laboratory and diagnostic procedures part1

REDUCTION OF RISK POTENTIAL:

LABORATORY AND DIAGNOSTIC PROCEDURES

Mr. Jaime R. Soriano. RN. RM.

OBJECTIVES OF THE SEMINAR

To identify different laboratory and diagnostic procedures according to body system.

To describe the appropriate preparation, teaching, and post test management for patients who are undergoing diagnostic and laboratory testing

DIAGNOSTIC AND LABORATORY PROCEDURES

1. Indications and Purposes2. Pre-test Preparation3. What will the patient feel?4. Post-test Management5. Nursing Considerations

NERVOUS SYSTEM

Skull and Spinal X-rayLumbar Puncture

CT ScanMRI

Electroencephalography

SKULL X-RAY

Radiographs of the skull:izehapeuture separationome calcificationhows erosion and fracture

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SKULL X-RAY

SPINAL X-RAYSpinal radiographs:

bnormal spine and dislocationone degenerationompressioneformed curvaturerosionracture

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SPINAL X-RAY

SKULL AND SPINAL X-RAY

-clude metal items from body parts

-eassure nursing support-ccurate documentation if

with thick and heavy hair

-ou immobilize

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LUMBAR PUNCTURE

LUMBAR PUNCTURE

Insertion of a spinal needle through the L3-L4

interspace into the lumbar subarachnoid space to

obtain cerebrospinal fluid, measure CSF fluid or

pressure, or instill air, dye, or medications.

LUMBAR PUNCTUREDIAGNOSTIC• Suspected meningitis• Subarachnoid hemorrhage• Hydrocephalus• Benign Intracranial hypertensionTHERAPEUTIC• Spinal anesthesia• Chemotherapy

LUMBAR PUNCTURE

CONTRAINDICATIONS

-coliosis-CP unidentified-oagulopathy-yphosis

SSIICCKK

LUMBAR PUNCTUREPRETEST

orm of informed consent

ree of urine bladderetal position

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LUMBAR PUNCTURE

INTRATEST

hrimp or Fetal positionpecimens to be collected terile vials- 4trict asepsis

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LUMBAR PUNCTUREPOSTTESTlat 12-24 hrsor vital signs and LOC

monitoringorce fluid unless

contraindicateduncture site for bleeding, CSF

leakageerform CMS assessment

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LUMBAR PUNCTURE

COMPLICATIONSpinal Headache

-lat-luids-ain Management

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CT SCANScans the following in

successive layers by a narrow beam of x-rays:

ngiogramelly and Pelvichest’ heartxtremities

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CT SCAN

CT SCANPRETEST:ssess allergies to iodine and seafoodse sure to obtain informed consentonscious sedation for claustrophobiao remove jewelries and hair pinsxplain hot flushed sensation and metallic

taste in the mouth when dye is injectedluids and hydrationive instruction to lie supine with small pillow

under the headold if pregnantt takes 20 minutes

ABCDE

FG

HI

CT SCANPOSTTEST:llergic reaction checke sure to replace fluidMSistal pulse checkxtremity color checkind bleeding and hematoma

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MRI

-RI is nonivasive-eveals types of tissue,

tumors and vscular abnormalities

-s similar to CT scan

MMRR

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MRI

MRIPRETEST-etal objects must be removed-ssess for ineligibility and contraindications-ive instruction to lie supine with small pillow

under the head-ormal audible humming, thumbing, grating, or

knocking sounds-ncourage conscious sedation for

claustrophobia-akes 45 to 60 minutes-nformed consent-ompletely enclosed in scanner

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TTIICC

MRIPOSTTEST

Resume normal activitiesFluids and hydration

MRIIneligible to undergo MRI:• Automatic Internal Defibrillator• Cerebral Aneurysm Clip• Cochlear Implant• Hip Replacement• Knee Replacement• Non-removable dental prosthesis• Pacemaker• Prosthetic Valve Replacement• Soldiers

EEG

EEG• graphic recording of electrical activity

of the brain by several small electrodes placed on the scalp

To diagnose:bnormal firing of electrical activityrain tumorsertain psychiatric disordersegenerative disordersnflammation of brain and spinal cord

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EEGPRETEST

ash the client’s hairssure that electrodes will not

cause electric shocktimulants and depressants

avoided for 24 to 48 hoursypoglycemia prevention, do not

omit breastfeeding

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EEGPOSTTEST

Wash the client’s hairMaintain side rails and safety

precaution, if the client was sedated

EEG

Sleep Deprivation EEG

CARDIOVASCULAR SYSTEMElectrolytes

Coagulation StudiesErythrocyte Studies

White Blood Cell CountSerum Enzymes and Cardiac Markers

Serum LipidsECGCVP

Pericardiocentesis

ELECTROLYTES

SODIUM-bsorbed from the small intestine

and excreted in the urine in amounts dependents dependent on dietary intake

-ustains osmotic pressure and acid base balance

-s major extracellular cation-ormal daily requirement is 15 mEq

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ELECTROLYTES

SODIUM

Nursing Consideration:• Drawing blood samples

soon after an intravenous infusion of sodium chloride will increase the level, producing an inaccurate result.

ELECTROLYTES

POTASSIUM-romote cellular water balance,

electrical conduction in muscle cells, and acid base balance

-btains K through dietary ingestion and the kidneys preserve or excrete K

-o evaluate cardiac, renal, and gastrointestinal function

- major intracellular cation

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ELECTROLYTES

POTASSIUMNursing Consideration:-ccurate note if the patient is

receiving K supplement-lood should not be drawn from site

where an IV infusion exists-lenching and unclenching of hand

can increase the level-o identify elevated WBC and

platelet counts

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ELECTROLYTESCHLORIDE

-ighly abundant body anion in the extracellular fluid

-ounterbalance cations and buffer

-ets digestion and maintenance of osmotic pressure and water balance

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ELECTROLYTES

CHLORIDENursing Consideration:-raw blood from an extremity that does

not have normal saline infusing into it

-o not allow the client to clench and unclench his or her hand before drawing blood

-iarrhea and prolong vomiting will alter cholride results

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ELECTROLYTES

MAGNESIUM

lotting mechanismontrols neuromuscular activityofactor that modifies activity

of many enzymesalcium metabolism

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ELECTROLYTES

MAGNESIUMNursing Consideration:-rolong use of magnesium

products will cause increased serum levels

-arenteral nutrition therapy or excessive loss of body fluids may decrease serum levels

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ELECTROLYTESCALCIUM

-one formation-n conversion of prothrombin

to thrombin-ransmission of nerve impulse-n contraction ok skeletal and

myocardial muscles

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ELECTROLYTES

CALCIUMNursing Consideration:Instruct the client to eat a diet

with a normal calcium level (800 mg/day) for 3 days before the test.

Instruct the client that fasting may be required for 8 hours before the test

COAGULATION STUDIESACTIVATED PARTIAL

THROMBOPLASTIN TIME (APTT)-mount of time it takes in seconds for

recalcified plasma to clot after partial thromboplastin is added

-erformed for patient receiving heparin-est for deficiencies and inhibitors of

clotting factors-ime: 20 to 36 seconds

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COAGULATION STUDIESACTIVATED PARTIAL THROMBOPLASTIN

TIME (APTT)Nursing Consideration:-spirate blood sample 1 hour before next

scheduled heparin dose-erform blood exraction from arm into which

heparin is not infusing-ransport specimen to the laboratory

immediately-ime: 1.5 to 2.5 times normal if on heparin

therapy

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COAGULATION STUDIESPROTHROMBIN TIME (PT) and

INTERNATIONAL NORMALIZED RATIO (INR)

-rothrombin is a vitamin K dependent glycoprotein produced by the liver for fibrin clot formation

-o monitor response to warfarin sodium (Coumadin)

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COAGULATION STUDIESPROTHROMBIN TIME (PT) and

INTERNATIONAL NORMALIZED RATIO (INR)

Normal Values:PT:

– 9.6 to 11.8 secs (male)– 9.5 to 11.3 secs (female)

INR:– 2.0 to 3.0 (standard warfarin tx)– 3.0 to 4.5 (high dose warfarin tx)

COAGULATION STUDIESPROTHROMBIN TIME (PT) and

INTERNATIONAL NORMALIZED RATIO (INR)

Nursing Considerations:- baseline PT should be drawn before anticoagulation

therapy-e sure to apply direct pressure to the venipuncture site-oncurrent warfarin therapy with heparin therapy can

lengthen the PT-iets high in green leafy vegetables can shorten PT-xpect 1.5 to 2 times longer PT if on anticoagulation therapy-or PT greater than 30 secs, initiate bleeding precautions

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COAGULATION STUDIESCLOTTING TIME

-lient should not receive heparin 3 hours before specimen collection

-ong on any anticoagulation therapy

-n thrombocytopenia-ime: 8 to 15 minutes

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COAGULATION STUDIESPLATELET COUNT

Plug formationClot retractionCoagulation factor

activation

COAGULATION STUDIESPLATELET COUNT 150T – 400T

cells/mm3

• <PLT – thrombocytopenia (risk for bleeding)

• >PLT – thrombocytosis (risk for clot) – prophylaxis of Anicoagulant - Lovenox

COAGULATION STUDIESPLATELET COUNT

Nursing Considerations:B-leeding precautions should be

instituted in clients with low platelet

M-onitor venipuncture siteC-hronic cold weather, high altitudes,

and exercise increase platelet count

ERYTHROCYTE STUDIES

ERYTHROCYTE SEDIMENTATION RATE (ESR)- 0 to 30 mm/hr

ndirectly measures how much inflammation is in the body.

pecial preparations not needed, but fatty meal may cause plasma alterations

ate at which erythrocytes settle out of anticoagulated blood in 1 hour

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ERYTHROCYTE STUDIES

RED BLOOD CELLSRED BLOOD CELLS

-esults in the delivery of oxygen to the body tissues

-lood diseases diagnosis-irculate for 120 days and are removed

from the blood via the liver, spleen, and bone marrow

-pecial preparation not needed

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ERYTHROCYTE STUDIES

RED BLOOD CELLS 4.5-5.5 million/mm3

• <RBC – Anemia (Faitgue, SOB)• >RBC – Polycythemia

(erythrocytosis) – management phlebotomy

ERYTHROCYTE STUDIES

HEMOGLOBIN and HEMATOCRITHemoglobin is the main component

of erythrocytes and serves as the vehicle for transporting O2 and CO2

Normal Values:– 14 to 16.5 g/dl (male)– 12 to 15 g/dl (female)

ERYTHROCYTE STUDIES

HEMOGLOBIN and HEMATOCRITHematocrit represents red blood cell

mass and is an important measurement in the identification of anemia or polycythemia

Normal Values:– 42% to 52% (male)– 35% to 47% (female)

WHITE BLOOD CELL COUNT

WHITE BLOOD CELLWHITE BLOOD CELLImmune defense system of the body

WBC 5,000-10,000 cells/mm3– <WBC – leukopenia (risk for

infection)– >WBC – leukocytosis

(infection/inflammation)– >100,000 – incapable of

phagocytosis (leukemia)

WHITE BLOOD CELL COUNT

WHITE BLOOD CELLWHITE BLOOD CELLNursing Consideration:SHIFT TO THE LEFT: increased number of

immature neutrophils is present on the blood

SHIFT TO THE RIGHT: cells have more than usual number of nuclear segments, found in liver disease, Down syndrome, pernicious anemia, and megaloblastic anemia

CARDIAC MARKERS

CREATINE KINASE (CK)

Found in:CK-MB (Cardiac)--- 0% to 5%CK-BB (Brain)--- 0%CK-MM (Muscles)--- 95% to 100%

CARDIAC MARKERS

CREATINE KINASE (CK)

R: 6 hoursP: 18 hoursN: 2 to 3 days

CARDIAC MARKERS

CREATINE KINASE (CK)Nursing Considerations:CK-MM: Avoid strenuous physical

activity for 24 hours before the testAvoid ingestion of alcohol for 24 hours

before the testInvasive procedures and intramuscular

injections may falsely elevate CK levels

CARDIAC MARKERS

LACTASE DEHYDROGENASE (LDH)

R: 24 hoursP: 48 to 72 hoursN: 7 to 14 days

CARDIAC MARKERS

LACTASE DEHYDROGENASE (LDH)

Nursing Considerations:LDH isoenzyme levels should

be interpreted in view of the clinical findings

Testing should be repeated on 3 consecutive days

CARDIAC MARKERS

TROPONIN

- and I-egulatory protein found in

striated muscle-n bloodstream when an

infarction causes damage to the myocardium

TTRR

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CARDIAC MARKERS

TROPONIN I>1.5 ng/ml… MI

R: 3 hoursN: 7 to 10 days

CARDIAC MARKERS

TROPONIN T>0.1 to 0.2 ng/ml… MI

R: 3 hoursN: 7 to 14 days

CARDIAC MARKERS

TROPONIN

Nursing Considerations:Testing is repeated in 12

hours, followed by daily testing for 3 to 5 days.

Rotate venipuncture sites.

CARDIAC MARKERS

MYOGLOBIN

Oxygen-binding protein found in striated muscle that releases oxygen at very low tensions

Injury to skeletal muscle will cause a release of myoglobin into the blood

CARDIAC MARKERS

MYOGLOBIN >90 mcg/L… MI

R: 1 to 2 hoursP: 4 to 6 hoursN: 24 to 36 hours

SERUM LIPIDS

Total Cholesterol--- 140 to 199 mg/dl

Low Density Lipoprotein (LDL)--- <130 mg/dl

High Density Lipoprotein (HDL)--- 30 to 70 mg/dl

Triglycerides--- < 200 mg/dl

SERUM LIPIDS

Nursing Considerations:

o oral contraceptivesPO except water for 12 to 14

hourso alcohol for 24 hourso high cholesterol foods the

evening meal before the test

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ECG-valuates heart rate and the

regularity of heartbeats. -ardiac dysrhythmias, MI,

and cardiac hypertrophy- raph of the electrical

impulses moving through the heart.

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ECGNursing Consideration:-lectrical shock will not occur-ardiac medications of the

patient should be documented-ive instructions to lie still,

breathe normally, and refrain from talking during the test

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BASIC ECG INTERPRETATIONNormal Sinus Rhythym

Sinus TachycardiaSinus BradycardiaAtrial TachycardiaAtrial Fibrillation

Atrial FlutterVentricular TachycardiaVentricular Fibrillation

Asystole

STANDARD LEAD PLACEMENTPRECORDIAL LEADS

White: Right ArmBlack: Left ArmGreen: Right LegRed: Left Leg

STANDARD LEAD PLACEMENTLIMBS LEADS

BASIC ECG INTERPRETATION

BASIC ECG INTERPRETATION

• P WAVE: Atrial depolarization• PR INTERVAL: AV conduction time• QRS COMPLEX: Ventricular

depolarization• ST SEGMENT: Time interval

between complete depolarization of ventricles and repolarization of ventricles

• T WAVE: Ventricular repolarization

NORMAL CARDIAC RHYTHM PARAMETERS

• NORMAL SINUS RHYTHM: 60 TO 100 bpm

• SINUS BRADYCARDIA: <60 bpm• SINUS TACHYCARDIA: >100 bpm• QRS WIDTH: 0.08 to 0.12 sec• PR INTERVAL: 0.12 to 0.20 sec• QT INTERVAL: 0.30 to 0.40 sec

FIGURING HEART RATE

1. 1500 method2. RR method3. 6-second method

FIGURING HEART RATE

1. 1500 method

FIGURING HEART RATE

2. RR method

FIGURING HEART RATE

3. 6-second method

NORMAL SINUS RHYTHM

Rate Rhythm P Waves P-R QRS60 to 100 Regular Present 0.12 to

0.20 secs0.08 tp

0.12 secs

SINUS TACHYCARDIA

Rate Rhythm P Waves P-R QRS>100 BPM Regular Present 0.12 to

0.20 secs0.08 to

0.12 secs

SINUS BRADYCARDIA

Rate Rhythm P Waves P-R QRS<60 BPM Regular Present 0.12 to

0.20 secs0.08 to

0.12 secs

ATRIAL TACHYCARDIA

Rate Rhythm P Waves P-R QRS150 to 250

bpmRegular Present Short

<0.12 0.08 to

0.12 secs

ATRIAL FIBRILLATION

Rate Rhythm P Waves P-R QRSVariable Irregularly-

IrregularAbsent Non-

discernibleNarrow

ATRIAL FLUTTER

Rate Rhythm P Waves P-R QRS250 to 350

bpmUsually regular

Sawtooth pattern

Non- discernible

Usuallynarrow

VENTRICULAR TACHYCARDIA

Rate Rhythm P Waves P-R QRS100 TO 220

BPMUsually regular

Absent NA Wide>0.12 sec

VENTRICULAR FIBRILLATION

Rate Rhythm P Waves P-R QRS350 TO

450BPMCompletely chaotic and disorganized

Absent NA Absent

ASYSTOLE

Rate Rhythm P Waves P-R QRSNo Rate No Rhythm Absent NA Absent

CVP-atheter is attached to an IV

infusion and H2O manometer by a three way stopcock

-eins external jugular, antecubital, or femoral

- ressure within the superior vena cava

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CVPNormal Value: 3 to 8 mmHgPosition:Cardiac Disease: Semi Fowler’sDressing or Tubing Change: Flat or

TrendelenburgCVP Reading and Monitoring: Flat,

Supine, or Dorsal RecumbentAir Embolism: Left Side Lying

CVP

1. Maintain zero point of manometer always at level of right atrium (intersection between midaxillary line and 4th ICS, also referred to as the phlebostatic axis)

2. Determine patency of catheter by opening IV infusion line

3. Turn stopcock to allow IV solution to run into manometer to a level of 10-20cm above expected pressure reading

4. Turn stopcock to allow IV solution to flow from manometer into catheter; fluid level in manometer fluctuates with respiration

5. Stop ventilatory assistance during measurement of CVP

6. After CVP reading, return stopcock to IV infusion position

7. Record CVP reading and position of client (angle of recline)

PERICARDIOCENTESIS

ericardial effusionunctureericardial sacericardial fluid

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PERICARDIOCENTESIS

PREPROCEDURE

erform blood analysisCGestriction of food and water is

recommended for six hours before the test.

V line for sedation

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PERICARDIOCENTESISINTRAPROCEDUREvail emergency resuscitative

equipment at bedsideed is elevated to 45 to 60

degreesardiac activity monitoringone in emergency room, ICU,

or at the bedside

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PERICARDIOCENTESISPOSTPROCEDURE

pical pulse monitoringlood pressureVPetect complications:

Ventricular or coronary artery puncture, dysrhythmias, pleural laceration, gastric puncture, myocardial trauma

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RESPIRATORY SYSTEMChest X-ray

Sputum SpecimenBronchoscopyThoracentesisLung BiopsyABG Analysis

Incentive SpirometerPeak Flow Meter

CHEST X-RAY

A-natomyA-natomyA-ppearance A-ppearance

CHEST X-RAYPREPROCEDURE:emove all jewelry and other metal

objects from the chest areassess the client’s ability to inhale

and hold his or her breathou question women regarding

pregnancy or possibility of pregnancy

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CHEST X-RAY

POSTPROCEDURE:Help the client get dressed

SPUTUM SPECIMENpecimen thru

expectorationuctioning of the

tracheaputum amount: 15

ml

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SPUTUM SPECIMENPREPROCEDURE:-lways collect the specimen

before antibiotic therapy-e sure that the client rinse

mouth with water-lient to take several deep

breaths and then cough deeply

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SPUTUM SPECIMEN

POSTPROCEDURE:

If a culture of sputum is prescribed, transport the specimen to the laboratory immediately

Assist the client with mouth care

BRONCHOSCOPYTo visualize:

LL BBTTarynx rachea ronchi

BRONCHOSCOPY

BRONCHOSCOPY

Purposes:-pply medications-rush biopsy-arefully remove

foreign objects-irect visualization

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BRONCHOSCOPYPREPROCEDURE:tain informed consentemove dentures or eyeglassesbtain vital signsPO postmidnightoagulation studies result must be checkedave emergency resuscitation equipment

readily vailable give IVF and medication for sedationuction equipment at bedside

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BRONCHOSCOPYPOSTPROCEDURE:ag reflex return ssess for bloody sputumive instruction that sore throat is commonespiratory status must be monitoredmesis basin at bedsideowler’s semi positionook out for complications like

bronchospasm or bronchial perforationlevated temperature and DOB- Notify!amine vital signs

GGAAGGRREEFFLL

EEXX

THORACENTESIS

Insertion of a needle through the chest wall:

• Obtain specimen• Remove pleural fluid

accumulation• Instill medication

THORACENTESIS

THORACENTESISPREPROCEDURE:o obtain informed consentealth teaching: not cough, breathe deeply, or

move during the testn doctor's office, in the X-ray department, ER,

OR or at bedsideidden on bed: Sidelying towards the unaffected

side with HOB elevatedmbulatory: Sit upright with arms and shoulders

supported by a table-ray or ultrasound before the procedure

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THORACENTESIS

POSTPROCEDURE:Monitor vital signsMonitor respiratory statusApply a pressure dressing Assess the puncture site for bleeding

and crepitusMonitor for signs of pneumothorax,

air embolism, and pulmonary edema

LUNG BIOPSYCC-ulture

CC-ytological exam

PP-ulmonary lesion

PP-leural effusion

LUNG BIOPSYPREPROCEDURE:-et the patient signs informed

consent-se of local anesthesia, pressure

during insertion of needle-PO-ive analgesics and sedatives as

prescribed

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LUNG BIOPSYPOSTPROCEDURE:-ital signs must be monitored-nspect biopsy site for drainage or

bleeding-n biopsy site dressing must be applied-neumothorax and air embolism-igns of respiratory distress must be

monitored-ou prepare the patient for chest x-ray

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ABG ANALYSISMeasurementOxygenCarbon dioxideArterial bloodAcid base state

ABG ANALYSISPREPROCEDURE:-llen’s test before drawing

radial artery specimens-efore specimen collection,

client to rest for 30 minutes-iving suction before drawing

ABG sample is avoided

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ABG ANALYSIS

POSTPROCEDURE:Place the specimen on iceNote the client’s temperature

on the laboratory formNote the oxygen and type of

ventilation that the client is receiving on the laboratory form

ABG ANALYSIS

POSTPROCEDURE:Apply pressure to the puncture

site for 5 to 10 minutes or longer if the client is taking anticoagulant therapy or has a bleeding disorder

Transport the specimen to the laboratory within 15 minutes

ABG ANALYSIS

Normal Arterial Blood Gas Values:

pH 7.35 to 7.45

PCO2 35 to 45 mmHg

HCO3 22 to 26 mmHg

PO2 80 to 100 mmHg

O2 sat 96% to 100 %

ABG ANALYSIS

R-espiratory O-ppositeM-etabolicE-qual

INCENTIVE SPIROMETERSustainedMaximalInspiration

INCENTIVE SPIROMETER

INCENTIVE SPIROMETERINDICATIONS:Upper-abdominal surgeryThoracic surgerySurgery in patients with chronic

obstructive pulmonary disease Pulmonary atelectasisPresence of a restrictive lung defect

associated with quadraplegia and/or dysfunctional diaphragm.

INCENTIVE SPIROMETERNursing ConsiderationsPREPROCEDURE-void smoking or eating heavy meal for 4

to 6 hours before the test-e sure to remove dentures-onsult with the physician regarding

holding bronchodilators before testing-etermine whether analgesic that may

depress the respiratory function is being administered

-ncourage to void and wear loose clothing

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INCENTIVE SPIROMETERNursing Considerations

POSTPROCEDURE

Resume:• Diet• Bronchodilators• Respiratory treatments

PEAK FLOW METER

determines the effectivity of bronchodilator for asthmatic patients

PEAK FLOW METERManagement:1. Diary2. Weeks period that the child is

well3. BlowsResults:GREEN: 80 to 100%... Very GoodYELLOW: 50 to 80%... Beginning

AttackRED: <50%... Bring to ER