effectiveness of thrombolytic therapy and the resolution of ST-segment

depression or elevation and T-wave changes.

Electrocardiography (ECG) Procedure

Patient Preparation for Electrocardiography (ECG)

1. Explain to the patient the need to lie still, relax, and breathe normally during the procedure.

2. Note current cardiac drug therapy on the test request form as well as any other pertinent clinical information, such as chest pain or pacemaker.

3. Explain that the test is painless and takes 5 to 10 minutes.

Implementation

1. Place the patient in a supine or semi-Fowler’s position.2. Expose the chest, ankles, and wrists.3. Place electrodes on the inner aspect of the wrists, on the medical aspect of the lower legs,

and on the chest.4. After all electrodes are in place, connect the lead wires.5. Press the START button and input any required information.6. Make sure that all leads are represented in the tracing. If not, determine which electrode

has come loose, reattach it, and restart the tracing.7. All recording and other nearby electrical equipment should be properly grounded.8. Make sure that the electrodes are firmly attached.

Nursing Interventions

1. Disconnect the equipment, remove the electrodes, and remove the gel with a moist cloth towel.

2. If the patient is having recurrent chest pain or if serial ECG’s are ordered, leave the electrode patches in place.

Interpretations

Normal Results

1. P wave that doesn’t exceed 2.5 mm (0.25 mV) in height or last longer than 0.12 second.2. PR interval (includes the P wave plus the PR segment) persisting for 0.12 to 0.2 second

for heart rates above 60 beats/min.3. QT interval that varies with the heart rate and lasts 0.4 to 0.52 second for heart rates

above 60 beats/min.4. Voltage of the R wave leads V1 through V6 that doesn’t exceed 27 mm.5. Total QRS complex lasting 0.06 to 0.1 second.

Abnormal Results

1. Myocardial infarction (MI), right or left ventricular hypertrophy, arrhythmias, right or left bundle-branch block, ischemia, conduction defects or pericarditis, and electrolyte abnormalities.

2. Abnormal wave forms during angina episodes or during exercise.

Precautions

The recording equipment and other nearby electrical equipment should be properly grounded to prevent electrical interference.

Double-check color codes and lead markings to be sure connectors march. Make sure that the electrodes are firmly attached, and reattached them if loose skin

contact is suspended. Don’t use cables that are broken, frayed, or bare.

Interfering Factors

Improper lead placement.

Complications

Skin sensitivity to the electrodes

Cerebrospinal fluid is a clear substance that circulates in the subarachnoid space, protects the brain and spinal cord from injury and transports products of neurosecretion, cellular biosynthesis, and cellular metabolism through the Central Nervous System.

For qualitative analysis, CSF is obtained most commonly by lumbar puncture (usually between the third and fourth lumbar vertebrae) and, rarely by cisternal or ventricular puncture. A CSF specimen may also be obtained during other neurologic tests such as myelography.

Purpose of Cerebrospinal Fluid Analysis

To measure cerebrospinal fluid (CSF) pressure as an aid in detecting an obstruction of CSF circulation.

To aid in the diagnosis of viral or bacterial meningitis, subarachnoid or intracranial hemorrhage, tumors, and brain abscesses.

To aid in the diagnosis of neurosyphilis and chronic central nervous system infections.

To check for alzheimer’s disease.

Cerebrospinal Fluid Analysis Procedure

Patient Preparation

1. Tell the patient that this test usually takes at least 15 minutes.2. Inform him that a headache is the most common adverse effect of lumbar puncture, but

reassure him that his cooperation during the test helps minimize the reaction.3. Make sure that the patient or a responsible family member has signed an informed

consent form.4. If the patient is unusually anxious, assess and report his vital signs.

Implementation

1. If the patient is positioned on his side, provide pillows to support the spine on a horizontal plane. This position allows full flexion of the spine and easy access to the lumbar subarachnoid space.

2. Help him maintain his position by placing one arm around his knees and the other arm around his neck.

3. If the sitting position is used, help the patient maintain this position throughout the procedure.

4. After the skin is prepared for injection, the area is draped.5. The anesthetic is injected, and the spinal needle is inserted in the midline between the

spinous vertebral process, usually between the third and fourth lumbar vertebrae.6. When the stylet is removed from the needle, CSF drips from it if the needle is properly

positioned.7. A stopcock and manometer are attached to the needle to measure initial (opening) CSF

pressure.8. After the specimen is collected, label the containers in the order in which they were filled

and record the doctor’s specific instruction for the laboratory.9. A final pressure reading is taken, and the needle is removed.10. Clean the puncture site with local antiseptic, such as providone-iodine solution, and apply

a small adhesive bandage.

11. Send the form and labeled specimens to the laboratory immediately.

Nursing Interventions

1. Check whether the patient must lie flat or if the head of his bed may be slightly elevated.2. Encourage the patient to drink fluids. Provide a flexible straw.3. Check for the puncture site for redness, swelling, and drainage every hour for the first 4

hours, and then every 4 hours for the first 24 hours.4. If CSF pressure is elevated, assess the patient’s neurologic status every 15 minutes for 4

hours. If he’s stable, assess him every hour for 2 hours and then every 4 hours or according to the present schedule.

Interpretation

Normal Results

Clear, colorless fluid. Cell count: No red blood cells (RBCs); 0 to 5 white blood cells (WBCs). Gram stain: No organism Pressure: 50 to 180 mm H2O

Abnormal Results

Cloudy, bloody, brown, orange, or yellow fluid. Cell count: RBCs present; increased WBCs Gram stain: Gram positive or gram-negative organisms. Pressure: Increased or decreased.

Precautions

Infection at the puncture site contraindicates CSF removal. In the patient with increased intracranial pressure, CSF should be removed with

extreme caution because fluid withdrawal can cause a rapid reduction in pressure and cerebellar tonsillar herniation and medullary compression.

Interfering Factors

Patient position and activity may possibly increase or decrease in CSF pressure. Crying, coughing, or straining. Delay between collection time and laboratory testing that may possibly invalidation of

test results, especially cell counts.

Complications

Reaction to anesthetic, meningitis, bleeding into the spinal canal, cerebellar tonsillar herniation, and medullary compression.

Signs of meningitis. Signs of herniation

Cardiac catheterization involves passing a catheter into the right or left side of the heart. Catheterization can determine blood pressure and blood flow in the chambers of the heart, permits blood sample collection, and record films of the heart’s ventricles (contrast ventriculography) or arteries (coronary arteriography or angiography).

Catheterization of the heart’s left side assesses the patency of the coronary arteries, mitral and aortic valve function, and left ventricular function. Catheterization of the heart’s right side assesses tricuspid and pulmonic valve function and pulmonary artery pressures.

Purpose of Cardiac Catheterization

To evaluate valvular insufficiency or stenosis, septal defects, congenital anomalies, myocardial function, myocardial blood supply, and cardiac wall motion.

To aid in diagnosing left ventricular enlargement, aortic root enlargement, ventricular aneurysms, and intracardiac shunts.

Cardiac Catheterization Procedure

Patient Preparation

1. Explain the procedure to the patient.2. Tell him to restrict fluids for at least 6 hours before the test. 3. Inform him that the test takes 1 to 2 hours.4. Tell him that he may receive a mild sedative but will remain conscious during the

procedure.5. Have the patient to void just before the procedure.6. Check the patient history for hypersensitivity to shellfish, iodine, or contrast media used

in other diagnostic tests. Discontinue any anticoagulant therapy as ordered.

Implementation

1. The patient is placed supine on padded table and his heart rate and rhythm, respiratory status, and blood pressure are monitored throughout the procedure.

2. An I.V. line is started, if not already in place, and a local anesthetic is injected at the insertion site.

3. A small incision is made into the artery or vein, depending on whether the test is for the left or right.

4. The catheter is passed through the sheath into the vessel and guided using fluoroscopy.5. In the right-sided catheterization, the catheter is inserted into the antecubital or femoral

vein and advanced through the vena cava into the right side of the heart and into the pulmonary artery.

6. If left-sided heart catheterization, the catheter is inserted into the brachial or femoral artery and advanced retrograde through the aorta into the coronary artery ostium and left ventricle.

7. When the catheter is in place, contrast medium is injected to make visible the cardiac vessels and structures.

8. Nitroglycerin is given to eliminate catheter-induced spasm or watch its effect on the coronary arteries.

9. After the catheter is removed, direct pressure is applied to the incision site until bleeding stops, and a sterile dressing is applied.

Nursing Interventions

1. Monitor the patient’s heart rate and rhythm, respiratory and pulse rates, and blood pressure frequently.

2. Monitor the patient’s vital signs every 15 minutes for 2 hours after the procedure, every 30 minutes for the next 2 hours, and then every hour for 2 hours.

3. If no hematoma or other problems arise, begin monitoring every 4 hours. If vital signs are unstable, check every 5 minutes and notify the practitioner.

4. Observe the insertion site for a hematoma or blood loss. Additional compression may be necessary to control bleeding.

5. Check the patient’s color, skin temperature, and peripheral pulse below the puncture site.6. Enforce bed rest for 8 hours. If the femoral route was used for catheter insertion, keep the

patient’s leg extended for 6 to 8 hours.7. If medications were withheld before the test, check with the practiotner about resuming

their administration.8. Administer prescribed analgesics.9. Make sure a posttest ECG is scheduled to check for possible myocardial damage.

Interpretation

Normal Results

No abnormalities of heart valves, chamber size, pressures, configuration, wall motion, or thickness, and blood flow.

Coronary arteries have a smooth and regular outline.

Abnormal Results

Coronary artery narrowing greater than 70% suggests significant coronary artery disease. Narrowing of the left main coronary artery and occlusion or narrowing high in the left

anterior descending artery suggests the need for revascularization surgery. Impaired wall motion suggests myocardial incompetence. A pressure gradient indicates valvular heart disease. Retrograde flow of the contrast medium across a valve during systole indicates valvular

incompetence.

Precautions

Coagulopathy, impaired renal function, and debilitation usually contraindicate catheterization of both sides of the heart. Unless a temporary pacemaker is inserted to counteract induced ventricular asystole, left bundle-branch block contraindicates catheterization of the right side of the heart.

If the patient has valvular heart disease, prophylactic antimicrobial therapy may be indicated to guard against subacute bacterial endocarditis.

Complications

Ineffective endocarditis in a patient with vulvular heart disease. Myocardial infarction, arrhythmias, cardiac tamponade, pulmonary edema, hematoma,

blood loss, adverse reaction to contrast media, and vasovagal response

Urea is the chief end product of protein metabolism. Formed in the liver from ammonia and excreted by the kidneys, urea constitutes 40% to 50% of the blood’s nonprotein nitrogen. Because the level of reabsorption of urea in the renal tubules is directly related to the rate of urine flow through the kidneys, the blood urea nitrogen (BUN) level is less reliable indicator or uremia than is the serum creatinine level. The BUN test measures the nitrogen fraction.

Purpose of Blood Urea Nitrogen Test

To confirm bacterecemia. To identify causative organism in bacterecemia and septicemia. To determine the cause of fever with an unknown origin.

Procedure for Blood Urea Nitrogen Test

Patient Preparation

1. Tell the patient that the BUN test is used to evaluate kidney function.2. Inform the patient that he need not to restrict food and fluids, but should avoid diet high

in meat.3. Tell the patient that the test requires a blood sample. Explain who will perform the

venipuncture and when.4. Explain to the patient that he may experience slight discomfort from the tourniquet and

needle puncture.5. Notify the laboratory and physician of medications the patient is taking that may affect

test results; they may need to be restricted.

Implementation

1. Clean the venipuncture site first with an alcohol swab and then with a providone-iodine swab, starting at the site and working outward in a circular motion.

2. Wait at least 1 minute for the skin to dry.

3. Perform a venipuncture and draw 10 to 20 ml of blood for an adult, or 2 to 6 ml for a child.

4. Clean the diaphragm tops of the culture bottles with alcohol or iodine and change the needle on the syringe.

5. If using broth, add blood to each bottle until achieving a 1:5 or 1:10 dilution. For example, add 10 ml of blood to a 100-ml bottle. Note that the size of the bottle may vary depending on hospital protocol.

6. If using a special resin, add blood to the resin in the bottles according to facility protocol, and invert gently to mix it.

7. Draw the blood directly into special collection processing tube if using lysis-centrifugation technique (Isolator).

8. Document the tentative diagnosis and current or recent antimicrobial therapy on the laboratory request.

9. Send each sample to the laboratory immediately.10. Collect blood cultures before giving antimicrobial agents whenever possible because

previous or current antimicrobial therapy may give false-negative results.11. To detect most causative agents, it’s best to perform the blood cultures on 2 consecutive

days.

Nursing Interventions

1. Use alcohol to remove the iodine from the venipuncture site.2. Monitor the venipuncture site for bleeding and signs of infection.

Interpretations

Normal Results

BUN values normally range form 8 to 20 mg/dl (SI, 2.9 to 7.5 mmol/L) In elderly patients, BUN will show slightly higher values, possibly to 69 mg/dl (SI, 25.8

mmol/L).

Abnormal Results

Elevated BUN levels occurs in renal disease, reduced renal blood flow (due to dehydration), urinary tract obstruction, and increased protein catabolism (such as with burns).

Low BUN levels occur in severe hepatic damage, malnutrition, and overhydration.

Interfering Factors

Hemolysis from rough handling of the sample. Use of chloramphenicol may possible decrease the BUN. Aminoglycosides, amphoterecin B, and methicillin may increase BUN by nephrotoxicity.

Complications

Hematoma at the puncture site.

Precaution

Handle the sample gently to prevent hemolysis

Bone marrow, the soft tissue contained in the medullary canals of long bone and the interstices of cancellous bone, may be removed by aspiration or needle biopsy under local anesthesia. In aspiration biopsy, a fluid specimen in which pustulae of marrow is suspended is removed. In needle biopsy, a core of marrows – cells, not fluid – its removed. These methods are commonly used concurrently to obtain the best possible marrow specimens. Red marrow, which constitutes about 50% of an adult’s marrow, actively produces stem cells that ultimately evolve into red blood cells, white blood cells and platelets. Yellow marrow contains fat cells and connective tissue and is inactive, but it can become active in response to the body’s needs.

Bleeding and infection may result from bone marrow biopsy at any site, but the most serious complications occur at the sternum. Such complications are rare but include puncture of the heart and major vessels, causing severe hemorrhage, and puncture of the mediastinum, causing mediastinitis of pneumomediastinum.

Purpose of Bone Marrow Aspiration and Biopsy

To diagnose thrombocytopenia, leukemia, granulomas, anemias, and primary and metastatic tumors.

To determine the causes of infection. To help stage disease such as with Hodgin’s disease. To evaluate chemotherapy. To monitor myelosuppression.

Bone Marrow Aspiration and Biopsy Procedure

Patient Preparation

1. Explain the procedure to the patient. A mild sedative will be given 1 hour before the test, if ordered.

2. Tell the patient the test usually takes only 5 to 10 minutes and that more than one bone marrow specimen may be required.

3. Let him know a blood sample will be collected before the biopsy for laboratory testing.4. Make sure the patient has signed a consent form.5. Check the patient for hypersensitivity to the local anesthetic.6. After confirming with the doctor, tell the patient which bone- sternum, anterior or

posterior iliac crest, vertebral spinous process, ribs, or tibia – will be used as the biopsy site.

Implementation

Aspiration Biopsy

1. The doctor prepares the biopsy site and injects a local anesthetic. He then inserts the needle through the skin, the subcutaneous tissue, and the cortex of the bone.

2. The doctor removes the stylet from the needle and attaches a 10 to 20 ml syringe. He aspirates 0.2 to 0.5 ml of marrow and withdraws the needle.

3. Pressure is applied to the site for 5 minutes while the marrow slides are being prepared. If the patient has thrombocytopenia, pressure is applied for 10 to 15 minutes.

4. The biopsy site is cleaned again, and a sterile adhesive bandage is applied.5. If the doctor doesn’t obtain an adequate marrow specimen on the first attempt, he may

reposition the needle or remove and reinsert it in another site within the anesthetized area. If the second attempt fails, a needle biopsy may be necessary.

Needle Biopsy

1. After preparing the biopsy site and draping the area, the examiner marks the skin at the site with an indelible pencil or marking pen.

2. A local anesthetic is then injected intradermally, subcutaneously, and at the bone’s surface.

3. The biopsy needle is inserted into the periosteum, and the needle guard is set as indicated. The needle is advanced with a steady boring motion until the outer needle passes through the bone’s cortex.

4. The inner needle with trephine tip is inserted into the outer needle. By alternately rotating the inner needle clockwise and counterclockwise, the examiner directs the needle into the marrow cavity and then removes a tissue plug.

5. The needle assembly is withdrawn, and the marrow is expelled into a labeled bottle containing Zenker’s acetic acid solution.

6. After the biopsy site is cleaned, a sterile adhesive bandage or a pressure dressing is applied.

Nursing Interventions

1. While the marrow slides are being prepared, apply pressure to the biopsy site until bleeding stops.

2. Clean the biopsy site and apply a sterile dressing.3. Monitor the patient’s vital signs and the biopsy site for signs and symptoms of

infection.

Interpretation

Normal Results

1. Yellow marrow contains fat cells and connective tissue.2. Red marrow contains hematopoietic cells, fat cells, and connective tissue.3. The iron satin, which measures hemosiderin (storage iron), has a +2 level.4. The sudan black B satin, which shows granulocytes is negative.

5. The periodic acid-Schiff (PAS) stain, which detects glycogen reactions, is negative.

Abnormal Results

1. Decreased hemosiderin levels in an iron stain may indicate a true iron deficiency.2. Increased hemosiderin levels may suggest other types of anemias or blood disorders.3. A positive stain can differentiate acute myelogenous leukemia from acute

lymphoblastic leukemia (negative stain).4. A positive stain may also suggest granulation in myeloblasts.5. A positive PAS stain may suggest acute or chronic lymphocyte leukemia, amyloidosis,

thalasemia, lymphoma, infectious mononucleosis, iron-deficiency anemia, or sideroblastic anemia.

Complications

1. Hemorrhage and infection2. Puncture of the mediastinum (sternum)

Precautions

Know that bone marrow biopsy is contraindicated in the patient with a severe bleeding disorder.

Send the tissue specimen or slide to the laboratory immediately.

Interfering Factors

Failure to obtain a representative specimen. Failure to use a fixative for histologic analysis

Barium swallow, also known as esophagography, is the radiographic or fluoroscopic examination of the pharynx and the fluoroscopic examination of the esophagus after ingestion of thick and thin mixtures of barium sulfate.

This test, is commonly performed as part of the upper GI series, is indicated for patients with history of dysphagia and regurgitation. Further testing is usually required for a definitive diagnosis.

After the barium is swallowed, it pours over the base of the tongue into the pharynx. A peristaltic wave propels it through the entire length of the esophagus in about 2 seconds. When the peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens, allowing the barium to enter the stomach. After passage of the barium, the cardiac sphincter closes. Normally, it evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.

Purpose of Barium Swallow

To diagnose hiatal hernia, diverticula, and varices. To detect strictures, ulcers, tumors, polyps, and motility disorders.

Procedure for Barium Swallow

Patient Preparation

1. Explain to the patient that this test evaluates the function of the pharynx and esophagus. 2. Instruct the patient to fast after midnight before the test. 3. If the patient is infant, delay the feeding to ensure complete digestion of the barium. 4. Explain that the test takes approximately 30 minutes. 5. Describe the milkshake consistency and chalky taste of the barium preparation the patient

will ingest; although it’s flavored, it may be unpleasant to swallow. 6. Tell him he’ll first receive a thick mixture and then a thin one and that he must drink 12

to 14 oz (355 to 414 ml) during the examination. 7. Inform him that he’ll be placed in various positions on a tilting radiograph table and that

radiographs will be taken. 8. If gastric reflux is suspected, withhold antacids, histamine-2 (H2) blockers, and proton

pump inhibitors, as ordered. 9. Just before the procedure, instruct the patient to put a hospital gown without snap

closures and to remove jewelry, dentures, hairpins, and other radiopaque objects from the radiograph field.

10. Check the patient history for contraindications to the barium swallow, such as intestinal obstruction and pregnancy. Radiation may have teratogenic effects.

Implementation

1. The patient is placed in an upright position behind the fluoroscopic screen, and his heart, lungs, and abdomen are examined.

2. The patient is instructed to take one swallow of the thick barium mixture; pharyngeal action is recorded using cineradiography.

3. The patient is instructed to take several swallows of the thin barium mixture. Passage of the barium is examined fluoroscopically; spot films of the esophageal region are taken from lateral angles and from the right and left posteroanterior angles.

4. To accentuate small strictures or demonstrate dysphagia, the patient may be asked to swallow a “barium marshmallow” (soft white bread soaked in barium) or a barium pill.

5. The patient is then secured to the X-ray table and rotated to trendelenburg position to evaluate esophageal peristalsis or demonstrate hiatal hernia and gastric reflux.

6. The patient is instructed to take several swallows of barium while the esophagus is examined fluoroscopically; spot films are taken.

7. After the table is rotated to a horizontal position, the patient takes several swallows of the barium so that the esophageal junction and peristalsis may be evaluated.

8. Passage of the barium is fluoroscopically observed and the spot films are taken with the patient in the supine and prone position.

9. During fluoroscopic examination of the esophagus, the stomach and the duodenum are also carefully studied because neoplasms in these areas may invade the esophagus and cause obstruction.

Nursing Interventions for Barium Swallow

1. Check the additional films and fluoroscopic evaluations haven’t been ordered before allowing the patient to resume his usual diet.

2. Instruct the patient to drink plenty of fluids, unless contraindicated, to help eliminate the barium.

3. Give cathartic as prescribed. 4. Tell the patient to notify the physician if he fails to expel the barium in 2 to 3 days. 5. Inform the patient that stools will be chalky and light colored for 24 to 72 hours.

Interpretation

Normal Results

The swallowed barium bolus pours over the base of the tongue into the pharynx. A peristaltic wave reaches the base of the esophagus, the cardiac sphincter opens,

allowing the bolus to enter the stomach. After the passage of the bolus, the cardiac sphincter closes.

The bolus evenly fills and distends the lumen of the pharynx and esophagus, and the mucosa appears smooth and regular.

Abnormal Results

Barium swallow may reveal hiatal hernia, diverticula, and varices. Strictures, tumors, polyps, ulcers, and motility disorders, such as pharyngeal muscular

disorders, esophageal spasms, and achalasia (cardiospasm) may be detected.

Complications

Barium retained in the intestine may harden, causing obstruction or fecal impaction. Abdominal distention and absent bowel sounds, which may indicate constipation and

may suggest barium impaction

You are here: Home / Medical Laboratory & Diagnostic Test / Pelvic Laparoscopy

Pelvic LaparoscopySeptember 5, 2010 by Lhynnelli, RN · Leave a Comment  ·   Email This Post ·  Print This Post

Laparoscopy permits visualization of the peritoneal cavity by the insertion of a small fiber-optic telescope (laparoscope) through the anterior abdominal wall. This surgical technique may be used diagnostically to detect abnormalities, such as cyst, adhesions, fibroids, and infection. It can also be used therapeutically to perform procedures, such as adhesion lysis; ovarian biopsy; tubal sterilization; removal of ectopic pregnancies, fibroids, hydrosalpinx, and foreign bodies; and fulguration of endometriotic implants.

Laparoscopy has largely replaced laparotomy because it requires a smaller incision, is faster, and reduces the risk of postoperative adhesions. Potential risks of laparoscopy include a punctured visceral organ, causing bleeding or spilling of intestinal contents into the peritoneum.

Purpose

To identify cause of pelvic pain. To detect endometriosis, ectopic pregnancy, or pelvic inflammatory disease (PID). To evaluate pelvic masses. To evaluate infertility. To stage a carcinoma.

Procedure

Preparation

1. Explain the procedure to the patient, and tell her that laparoscopy is used to detect abnormalities of the uterus, fallopian tubes, and ovaries.

2. Instruct the patient to fast for at least 8 hours before surgery.3. Tell the patient who will perform the procedure and where it will take place.4. Tell the patient whether she’ll receive a general anesthetic and whether the procedure will

require an outpatient visit or overnight hospitalization.5. Warn the patient that she may experience pain at the puncture site and in the shoulder.6. Make sure that the patient or a responsible family member has signed an informed

consent form.7. Check the patient’s history for hypersensitivity to the anesthetic.8. Make sure laboratory work is completed and results are reported before the test.9. Instruct the patient to empty her bladder just before the test.

Implementation

1. The patient is anesthetized and placed in the lithotomy position.2. The doctor catheterizes the bladder and then performs a bimanual examination of the

pelvic area to detect abnormalities that may contraindicate the test and to ensure that the bladder is empty.

3. The doctor makes an incision at the inferior rim of the umbilicus. He inserts a special needle into the peritoneal cavity and insufflates 2 to 3 liters of carbon dioxide or nitrous oxide.

4. The doctor then removes the needle and inserts a trocar and sheath into the peritoneal cavity.

5. After removing the trocar, the doctor inserts the laparoscope through the sheath to examine the pelvis and abdomen.

6. To evaluate tubal patency, the doctor infuses a dye through the cervix and observes the fimbria (the fingerlike extremity of the fallopian tube) for spillage.

7. After the examination, he may perform minor surgical procedures such as ovarian biopsy.8. The doctor may insert a second trocar at the pubic hairline to provide a channel for

inserting other instruments.

Nursing Interventions

1. Instruct the patient to resume his usual diet.2. Instruct the patient to restrict activity for 2 to 7 days.3. Explain that abdominal and shoulder pain should disappear within 24 to 36 hours.4. Provide analgesics.5. Monitor vital signs.6. Monitor the patient for adverse reactions to anesthetic.7. Monitor intake and output.8. Watch for bleeding and signs and symptoms of infection.

Interpretation

Normal Results

The uterus and fallopian tubes are of normal size and shape, free form adhesions, and mobile.

The ovaries are of normal size and shape; cysts and endometriosis are absent. Dye injected through the cervix flows freely from the fimbria.

Abnormal Results

A bubble on the surface of the ovary suggests a possible ovarian cyst. Sheets of strands of tissue suggest possible adhesions. Small, blue powder burns on the peritoneum or serosa suggest endometriosis. Growths on the uterus suggest fibroids. An enlarged fallopian tube suggests possible hydrosalphinx. An enlraged fallopian tube suggests a possible ectopic pregnancy. Infection or abscess suggests possible pelvic inflammation disease.

Precautions

Be aware that laparoscopy is contraindicated in the patient with advanced abdominal wall cancer, advanced pulmonary or cardiovascular disease, intestinal obstruction, palpable abdominal mass, large abdominal hernia, chronic tuberculosis, or a history of peritonitis.

During the procedure, check for proper catheter drainage.

Interfering Factors

Adhesions or marked obesity which may obstruct to visualization. Tissue or fluid becoming attached to the lens that may also obstruct to visualization.

Complications

Punctured visceral organ. Peritonities.

Alpha-fetoprotein (AFP) is a glycoprotein produced by fetal tissue and tumors that differentiate from midline embryonic structures. During fetal development, AFP levels in serum and amniotic fluid rise; because this problem crosses the placenta, it appears in maternal serum. In late stages of pregnancy, AFP levels in fetal and maternal serum and in amniotic fluid begin to diminish. During the first year of life, serum AFP levels continue to decline and usually remain how low thereafter.

High maternal serum AFP levels may suggest fetal tube defects, such as spina bifida and anencephaly; but positive confirmation requires amniocentesis and ultrasongraphy. Other congenital anomalies, such as Down syndrome and other chromosomal disorders, may be associated with low maternal serum AFP concentrations.

Elevated serum AFP levels in 70% of nonpregnant persons may indicate hepatocellular carcinoma (although low AFP levels don’t rule it out) or germ cell tumor of gonadal, retroperitoneal, or mediastinal origin.

Serum AFP level rises in patients with ataxiatelangiectasia and in patients with cancer of the pancreas, stomach, or biliary system. Transient modest elevations can occur in nonneoplastic hepatocellular disease, such as alcoholic cirrhosis and acute or chronic hepatitis. Elevation of AFP levels after remission suggests tumor recurrence.

Purpose

To monitor the effectiveness of therapy in malignant conditions, such as hepatomas and germ cell tumors, and certain nonmalignant conditions such as ataxiatelengiectasia.

To screen those patients needs amniocentesis or high-resolution ultrasonography during pregnancy.

Procedure

Preparation

1. Explain that the AFP tests helps in monitoring fetal development, screens for a need for further testing, helps detect possible congenital defects in the fetus, and monitors the patient’s response to therapy by measuring a specific blood protein, as appropriate.

2. Inform the patient that she need not restrict food, fluids, or medications.3. Tell the patient that the test requires a blood sample. Explain who will perform the

venipuncture and when.4. Explain to the patient that she may experience slight discomfort from the tourniquet and

needle puncture.

Implementation

1. Perform a venipuncture and collect the sample in a 7 ml clot-activator tube.2. Record the patient’s age, race, weight, and week of gestation on the laboratory request.3. Handle the sample gently to prevent hemolysis.

Nursing Interventions

1. Place the patient in comfortable position.2. Encourage deep breathing exercise to alleviate fear.3. Apply direct pressure to the venipuncture site until bleeding stops.

Interpretation

Normal Results

When testing by immunoassay, AFP values are less than 15 ng/ml (SI, <15 mg/l) in male patients and nonpregnant female patients.

Values in maternal serum normally are less 25 ng/ml (SI, 25 ug/L). At 15 to 18 weeks gestation, values range from 10 to 150 ng/ml (SI, 10 to 150 ug/L).

Abnormal Results

Elevated maternal serum AFP level may suggest neural tube defect or other tube anomalies.

Definitive diagnosis requires ultrasonography and amniocentesis. High AFP levels may indicate intrauterine death, or high levels indicate other anomalies,

such as duodenal atresia, omphalocele, tetralogy of fallot, and Tuner’s syndrome. Elevated serum AFP levels occur in 70% of nonpregnant patients with hepatocellular

carcinoma. Elevated levels are also related to germ cell tumor of gonadal, retroperitoneal, or

mediastinal origin. Transient modest elevations can occur in nonneoplastic hepatocellular disease, such as

alcoholic cirrhosis and acute or chronic hepatitis. Elevation of AFP levels after remission suggests tumor recurrence.

Precautions

Handle the sample gently to prevent hemolysis.

Interfering Factors

Hemolysis from rough handling of the sample. Multiple pregnancies that may cause false positive result.

Complication

Hematoma at the venipuncture site

Arthrography allows radiographic examination of a joint after injection of a radioopaque dye, air, or both (double-contrast arthrogram) to outline soft tissue structures and the contour of the joint. The joint is put through its range of motion while a series of radiographs are taken.

Indications for arthography include persistent unexplained joint discomfort or pain. Magnetic resonance imaging of the joint may be used in place of this test.

Arthrography Purpose

To outline joint contour and soft tissue structures To evaluate persistent unexplained joint discomfort or pain To identify acute or chronic tears or other abnormalities of the joint capsule or supporting

ligaments of the knee, shoulder, ankle, hips, or wrist. To detect internal joint derangements. To locate synovial cysts. To evaluate damage from recurrent dislocations.

Arthrography Patient Preparation

1. Describe arthrography to the patient and answer any questions he may have. Explain that this test permits examination of a joint.

2. Inform the patient that he need not restrict food and fluids.3. Tell the patient who will perform the procedure and where it will take place.4. Explain that the fluoroscope allows the physician to track the contrast medium as it fills

the joint space.5. Inform the patient that standard X-ray films will also be taken after diffusion of the

contrast medium.6. Tell the patient that, although the joint area will be anesthetized, he may experience a

tingling sensation or pressure in the joint when the contrast medium is injected.7. Instruct the patient to remain as still as possible during the procedure, except when

following instructions to change position.8. Stress to the patient the importance of his cooperation in assuming various positions

because films must be taken as quickly as possible to ensure optimum quality.

9. Check the patient’s history to determine if he’s hypersensitive to local anesthetics, iodine, seafood, or dyes used for diagnostics tests.

Arthrography Procedure

Knee Arthrography

1. The knee is cleaned with an antiseptic solution and the area around the puncture site is anesthetized.

2. A 2” needle is then inserted into the joint space between the patella and femoral condyle and fluid is separated. The aspirated fluid is usually sent to the laboratory for analysis.

3. While the needle is still in place, the aspirating syringe is removed and replaced with a syringe containing dye.

4. If fluoroscopic examination demonstrates correct placement of the needle, the dye is injected into the joint space.

5. After the needle is removed, the site is rubbed with sterile sponge and the wound may be sealed with collodion.

6. The patient is asked to walk a few steps or to move the knee through a range of motion to distribute the dye in the joint space. A film series is quickly take with the knee held in various positions.

7. If the films are clean and demonstrate proper dye placement, the knee is bandaged, typically with an elastic bandage.

8. Tell the patient to keep the bandage in place for several days and teach him how to rewrap it.

Shoulder Arthrography

1. The skin is prepared and local anesthetics are injected subcutaneously just in front of the acromioclavicular joint.

2. Additional anesthetic is injected directly onto the head of the humerus.3. The short lumbar puncture needle is inserted until the point is embedded into the joint

cartilage.4. The stylet is removed, a syringe of contrast medium is attached and, using fluoroscopic

guidance, about 1 ml of dye is injected into the joint space, as the needle is withdrawn slightly.

5. If fluoroscopic examination demonstrates correct needle placement, the rest of the dye is injected while the needle is slowly withdrawn and the site is wiped with a sterile sponge.

6. A film series is taken quickly to achieve maximum contrats.

Nursing Interventions for Arthrography

1. Tell the patient to rest the joint for 6 to 12 hours.2. Wrap the knee in an elastic bandage for several days if a knee arthrography was

performed.3. Apply ice to the joint for swelling.4. Give the patient an analgesic.

5. Ask the patient to report signs and symptoms of infection.

Arthrography Precautions

1. Know that arthrography is contraindicated during pregnancy and in the patient with active arthritis, joint infection, or previous sensitivity to radiopaque media.

Arthrography Interpretation

Normal Results

A knee arthrogram shows a characteristic wedge shaped shadow pointed toward the interior of the joint, indicating a normal medial meniscus.

A shoulder arthrogram shows the bicipital tendon sheath, redundant inferior joint capsule, and intact subscapular bursa.

Abnormal Results

Structural abnormalities of the knee commonly suggest tears and lacerations of the meniscus.

Extrameniscal lesion may suggest osteochondral fractures, cartilaginous abnormalities, synovial abnormalities, cruciate ligament tears, and joint capsule and collateral ligament disruptions.

Shoulder abnormalities may suggest adhesive capsulitis, bicipital tenosynovitis or rupture, and rotator cuff tears.

Interfering Factors

Incomplete aspiration of joint effusion dilutes the contrast medium and diminishes film quality.

Arthrography Complications

1. Hypersensitivity reactions to contrast medium.2. Persistent joint swelling, or crepitus.3. Infection

A noninvasive technique, skeletal magnetic resonance imaging (MRI) produces clear and sensitive images of bone and soft tissue. The scan provides superior contrast of body tissues and allows imaging of multiple planes, including direct sagittal and coronal views in regions that can’t be easily visualized with X-rays or computed tomography scans. MRI eliminates any risks associated with exposure to X-ray beams and causes no known harm to cells.

There are two types of MRI. Closed MRI uses scanning equipment that resembles a tunnel like chamber. While open MRI uses more sophisticated equipment. During open MRI, the patient

can comfortably see the surroundings from all views while the scan is in progress. This is ideal for patients who are claustrophobic or anxious, children, elderly, and the very obese.

Purpose

To evaluate bony and soft-tissue tumors. To identify changes in bone marrow composition. To identify spinal disorders.

Patient Preparation

1. Make sure the scanner can accommodate the patient’s weight and abdominal girth.2. Explain to the patient that skeletal MRI assesses bone and soft tissue. Tell him who will

perform the test and where it will take place.3. Explain that the test takes 30 to 90 minutes.4. Explain to the patient that although MRI is painless and involves no exposure to radiation

from the scanner, a contrast medium may be used, depending on the type of tissue being studied.

5. If the patient is claustrophobic or if extensive time is required for scanning, explain to him that a mild sedative may be administered to reduce anxiety. Open scanners have been developed for use on the patient with extreme claustrophobia or morbid obesity, but tests using such machine take longer.

6. An anesthesiologist may need to be present to monitor a heavily sedated patient.7. Tell the patient that he must lie flat, and describe the test procedure.8. Explain to the patient that he’ll hear the scanner clicking, whirring, and thumping as it

moves inside its housing.9. Reassure the patient that he’ll be able to communicate with the technician at all times.10. Instruct the patient to remove all metallic objects, including jewelry, hairpins, or watches.11. Stop I.V. infusion pumps, feeding tubes with metal tips, pulmonary artery catheters, and

similar devices before the test.12. Ask whether the patient has any surgically implanted joints, pins, clips, valves, pumps, or

pacemakers containing metal that could be attracted to strong MRI magnet. If he does, he won’t be able to have the test.

13. Note and report all allergies.14. Make sure that the patient or a responsible family member has signed an informed

consent form, if required.

MRI Procedure

1. At the scanner room door, check the patient one last time for metal objects.2. The patient is placed on a narrow, padded, nonmetallic table that moves into the scanner

tunnel. Fans continuously circulate air in the tunnel, and a call bell or intercom is used to maintain verbal contact.

3. Remind the patient to remain still throughout the procedure.4. While the patient lies within the strong magnetic field, the area to be studied in stimulated

with radio-frequency waves.

5. If the test is prolonged with the patient lying flat, monitor him for orthostatic hypotension.

6. Provide comfort measures and pain medication as needed and ordered because of prolonged positioning in the scanner.

7. After the test, tell the patient that he may resume his usual activity.8. Provide emotional support to the patient with claustrophobia or anxiety over his

diagnosis.

Nursing Interventions for MRI

1. Provide patient with comfort measures as needed.2. Tell the patient to resume his normal diet and activities unless otherwise indicated.3. Monitor vital signs.4. Monitor the patient for orthostatic hypotension.

MRI Precautions

1. Be aware that MRI can’t be performed on a patient with a pacemaker, intracranial aneurysm clip, or other ferrous metal implants. Ventilators, I.V. infusion pumps, oxygen tanks, and other metallic or computer based equipment must be kept out of the MRI area.

2. If the patient is unstable, make sure an I.V. line without metal components is in place and that all equipment is compatible with MRI imaging. If necessary, monitor the patient’s oxygen saturation, cardiac, rhythm, and respiratory status during the test. An anesthesiologist may be needed to monitor a heavily sedated patient.

3. Make sure that the technician maintains verbal contact with the conscious patient.

MRI Interpretation

Normal Results

MRI should reveal no evidence of pathology in bone, muscles, and joints.

Abnormal Findings

MRI is excellent for visualizing disease of the spinal canal and cord and for identifying primary and metastatic bone tumors. It’s beneficial in anatomic delineation of muscles, ligaments, and bones. The image show superior contrast of body tissues and sharply defines healthy, benign, and malignant tissues.

Interfering Objects

Metal objects, such as I.V. pumps, ventilators, other metallic equipment, or computer-based equipment, in the MRI area.

MRI Complications

Orthostatic hypotension Anxiety Claustrophobia

Colonoscopy uses a flexible fiber-optic video endoscope to permit visual examination of the lining of the large intestine. It’s indicated for patients with history of constipation or diarrhea, persistent rectal bleeding, and lower abdominal pain when the results of proctosigmoidoscopy and a barium enema test are negative or inconclusive.Purpose

To detect or evaluate inflammatory and ulcerative bowel disease. To locate the origin of lower gastro intestinal bleeding. To aid in the diagnosis of colonic strictures and benign or malignant lesions. To evaluate the colon postoperatively for recurrence of polyps and malignant lesions.

Patient Procedure

1. Check the patient’s medical history for allergies, medications, and information pertinent to the current complaint.

2. Tell the patient to maintain a clear liquid diet for 24 to 48 hours before the test and to take nothing by mouth after midnight the night before.

3. Instruct the patient regarding the appropriate bowel preparation.4. Inform the patient that he’ll receive an I.V. line and I.V. sedation before the procedure.5. Tell the patient that the colonoscope is well lubricated to ease insertion and initially feels

cool.6. Explain that he may feel an urge to defecate when it’s inserted and advanced.7. Inform him that air may be introduced through the colonoscope to distend the intestinal

wall and to facilitate viewing the lining and advancing the instrument.

Colonoscopy Procedure

1. The patient is assisted onto his left side with knees flexed.

2. Cover the patient with drape.3. Baseline vital signs are obtained.4. Vital signs and electrocardiogram are monitored during the procedure.5. Continuous or periodic pulse oximetry is advisable.6. The physician palpates the mucosa of the anus and rectum and inserts the lubricated

colonoscope through the patient’s anus into the sigmoid colon under direct vision.7. A small amount of air is insufflated to locate the bowel lumen and then advance the scope

through the rectum.8. Abdominal palpation or fluoroscopy may be used to help guide the colonoscope through

the large intestine.9. Suction may be used to remove blood and secretions that obscure vision.10. Biopsy forceps or a cytology brush may be passes through the colonoscope to obtain

specimens for histologic or cytologic examination; an electro-cautery snare may be used to remove polyps.

11. Tissue specimens are immediately placed in a specimen bottle containing 10% formalin and cytology smears in a Coplin jar containing 95% ethyl alcohol.

12. Specimens are sent to the laboratory immediately.

Nursing Interventions for Colonoscopy

1. The patient is observed closely for signs of bowel perforation.2. Check the patient’s vital signs and document them accordingly.3. Watch the patient closely for adverse effects of the sedative.4. After recovery from the sedation, he may resume his usual diet unless the physician

orders otherwise.5. The patient may pass large amounts of flatus after insufflation.6. After polyp removal, the stool may contain some blood. Report excessive bleeding

immediately.7. If a polyp is removed, but not retrieved, give enema and strain the stools to retrieve it.

Precautions

1. Although it’s usually a safe procedure, beware that colonoscopy can cause perforation of the large intestine, excessive bleeding, and retroperitoneal emphysema.

2. This procedure is contraindicated in pregnant woman near term, the patient who has had a recent acute myocardial infarction or abdominal surgery, and one with ischemic bowel disease, acute diverticulitis, peritonitis, fulminant granulomatous colitis, perforated viscus, or fulminant ulcerative colitis. For these cases of for screening purposes, a virtual colonoscopy may be an option to help visualize polyps early before they become concerns.

InterpretationsNormal Results

Normally, the mucosa of the large intestine beyond the sigmoid colon appears light pink-orange and is marked by semilunar folds and deep tubular pits.

Blood vessels are visible beneath the intestinal mucosa, which glistens from mucus secretions.

Abnormal Results

Visual examination of the large intestine, coupled with histologic and cytologic test results, may indicate procrititis, granulomatous or ulcerative colitis, Crohn’s disease, and malignant or benign lesions. Diverticular disease or the site of lower gastrointestinal bleeding can be detected through colonoscopy alone.

Interfering Factors

Fixation of the sigmoid colon due to inflammatory bowel disease, surgery, or radiation therapy that may hinder passage of the colonoscope. Blood from acute colonic hemorrhage that hinders visualization. Insufficient bowel preparation or barium retained in the intestine from previous diagnostic studies which makes accurate visual examination impossible.

Complications

Perforation of the large intestine, excessive bleeding and retroperitoneal emphysema